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Steinmetz LM, Coselli JS. Endovascular Repair in Patients with Marfan Syndrome: Concerns Amid Controversy. Ann Vasc Surg 2022:S0890-5096(22)00236-9. [PMID: 35595210 DOI: 10.1016/j.avsg.2022.04.049] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 04/21/2022] [Indexed: 11/25/2022]
Abstract
Endovascular aortic repair is widely used to treat patients with degenerative aneurysms or aortic dissection within the distal aorta. Thoracic endovascular aortic repair (TEVAR) is generally associated with fewer short-term complications than open surgical repair, which is particularly important for older patients with significant comorbid conditions. However, for patients with Marfan syndrome, a heritable thoracic aortic disease associated with aortic dilatation, dissection, and rupture, the utility of endovascular aortic repair remains questionable. Marfan patients have friable aortic tissue and are typically treated at a relatively young age; they therefore need a durable solution. Furthermore, those who need distal aortic repair tend to have chronic aortic dissection. Although TEVAR is generally superior to open surgery with regard to short-term complications, it is less durable, and TEVAR reintervention rates are highest in patients with chronic aortic dissection. Thus, Marfan patients seeking definitive aortic repair are often better served by open repair. Nonetheless, TEVAR may be useful in patients with Marfan syndrome as a bridge to open repair or as treatment for late complications of previous open repair.
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Affiliation(s)
- Leah M Steinmetz
- Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Joseph S Coselli
- 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; Department of Cardiovascular Surgery, CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, Texas, USA; Cardiovascular Research Institute, Baylor College of Medicine, Houston, Texas, USA.
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Anastasiadou C, Trellopoulos G, Kastora S, Kakisis I, Papapetrou A, Galyfos G, Geroulakos G, Megalopoulos A. A systematic review of therapies for aortobronchial fistulae. J Vasc Surg 2021; 75:753-761.e3. [PMID: 34624495 DOI: 10.1016/j.jvs.2021.08.108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Accepted: 08/22/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The aim of the study was to summarize epidemiologic data about aortobronchial fistulas and compare outcomes (mortality, recurrence, re-operation) of open, staged, and endovascular repair of aortobronchial fistula. METHODS A systematic literature review was conducted to identify eligible studies published between January of 1999 and December of 2019. The Cochrane Library, PubMed and Scopus databases were used as search engines. Eligible studies included articles reporting postoperative outcomes (death/follow-up). Literature review revealed only case reports and small case series and thus, only descriptive data with data heterogeneity was available. The corresponding authors were contacted to provide additional information or outcome updates (recurrence/reoperation/death). RESULTS Overall, 214 patients (90 studies) underwent 271 procedures (including re-do procedures and staged procedures). Most of the patients were treated by endovascular means (72.42%). Open surgical repair was performed in 21.96% and staged procedures in 5.6%. Aortobronchial fistulae located most often in the descending thoracic aorta (Zone 3,4) (64,6%) and in Zone 2 (23,8%). Fourteen percent of aortobronchial fistulae developed after thoracic endovascular aneurysm repair. Recurrence or infection occurred in 20% (43 patients). Recurrences were at some extend associated with the presence of endoleak. Long-term antibiotic administration (>1 month) was instituted in 63 patients (29.4%), whilst 90 patients (42%) did not receive antibiotics beyond hospitalization. From the remaining 61, 3 received life-long antibiotics and for 58 patients data were not available. Considering outcomes, mean follow-up was 25.1 months (0-188 months) and not significantly different among treatments. LIMITATIONS Literature review has revealed only case reports and small case series and thus, only descriptive data were available. Randomized controlled trials are not available due to the rarity of the disease which significantly decreases the power of the present study. Also, this study reflects significant data heterogeneity due to the nature of the analyzed manuscripts and would benefit from large patient cohort studies which till today have not been conducted. CONCLUSION Aortobronchial fistula is a complex disease. Endoleaks may be involved in the development and in recurrence process and they should not be disregarded. Considering major outcomes (length of follow-up), the available treating strategies are equal and thus, surgeons should feel confident to apply the treatment of their choice, taking in mind their experience, patient's age, and clinical condition.
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Affiliation(s)
| | - George Trellopoulos
- Department of Vascular Surgery - General Hospital of Thessaloniki "Georgios Papanikolaou"
| | | | - Ioannis Kakisis
- Department of Vascular Surgery -"Attikon" University Hospital, Medical School, National and Kapodistrian University of Athens
| | | | - George Galyfos
- Department of Vascular Surgery - General Hospital of Attica "KAT"
| | - George Geroulakos
- Department of Vascular Surgery -"Attikon" University Hospital, Medical School, National and Kapodistrian University of Athens
| | - Angelos Megalopoulos
- Department of Vascular Surgery - General Hospital of Thessaloniki "Georgios Papanikolaou"
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Abstract
Aortobronchial fistulas (ABFs) are rare but fatal if left untreated. Hemoptysis is the most common symptom of the patients. ABFs may occur after any thoracic aortic lesions or maneuveurs for these lesions. The treatment of ABF can be surgical or thoracic endovascular aortic repair. Thoracic endovascular aortic repair can be a safe and less invasive procedure for the treatment of ABFs. However, ABFs might occur in much shorter time after thoracic endovascular aortic repair than any other etiologies. The prognoses of patients with ABFs are poor with a high morbidity and mortality. The selection of a suitable endovascular graft and avoidance of postinterventional complications might effectively prevent the occurrence of ABFs.
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Affiliation(s)
- Shi-Min Yuan
- Department of Cardiothoracic Surgery, The First Hospital of Putian, Teaching Hospital, Fujian Medical University, 389 Longdejing Street, Chengxiang District, Putian, 351100, Fujian Province, People's Republic of China.
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Ouzounian M, LeMaire SA. How can genetic diagnosis inform the decision of when to operate? J Vis Surg 2018; 4:68. [PMID: 29780714 DOI: 10.21037/jovs.2018.03.08] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Accepted: 03/07/2018] [Indexed: 12/16/2022]
Abstract
Genetic discovery for heritable thoracic aortic disease (HTAD) has been progressing at a brisk pace. Surgical management of thoracic aortic aneurysms and dissections has become more personalized, with genetic factors increasingly informing the decision of when to operate on patients. An improved understanding of genotype-phenotype correlations in patients with HTAD will ultimately lead to gene- and mutation-specific recommendations for surgical repair. Until more robust data from larger cohorts can inform our decisions, patients with HTAD should be seen by an aortic specialist for a tailored approach to elective surgical repair.
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Affiliation(s)
- Maral Ouzounian
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, Canada.,Department of Surgery, University of Toronto, Toronto, Canada
| | - Scott A LeMaire
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, and the Cardiovascular Research Institute, Baylor College of Medicine, Houston, Texas, USA.,Cardiovascular Surgery Service, The Texas Heart Institute, Houston, Texas, USA
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Open descending thoracic or thoracoabdominal aortic approaches for complications of endovascular aortic procedures: 19-year experience. J Thorac Cardiovasc Surg 2018; 155:10-18. [DOI: 10.1016/j.jtcvs.2017.08.023] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Revised: 07/20/2017] [Accepted: 08/11/2017] [Indexed: 11/19/2022]
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Domanin M, Romagnoni G, Romagnoli S, Rolli A, Gabrielli L. Emergency Hybrid Approach to Ruptured Femoral Pseudoaneurysm in HIV-positive Intravenous Drug Abusers. Ann Vasc Surg 2016; 40:297.e5-297.e12. [PMID: 27908808 DOI: 10.1016/j.avsg.2016.07.086] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Revised: 07/06/2016] [Accepted: 07/30/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND Chronic traumatism of the common femoral artery due to intravenous injection in drug abusers, in association with local infections and arterial wall weakening caused by human immunodeficiency virus (HIV), can lead to the development of pseudoaneurysms (PSAs). Rupture of PSA is a dramatic event in such patients, and its correction is difficult and controversial. Most of the cases reported describe open surgical elective options, which consist in ligation, repair, or substitution of the damaged arterial segment, using when possible biological grafts. In literature, few cases describe an endovascular repair with covered stent deployment. METHODS We present 2 cases of HIV-positive intravenous injection in drug abusers who needed emergency treatment for active bleeding in ruptured PSA of the right common femoral artery. In both cases, under general anesthesia needed for lack of patient's compliance and unstable hemodynamics, a short dissection to the distal superficial femoral artery was required. RESULTS Then, maintaining a manual compression on the bleeding site to stop hemorrhage, we deployed a covered stent graft in the site of the arterial breakdown through a retrograde approach. CONCLUSIONS The favorable results and progressive healing of wound and local infections persuaded us not to perform any further surgical correction. The absence of recurrences and late complications, after 3 years in the first case and 1 year in the second one, lead us to consider this hybrid endovascular approach as a valuable alternative to open surgery in HIV intravenous injection in drug abuser patients, in particularly when emergency conditions occur.
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Affiliation(s)
- Maurizio Domanin
- Dipartimento di Scienze Cliniche e di Comunità, Università degli Studi di Milano, Milan, Italy; Unità Operativa di Chirurgia Vascolare, Fondazione I.R.C.C.S. Ca' Granda Ospedale Maggiore Policlinico Milano, Milan, Italy.
| | - Giovanni Romagnoni
- Dipartimento di Scienze Cliniche e di Comunità, Università degli Studi di Milano, Milan, Italy
| | - Silvia Romagnoli
- Unità Operativa di Chirurgia Vascolare, Fondazione I.R.C.C.S. Ca' Granda Ospedale Maggiore Policlinico Milano, Milan, Italy
| | - Antonio Rolli
- Unità Operativa di Chirurgia Vascolare, Fondazione I.R.C.C.S. Ca' Granda Ospedale Maggiore Policlinico Milano, Milan, Italy
| | - Livio Gabrielli
- Dipartimento di Scienze Cliniche e di Comunità, Università degli Studi di Milano, Milan, Italy; Unità Operativa di Chirurgia Vascolare, Fondazione I.R.C.C.S. Ca' Granda Ospedale Maggiore Policlinico Milano, Milan, Italy
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Chimneys and sandwiches for endovascular arch repair in patients with Marfan syndrome: Are we snorkeling in cloudy waters? J Thorac Cardiovasc Surg 2016; 152:1195-6. [DOI: 10.1016/j.jtcvs.2016.07.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2016] [Accepted: 07/06/2016] [Indexed: 11/21/2022]
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Open aortic surgery after thoracic endovascular aortic repair. Gen Thorac Cardiovasc Surg 2016; 64:441-9. [DOI: 10.1007/s11748-016-0658-8] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Accepted: 05/13/2016] [Indexed: 01/10/2023]
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Gagné-Loranger M, Voisine P, Dagenais F. Should Endovascular Therapy Be Considered for Patients With Connective Tissue Disorder? Can J Cardiol 2016; 32:1-3. [DOI: 10.1016/j.cjca.2015.06.026] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Revised: 06/29/2015] [Accepted: 06/29/2015] [Indexed: 11/28/2022] Open
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Nauta FJH, Conti M, Kamman AV, van Bogerijen GHW, Tolenaar JL, Auricchio F, Figueroa CA, van Herwaarden JA, Moll FL, Trimarchi S. Biomechanical Changes After Thoracic Endovascular Aortic Repair in Type B Dissection. J Endovasc Ther 2015; 22:918-33. [DOI: 10.1177/1526602815608848] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Thoracic endovascular aortic repair (TEVAR) has evolved into an established treatment option for type B aortic dissection (TBAD) since it was first introduced 2 decades ago. Morbidity and mortality have decreased due to the minimally invasive character of TEVAR, with adequate stabilization of the dissection, restoration of true lumen perfusion, and subsequent positive aortic remodeling. However, several studies have reported severe setbacks of this technique. Indeed, little is known about the biomechanical behavior of implanted thoracic stent-grafts and the impact on the vascular system. This study sought to systematically review the performance and behavior of implanted thoracic stent-grafts and related biomechanical aortic changes in TBAD patients in order to update current knowledge and future perspectives.
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Affiliation(s)
- Foeke J. H. Nauta
- Thoracic Aortic Research Center, Policlinico San Donato IRCCS, University of Milan, Italy
- Departments of Surgery and Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
- Department of Vascular Surgery, University Medical Center Utrecht, the Netherlands
| | - Michele Conti
- Department of Civil Engineering and Architecture, University of Pavia, Italy
| | - Arnoud V. Kamman
- Thoracic Aortic Research Center, Policlinico San Donato IRCCS, University of Milan, Italy
- Departments of Surgery and Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
- Department of Vascular Surgery, University Medical Center Utrecht, the Netherlands
| | | | - Jip L. Tolenaar
- Department of General Surgery, St. Antonius Hospital, Nieuwegein, the Netherlands
| | | | - C. Alberto Figueroa
- Departments of Surgery and Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
| | | | - Frans L. Moll
- Department of Vascular Surgery, University Medical Center Utrecht, the Netherlands
| | - Santi Trimarchi
- Thoracic Aortic Research Center, Policlinico San Donato IRCCS, University of Milan, Italy
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