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Bischoff MS, Skrypnik D, Fiori W, Schöffski O, Böckler D. [Cost-revenue aspects of endovascular treatment of distal aortic arch pathologies with respect to the introduction of a new thoracic side-branch prosthesis]. CHIRURGIE (HEIDELBERG, GERMANY) 2024; 95:473-479. [PMID: 38498124 PMCID: PMC11096206 DOI: 10.1007/s00104-024-02072-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/23/2024] [Indexed: 03/20/2024]
Abstract
BACKGROUND The standard vascular surgical procedure (SV) for the treatment of distal aortic arch pathologies involves a hybrid approach using a left carotid-subclavian bypass and thoracic endovascular aortic repair. Considering the introduction of a thoracic side branch prosthesis (TBE), the aim of this study was to analyze the cost-revenue aspects of both procedures. MATERIAL AND METHODS A retrospective analysis was conducted on cases treated by SV from 2017 to 2022. To draw conclusions regarding the use of TBE, the main diagnoses and procedures of SV were recoded based on current classifications (ICD/OPS 2023) for revenue calculations and regrouped according to aG-DRG 2023. An OPS modification and regrouping were performed for modeling TBE revenues. RESULTS A total of 13 cases were identified (mean age 62.5 ± 13.8 years; 10 males). After regrouping, the following DRGs were obtained: F42Z in N = 5, F51A in N = 4, F08B in N = 2, and F07A and F36B each in N = 1. The total revenue after regrouping was € 666,514.13, including an additional payment (ZE) of € 132,729.14. With the modeled application of TBE, a total revenue of € 659,212.19 was achieved. Compared to SV, this represents a revenue decrease of € 16,886.71 (changed DRG), but with an increase in ZE revenue by € 65,559.78 (different ZE). The use of TBE resulted in a saving of 74 occupancy days, including 13.5 days in intensive care. CONCLUSION A cost coverage seems probable with a change in the procedure, despite the yet to be determined pricing of TBE. This is highly dependent on the coding quality and the future development of ZE, given the annually changing DRG relative weights. Precise and transparent performance and cost documentation are essential for determining the pricing.
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Affiliation(s)
- Moritz S Bischoff
- Klinik für Gefäßchirurgie und Endovaskuläre Chirurgie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Deutschland.
| | - Denis Skrypnik
- Klinik für Gefäßchirurgie und Endovaskuläre Chirurgie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Deutschland
| | - Wolfgang Fiori
- DRG-Research-Group, Roeder & Partner Ärzte PartG, Senden, Deutschland, Am Dorn 10, 48308
| | - Oliver Schöffski
- Lehrstuhl für Gesundheitsmanagement, Universität Erlangen-Nürnberg, Nürnberg, Deutschland, Lange Gasse 20, 90403
| | - Dittmar Böckler
- Klinik für Gefäßchirurgie und Endovaskuläre Chirurgie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Deutschland
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Hagedorn MN, Meisenbacher K, Skrypnik D, Bischoff MS, Böckler D. Standing the test of time: total aortic remodeling 13 years after TEVAR for acute type B aortic dissection. Indian J Thorac Cardiovasc Surg 2024; 40:86-90. [PMID: 38125333 PMCID: PMC10728030 DOI: 10.1007/s12055-023-01586-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 07/27/2023] [Accepted: 07/29/2023] [Indexed: 12/23/2023] Open
Abstract
Long-term outcome after thoracic endovascular aortic repair (TEVAR) of acute type B aortic dissection (aTBAD) is still underreported in current literature. This case report shows persistence of aortic remodeling without secondary complication or need of reintervention 13 years after TEVAR. A 45-year-old woman was referred to the emergency room with aTBAD. Due to early diameter progression in combination with therapy-refractory pain and uncontrolled hypertension, TEVAR was performed. Hereafter, the patient showed complete remodeling of the descending thoracic aorta without persistent false lumen perfusion in this segment and with stable true and false lumen diameter in the untreated abdominal segment for a 13-year period. No aortic-related reintervention was needed. With contemporary devices and adapted therapy, TEVAR seems able to treat complex thoracic disease. Long-term follow-up (FU) is mandatory to monitor the efficacy and durability of endovascular treatment in aortic disease.
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Affiliation(s)
- Matthias Niklas Hagedorn
- Department of Vascular and Endovascular Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany
| | - Katrin Meisenbacher
- Department of Vascular and Endovascular Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany
| | - Denis Skrypnik
- Department of Vascular and Endovascular Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany
| | - Moritz Sebastian Bischoff
- Department of Vascular and Endovascular Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany
| | - Dittmar Böckler
- Department of Vascular and Endovascular Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany
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3
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Doberne JW, Sabe AA, Vekstein AM, Wojnarski CM, Anand J, Voight S, Raman V, Halpern S, Armstrong JL, Zhu A, Weissler EH, Jawitz OK, Williams AR, Hughes GC. Stent Graft-Induced Aortic Wall Injury (SAWI) - Incidence, Risk Factors, and Outcomes. Ann Thorac Surg 2022; 114:684-692. [PMID: 35150615 DOI: 10.1016/j.athoracsur.2022.01.028] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Revised: 01/02/2022] [Accepted: 01/04/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Stent graft-induced new entry (SINE) has been described in thoracic endovascular aortic repair (TEVAR) for aortic dissection. The incidence of stent graft-induced aortic wall injury (SAWI) related to iatrogenic injury in non-dissections is incompletely described. We describe incidence, risk factors, and outcomes of SAWI. METHODS All post-TEVAR CT angiograms (1/2005-12/2018) were reviewed for radiographic evidence of SAWI. Endograft-induced aortic dissections were likewise considered SAWI. Patient characteristics, time to SAWI, and need for re-intervention were noted. Cox proportional hazards modeling was used to identify risk factors for SAWI. RESULTS Within the study cohort (n=430), 38 (9%) patients developed SAWI during a median follow-up of 2.3 years (IQR 4.8 years). 42% (n=16) of SAWI were proximal, 53% (n=20) distal and 5% (n=2) both proximal and distal. Nine (23%) were distal intimal flap injuries in dissection cases, thus sub-classifying them as SINE. 29% (n=11) of SAWI required re-intervention. Of these, 45% (n=5) were open and 55% (n=6) endovascular. TEVAR for acute dissection had a higher incidence of SAWI development (HR 4.6, 95% CI: [2.4, 9.0]; p<0.001) as compared to other indications. Use of devices with proximal bare springs or barbs was also associated with increased SAWI incidence (HR 5.3, 95% CI: [2.6, 11.0]; p<0.001). CONCLUSIONS The rate of SAWI following TEVAR is low (9%), but nearly one-third will require re-intervention. TEVAR in the setting of acute dissection and use of devices with proximal bare springs or barbs were associated with an increased incidence of SAWI.
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Affiliation(s)
- Julie W Doberne
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Ashraf A Sabe
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Andrew M Vekstein
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Charles M Wojnarski
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Jatin Anand
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Soraya Voight
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Vignesh Raman
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Samantha Halpern
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Jenna L Armstrong
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Alexander Zhu
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - E Hope Weissler
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Oliver K Jawitz
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Adam R Williams
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - G Chad Hughes
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC.
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4
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Identification of geometric and mechanical factors predictive of bird-beak configuration in thoracic endovascular aortic repair using computational models of stent graft deployment. JVS Vasc Sci 2022; 3:259-273. [PMID: 35938091 PMCID: PMC9352945 DOI: 10.1016/j.jvssci.2022.05.056] [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: 02/22/2022] [Accepted: 05/25/2022] [Indexed: 11/21/2022] Open
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Skrypnik D, Bischoff MS, Meisenbacher K, Kronsteiner DB, Böckler D. A 10-Year Single-Center Experience With the GORE TAG Conformable Thoracic Stent Graft in the Treatment of Thoracic Aortic Disease. J Endovasc Ther 2021; 29:370-380. [PMID: 34632839 PMCID: PMC9096584 DOI: 10.1177/15266028211049340] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective: The aim of this study was to report 10-year real-world single-center experience with the GORE TAG conformable thoracic aortic graft (CTAG), focusing on rupture-free survival, aortic-related reintervention, and device-related complications during midterm and long-term follow-up (FU). Methods: This retrospective study analyzes results of thoracic endovascular aortic repair (TEVAR) performed between January 2009 and December 2018. Out of 419 TEVAR procedures within this period, 194 patients (male 57.2%, 111/194), with a mean age of 65 ± 13 years, were treated with the CTAG device. Indication for TEVAR was a thoracic aortic aneurysm in 24.7% (48/194), type B aortic dissection in 32.5% (63/194), penetrating aortic ulcer 15.5% (30/194), and miscellaneous 27.3% (53/194). Emergently were operated 43.8% (85/194) patients. Median follow-up (FU) including computed tomography imaging was 43.5 months (Q1-Q3: 8.6–67.0) and was completed in 91.2% (177/194) of patients. Results: Overall survival rates were 75.8% (95% confidence interval [CI] = [0.76–0.70]) and 56.6% (95% CI = [0.57–0.50]) at 12 and 60 months, respectively. Cumulative incidence for aortic rupture was 11.9% (95% CI = [0.07–0.17]) at 60 and 90 months, respectively. Cumulative incidence for aortic-related reintervention was 27.5% (95% CI = [0.21–0.34]) at 60 and 90 months. Cumulative incidence for migration was 2.8% (95% CI = [0.004–0.05]) and 3.9% (95% CI = [0.007–0.07]) at 60 and 90 months, respectively. New endograft infections or material fatigue were not observed. Conclusions: The herein reported 10-year real-world single-center experience with the CTAG observed favorable long-term outcome. Thus, the device demonstrates appropriate persistent safety, efficacy, and clinical durability up to long-term FU in the treatment of diverse thoracic aortic pathologies.
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Affiliation(s)
- Denis Skrypnik
- Department of Vascular and Endovascular Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Moritz S Bischoff
- Department of Vascular and Endovascular Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Katrin Meisenbacher
- Department of Vascular and Endovascular Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Dorothea B Kronsteiner
- Institute of Medical Biometry and Informatics, Heidelberg University, Heidelberg, Germany
| | - Dittmar Böckler
- Department of Vascular and Endovascular Surgery, University Hospital Heidelberg, Heidelberg, Germany
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6
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Böckler D, Bischoff MS, Kronsteiner D, Skrypnik D, Meisenbacher K. Outcome analysis of the Gore Conformable Thoracic Stent Graft with active control system for the treatment of arch and descending thoracic aortic disease. Eur J Cardiothorac Surg 2021; 60:1455-1463. [PMID: 34337659 DOI: 10.1093/ejcts/ezab289] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 04/20/2021] [Accepted: 05/13/2021] [Indexed: 01/25/2023] Open
Abstract
OBJECTIVES The aim of this study was to evaluate technical/clinical outcomes of the Gore TAG Conformable Thoracic Stent Graft with Active Control System (CTAG with ACS) in thoracic aortic disease since its introduction in Europe in 2017. METHODS Patients undergoing thoracic endovascular aortic repair (TEVAR) with the device between 2017 and 2020 were identified from a prospectively maintained single-centre database and retrospectively analysed. Predominant indications were aortic dissection (n = 46), thoracic/thoraco-abdominal aneurysm (n = 20/n = 7), penetrating ulcer (n = 14) and intramural haematoma (n = 12). Emergency procedures were performed in 47% (54/115). The primary outcome was technical success. Secondary outcomes were clinical success, serious adverse events and procedure-related reintervention. ACS was assessed regarding angulation, accuracy and apposition. The median follow-up was 8.46 months (interquartile range: 3.18-16.89 months). RESULTS A total of 115 consecutive patients (82 males, median age 63; interquartile range: 53-74 years) have been included. Technical success was achieved in 95.7% (110/115). Clinical success rate was 80.9% (93/115); mostly due to procedure-related death (n = 14). Overall mortality was 19.1% (22/115), with significant differences between elective/emergency procedures (log-rank: P < 0.001). Procedure-related serious adverse event rate was 44.3% (51/115). Procedure-related reintervention was performed in 20.9% (24/115). The cumulative incidence for reintervention differed significantly between elective/emergency cases (Gray's test: P = 0.0033). Angulation was used in 40.9% of patients (47/115), mostly in type II arches (52.7%). Deployment accuracy was 87.8% (101/115). Sufficient apposition was present in 93.0% (107/115). CONCLUSIONS This single-centre study shows encouraging performance of the CTAG with ACS in an array of aortic pathologies. Although longer-term data must be awaited, ACS leads to overall favourable device placement. Despite ongoing advances in device technology, TEVAR remains challenging and is associated with significant burden inherent to the underlying disease.
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Affiliation(s)
- Dittmar Böckler
- Department of Vascular and Endovascular Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Moritz S Bischoff
- Department of Vascular and Endovascular Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Dorothea Kronsteiner
- Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - Denis Skrypnik
- Department of Vascular and Endovascular Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Katrin Meisenbacher
- Department of Vascular and Endovascular Surgery, Heidelberg University Hospital, Heidelberg, Germany
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7
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Howard C, Sheridan J, Picca L, Reza S, Smith T, Ponnapalli A, Calow R, Cross O, Iddawela S, George M, Livra Dias D, Srinivasan A, Munir W, Bashir M, Idhrees M. TEVAR for complicated and uncomplicated type B aortic dissection-Systematic review and meta-analysis. J Card Surg 2021; 36:3820-3830. [PMID: 34310731 DOI: 10.1111/jocs.15827] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 06/23/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Type B aortic dissection (TBAD), is defined as a dissection involving the aorta distal to left subclavian artery with the ascending aorta and the aortic arch not affected. TBAD is classified due to the time frame and presence of complications. Complicated TBAD (co-TBAD) patients have a greater mortality rate than uncomplicated TBAD (un-TBAD) and thoracic endovascular aortic repair (TEVAR) is considered the gold-standard intervention for these clinical challenges. METHODS We undertook a systematic review of the literature regarding TEVAR intervention in co-TBAD and un-TBAD. A comprehensive search was undertaken across four major databases and was evaluated and assessed until June 2020. RESULTS A total of 16,104 patients were included in the study (7772 patients co-TBAD and 8352 un-TBAD). A significantly higher proportion of comorbidities were seen in co-TBAD patients compared with un-TBAD. Acute dissection was more frequent in the co-TBAD group (73.55% vs. 66.91%), while chronic dissection was more common in un-TBAD patients (33.8% vs. 70.73%). Postprocedure stroke was higher in co-TBAD (5.85% vs. 3.92%; p < .01), while postprocedural renal failure was higher in un-TBAD patients (7.23 vs. 11.38%; p < .01). No difference was observed in in-hospital mortality however the 30 days mortality was higher in the co-TBAD group. One-year survival was higher in the uncomplicated group but this difference was not observed in the 5-year survival. CONCLUSION In our analysis we can appreciate that despite significantly higher comorbidities in the co-TBAD cohort, there was no difference in in-hospital mortality between the two groups and the 5-year survival did not have any difference.
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Affiliation(s)
- Callum Howard
- Faculty of Biology, Medicine & Health, University of Manchester, Manchester, UK
| | - Jonathan Sheridan
- Academic Unit of Medical Education, The University of Sheffield, Sheffield, UK
| | - Leonardo Picca
- Faculty of Biology, Medicine & Health, University of Manchester, Manchester, UK
| | - Sihab Reza
- Faculty of Biology, Medicine & Health, University of Manchester, Manchester, UK
| | - Tristan Smith
- Faculty of Biology, Medicine & Health, University of Manchester, Manchester, UK
| | - Anuradha Ponnapalli
- Faculty of Biology, Medicine & Health, University of Manchester, Manchester, UK
| | - Rachel Calow
- Faculty of Biology, Medicine & Health, University of Manchester, Manchester, UK
| | - Olivia Cross
- School of Medicine, Keele University, Staffordshire, UK
| | - Sashini Iddawela
- Department of Respiratory Medicine, University Hospitals Birmingham, Birmingham, UK
| | - Melvin George
- Clinical Pharmacology, SRM Medical College Hospital, Kancheepuram, Tamil Nadu, India
| | - Deidre Livra Dias
- Senior Medical Reviewer, Cognizant Technology Solutions, Pune, India
| | - Anand Srinivasan
- Department of Pharmacology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | - Wahaj Munir
- Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Mohammad Bashir
- Vascular and Endovascular Surgery, NHS Wales Health Education and Improvement, Cardiff, UK
| | - Mohammed Idhrees
- Institute of Cardiac and Aortic Disorders (ICAD), SRM Institutes for Medical Science (SIMS Hospital), Vadapalani, Chennai, India
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Cao L, Ge Y, He Y, Wang X, Rong D, Lu W, Liu X, Guo W. Association between aortic arch angulation and bird-beak configuration after thoracic aortic stent graft repair of type B aortic dissection. Interact Cardiovasc Thorac Surg 2021; 31:688-696. [PMID: 33025008 DOI: 10.1093/icvts/ivaa171] [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: 04/03/2020] [Revised: 07/06/2020] [Accepted: 07/15/2020] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES The goal of this study was to investigate factors favouring the bird-beak configuration after thoracic endovascular aortic repair (TEVAR) for type B aortic dissection. METHODS We retrospectively analysed 76 patients with type B aortic dissection who underwent landing zone 1 and 2 TEVAR from December 2015 to January 2018. Preoperative aortic arch geometry (aortic arch length, maximal diameter and angulation), stent graft details and operative details were evaluated. A bird-beak configuration was defined as a ≥5-mm gap between the proximal end of the stent and the aortic wall of the lesser curvature. RESULTS Patients were stratified into those with (n = 46) and without (n = 30) a bird-beak configuration. The baseline demographics, dissection chronicity, clinical features and implanted devices were largely similar between the 2 groups. No significant difference was observed in the arch length or maximal arch diameter. However, the mean aortic arch angulation was greater in patients with than without a bird-beak configuration (61.4° vs 51.3°; P < 0.001). No influence of either the stent graft brand or the proximal stent graft type was observed. The multivariable analysis showed that the aortic arch angulation was an independent risk factor for a bird-beak configuration (odds ratio 1.15, 95% confidence interval 1.07-1.24; P < 0.001). A cut-off angle of 59.15° was predictive of a bird-beak configuration (sensitivity 59%; specificity 77%). CONCLUSIONS The preoperative aortic arch angulation was an independent predictor of a postoperative bird-beak configuration in patients with type B aortic dissection who underwent TEVAR that involved the aortic arch. An angle of >59.15° may imply a relatively hostile anatomy with a higher risk of a bird-beak configuration.
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Affiliation(s)
- Long Cao
- Department of Vascular and Endovascular Surgery, Chinese PLA General Hospital, Beijing, China.,Department of General Surgery, Chinese PLA No. 983 Hospital, Tianjin, China
| | - Yangyang Ge
- Department of Vascular and Endovascular Surgery, Chinese PLA General Hospital, Beijing, China
| | - Yuan He
- Department of Vascular and Endovascular Surgery, Chinese PLA General Hospital, Beijing, China
| | - Xinhao Wang
- Department of Vascular and Endovascular Surgery, Chinese PLA General Hospital, Beijing, China
| | - Dan Rong
- Department of Vascular and Endovascular Surgery, Chinese PLA General Hospital, Beijing, China
| | - Weihang Lu
- Department of General Surgery, The Sixth Medical Center of Chinese, PLA General Hospital, Beijing, China
| | - Xiaoping Liu
- 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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9
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Ahmed Y, Houben IB, Figueroa CA, Burris NS, Williams DM, Moll FL, Patel HJ, van Herwaarden JA. Endovascular ascending aortic repair in type A dissection: A systematic review. J Card Surg 2021; 36:268-279. [PMID: 33169411 PMCID: PMC8463007 DOI: 10.1111/jocs.15192] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 09/01/2020] [Accepted: 09/08/2020] [Indexed: 11/27/2022]
Abstract
PURPOSE Up to 10% of acute type A aortic dissection (TAAD) patients are deemed unfit for open surgical repair, exposing these patients to high mortality rates. In recent years, thoracic endovascular aortic repair has proven to be a promising alternative treatment modality in specific cases. This study presents a comprehensive overview of the current state of catheter-based interventions in the setting of primary TAAD. METHODS A literature search was conducted, using MEDLINE and PubMed databases according to PRISMA guidelines, updated until January 2020. Articles were selected if they reported on the endovascular repair of DeBakey Type I and II aortic dissections. The exclusion criteria were retrograde type A dissection, hybrid procedures, and combined outcome reporting of mixed aortic pathologies (e.g., pseudoaneurysm and intramural hematoma). RESULTS A total of 31 articles, out of which 19 were case reports and 12 case series, describing a total of 92 patients, were included. The median follow-up was 6 months for case reports and the average follow-up was 14 months for case series. Overall technical success was 95.6% and 30-day mortality of 9%. Stroke and early endoleak rates were 6% and 18%, respectively. Reintervention was required in 14 patients (15%). CONCLUSION This review not only demonstrates that endovascular repair in the setting of isolated TAAD is feasible with acceptable outcomes at short-term follow-up, but also underlines a lack of mid-late outcomes and reporting consistency. Studies with longer follow-up and careful consideration of patient selection are required before endovascular interventions can be widely introduced.
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Affiliation(s)
- Yunus Ahmed
- Department of Vascular Surgery, Utrecht University Medical Center, Utrecht, The Netherlands
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Ignas B. Houben
- Department of Vascular Surgery, Utrecht University Medical Center, Utrecht, The Netherlands
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - C. Alberto Figueroa
- Departments of Surgery & Biomedical Engineering, University of Michigan, Ann Arbor, Michigan, USA
| | - Nicholas S. Burris
- Department of Radiology, University of Michigan, Ann Arbor, Michigan, USA
| | - David M. Williams
- Department of Radiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Frans L. Moll
- Department of Vascular Surgery, Utrecht University Medical Center, Utrecht, The Netherlands
| | - Himanshu J. Patel
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan, USA
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Tanaka S, Kato N, Oue K, Noda Y, Kato H, Miyake Y. Aortic Valve Perforation During Endovascular Repair of an Abdominal Aortic Aneurysm-A Case Report. Vasc Endovascular Surg 2020; 55:183-185. [PMID: 32885727 DOI: 10.1177/1538574420953950] [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: 11/17/2022]
Abstract
Although complications associated with endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms are rarely observed above the diaphragm, they could lead to catastrophic outcomes once they develop. Aortic valve perforation is one of those rare and major adverse events. In this report, we describe a case of an 82-year-old woman who suffered aortic valve perforation during EVAR caused by the wire-push technique. Her hemodynamics became unstable during the procedure and did not improve thereafter. Echocardiography performed 8 days after EVAR revealed aortic valve perforation. Surgical intervention was abandoned because her general condition was poor. The patient died 4 months after EVAR due to heart failure. It should be reminded that inadvertent manipulation of the wire can cause aortic valve perforation even during EVAR.
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Affiliation(s)
- Satofumi Tanaka
- Department of Cardiothoracic Surgery, 47717Kochi Health Sciences Center, Japan
| | - Noriyuki Kato
- Department of Radiology, 38072Mie University Hospital, Japan
| | - Kensuke Oue
- Department of Cardiothoracic Surgery, 47717Kochi Health Sciences Center, Japan
| | - Yoshihiro Noda
- Department of Radiology, 47717Kochi Health Sciences Center, Japan
| | - Hiroaki Kato
- Department of Radiology, 38072Mie University Hospital, Japan
| | - Yoichiro Miyake
- Department of Cardiothoracic Surgery, 47717Kochi Health Sciences Center, Japan
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Marrocco-Trischitta MM, Spampinato B, Mazzeo G, Mazzaccaro D, Milani V, Alaidroos M, Ambrogi F, Nano G. Impact of the Bird-Beak Configuration on Postoperative Outcome After Thoracic Endovascular Aortic Repair: A Meta-analysis. J Endovasc Ther 2019; 26:771-778. [DOI: 10.1177/1526602819865906] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Purpose: To investigate the association between the bird-beak configuration (BBC), a wedge-shaped gap between the undersurface of a thoracic endograft and the lesser curvature of the arch after thoracic endovascular aortic repair (TEVAR), and postoperative outcome after TEVAR. Methods: The study was performed according to the PRISMA guidelines. The PubMed, EMBASE, and Cochrane databases were searched to identify all case series reporting BBC after TEVAR between 2006 and April 2018. Data analysis was performed considering the difference in the risk of complications for presence vs absence of BBC. After screening 1633 articles, 21 studies were identified that matched the selection criteria; 12 of these reported detailed information to investigate the postoperative outcome using proportion meta-analysis with a random effects model. The pooled risk difference is reported with the 95% confidence interval (CI). Heterogeneity of the included studies was assessed with the I2 statistic (low 25%, medium 50%, high 75%). Results: Complications occurred within a range of 0 to 72 months in 14.7% (95% CI 7.4% to 27.3%) of patients with BBC and in 6.3% (95% CI 2.5% to 15.4%) of patients without BBC. A cumulative incidence could not be assessed. The summary risk difference was 11.1% (95% CI −0.1% to 22.3%, p=0.052). There was significant heterogeneity ( I2=85.6%). The Egger test did not show evidence of publication bias (p=0.975). When specifically considering type Ia endoleak and endograft migration, the risk difference between BBC and non-BBC patients was 8.2% (95% CI 0.3% to 16.1%, p=0.042; I2=69.0%). The specific risk difference for endograft collapse/infolding and thrombosis was 3.7% (95% CI −3.5% to 11.1%, p=0.308; I2=10.2%). Conclusion: At present the literature does not provide statistical evidence to establish an overall prognostic value of the BBC. Nevertheless, the BBC appears to be associated with a high risk of type Ia endoleak and endograft migration, which warrants specific and long-term surveillance. Clinically relevant values for BBC grading should be established to perhaps define indications for preemptive treatment based on the presence of BBC only.
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Affiliation(s)
- Massimiliano M. Marrocco-Trischitta
- Clinical Research Unit, Cardiovascular Department, IRCCS Policlinico San Donato, Milan, Italy
- Vascular Surgery Unit, Cardiovascular Department, IRCCS Policlinico San Donato, Milan, Italy
| | - Benedetta Spampinato
- Vascular Surgery Unit, Cardiovascular Department, IRCCS Policlinico San Donato, Milan, Italy
- Residency Program in Vascular Surgery, University of Milan, Italy
| | - Girolomina Mazzeo
- Vascular Surgery Unit, Cardiovascular Department, IRCCS Policlinico San Donato, Milan, Italy
- Residency Program in Vascular Surgery, University of Milan, Italy
| | - Daniela Mazzaccaro
- Vascular Surgery Unit, Cardiovascular Department, IRCCS Policlinico San Donato, Milan, Italy
| | - Valentina Milani
- Biostatistics Service, IRCCS Policlinico San Donato, Milan Italy
| | - Moad Alaidroos
- Vascular Surgery Unit, Policlinico San Marco, Zingonia, Italy
| | - Federico Ambrogi
- Biostatistics Service, IRCCS Policlinico San Donato, Milan Italy
- Laboratory of Medical Statistics, University of Milan, Italy
| | - Giovanni Nano
- Vascular Surgery Unit, Cardiovascular Department, IRCCS Policlinico San Donato, Milan, Italy
- Department of “Scienze Biomediche per la Salute,” University of Milan, Italy
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Antonello M, Squizzato F, Dall’Antonia A, Grego F, Piazza M. GORE TAG Thoracic Endograft with Active Control System: Landing Accuracy and Wall Apposition in an Initial Clinical Experience. Ann Vasc Surg 2019; 58:261-269. [DOI: 10.1016/j.avsg.2018.11.020] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 10/29/2018] [Accepted: 11/03/2018] [Indexed: 10/27/2022]
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13
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Early outcomes of the conformable stent graft for acute complicated and uncomplicated type B aortic dissection. J Vasc Surg 2017; 66:1644-1652. [DOI: 10.1016/j.jvs.2017.04.050] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Accepted: 04/18/2017] [Indexed: 01/16/2023]
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14
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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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