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Hong X, Lin Y, Xie X, Huang Y, Chen G, Chen Y, Hong S, Lu W, Fu W, Wang L. Long-term outcomes of thoracic endovascular aortic repair for chronic Stanford type B aortic dissection. Vascular 2024; 32:483-489. [PMID: 36690933 DOI: 10.1177/17085381231153695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJECTIVES The aim of this study was to report the long-term outcomes of proximal thoracic endovascular aortic repair (TEVAR) for chronic Stanford type B aortic dissection (cTBAD). METHODS We retrospectively analyzed the clinical data of 48 cases of patients with cTBAD who underwent proximal TEVAR in Zhongshan Hospital Fudan University from January 2010 to September 2013. The preoperative and postoperative imaging examinations, overall survival rate, aortic-related survival rate, and freedom from reintervention rate data were collected to evaluate aortic remodeling and clinical outcomes. The enrolled patients received follow-up at 1, 3, 6, and 12 months following treatment and annually thereafter. RESULTS A total of 48 patients (mean age, 58.3 ± 10.6 years; men:women, 40:8) were included, of which 38 cases (79.2%) were uncomplicated dissection and 10 cases (20.8%) were complicated. The mean follow-up time was 48.7 ± 40 months (1-120 months). The mean time interval from the initial procedure to reintervention was 50.6 ± 32.7 months (11-98 months). The following changes were observed at preoperative versus last follow-up timepoints. Descending aortic level: true lumen, 19.2 ± 7.01 mm vs. 36.9 ± 9.53 mm (p < 0.001); false lumen, 30.47 ± 15.89 mm vs. 19.16 ± 15.33 mm (p < 0.001); maximum diameter, 49.67 ± 13.96 mm vs. 56.66 ± 14.95 mm (p = 0.018). Diaphragm level: true lumen, 16.24 ± 5.41 mm vs. 24.41 ± 8.04 mm (p < 0.001); false lumen, 12.37 ± 11.49 mm vs. 14.92 ± 12.25 mm (p = 0.196); and maximum diameter, 34 ± 7.81 mm vs. 38.04 ± 7.7 mm (p < 0.001). The freedom from reintervention rate was 81% in 5 years and 50.6% in 10 years. The overall 10-years survival rate was 83% (6 of 48), and the aortic-related survival rate was 92.3% (3 of 48). CONCLUSIONS TEVAR is a safe and effective proximal repair intervention for cTBAD that can reliably induce the positive remodeling of the descending aorta.
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Affiliation(s)
- Xiang Hong
- Department of Vascular Surgery, Zhongshan Hospital (Xiamen) Fudan University, Xiamen, China
| | - Yue Lin
- Department of Vascular Surgery, Zhongshan Hospital (Xiamen) Fudan University, Xiamen, China
| | - Xinsehng Xie
- Department of Vascular Surgery, Zhongshan Hospital (Xiamen) Fudan University, Xiamen, China
| | - Yulong Huang
- Department of Vascular Surgery, Zhongshan Hospital (Xiamen) Fudan University, Xiamen, China
| | - Gang Chen
- Department of Vascular Surgery, Zhongshan Hospital (Xiamen) Fudan University, Xiamen, China
| | - Yihui Chen
- Department of Vascular Surgery, Zhongshan Hospital (Xiamen) Fudan University, Xiamen, China
| | - Shichai Hong
- Department of Vascular Surgery, Zhongshan Hospital (Xiamen) Fudan University, Xiamen, China
| | - Weifeng Lu
- Department of Vascular Surgery, Zhongshan Hospital (Xiamen) Fudan University, Xiamen, China
| | - Weiguo Fu
- Department of Vascular Surgery, Zhongshan Hospital (Xiamen) Fudan University, Xiamen, China
- Department of Vascular Surgery, Zhongshan Hospital Fudan University, Shanghai, China
| | - Lixin Wang
- Department of Vascular Surgery, Zhongshan Hospital (Xiamen) Fudan University, Xiamen, China
- Department of Vascular Surgery, Zhongshan Hospital Fudan University, Shanghai, China
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Ogino H, Iida O, Akutsu K, Chiba Y, Hayashi H, Ishibashi-Ueda H, Kaji S, Kato M, Komori K, Matsuda H, Minatoya K, Morisaki H, Ohki T, Saiki Y, Shigematsu K, Shiiya N, Shimizu H, Azuma N, Higami H, Ichihashi S, Iwahashi T, Kamiya K, Katsumata T, Kawaharada N, Kinoshita Y, Matsumoto T, Miyamoto S, Morisaki T, Morota T, Nanto K, Nishibe T, Okada K, Orihashi K, Tazaki J, Toma M, Tsukube T, Uchida K, Ueda T, Usui A, Yamanaka K, Yamauchi H, Yoshioka K, Kimura T, Miyata T, Okita Y, Ono M, Ueda Y. JCS/JSCVS/JATS/JSVS 2020 Guideline on Diagnosis and Treatment of Aortic Aneurysm and Aortic Dissection. Circ J 2023; 87:1410-1621. [PMID: 37661428 DOI: 10.1253/circj.cj-22-0794] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/05/2023]
Affiliation(s)
- Hitoshi Ogino
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Osamu Iida
- Cardiovascular Center, Kansai Rosai Hospital
| | - Koichi Akutsu
- Cardiovascular Medicine, Nippon Medical School Hospital
| | - Yoshiro Chiba
- Department of Cardiology, Mito Saiseikai General Hospital
| | | | | | - Shuichiro Kaji
- Department of Cardiovascular Medicine, Kansai Electric Power Hospital
| | - Masaaki Kato
- Department of Cardiovascular Surgery, Morinomiya Hospital
| | - Kimihiro Komori
- Division of Vascular and Endovascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine
| | - Hitoshi Matsuda
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center
| | - Kenji Minatoya
- Department of Cardiovascular Surgery, Graduate School of Medicine, Kyoto University
| | | | - Takao Ohki
- Division of Vascular Surgery, Department of Surgery, The Jikei University School of Medicine
| | - Yoshikatsu Saiki
- Division of Cardiovascular Surgery, Graduate School of Medicine, Tohoku University
| | - Kunihiro Shigematsu
- Department of Vascular Surgery, International University of Health and Welfare Mita Hospital
| | - Norihiko Shiiya
- First Department of Surgery, Hamamatsu University School of Medicine
| | | | - Nobuyoshi Azuma
- Department of Vascular Surgery, Asahikawa Medical University
| | - Hirooki Higami
- Department of Cardiology, Japanese Red Cross Otsu Hospital
| | | | - Toru Iwahashi
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Kentaro Kamiya
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Takahiro Katsumata
- Department of Thoracic and Cardiovascular Surgery, Osaka Medical College
| | - Nobuyoshi Kawaharada
- Department of Cardiovascular Surgery, Sapporo Medical University School of Medicine
| | | | - Takuya Matsumoto
- Department of Vascular Surgery, International University of Health and Welfare
| | | | - Takayuki Morisaki
- Department of General Medicine, IMSUT Hospital, the Institute of Medical Science, the University of Tokyo
| | - Tetsuro Morota
- Department of Cardiovascular Surgery, Nippon Medical School Hospital
| | | | - Toshiya Nishibe
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Kenji Okada
- Department of Surgery, Division of Cardiovascular Surgery, Kobe University Graduate School of Medicine
| | | | - Junichi Tazaki
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Masanao Toma
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center
| | - Takuro Tsukube
- Department of Cardiovascular Surgery, Japanese Red Cross Kobe Hospital
| | - Keiji Uchida
- Cardiovascular Center, Yokohama City University Medical Center
| | - Tatsuo Ueda
- Department of Radiology, Nippon Medical School
| | - Akihiko Usui
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine
| | - Kazuo Yamanaka
- Cardiovascular Center, Nara Prefecture General Medical Center
| | - Haruo Yamauchi
- Department of Cardiac Surgery, The University of Tokyo Hospital
| | | | - Takeshi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | | | - Yutaka Okita
- Department of Surgery, Division of Cardiovascular Surgery, Kobe University Graduate School of Medicine
| | - Minoru Ono
- Department of Cardiac Surgery, Graduate School of Medicine, The University of Tokyo
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Yamana K, Takami Y, Niwa W, Matsuhashi K, Sakurai Y, Amano K, Akita K, Maekawa A, Takagi Y. Mid-term results of distal anastomosis to the true lumen for chronic type B aortic dissection. Heart Vessels 2023; 38:849-856. [PMID: 36719451 DOI: 10.1007/s00380-023-02234-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 01/12/2023] [Indexed: 02/01/2023]
Abstract
We investigated whether distal anastomosis to the true lumen in open surgical repair of descending aorta for chronic type B aortic dissection improved the long-term outcomes with aortic remodeling. We retrospectively reviewed 71 patients with chronic type B aortic dissection, excluding those with connective tissue disorder, from October 2001 to June 2021. The patients who underwent distal true lumen anastomosis (group T, n = 36) were compared to those with both lumens' anastomosis (group B, n = 35), regarding survival, overall and distal aortic events. The growth rates of the distal aorta (maximum diameter in descending thoracic, suprarenal and infrarenal abdominal aorta) were also investigated. Median age was significantly higher in group T (T; 66 vs B; 60, P = .001). Group T had significantly higher rates of complete and partial thrombosis formation in the false lumen than group B postoperatively (26.9 vs 0%, P = .01 for complete, 65.4 vs 3.9%, P < .0001 for partial, respectively). At median follow-up for 6.8 years of 63 patients (88.7%), survival, overall and distal aortic event-free rates, and the growth rates of the distal aorta were not significantly different between the groups. Distal anastomosis to the true lumen did not improve mid-term survival, aortic event-free rates and the growth rates of the distal aorta compared with that of both lumens for chronic type B aortic dissection.
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Affiliation(s)
- Koji Yamana
- Department of Cardiovascular Surgery, Fujita Health University, 1-98, Dengakugakubo, Kutsukake-Cho, Toyoake, Aichi, 470-1192, Japan.
| | - Yoshiyuki Takami
- Department of Cardiovascular Surgery, Fujita Health University, 1-98, Dengakugakubo, Kutsukake-Cho, Toyoake, Aichi, 470-1192, Japan
| | - Wakana Niwa
- Department of Cardiovascular Surgery, Fujita Health University, 1-98, Dengakugakubo, Kutsukake-Cho, Toyoake, Aichi, 470-1192, Japan
| | - Kazuki Matsuhashi
- Department of Cardiovascular Surgery, Fujita Health University, 1-98, Dengakugakubo, Kutsukake-Cho, Toyoake, Aichi, 470-1192, Japan
| | - Yusuke Sakurai
- Department of Cardiovascular Surgery, Fujita Health University, 1-98, Dengakugakubo, Kutsukake-Cho, Toyoake, Aichi, 470-1192, Japan
| | - Kentaro Amano
- Department of Cardiovascular Surgery, Fujita Health University, 1-98, Dengakugakubo, Kutsukake-Cho, Toyoake, Aichi, 470-1192, Japan
| | - Kiyotoshi Akita
- Department of Cardiovascular Surgery, Fujita Health University, 1-98, Dengakugakubo, Kutsukake-Cho, Toyoake, Aichi, 470-1192, Japan
| | - Atsuo Maekawa
- Department of Cardiovascular Surgery, Fujita Health University, 1-98, Dengakugakubo, Kutsukake-Cho, Toyoake, Aichi, 470-1192, Japan
| | - Yasushi Takagi
- Department of Cardiovascular Surgery, Fujita Health University, 1-98, Dengakugakubo, Kutsukake-Cho, Toyoake, Aichi, 470-1192, Japan
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Sultan S, Acharya Y, Chua Vi Long K, Hatem M, Hezima M, Veerasingham D, Soliman O, Hynes N. Management of acute aortic syndrome with evolving individualized precision medicine solutions: Lessons learned over two decades and literature review. Front Surg 2023; 10:1157457. [PMID: 37065997 PMCID: PMC10097442 DOI: 10.3389/fsurg.2023.1157457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 03/15/2023] [Indexed: 03/30/2023] Open
Abstract
BackgroundThoracoabdominal acute aortic syndrome is associated with high morbidity and mortality. We aim to scrutinize our evolving strategies for acute aortic syndrome (AAS) management using minimally invasive and adaptive surgical techniques over two decades.MethodsThis is a longitudinal observational study at our tertiary vascular centre from 2002 to 2021. Out of 22,349 aortic referrals, we performed 1,555 aortic interventions over twenty years. Amongst 96 presented with symptomatic aortic thoracic pathology, 71 patients had AAS. Our primary endpoint is combined aneurysm-related and cardiovascular-related mortality.ResultsThere were 43 males and 28 females (5 Traumatic Aortic Transection (TAT), 8 Acute Aortic Intramural Hematoma (IMH), 27 Symptomatic Aortic Dissection (SAD) and 31 Thoracic Aortic Aneurysm (TAA) post-SAD) with a mean age of 69. All the patients with AAS received optimal medical therapy (OMT), but TAT patients underwent emergency thoracic endovascular aortic repair (TEVAR). Fifty-eight patients had an aortic dissection, of which 31 developed TAA. These 31 patients with SAD and TAA received OMT initially and interval surgical intervention with TEVAR or sTaged hybrId sinGle lumEn Reconstruction (TIGER). To increase our landing area, we performed a left subclavian chimney graft with TEVAR in twelve patients. The average follow-up duration was 78.2 months, and eleven patients (15.5%) had combined aneurysm and cardiovascular-related mortality. Twenty-six percentage of the patients developed endoleaks (EL), of which 15% required re-intervention for type II and III. Four patients who had paraplegia (5.7%) and developed renal failure died. None of our patients had a stroke or bowel ischaemia. Twenty patients had OMT, eight of these were patients with acute aortic hematoma, and all eight died within 30 days of presentation.ConclusionAcute aortic hematoma is a sinister finding, which must be closely monitored, and consideration is given to early intervention. Paraplegia and renal failure result in an increased mortality rate. TIGER technique with interval TEVAR has salvaged complex situations in young patients. Left subclavian chimney increases our landing area and abolishes SINE. Our experience shows that minimally invasive techniques could be a viable option for AAS.
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Affiliation(s)
- Sherif Sultan
- Western Vascular Institute, Department of Vascular and Endovascular Surgery, University Hospital Galway, University of Galway, Galway, Ireland
- Department of Vascular Surgery and Endovascular Surgery, Galway Clinic, Royal College of Surgeons in Ireland and University of Galway, Galway Affiliated Hospital, Doughiska, Ireland
- CORRIB-CURAM-Vascular Group, University of Galway, Galway, Ireland
- Correspondence: Sherif Sultan
| | - Yogesh Acharya
- Western Vascular Institute, Department of Vascular and Endovascular Surgery, University Hospital Galway, University of Galway, Galway, Ireland
- Department of Vascular Surgery and Endovascular Surgery, Galway Clinic, Royal College of Surgeons in Ireland and University of Galway, Galway Affiliated Hospital, Doughiska, Ireland
| | - Keegan Chua Vi Long
- Western Vascular Institute, Department of Vascular and Endovascular Surgery, University Hospital Galway, University of Galway, Galway, Ireland
| | - Mohamed Hatem
- Western Vascular Institute, Department of Vascular and Endovascular Surgery, University Hospital Galway, University of Galway, Galway, Ireland
| | - Mohieldin Hezima
- Western Vascular Institute, Department of Vascular and Endovascular Surgery, University Hospital Galway, University of Galway, Galway, Ireland
| | - David Veerasingham
- Department of Cardiothoracic Surgery, University Hospital Galway, University of Galway, Galway, Ireland
| | - Osama Soliman
- CORRIB-CURAM-Vascular Group, University of Galway, Galway, Ireland
| | - Niamh Hynes
- Department of Vascular Surgery and Endovascular Surgery, Galway Clinic, Royal College of Surgeons in Ireland and University of Galway, Galway Affiliated Hospital, Doughiska, Ireland
- CORRIB-CURAM-Vascular Group, University of Galway, Galway, Ireland
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Li Q, Wu Q, Wu W, Dai X, Fang G, Xie X, Chen L. Triple-Branched Stent Graft Implantation for Acute Non-A-non-B Aortic Dissection. Ann Thorac Surg 2023; 115:583-589. [PMID: 34971594 DOI: 10.1016/j.athoracsur.2021.11.059] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 10/26/2021] [Accepted: 11/22/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND The optimal treatment for acute non-A-non-B aortic dissection remains controversial. Triple-branched stent graft (TBSG) implantation has been used to treat acute type A aortic dissection. This study aimed to evaluate the safety and efficacy of TBSG as a treatment for acute non-A-non-B aortic dissection. METHODS Fifty patients with non-A-non-B dissection received TBSG implantation in our center between January 2014 and December 2019. Early mortality, morbidity, and dissected aorta remodeling during follow-up were calculated. RESULTS There were no deaths in-hospital or within 30 days. Postoperative complications included pneumonia (n = 12), acute kidney injury (n = 6; preoperative renal malperfusion, n = 4), transient cerebral injury (n = 6; preoperative cerebral malperfusion, n = 4), pleural effusion (n = 4), and pericardial effusion (n = 2). During follow-up, 1 patient experienced a stroke, and 2 patients required secondary interventional therapy for residual dissection below the level of the TBSG. All implanted TBSGs had good positioning, and all sidearm stent graft grafts were fully patent. No retrograde aortic dissection or type I endoleak was detected. CONCLUSIONS TBSG implantation for acute non-A-non-B aortic dissection had a low incidence of mortality and morbidity, featuring good remodeling of the dissected aortic wall during follow-up. The early outcomes of this technique were satisfactory.
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Affiliation(s)
- Qianzhen Li
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, Fujian, China; Fujian Key Laboratory of Vascular Aging, Fujian Medical University, Fujian, China; Fujian Key Laboratory of Cardio-Thoracic Surgery, Fujian Medical University, Fujian, China
| | - Qingsong Wu
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, Fujian, China; Fujian Key Laboratory of Cardio-Thoracic Surgery, Fujian Medical University, Fujian, China
| | - Weixiong Wu
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, Fujian, China; Fujian Key Laboratory of Cardio-Thoracic Surgery, Fujian Medical University, Fujian, China
| | - Xaofu Dai
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, Fujian, China; Fujian Key Laboratory of Cardio-Thoracic Surgery, Fujian Medical University, Fujian, China
| | - Guanhua Fang
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, Fujian, China; Fujian Key Laboratory of Cardio-Thoracic Surgery, Fujian Medical University, Fujian, China
| | - Xianbiao Xie
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, Fujian, China; Fujian Key Laboratory of Cardio-Thoracic Surgery, Fujian Medical University, Fujian, China
| | - Liangwan Chen
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, Fujian, China; Fujian Key Laboratory of Vascular Aging, Fujian Medical University, Fujian, China; Fujian Key Laboratory of Cardio-Thoracic Surgery, Fujian Medical University, Fujian, China.
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Li F, Zhu Y, Song H, Zhang H, Chen L, Guo W. Analysis of Postoperative Remodeling Characteristics after Modular Inner Branched Stent-Graft Treatment of Aortic Arch Pathologies Using Computational Fluid Dynamics. Bioengineering (Basel) 2023; 10:bioengineering10020164. [PMID: 36829658 PMCID: PMC9952632 DOI: 10.3390/bioengineering10020164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Revised: 01/14/2023] [Accepted: 01/24/2023] [Indexed: 01/31/2023] Open
Abstract
The modular inner branched stent-graft (MIBSG), a novel interventional therapy, has demonstrated good effects in the endovascular treatment of aortic arch pathologies, especially those involving the supra-aortic branches. Nevertheless, the long-term efficacy of the MIBSG and in-depth quantitative evaluation of postoperative outcomes remain to be examined. Moreover, the regularity of postoperative vascular remodeling induced by MIBSG implantation has yet to be explored. To address these questions, we constructed four models (normal, preoperative, 1 week postoperative, and 6 months postoperative) based on a single patient case to perform computational fluid dynamics simulations. The morphological and hemodynamic characteristics, including the velocity profile, flow rate distribution, and hemodynamic parameter distribution (wall shear stress and its derivative parameters), were investigated. After MIBSG implantation, the morphology of the supra-aortic branches changed significantly, and the branch point moved forward to the proximal ascending aorta. Moreover, the curvature radius of the aortic arch axis continued to change. These changes in morphology altered the characteristics of the flow field and wall shear stress distribution. As a result, the local forces exerted on the vessel wall by the blood led to vessel remodeling. This study provides insight into the vascular remodeling process after MIBSG implantation, which occurs as a result of the interplay between vascular morphological characteristics and blood flow characteristics.
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Affiliation(s)
- Fen Li
- College of Mechanical and Vehicle Engineering, Taiyuan University of Technology, Taiyuan 030024, China
- Institute of Applied Mechanics, Taiyuan University of Technology, Taiyuan 030024, China
| | - Yating Zhu
- First Medical Center of Chinese PLA General Hospital, Department of Vascular Surgery, Beijing 100853, China
| | - Hui Song
- College of Mechanical and Vehicle Engineering, Taiyuan University of Technology, Taiyuan 030024, China
- Institute of Applied Mechanics, Taiyuan University of Technology, Taiyuan 030024, China
| | - Hongpeng Zhang
- First Medical Center of Chinese PLA General Hospital, Department of Vascular Surgery, Beijing 100853, China
| | - Lingfeng Chen
- College of Biomedical Engineering, Taiyuan University of Technology, Taiyuan 030024, China
- Correspondence: (L.C.); (W.G.)
| | - Wei Guo
- First Medical Center of Chinese PLA General Hospital, Department of Vascular Surgery, Beijing 100853, China
- Correspondence: (L.C.); (W.G.)
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Capoccia M, Sherif MA, Nassef A, Shaw D, Walker P, Evans B, Kaul P, Elmahdy W. Aortic arch surgery for type B aortic dissection: How far should we go? The value of a hybrid approach. Clin Case Rep 2023; 11:e6742. [PMID: 36619481 PMCID: PMC9810843 DOI: 10.1002/ccr3.6742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 11/21/2022] [Accepted: 12/04/2022] [Indexed: 01/05/2023] Open
Abstract
Traditionally, the management of type B aortic dissection has been the domain of the vascular surgeons. Timing and type of intervention still generate debate. We sought to review our early experience with the treatment of this condition based on a hybrid approach following an aortic multi-disciplinary team meeting involving close cooperation between cardiac surgeons, vascular surgeons, interventional radiologists, vascular anesthetists, and cardiac anesthetists. Four patients (age 41-56 years; 3 males; 1 female) with type B aortic dissection underwent aortic arch surgery through a hybrid approach: one elective procedure consisting of ascending aorta and hemi-arch replacement with debranching followed by thoracic endovascular aortic repair (TEVAR); one redo procedure requiring aortic arch replacement with hybrid frozen elephant trunk; two acute presentations (aortic arch replacement and debranching followed by TEVAR; AVR with ascending aorta, arch, and proximal descending thoracic aorta replacement with conventional elephant trunk and debranching). Deep hypothermic circulatory arrest was required in three patients. Despite respiratory complications and slightly prolonged postoperative course, all patients survived without onset of stroke, paraplegia, malperfusion, endoleak, or need for re-exploration. Follow-up remains satisfactory. Different factors may affect outcome following complex aortic procedures. Nevertheless, close cooperation between cardiac surgeons, vascular surgeons, and interventional radiologists may reduce potential for complications and address aspects that may not be completely within the domain of individual specialists.
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Affiliation(s)
- Massimo Capoccia
- Cardiac Surgery, Yorkshire Heart CentreLeeds Teaching Hospitals NHS TrustLeedsUK
| | - Mohamed Ashur Sherif
- Cardiac Surgery, Yorkshire Heart CentreLeeds Teaching Hospitals NHS TrustLeedsUK
| | - Ahmed Nassef
- Vascular SurgeryLeeds Teaching Hospitals NHS TrustLeedsUK
| | - David Shaw
- Interventional RadiologyLeeds Teaching Hospitals NHS TrustLeedsUK
| | - Paul Walker
- Interventional RadiologyLeeds Teaching Hospitals NHS TrustLeedsUK
| | - Betsy Evans
- Cardiac Surgery, Yorkshire Heart CentreLeeds Teaching Hospitals NHS TrustLeedsUK
| | - Pankaj Kaul
- Cardiac Surgery, Yorkshire Heart CentreLeeds Teaching Hospitals NHS TrustLeedsUK
| | - Walid Elmahdy
- Cardiac Surgery, Yorkshire Heart CentreLeeds Teaching Hospitals NHS TrustLeedsUK
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Burbelko M, Wagner HJ, Mahnken AH. [Chronic type B aortic dissection-what to do?]. RADIOLOGIE (HEIDELBERG, GERMANY) 2022; 62:556-562. [PMID: 35737001 DOI: 10.1007/s00117-022-01022-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/24/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Chronic type B aortic dissection requires optimal medical therapy. However, secondary complications like organ or extremity malperfusion or development of aneurysmal dilatation require interventional therapy. OBJECTIVES Presentation of different endovascular treatment options for complications of chronic type B aortic dissection. MATERIALS AND METHODS Analysis of current literature with regard to indications, techniques, results, and differential indications of interventional techniques for the treatment of chronic type B aortic dissection complications. RESULTS Endovascular implantation of an aortic stent graft is interventional standard therapy for treatment of aneurysmal dilatation of the aorta following type B dissection. Technical problems are the proximal and distal landing zones and the treatment of persistent flow in the false lumen. CONCLUSION Endovascular treatment of chronic complicated type B aortic dissection is increasingly used compared to open surgical treatment because not only are more complex stent grafts (fenestrated and branched devices) available but also because of newly developed techniques for effective occlusion of flow in the false lumen (e.g., candy plug).
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Affiliation(s)
- Michael Burbelko
- Institut für Radiologie und Interventionelle Therapie, Vivantes Klinikum im Friedrichshain, Landsberger Allee 49, 10249, Berlin, Deutschland
| | - Hans-Joachim Wagner
- Institut für Radiologie und Interventionelle Therapie, Vivantes Klinikum im Friedrichshain, Landsberger Allee 49, 10249, Berlin, Deutschland.
| | - Andreas H Mahnken
- Klinik für Diagnostische und Interventionelle Radiologie, UKGM Marburg, Philipps-Universität Marburg, Marburg, Deutschland
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Geragotellis A, Al-Tawil M, Jubouri M, Tan SZCP, Williams I, Bashir M. Risk profile analysis of uncomplicated type B aortic dissection patients undergoing thoracic endovascular aortic repair: Laboratory and radiographic predictors. J Card Surg 2022; 37:2811-2820. [PMID: 35652486 DOI: 10.1111/jocs.16655] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Accepted: 04/22/2022] [Indexed: 01/16/2023]
Abstract
BACKGROUND There is emerging evidence to support pre-emptive thoracic endovascular aortic repair (TEVAR) intervention for uncomplicated type B aortic dissection (unTBAD). Pre-emptive intervention would be particularly beneficial in patients that have a higher baseline risk of progressing to complicated TBAD (coTBAD). There remain debate on the optimal clinical, laboratory, morphological, and radiological parameters, which would identify the highest-risk patients that would benefit most from pre-emptive TEVAR. AIM This review summarizes evidence on the clinical, laboratory, and morphological parameters that increase the risk profiles of unTBAD patients. METHODS A comprehensive literature search was carried out on multiple electronic databases including PubMed, EMBASE, Ovid, and Scopus to collate all research evidence on the clinical, laboratory, and morphological parameters that increase the risk profiles of unTBAD patients RESULTS: At present, there are no clear clinical guidelines using risk-stratification to inform the selection of unTBAD patients for TEVAR. However, there are noticeable literature trends that can assist with the identification of the most at-risk unTBAD patients. Patients are at particular risk when they have refractory pain and/or hypertension, elevated C-reactive protein (CRP), larger aortic diameter, and larger entry tears. These risks should be considered alongside factors that increase the procedural risk of TEVAR to create a well-balanced approach. Advances in biomarkers and imaging are likely to identify more pertinent parameters in the future to optimize the development of balanced, risk-stratified treatment protocols. CONCLUSION There are a variety of risk profiling parameters that can be used to identify the high-risk unTBAD patient, with novel biomarkers and imaging parameters emerging. Longer-term evidence verifying these parameters would be ideal. Further randomized controlled trials and multicentre registry analyses are also warranted to guide risk-stratified selection protocols.
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Affiliation(s)
| | | | - Matti Jubouri
- Hull York Medical School, University of York, York, UK
| | - Sven Z C P Tan
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Ian Williams
- Department of Vascular Surgery, Heath Park, University Hospital of Wales, Cardiff, UK
| | - Mohamad Bashir
- Vascular & Endovascular Surgery, Health Education & Improvement Wales (HEIW), Velindre University NHS Trust, Cardiff, UK
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Williams ML, de Boer M, Hwang B, Wilson B, Brookes J, McNamara N, Tian DH, Shiraev T, Preventza O. Thoracic endovascular repair of chronic type B aortic dissection: a systematic review. Ann Cardiothorac Surg 2022; 11:1-15. [PMID: 35211380 PMCID: PMC8807414 DOI: 10.21037/acs-2021-taes-25] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 10/04/2021] [Indexed: 04/12/2024]
Abstract
BACKGROUND At present, the optimal management strategy for chronic type B aortic dissection (CTBAD) remains unknown, as equipoise remains regarding medical management versus endovascular treatment versus open surgery. However, the results over recent years of thoracic endovascular aortic repair (TEVAR) in CTBAD appear promising. The aim of this systematic review was to provide a comprehensive analysis of the available data reporting outcomes and survival rates for TEVAR in CTBAD. METHODS Electronic searches of six databases were performed from inception to April 2021. All studies reporting outcomes, specifically 30-day mortality rates, for endovascular repair of CTBAD were identified. Relevant data were extracted, and a random-effects meta-analysis of proportions or means was performed to aggregate the data. Survival data were pooled using data derived from original Kaplan-Meier curves, which allows reconstruction of individual patient data. RESULTS Forty-eight studies with 2,641 patients were identified. Early (<30 days) all-cause and aortic-related mortality rates were low at 1.6% and 0.5%, respectively. Incidence of retrograde type A dissection in the post-operative period was only 1.4%. There were also low rates of cerebrovascular accidents and spinal cord injury (1.1% and 0.9%, respectively). Late follow-up all-cause mortality was 8.0%, however, late aortic-related mortality was only 2.4%. Reintervention rates were 10.1% for endovascular and 6.7% for surgical reintervention. Pooled rates of overall survival at 1-, 3-, 5- and 10-year were 91.5%, 84.7%, 77.7% and 56.3%, respectively. CONCLUSIONS The significant heterogeneity in the available evidence and absence of consensus reporting standards are important considerations and concern when interpreting the data. Evaluation of the evidence suggests that TEVAR for CTBAD is a safe procedure with low rates of complications. However, the optimal treatment strategy for CTBAD remains debatable and requires further research. Evidence from high-quality registries and clinical trials are required to address these challenges.
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Affiliation(s)
- Michael L. Williams
- Department of Cardiothoracic Surgery, John Hunter Hospital, Newcastle, Australia
- The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia
- School of Medicine and Public Health, University of Newcastle, Newcastle, Australia
| | - Madeleine de Boer
- Department of Vascular Surgery, Royal Prince Alfred Hospital, Sydney, Australia
| | - Bridget Hwang
- The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia
| | - Bruce Wilson
- The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia
| | - John Brookes
- The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia
- Department of Cardiothoracic Surgery, University Hospital Geelong, Geelong, Australia
| | - Nicholas McNamara
- Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, Sydney, Australia
| | - David H. Tian
- Department of Anaesthesia and Perioperative Medicine, Westmead Hospital, Sydney, Australia
| | - Timothy Shiraev
- Department of Vascular Surgery, Royal Prince Alfred Hospital, Sydney, Australia
| | - Ourania Preventza
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
- Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas, USA
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11
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Stana J, Peterß S, Prendes CF, Stavroulakis K, Rantner B, Pichlmaier M, Tsilimparis N. [Ascending Aorta and Aortic Arch - Endovascular Therapy Today and in the Future]. Zentralbl Chir 2021; 146:479-485. [PMID: 34666362 DOI: 10.1055/a-1644-1759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Pathologies in the region of the aortic arch may occur in isolation, but adjacent segments of the thoracic aorta - the ascending or descending aorta - are much more commonly affected. The first surgical procedures to treat the aortic arch were performed nearly six decades ago. Despite numerous improvements and innovations in the 20th and early 21st centuries, these procedures are still associated with relevant operative mortality and neurological complication rates. Endovascular techniques and modern hybrid procedures are increasingly expanding the therapeutic spectrum in the aortic arch, although the open surgical approach is currently still the gold standard. Endovascular treatment of aortic aneurysm was first performed in the early 1990s in the infrarenal abdominal aorta. It was not long before the first attempts at endovascular therapy were made for the treatment of the aortic arch. In 1996, Inoue et al. reported the use of the first commonly used endoprosthesis to treat aneurysms in the aortic arch. Continuous improvements and refinements in implantation techniques and also implanted material have resulted in endovascular therapy now being an increasingly important option compared to open surgical procedures in the descending thoracic and abdominal aorta and has partially replaced them as the gold standard. This review article aims to provide an overview of the prerequisites, results, but also limitations of endovascular surgery of the aortic arch.
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Affiliation(s)
- Jan Stana
- Abteilung für Gefäßchirurgie, Klinikum der Ludwig-Maximilians-Universität München, Deutschland
| | - Sven Peterß
- Abteilung für Gefäßchirurgie, Klinikum der Ludwig-Maximilians-Universität München, Deutschland
| | | | | | - Barbara Rantner
- Abteilung für Gefäßchirurgie, Klinikum der Ludwig-Maximilians-Universität München, Deutschland
| | - Maximilian Pichlmaier
- Herzchirurgische Klinik und Poliklinik, Klinikum der Ludwig-Maximilians-Universität München, Standort Großhadern, München, Deutschland
| | - Nikolaos Tsilimparis
- Abteilung für Gefäßchirurgie, Klinikum der Ludwig-Maximilians-Universität München, Deutschland
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12
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Nejim B, Mathlouthi A, Naazie I, Malas MB. The Effect of Intravenous and Oral Beta-Blocker Use in Patients with Type B Thoracic Aortic Dissection. Ann Vasc Surg 2021; 80:170-179. [PMID: 34656722 DOI: 10.1016/j.avsg.2021.07.056] [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: 10/23/2020] [Revised: 07/22/2021] [Accepted: 07/26/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Beta-blockers have become the cornerstone for medical management in patients with chronic type B aortic dissection (TBAD). However, the effect of being on and/or receiving intravenous beta-blockers during hospitalization on outcomes of surgical repair of TBAD is not fully described. We sought to investigate this association during open surgical repair (OSR) and endovascular (Endo) intervention for nontraumatic TBAD. METHODS The Premier Healthcare Database was inquired (June/2009-March/2015). Patients with nontraumatic isolated TBAD were identified via ICD-9-CM diagnosis and procedural codes. Patients with codes that indicated TAAD were excluded. In-hospital mortality, cardiac complications (CHF, MI, arrythmia) and stroke were evaluated. Log binomial regression analyses with bootstrapping were performed to assess the relative risk of adverse outcomes. RESULTS A total of 1,752 were admitted for OSR (54.3%) and Endo (45.7%) TBAD repair. Use of oral beta blocker (BB) was 16.0% in OSR and 56.4% in Endo groups. In each arm, patients on BB were more likely to be diabetic, on aspirin or statin and more likely to receive additional IV BB than nonBB patients. There was no significant difference in age, sex, race, or prior history of CHF between BB and nonBB groups. Mortality was proportionally lower in patients on BB in OSR group (7.9% vs. 16.7%; P = 0.006) and Endo (3.3% vs. 9.2%; P < 0.001). The adjusted relative risk for mortality and stroke were significantly lower in oral BB recipients compared with none [aRR (95% CI): 0.53 (0.32-0.90) and 0.46 (0.25-0.87); both P ≤ 0.02]. IV metoprolol was the only IV BB that reduced mortality [aRR (95% CI): 0.62 (0.46-0.85); P = 0.003]. A dose of ≤10 mg was associated with significant mortality reduction: 6.3% (3.0-9.5%) compared with 8.1% (4.6-11.6%) in no IV BB group. Cardiac complications were not affected by BB use. CONCLUSIONS For patients with nontraumatic TBAD, use of oral BB was associated with significant protection against in-hospital mortality and stroke following repair. Metoprolol was the only Intravenous BB type associated with improved survival. Further research is warranted to elucidate the effect of beta-blockers on the long-term surgical outcomes of TBAD.
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Affiliation(s)
- Besma Nejim
- Department of Vascular Surgery, Penn State Health, Milton S. Hershey Medical Center, Hershey, PA
| | - Asma Mathlouthi
- Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla, CA
| | - Isaac Naazie
- Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla, CA
| | - Mahmoud B Malas
- Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla, CA..
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Makhija RR, Mukherjee D. Endovascular therapies for Type B Aortic Dissection. Cardiovasc Hematol Disord Drug Targets 2021; 21:167-178. [PMID: 34565325 DOI: 10.2174/1871529x21666210924141446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 07/30/2021] [Accepted: 08/20/2021] [Indexed: 11/22/2022]
Abstract
Aortic dissection is a life-threatening condition resulting from a tear in the intimal layer of the aorta, requiring emergent diagnosis and prompt multi-disciplinary management strategy for best patient outcomes. While type A dissection involving ascending aorta is best managed surgically due to high early mortality, type B aortic dissection (TBAD) involving descending aorta generally has better outcomes with conservative management and medical therapy as primary strategy is favored. However, there has been a recent paradigm shift in management of TBAD due to late aneurysmal degeneration of TBAD increasing morbidity and mortality at longer-term. Late surgical intervention can be prevented by early endovascular intervention when combined with optimal medical therapy. In this narrative review, we explore available literature on different endovascular therapies for TBAD in different populations of patients.
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Affiliation(s)
- Rakhee R Makhija
- Division of Cardiovascular Medicine, Texas Tech University, El Paso. United States
| | - Debabrata Mukherjee
- Department of Internal Medicine, Division of Cardiovascular Medicine, Texas Tech University, El Paso, United States. United States
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Konstantinou N, Kölbel T, Debus ES, Rohlffs F, Tsilimparis N. Fenestrated versus debranching thoracic endovascular aortic repair for endovascular treatment of distal aortic arch and descending aortic lesions. J Vasc Surg 2020; 73:1915-1924. [PMID: 33253872 DOI: 10.1016/j.jvs.2020.10.078] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Accepted: 10/21/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Cervical debranching, followed by thoracic endovascular aortic repair (TEVAR), is well-established for treating aortic arch lesions. However, total endovascular repair with fenestrated endografts has not been adequately studied. Thus, we performed a comparison of the two techniques. METHODS The present study was a single-center, retrospective study comparing the treatment of thoracic aortic lesions with custom-made fenestrated stent-grafts (fenestrated TEVAR [fTEVAR]) with a single fenestration for the left subclavian artery (LSA), a scallop for the left carotid artery, and hybrid repair with a thoracic stent-graft and cervical debranching of the LSA. Emergency cases were excluded. RESULTS From 2012 to 2018, 19 patients (58% male) underwent elective fTEVAR (group A) and 17 patients (82% male) underwent debranching TEVAR (dTEVAR; group B). The mean age ± standard deviation in group A was 65.8 ± 2 years and 68 ± 3 years in group B. Left carotid-subclavian bypass was performed in 15 of 17 patients (88%) and transposition of the LSA in 2 of 17 patients (12%) in group B. The two groups were comparable regarding comorbidities, except for peripheral arterial disease: 5 of 19 patients in group A (26%) and none in group B had had peripheral arterial disease (P = .049). Dissection or post-dissection aneurysm was the indication for treatment in 6 of 19 patients in the fTEVAR group (group A) and in 12 of 17 patients in the dTEVAR group (group B; 31.6% vs 70.6%; P = .04). The indication for the remaining patients was a degenerative aortic aneurysm. Technical success was achieved in all cases, except for one case of dTEVAR owing to a type Ia endoleak. The mean endovascular operative time was 191 ± 120 minutes for fTEVAR and 130 ± 75 minutes for dTEVAR (P = NS). The mean operative time for the debranching procedure was 181 ± 97 minutes. No deaths or major strokes had occurred in the early postoperative period (30 days). Of the 17 patients in group B, 5 (29.4%) had experienced a local complication related to the debranching procedure. The mean follow-up was 14.6 ± 2 months for group A and 17 ± 2 months for group B. Of the 19 patients in group A and 17 patients in group B, 2 (10.5%) and 6 (35.3%) had required an unplanned reintervention related to the thoracic stent-graft during the follow-up period, respectively (P = NS). The estimated freedom from unplanned reintervention at 12 months was 86% for group A and 81% for group B. Primary patency of the LSA stent-graft or the carotid-subclavian bypass/transposition was 100% in both groups. CONCLUSIONS Both techniques showed excellent midterm patency rates for the target vessel and high technical success rate. The operation times were shorter for the fTEVAR group and complications related to the debranching procedure were avoided.
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Affiliation(s)
- Nikolaos Konstantinou
- Department of Vascular Medicine, German Aortic Center Hamburg, University Heart Center, Hamburg, Germany; Department of Vascular Surgery, University Hospital, LMU Munich, Munich, Germany.
| | - Tilo Kölbel
- Department of Vascular Medicine, German Aortic Center Hamburg, University Heart Center, Hamburg, Germany
| | - Eike S Debus
- Department of Vascular Medicine, German Aortic Center Hamburg, University Heart Center, Hamburg, Germany
| | - Fiona Rohlffs
- Department of Vascular Medicine, German Aortic Center Hamburg, University Heart Center, Hamburg, Germany
| | - Nikolaos Tsilimparis
- Department of Vascular Medicine, German Aortic Center Hamburg, University Heart Center, Hamburg, Germany; Department of Vascular Surgery, University Hospital, LMU Munich, Munich, Germany
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15
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Profound Hypotension before Aortic Clamping Can Exacerbate Spinal Cord Ischemic Injury after Aortic Surgery in Rats. J Clin Med 2020; 9:jcm9113395. [PMID: 33113913 PMCID: PMC7690663 DOI: 10.3390/jcm9113395] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 10/16/2020] [Accepted: 10/19/2020] [Indexed: 11/23/2022] Open
Abstract
Spinal cord ischemia is one of the most serious complications of aortic repair in patients with acute aortic syndrome. However, the effect of hypotension before aortic clamping on spinal cord injury has not been documented. A total of 48 male Sprague-Dawley rats were randomly divided into four groups: the sham group; control group (mean arterial pressure (MAP) < 90% of baseline value before aortic clamping); mild hypotension group (MAP < 80%); and profound hypotension group (MAP < 60%). Spinal cord ischemia was induced using a balloon-tipped catheter placed in the descending thoracic aorta. Neurological function of the hind limbs was evaluated for seven days after reperfusion and recorded using a motor deficit index (MDI). The spinal cord was then harvested for histopathological examination and evaluation of oxidative stress and inflammation. The profound hypotension group demonstrated a significantly higher MDI 48 h post-reperfusion and lower number of normal motor neurons than the other groups (p < 0.001). The levels of tissue malondialdehyde and tumor necrosis factor-α (TNF-α) were also significantly increased in the profound hypotension group compared with other groups. Profound hypotension before aortic clamping can aggravate neurologic outcomes after aortic surgery by exacerbating neurologic injury and reducing the number of normal motor neurons.
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16
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Spanos K, Kölbel T. Role of Endoluminal Techniques in the Management of Chronic Type B Aortic Dissection. Cardiovasc Intervent Radiol 2020; 43:1808-1820. [PMID: 32601718 PMCID: PMC8490267 DOI: 10.1007/s00270-020-02566-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Accepted: 06/20/2020] [Indexed: 12/22/2022]
Abstract
In recent guidelines of international societies, the most frequent indication for treatment after chronic type B aortic dissection (cTBAD) is aneurysmal dilatation. Endovascular repair is recommended in patients with moderate to high surgical risk or with contraindications to open repair. During the last decade, many advances have been made in the field of endovascular techniques and devices. The aim of this article is to address the current status of endoluminal techniques for the management of cTBAD including standard thoracic endovascular repair, new devices, fenestrated and branched abdominal aortic devices and false lumen occlusion techniques.
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Affiliation(s)
- Konstantinos Spanos
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart Center, University Hospital Hamburg Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
| | - Tilo Kölbel
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart Center, University Hospital Hamburg Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
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17
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Vardakis JC, Bonfanti M, Franzetti G, Guo L, Lassila T, Mitolo M, Hoz de Vila M, Greenwood JP, Maritati G, Chou D, Taylor ZA, Venneri A, Homer-Vanniasinkam S, Balabani S, Frangi AF, Ventikos Y, Diaz-Zuccarini V. Highly integrated workflows for exploring cardiovascular conditions: Exemplars of precision medicine in Alzheimer's disease and aortic dissection. Morphologie 2019; 103:148-160. [PMID: 31786098 DOI: 10.1016/j.morpho.2019.10.045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 10/12/2019] [Accepted: 10/16/2019] [Indexed: 12/31/2022]
Abstract
For precision medicine to be implemented through the lens of in silico technology, it is imperative that biophysical research workflows offer insight into treatments that are specific to a particular illness and to a particular subject. The boundaries of precision medicine can be extended using multiscale, biophysics-centred workflows that consider the fundamental underpinnings of the constituents of cells and tissues and their dynamic environments. Utilising numerical techniques that can capture the broad spectrum of biological flows within complex, deformable and permeable organs and tissues is of paramount importance when considering the core prerequisites of any state-of-the-art precision medicine pipeline. In this work, a succinct breakdown of two precision medicine pipelines developed within two Virtual Physiological Human (VPH) projects are given. The first workflow is targeted on the trajectory of Alzheimer's Disease, and caters for novel hypothesis testing through a multicompartmental poroelastic model which is integrated with a high throughput imaging workflow and subject-specific blood flow variability model. The second workflow gives rise to the patient specific exploration of Aortic Dissections via a multi-scale and compliant model, harnessing imaging, computational fluid-dynamics (CFD) and dynamic boundary conditions. Results relating to the first workflow include some core outputs of the multiporoelastic modelling framework, and the representation of peri-arterial swelling and peri-venous drainage solution fields. The latter solution fields were statistically analysed for a cohort of thirty-five subjects (stratified with respect to disease status, gender and activity level). The second workflow allowed for a better understanding of complex aortic dissection cases utilising both a rigid-wall model informed by minimal and clinically common datasets as well as a moving-wall model informed by rich datasets.
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Affiliation(s)
- J C Vardakis
- Centre for Computational Imaging & Simulation Technologies in Biomedicine (CISTIB), School of Computing, University of Leeds, UK.
| | - M Bonfanti
- Department of Mechanical Engineering, University College London, Torrington Place, London, WC1E 7JE, UK; Wellcome/EPSRC Centre for Interventional and Surgical Sciences (WEISS), Department of Medical Physics and Biomedical Engineering, University College London, UK
| | - G Franzetti
- Department of Mechanical Engineering, University College London, Torrington Place, London, WC1E 7JE, UK
| | - L Guo
- Department of Mechanical Engineering, University College London, Torrington Place, London, WC1E 7JE, UK
| | - T Lassila
- Centre for Computational Imaging & Simulation Technologies in Biomedicine (CISTIB), School of Computing, University of Leeds, UK
| | - M Mitolo
- Functional MR Unit, Policlinico S. Orsola e Malpighi, Department of Biomedical and NeuroMotor Sciences (DiBiNeM), Bologna, Italy
| | - M Hoz de Vila
- Centre for Computational Imaging & Simulation Technologies in Biomedicine (CISTIB), School of Computing, University of Leeds, UK
| | - J P Greenwood
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, UK; Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - G Maritati
- Ospedale A. Perrino, Brindisi, Italy; Azienda Ospedaliera San Camillo-Forlanini, Rome, Italy
| | - D Chou
- Department of Mechanical Engineering, National Central University, Taoyuan County, Taiwan
| | - Z A Taylor
- Centre for Computational Imaging & Simulation Technologies in Biomedicine (CISTIB), School of Mechanical Engineering, University of Leeds, UK
| | - A Venneri
- Department of Neuroscience, Medical School, University of Sheffield, UK
| | - S Homer-Vanniasinkam
- Department of Mechanical Engineering, University College London, Torrington Place, London, WC1E 7JE, UK; Leeds Teaching Hospitals NHS Trust, Leeds, UK; University of Warwick Medical School & University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - S Balabani
- Department of Mechanical Engineering, University College London, Torrington Place, London, WC1E 7JE, UK
| | - A F Frangi
- Centre for Computational Imaging & Simulation Technologies in Biomedicine (CISTIB), School of Computing, University of Leeds, UK
| | - Y Ventikos
- Department of Mechanical Engineering, University College London, Torrington Place, London, WC1E 7JE, UK
| | - V Diaz-Zuccarini
- Department of Mechanical Engineering, University College London, Torrington Place, London, WC1E 7JE, UK; Wellcome/EPSRC Centre for Interventional and Surgical Sciences (WEISS), Department of Medical Physics and Biomedical Engineering, University College London, UK.
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Alfonsi J, Murana G, Smeenk HG, Kelder H, Schepens M, Sonker U, Morshuis WJ, Heijmen RH. Open surgical repair of post-dissection thoraco-abdominal aortic aneurysms: early and late outcomes of a single-centre study involving over 200 patients. Eur J Cardiothorac Surg 2019; 54:382-388. [PMID: 29462490 DOI: 10.1093/ejcts/ezy050] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2017] [Accepted: 01/13/2018] [Indexed: 01/16/2023] Open
Abstract
OBJECTIVES Chronic, post-dissection thoraco-abdominal aortic aneurysms (TAAAs) are increasingly being treated by (hybrid) endovascular means. Although it is less invasive, thoracic endovascular aortic repair is technically complex with the risk of incomplete aneurysm exclusion, necessitating frequent reinterventions with potentially reduced long-term outcomes. The aim of this study was to evaluate contemporary early and late outcomes after open surgical repair of post-dissection TAAA. METHODS At our centre, 633 patients underwent open repair for TAAA over a 20-year period (1994-2015), including 217 (34%) patients for post-dissection TAAA, who were included in this analysis. Circulatory support was obtained by either left heart bypass (173 patients, 79.7%), deep hypothermic circulatory arrest (41 patients, 18.9%) or simple aortic cross-clamping in 3 patients. We analysed all relevant perioperative and intraoperative variables with respect to adverse outcomes. Additionally, long-term survival and the need for aortic reinterventions were studied. RESULTS The mean age was 60.2 ± 11.9 years (men 68.2%). We identified 66 Type I (30.4%), 113 Type II (52.1%), 25 Type III (11.5%), 10 Type IV (4.6%) and 3 Type V (1.4%) TAAAs. Early mortality and spinal cord deficit were 5.9% and 5.5%, respectively. Follow-up was 100% complete (mean 6.0 ± 5.8 years), with long-term survival of 71.4% at 10 years, and freedom from death and reoperation was 68.2% at 10 years. CONCLUSIONS Although it is more invasive than current endovascular approaches for post-dissection TAAA, open surgical repair can be performed safely with acceptable rates of morbidity and mortality when it is done in a specialized aortic centre. Long-term survival and freedom from aortic reintervention are excellent and should also be taken into account when evaluating less invasive alternatives.
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Affiliation(s)
- Jacopo Alfonsi
- Department of Cardiothoracic Surgery, St Antonius Hospital, Nieuwegein, Netherlands
| | - Giacomo Murana
- Department of Cardiothoracic Surgery, St Antonius Hospital, Nieuwegein, Netherlands
| | - Henri G Smeenk
- Department of Cardiothoracic Surgery, St Antonius Hospital, Nieuwegein, Netherlands
| | - Hans Kelder
- Department of Cardiology Research and Statistical Analysis, St. Antonius Hospital, Nieuwegein, Netherlands
| | - Marc Schepens
- Department of Cardiothoracic Surgery, AZ St. Jan, Bruges, Belgium
| | - Uday Sonker
- Department of Cardiothoracic Surgery, St Antonius Hospital, Nieuwegein, Netherlands
| | - Wim J Morshuis
- Department of Cardiac Surgery, Radboud University Medical Center, Nijmegen, Netherlands
| | - Robin H Heijmen
- Department of Cardiothoracic Surgery, St Antonius Hospital, Nieuwegein, Netherlands.,Department of Cardiothoracic Surgery, Academic Medical Center, Amsterdam, Netherlands
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Editor's Choice – Current Options and Recommendations for the Treatment of Thoracic Aortic Pathologies Involving the Aortic Arch: An Expert Consensus Document of the European Association for Cardio-Thoracic Surgery (EACTS) & the European Society for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg 2019; 57:165-198. [DOI: 10.1016/j.ejvs.2018.09.016] [Citation(s) in RCA: 122] [Impact Index Per Article: 24.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Kitamura T. Preemptive endovascular treatment of uncomplicated Stanford Type B aortic dissection. J Thorac Dis 2019; 10:S3862-S3864. [PMID: 30631499 DOI: 10.21037/jtd.2018.09.120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Tadashi Kitamura
- Department of Cardiovascular Surgery, Kitasato University School of Medicine, Kanagawa, Japan
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21
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Czerny M, Schmidli J, Adler S, van den Berg JC, Bertoglio L, Carrel T, Chiesa R, Clough RE, Eberle B, Etz C, Grabenwöger M, Haulon S, Jakob H, Kari FA, Mestres CA, Pacini D, Resch T, Rylski B, Schoenhoff F, Shrestha M, von Tengg-Kobligk H, Tsagakis K, Wyss TR, Debus S, de Borst GJ, Di Bartolomeo R, Lindholt J, Ma WG, Suwalski P, Vermassen F, Wahba A, von Ballmoos MCW. Current options and recommendations for the treatment of thoracic aortic pathologies involving the aortic arch: an expert consensus document of the European Association for Cardio-Thoracic surgery (EACTS) and the European Society for Vascular Surgery (ESVS). Eur J Cardiothorac Surg 2019; 55:133-162. [PMID: 30312382 DOI: 10.1093/ejcts/ezy313] [Citation(s) in RCA: 277] [Impact Index Per Article: 55.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Affiliation(s)
- Martin Czerny
- Department of Cardiovascular Surgery, University Heart Center Freiburg-Bad Krozingen, Freiburg, Germany
| | - Jürg Schmidli
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Sabine Adler
- Department for Rheumatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jos C van den Berg
- Department of Radiology, Centro Vascolare Ticino, Ospedale Regionale di Lugano, Lugano, Switzerland.,Department of Radiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Luca Bertoglio
- Division of Vascular Surgery, "Vita salute" University, Ospedale San Raffaele, Milan, Italy
| | - Thierry Carrel
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Roberto Chiesa
- Division of Vascular Surgery, "Vita salute" University, Ospedale San Raffaele, Milan, Italy
| | - Rachel E Clough
- Division of Imaging Sciences and Biomedical Engineering, St Thomas' Hospital, King's College London, London, UK
| | - Balthasar Eberle
- Department for Anesthesiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Christian Etz
- Department of Cardiac Surgery, Heart Center Leipzig, Leipzig, Germany
| | | | - Stephan Haulon
- Aortic Center, Hôpital Marie Lannelongue, Université Paris Sud, Le Plessis-Robinson, France
| | | | - Fabian A Kari
- Department of Cardiovascular Surgery, University Heart Center Freiburg-Bad Krozingen, Freiburg, Germany
| | - Carlos A Mestres
- University Clinic for Cardiovascular Surgery, University Hospital Zurich, Zurich, Switzerland
| | | | - Timothy Resch
- Department of Vascular Surgery, Vascular Center Skåne University Hospital, Malmö, Sweden
| | - Bartosz Rylski
- Department of Cardiovascular Surgery, University Heart Center Freiburg-Bad Krozingen, Freiburg, Germany
| | - Florian Schoenhoff
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Malakh Shrestha
- Department of Cardio-thoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Hendrik von Tengg-Kobligk
- Department of Diagnostic, Interventional and Pediatric Radiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | | | - Thomas R Wyss
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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22
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Toronto PowerWire fenestration technique to access false lumen branches in fenestrated endovascular aneurysm repair for chronic type B dissection. J Vasc Surg 2019; 69:249-252. [DOI: 10.1016/j.jvs.2018.06.200] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 06/18/2018] [Indexed: 11/20/2022]
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23
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Giles KA, Beck AW, Lala S, Patterson S, Back M, Fatima J, Arnaoutakis DJ, Arnaoutakis GJ, Beaver TM, Berceli SA, Upchurch GR, Huber TS, Scali ST. Implications of secondary aortic intervention after thoracic endovascular aortic repair for acute and chronic type B dissection. J Vasc Surg 2018; 69:1367-1378. [PMID: 30553732 DOI: 10.1016/j.jvs.2018.07.080] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Accepted: 07/29/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND Thoracic endovascular aortic repair (TEVAR) has become a mainstay of therapy for acute and chronic type B aortic dissection (TBAD). Dynamic aortic morphologic changes, untreated dissected aorta, and persistent false lumen perfusion have significant consequences for reintervention after TEVAR for TBAD. However, few reports contrast differences in secondary aortic intervention (SAI) after TEVAR for TBAD or describe their influence on mortality. This analysis examined incidence, timing, and types of SAI after TEVAR for acute and chronic TBAD and determined their impact on survival. METHODS All TEVAR procedures for acute and chronic TBAD (2005-2016) were retrospectively reviewed. Patients with staged (<30 days) or concomitant ascending aortic arch repair or replacement were excluded. Acuity was defined by symptom onset (0-30 days, acute; >30 days, chronic). SAI procedures were grouped into open (intended treatment zone or remote aortic site), major endovascular (TEVAR extension or endograft implanted at noncontiguous site), and minor endovascular (side branch or false lumen embolization) categories. Kaplan-Meier methodology was used to estimate freedom from SAI and survival. Cox proportional hazards were used to identify SAI predictors. RESULTS TEVAR for TBAD was performed in 258 patients (acute, 49% [n = 128]; chronic, 51% [n = 130]). Mean follow-up was 17 ± 22 months with an overall SAI rate of 27% (n = 70; acute, 22% [28]; chronic, 32% [42]; odds ratio, 1.7; 95% confidence interval, 0.9-2.9; P = .07]. Median time to SAI was significantly less after acute than after chronic dissection (0.7 [0-12] vs 7 [0-91] months; P < .001); however, freedom from SAI was not different (1-year: acute, 67% ± 4%, vs chronic, 68% ± 5%; 3-year: acute, 65% ± 7%, vs chronic, 52% ± 8%; P = .7). Types of SAI were similar (acute vs chronic: open, 61% vs 55% [P = .6]; major endovascular, 36% vs 38% [P = .8]; minor endovascular, 21% vs 21% [P = 1]). The open conversion rate (either partial or total endograft explantation: acute, 10% [13/128]; chronic, 15% [20/130]; P = .2) and incidence of retrograde dissection (acute, 6% [7/128]; chronic, 4% [5/130]; P = .5) were similar. There was no difference in survival for SAI patients (5-year: acute + SAI, 55% ± 9%, vs acute without SAI, 67% ± 8% [P = .3]; 5-year: chronic + SAI, 72% ± 6%, vs chronic without SAI, 72% ± 7% [P = .7]). Factors associated with SAI included younger age, acute dissection with larger maximal aortic diameter at presentation, Marfan syndrome, and use of arch vessel adjunctive procedures with the index TEVAR. Indication for the index TEVAR (aneurysm, malperfusion, rupture, and pain or hypertension) or remote preoperative history of proximal arch procedure was not predictive of SAI. CONCLUSIONS SAI after TEVAR for TBAD is common. Acute TBAD has a higher proportion of early SAI; however, chronic TBAD appears to have ongoing risk of remediation after the first postoperative year. SAI types are similar between groups, and the occurrence of aorta-related reintervention does not affect survival. Patients' features and anatomy predict need for SAI. These data should be taken into consideration for selection of patients, device design, and surveillance strategies after TEVAR for TBAD.
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Affiliation(s)
- Kristina A Giles
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Fla.
| | - Adam W Beck
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama, Birmingham, Ala
| | - Salim Lala
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Fla
| | - Suzannah Patterson
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Fla
| | - Martin Back
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Fla
| | - Javairiah Fatima
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Fla
| | - Dean J Arnaoutakis
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Fla
| | - George J Arnaoutakis
- Division of Thoracic and Cardiovascular Surgery, University of Florida, Gainesville, Fla
| | - Thomas M Beaver
- Division of Thoracic and Cardiovascular Surgery, University of Florida, Gainesville, Fla
| | - Scott A Berceli
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Fla
| | - Gilbert R Upchurch
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Fla
| | - Thomas S Huber
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Fla
| | - Salvatore T Scali
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Fla
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24
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Castro-Ferreira R, Dias PG, Sampaio SM, Teixeira JF, Lachat M. Simplified hybrid repair with true lumen recycling for retrograde renovisceral perfusion in a complex chronic aortic dissection. J Vasc Surg Cases Innov Tech 2018; 4:226-230. [PMID: 30175296 PMCID: PMC6116411 DOI: 10.1016/j.jvscit.2018.03.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 03/16/2018] [Indexed: 01/16/2023] Open
Abstract
A 59-year-old man was referred with complicated chronic type B aortic dissection. Despite the false lumen's being dominant in terms of caliber and limb perfusion, visceral arteries originated in a 9-mm true lumen. A staged approach was performed: open aortobi-iliac bypass with preservation of both lumens to the infrarenal aorta, with reinforcement of the aorta and anastomosis with Dacron (wrap technique); exclusion of the dissection by endografting all of the false lumen with three successive thoracic endoprostheses; and maintenance of true lumen perfusion using two periscopes with self-expanding nitinol stents. The patient remains asymptomatic after 1 year of follow-up.
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Affiliation(s)
- Ricardo Castro-Ferreira
- Serviço de Angiologia e Cirurgia Vascular, Centro Hospitalar de São João, Porto, Portugal.,Departamento de Cirurgia e Fisiologia, Unidade de Investigação Cardiovascular, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | - Paulo Gonçalves Dias
- Serviço de Angiologia e Cirurgia Vascular, Centro Hospitalar de São João, Porto, Portugal
| | - Sérgio Moreira Sampaio
- Serviço de Angiologia e Cirurgia Vascular, Centro Hospitalar de São João, Porto, Portugal.,Centro de Investigação em Tecnologias e Serviços de Saúde, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | - José Fernando Teixeira
- Serviço de Angiologia e Cirurgia Vascular, Centro Hospitalar de São João, Porto, Portugal
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25
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Al-Hakim R, Schenning R. Advanced Techniques in Thoracic Endovascular Aortic Repair: Chimneys/Periscopes, Fenestrated Endografts, and Branched Devices. Tech Vasc Interv Radiol 2018; 21:146-155. [DOI: 10.1053/j.tvir.2018.06.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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26
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Tinelli G, Ferraresi M, Watkins AC, Soler R, Fadel E, Fabre D, Haulon S. Frozen elephant trunk and arch endografts for chronic thoracoabdominal aortic dissections. THE JOURNAL OF CARDIOVASCULAR SURGERY 2018; 59:775-783. [PMID: 29786413 DOI: 10.23736/s0021-9509.18.10579-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Chronic aortic dissecting aneurysms (TAAD) presenting after acute Stanford type A or B dissection includes both arch and/or thoracoabdominal aortic aneurysms (TAAA). Approximately 60% of patients who survive surgical treatment of acute type A aortic dissections will require another aortic procedure. Similarly, more than 70% of patients with chronic type B aortic dissections will experience false lumen dilation at 5-year follow-up, often requiring intervention. Open or hybrid aortic repairs of complex TAAD involving the arch and the TAAA are very demanding procedures for both patients and clinicians. Open surgery remains the first line therapy in fit patients. Recent development of branched arch devices has offered an alternative option for high-risk patients. Technical challenges associated with the endovascular management of these complex aneurysms include proximal sealing zone often located in the aortic arch or the ascending aorta, narrow true lumen working space, and aortic branch perfusion by either the true or false lumen, or both. Recent studies have reported encouraging results with endovascular treatment of these complex dissecting aneurysms, especially following open ascending aortic repair. The aim of this review was to describe the available strategies for arch repair in the setting of a chronic TAAD and to determine the subset of patients that can benefit from of a totally endovascular approach.
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Affiliation(s)
- Giovanni Tinelli
- Unit of Vascular Surgery, Center for Cardiovascular and Thoracic Surgery, Policlinico A. Gemelli University Foundation, Rome, Italy
| | - Marco Ferraresi
- Unit of Vascular Surgery, Center for Cardiovascular and Thoracic Surgery, Policlinico A. Gemelli University Foundation, Rome, Italy
| | - A Claire Watkins
- Aortic Center, Marie Lannelongue Hospital, Le Plessis Robinson, Paris Sud University, Paris, France.,Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Raphael Soler
- Aortic Center, Marie Lannelongue Hospital, Le Plessis Robinson, Paris Sud University, Paris, France
| | - Elie Fadel
- Aortic Center, Marie Lannelongue Hospital, Le Plessis Robinson, Paris Sud University, Paris, France
| | - Dominique Fabre
- Aortic Center, Marie Lannelongue Hospital, Le Plessis Robinson, Paris Sud University, Paris, France
| | - Stéphan Haulon
- Aortic Center, Marie Lannelongue Hospital, Le Plessis Robinson, Paris Sud University, Paris, France -
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27
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Yuan X, Mitsis A, Ghonem M, Iakovakis I, Nienaber CA. Conservative management versus endovascular or open surgery in the spectrum of type B aortic dissection. J Vis Surg 2018; 4:59. [PMID: 29682469 DOI: 10.21037/jovs.2018.02.15] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Accepted: 02/09/2018] [Indexed: 01/16/2023]
Abstract
Background Type B aortic dissection is a life-threatening acute aortic condition often with acute ischemic signs or symptoms. With initial management focusing on alleviating malperfusion and pain, and avoiding propagation of dissection or rupture both systolic blood and pulse pressure should be reduced initially by an aggressive medical approach. In the setting of persistent signs of complications endovascular strategies have replaced open surgery and led to a fourfold increase in early survival and better long-term outcomes. Methods An electronic health database search was performed on articles published between January 2006 and July 2017. Publications were included in this review if (I) the index aortic pathology was type B aortic (distal) dissection; (II) when medical management, open surgical replacement or thoracic endovascular aortic repair were among those options; (III) when at least one of all basic outcome criteria such as survival, spinal cord ischemia and cerebrovascular accident was reported; (IV) when ≥15 serial patients were included. A total of 62 studies were eligible and analysed. Results Our manuscript has summarized data collected over 12 years on management specific outcomes in the setting of distal aortic dissection and provides an up-to-date interpretation of the published evidence. For complicated cases, treated acutely, the 30-day or in-hospital mortality was 7.3% when managed by endovascular means, whereas the pooled rate for 30-day or in-hospital mortality was 19.0% when subjected to open repair. For acute uncomplicated type B dissection usually treated with blood pressure lowering medications, the pooled 30-day or in-hospital mortality rate was 2.4%. Survival rates at 5 years averaged at 60% (40% mortality). Freedom from any aortic event ranged from 34.0% to 83.9%, underlining an inherent risk of progression and late complications. For chronic complicated type B dissection, the rates of stroke, paraplegia and operative mortality following endovascular repair ranged from 5% to 13%, 2% to 13% and 2 to 13%, respectively, while 5-year survival rates after open repair ranged from 60% to 90%. In chronic uncomplicated type B dissection almost 90% of patients survive initial hospitalization and were subjected to medical management with a 5-year survival of 50-80%. However, up to 20-55% of medically treated patients develop aneurysmal degeneration after 5 years with an unknown risk of rupture. Conclusions Currently, the less invasive strategy of endovascular repair (as compared to open surgery) provides improved 30-day or in-hospital survival in the setting of complicated acute type B aortic dissection and may seek broad application. Open surgical aortic reconstruction should be left to experienced aortic centres if endovascular management is not an option.
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Affiliation(s)
- Xun Yuan
- Cardiology and Aortic Centre, Royal Brompton & Harefield NHS Foundation Trust and Imperial College, London, UK
| | - Andreas Mitsis
- Cardiology and Aortic Centre, Royal Brompton & Harefield NHS Foundation Trust and Imperial College, London, UK
| | - Mohammed Ghonem
- Cardiology and Aortic Centre, Royal Brompton & Harefield NHS Foundation Trust and Imperial College, London, UK
| | - Ilias Iakovakis
- Cardiac Surgery Department, Royal Brompton & Harefield NHS Foundation Trust and Imperial College, London, UK
| | - Christoph A Nienaber
- Cardiology and Aortic Centre, Royal Brompton & Harefield NHS Foundation Trust and Imperial College, London, UK
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Liu J, Zhang R, Feng R, Feng J, Zhao Z, Li Z, Zhao Y, Li Y, Zhou J, Jing Z. Unplanned stents in thoracic endovascular aortic repair for type B aortic dissection: A 16-year single-center report. Vascular 2017; 26:400-409. [PMID: 29235924 DOI: 10.1177/1708538117746555] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Unplanned stents in thoracic endovascular aortic repair mean additional stents implantation beyond the preoperative planning to achieve operation success. This study aimed to reveal the prevalence and consequences of unplanned stents in thoracic endovascular aortic repair for type B aortic dissection and explore the reasons, risk factors and solutions for unplanned stents. Methods Retrospectively analysis consecutive patients diagnosed as type B aortic dissection with initial tear originating distal from the left subclavian artery and underwent thoracic endovascular aortic repair from September 1998 to June 2014 in our center. Results Under the criteria, this study enrolled 322 patients, with 83 (25.8%) patients in unplanned group. The incidence rate of unplanned stents in thoracic endovascular aortic repair for type B aortic dissection in each year demonstrates as a bimodal curve. The curve showed that, 2003 and, 2004 was the first and highest peak and 2007 was the second peak. There was no difference in five-year survival rate between planned and unplanned patients (log-rank test, p = 0.994). The unplanned group had higher hospitalization expenses (142,699.08 ± 78,446.75 yuan vs. 175,238.58 ± 34,838.01 yuan; p = 0.019), longer operation time (104.50 ± 93.24 min vs. 179.08 ± 142.47 min; p < 0.001) and hospitalization time (17.07 ± 16.62 d vs. 24.00 ± 15.34 d; p = 0.001). The reasons for unplanned stents were type Ia endoleak (46 patients, 55.4%), bird beak (25 patients, 30.1%), and inappropriate shaping of stent (9 patients, 10.8%). Asymptomatic aortic dissection patients had higher incidence of unplanned stents. Short proximal neck length (2.66 ± 0.59 mm vs. 2.50 ± 0.51 mm; p = 0.016), short stent coverage length (154.62 ± 41.12 mm vs. 133.60 ± 44.33 mm; p = 0.002), and large distal stent oversize (75.44±10.77% vs. 82.68±15.80%; p <0.001) were risk factors for unplanned stents in thoracic endovascular aortic repair. Conclusion There are some special risk factors and reasons for unplanned stents in thoracic endovascular aortic repair for type B aortic dissection. Knowing these can we reduce the utilization of unplanned stents with appropriate methods.
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Affiliation(s)
- Junjun Liu
- Department of Vascular Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China
- Department of Vascular Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Rongjie Zhang
- Department of Vascular Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Rui Feng
- Department of Vascular Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Jiaxuan Feng
- Department of Vascular Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Zhiqing Zhao
- Department of Vascular Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Zhenjiang Li
- Department of Vascular Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Yuxi Zhao
- Department of Vascular Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Yiming Li
- Department of Vascular Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Jian Zhou
- Department of Vascular Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Zaiping Jing
- Department of Vascular Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China
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Murana G, Alfonsi J, Di Marco L, Pacini D. Open thoracoabdominal aortic aneurysm repair in expert hands: "all roads lead to Rome". ANNALS OF TRANSLATIONAL MEDICINE 2017; 5:414. [PMID: 29152514 DOI: 10.21037/atm.2017.08.03] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Giacomo Murana
- Cardiac Surgery Unit, Cardio-Thoraco-Vascular Department, S. Orsola Hospital, University of Bologna, Bologna, Italy
| | - Jacopo Alfonsi
- Cardiac Surgery Unit, Cardio-Thoraco-Vascular Department, S. Orsola Hospital, University of Bologna, Bologna, Italy
| | - Luca Di Marco
- Cardiac Surgery Unit, Cardio-Thoraco-Vascular Department, S. Orsola Hospital, University of Bologna, Bologna, Italy
| | - Davide Pacini
- Cardiac Surgery Unit, Cardio-Thoraco-Vascular Department, S. Orsola Hospital, University of Bologna, Bologna, Italy
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30
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Fleerakkers J, Schepens M. How should we manage type B aortic dissections? Gen Thorac Cardiovasc Surg 2017; 67:154-160. [PMID: 28852959 DOI: 10.1007/s11748-017-0818-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2017] [Accepted: 08/17/2017] [Indexed: 12/16/2022]
Abstract
Dissection of the descending aorta is a serious and potentially lethal event. Treatment options consist of medical therapy, open surgical replacement of the affected aorta and thoracic endovascular repair. In acute cases, medical treatment is started initially. When complicated, endovascular repair is generally considered as first choice treatment, except for connective tissue disorders where open surgery remains the standard. In stable, uncomplicated patients with risk factors for future aortic growth pre-emptive endovascular repair should be considered in the sub-acute phase of the dissection. The treatment strategy in chronic dissections is somewhat debated. Long-term results and aortic remodeling of endovascular repair are disappointing and open surgery remains the standard.
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Affiliation(s)
- J Fleerakkers
- Department of Cardiac Surgery, AZ Sint-Jan, Ruddershove 10, 8000, Brugge, Belgium.
| | - M Schepens
- Department of Cardiac Surgery, AZ Sint-Jan, Ruddershove 10, 8000, Brugge, Belgium
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31
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Schäfers HJ. Toward a more rational approach in treating type B aortic dissection. J Thorac Cardiovasc Surg 2017; 154:1201-1202. [PMID: 28587879 DOI: 10.1016/j.jtcvs.2017.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2017] [Accepted: 05/05/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Hans-Joachim Schäfers
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg/Saar, Germany.
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32
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Hsu HL, Shih CC. Re-intervention after thoracic endovascular aortic repair is high, but we should keep optimistic. J Thorac Dis 2017; 9:E162-E163. [PMID: 28275505 DOI: 10.21037/jtd.2017.02.12] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Affiliation(s)
- Hung-Lung Hsu
- School of Medicine, National Yang-Ming University, Taipei, Taiwan; ; Department of Cardiovascular Surgery, Far Eastern Memorial Hospital, New Taipei City, Taiwan; ; Division of Cardiovascular Surgery, Department of Surgery, Mennonite Christian Hospital, Hualien, Taiwan
| | - Chun-Che Shih
- School of Medicine, National Yang-Ming University, Taipei, Taiwan; ; Division of Cardiovascular Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan; ; Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
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