1
|
Vervoort D, An KR, Deng MX, Elbatarny M, Fremes SE, Ouzounian M, Tarola C. The Call for the "Interventional/Hybrid" Aortic Surgeon: Open, Endovascular, and Hybrid Therapies of the Aortic Arch. Can J Cardiol 2024; 40:478-495. [PMID: 38052303 DOI: 10.1016/j.cjca.2023.11.038] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 11/29/2023] [Accepted: 11/29/2023] [Indexed: 12/07/2023] Open
Abstract
Aortic arch pathology is relatively rare but potentially highly fatal and associated with considerable comorbidity. Operative mortality and complication rates have improved over time but remain high. In response, aortic arch surgery is one of the most rapidly evolving areas of cardiac surgery in terms of surgical volume and improved outcomes. Moreover, there has been a surge in novel devices and techniques, many of which have been developed by or codeveloped with vascular surgeons and interventional radiologists. Nevertheless, the extent of arch surgery, the choice of nadir temperature, cannulation, and perfusion strategies, and the use of open, endovascular, or hybrid options vary according to country, centre, and surgeon. In this review article, we provide a technical overview of the surgical, total endovascular, and hybrid repair options for aortic arch pathology through historical developments and contemporary results. We highlight key information for surgeons, cardiologists, and trainees to understand the management of patients with aortic arch pathology. We conclude by discussing training paradigms, the role of aortic teams, and gaps in knowledge, arguing for the need for wire skills for the future "interventional aortic surgeon" and increased research into techniques and novel devices to continue improving outcomes for aortic arch surgery.
Collapse
Affiliation(s)
- Dominique Vervoort
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Kevin R An
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Mimi X Deng
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Malak Elbatarny
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Stephen E Fremes
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada; Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada.
| | - Maral Ouzounian
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada; Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Christopher Tarola
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada; Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
2
|
Minici R, Serra R, Ierardi AM, Petullà M, Bracale UM, Carrafiello G, Laganà D. Thoracic endovascular repair for blunt traumatic thoracic aortic injury: Long-term results. Vascular 2024; 32:5-18. [PMID: 36121832 DOI: 10.1177/17085381221127740] [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: 11/17/2022]
Abstract
OBJECTIVE This study aims to evaluate the endoprosthesis complications in patients undergoing TEVAR for blunt traumatic thoracic aortic injury, through long-term clinical and diagnostic follow-up. METHODS During the study interval (November 2000-October 2020), a total of 38 patients (63% male; average age 37.5 years) with thoracic aortic injury underwent thoracic endovascular aortic repair. Patients underwent routine follow-up with clinical examination and radiological evaluation (CT-angiography or MRI-angiography plus chest radiograph), scheduled at 1 month, at 6 months (only in the cases of thoracic aortic dissection), at 1 year after the procedure and every 1 year thereafter. RESULTS Technical success was achieved in 38 procedures (100%). The TEVAR-related mortality rate was 0%. No immediate major complications related to the endovascular procedure were observed. The median duration of diagnostic follow-up was 80 months. A total of four procedure-related complications (10.5%) were identified at the follow-up. Three (7.9%) distal infoldings and collapses of the thoracic endoprosthesis and one (2.6%) type Ia endoleak were observed. No thrombosis of the prosthesis, nor signs of aortic pseudocoarctation were identified. No further complications related to endograft (endoleaks, infections, rupture, partial or complete thrombosis) occurred. No changes in the native aorta, stenosis, or increases in the endograft's diameters were observed. A total of 20 patients (52.6%) underwent MRI-angiography examinations, while a total of 34 patients (89.5%) underwent chest radiographs at the follow-up. In all cases, CT-angiography examinations were performed at the follow-up. CONCLUSIONS Procedure-related complications were observed within one year of TEVAR, limiting concerns related to the durability of the prosthesis. No morphological changes in the aorta were observed despite long-term follow-up. The consequences of lifelong surveillance in terms of radiation exposure deserve special consideration, especially in younger patients treated for TAI.
Collapse
Affiliation(s)
- Roberto Minici
- Radiology Division, Department of Experimental and Clinical Medicine, University Hospital Mater Domini, Magna Graecia University of Catanzaro, Catanzaro, Italy
| | - Raffaele Serra
- Vascular Surgery Division, Department of Medical and Surgical Sciences, University Hospital Mater Domini, Magna Graecia University of Catanzaro, Catanzaro, Italy
| | - Anna Maria Ierardi
- Radiology Division, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy
| | - Maria Petullà
- Radiology Division, Department of Experimental and Clinical Medicine, University Hospital Mater Domini, Magna Graecia University of Catanzaro, Catanzaro, Italy
| | - Umberto M Bracale
- Department of Public Health, University of Naples Federico II, Naples, Italy
| | - Gianpaolo Carrafiello
- Radiology Division, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy
- Department of Health Sciences, Università Degli Studi di Milano, Milan, Italy
| | - Domenico Laganà
- Radiology Division, Department of Experimental and Clinical Medicine, University Hospital Mater Domini, Magna Graecia University of Catanzaro, Catanzaro, Italy
| |
Collapse
|
3
|
Kumins NH, Ambani RN, Bose S, King AH, Cho JS, Colvard B, Kashyap VS. Anatomic Utility of Single Branched Thoracic Endograft During Thoracic Endovascular Aortic Repair. Vasc Endovascular Surg 2023; 57:680-688. [PMID: 36961838 DOI: 10.1177/15385744231165988] [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: 03/25/2023]
Abstract
INTRODUCTION Single branched thoracic endografts (SBTEs) have been designed for pathology requiring zone 2 seal during thoracic endovascular aortic repair (TEVAR). Numerous criteria must be met to allow for their implantation. Our aim was to analyze anatomic suitability for a next generation SBTE. METHODS We reviewed 150 TEVAR procedures between 2015 and 2019. Proximal seal was: zone 0 in 21 (16%), zone 1 in 4 (3%), zone 2 in 52 (40%), zone 3 in 45 (35%), and zone 4 or distal in 7 (5%). We analyzed the Zone 2 patient's angiograms and CT angiograms using centerline software to measure arterial diameters and length in relation to the left common carotid artery (LCCA), left subclavian artery (LSA) and proximal extent of aortic disease to determine if patients met anatomic criteria of a novel SBTE. RESULTS Zone 2 average age was 64.4 ± 16.3 years; 34 patients were male (65%). Indications for repair were aneurysm (N = 9, 17%), acute dissection (N = 14, 27%), chronic dissection with aneurysmal degeneration (N = 7, 13%), intramural hematoma (N = 9, 17%), penetrating aortic ulcer (N = 5, 10%), and blunt traumatic aortic injury (BTAI, N = 8, 15%). LSA revascularization occurred in 27 patients (52%). Overall, 20 (38.5%) of the zone 2 patients met anatomic criteria. Patients with dissection met anatomic criteria less frequently than aneurysm (33% [10 of 30] vs 64% [9 of 14]). Patients treated for BTAI rarely met the anatomic criteria (1 of 8, 13%). The main anatomic constraints were an inadequate distance from the LCCA to the LSA takeoff and from the LCCA to the start of the aortic disease process. CONCLUSION Less than half of patients who require seal in zone 2 met criteria for this SBTE. Patients with aneurysms met anatomic criteria more often than those with dissection. The device would have little applicability in treating patients with BTAI.
Collapse
Affiliation(s)
- Norman H Kumins
- Department of Vascular Surgery, The Heart and Vascular Institute, The Cleveland Clinic, Cleveland, OH, USA
| | - Ravi N Ambani
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University Hospitals, Cleveland Medical Center and Case Western Reserve University, Cleveland, OH, USA
| | - Saideep Bose
- Division of Vascular and Endovascular Surgery, Department of Surgery, St Louis University, St Louis, MO, USA
| | - Alexander H King
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University Hospitals, Cleveland Medical Center and Case Western Reserve University, Cleveland, OH, USA
| | - Jae S Cho
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University Hospitals, Cleveland Medical Center and Case Western Reserve University, Cleveland, OH, USA
| | - Benjamin Colvard
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University Hospitals, Cleveland Medical Center and Case Western Reserve University, Cleveland, OH, USA
| | - Vikram S Kashyap
- Division of Vascular Surgery, Frederik Meijer Heart and Vascular Institute, Spectrum Health, Grand Rapids, MI, USA
| |
Collapse
|
4
|
Fankhauser K, Wamala I, Penkalla A, Heck R, Hammerschmidt R, Falk V, Buz S. Outcomes and survival following thoracic endovascular repair in patients with aortic aneurysms limited to the descending thoracic aorta. J Cardiothorac Surg 2023; 18:194. [PMID: 37340389 DOI: 10.1186/s13019-023-02285-3] [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: 01/06/2023] [Accepted: 04/10/2023] [Indexed: 06/22/2023] Open
Abstract
BACKGROUND Thoracic endovascular aortic repair (TEVAR) is a well-established therapy for descending aortic aneurysms (DTA). There is a paucity of large series reporting the mid- and long-term outcomes from this era. The main aim of this study was to evaluate the outcomes of TEVAR with regards to the effect of aortic morphology and procedure-related variables on survival, reintervention and freedom from endoleaks. METHODS In this retrospective single center study, we evaluated the clinical outcomes among 158 consecutive patients with DTA than underwent TEVAR between 2006 and 2019 at our center. The cohort included 51% patients with device landing zones proximal to the subclavian artery and 25.9% patients undergoing an emergent or urgent TEVAR. The primary outcome was survival, and secondary outcomes were reintervention and occurrence of endoleaks. RESULTS Median follow-up was 33 months [IQR 12 to 70] while 50 patients (30.6%) had longer than 5-year follow-up. With a median patient age of 74 years, post-operative Kaplan Meyer survival estimates were 94.3% (95%CI 90.8-98.0, SE 0.018%) at 30 days, 76.4% (95%CI 70.0-83.3, SE 0.034%) at one year and, 52.9% (95%CI 45.0-62.2, SE 0.043%) at five years. Freedom from reintervention at 30 days, one year, and five years was 92.9% (95%CI 89.0-97.1, SE 0.021%), 80.0% (95%CI 72.6-88.1, SE 0.039%), and 52.8% (95%CI 41.4-67.4, SE 0.065%), respectively. On cox regression analysis greater aneurysm diameter, and the use of device landing zones in aortic regions 0-1 were associated with an increased probability of all-cause mortality, and with reintervention during follow-up. Independent of aneurysm size undergoing urgent or emergent TEVAR was associated with higher mortality risk for the first three years post-operative but not on long-term follow-up. CONCLUSIONS Larger aneurysms and those requiring stent-graft landing in aortic zones 0 or 1, are associated with higher risk for mortality and reintervention. There remains a need to optimize clinical management and device design for larger proximal aneurysms.
Collapse
Affiliation(s)
- Katharina Fankhauser
- Deutsches Herzzentrum der Charité (DHZC), Department of Cardiothoracic and Vascular Surgery, Augustenburger Platz 1, 13353, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Isaac Wamala
- Deutsches Herzzentrum der Charité (DHZC), Department of Cardiothoracic and Vascular Surgery, Augustenburger Platz 1, 13353, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Adam Penkalla
- Deutsches Herzzentrum der Charité (DHZC), Department of Cardiothoracic and Vascular Surgery, Augustenburger Platz 1, 13353, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Roland Heck
- Deutsches Herzzentrum der Charité (DHZC), Department of Cardiothoracic and Vascular Surgery, Augustenburger Platz 1, 13353, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany
- German Center for Cardiovascular Research (DHZK), Partner Site Berlin, Berlin, Germany
| | - Robert Hammerschmidt
- Deutsches Herzzentrum der Charité (DHZC), Department of Cardiothoracic and Vascular Surgery, Augustenburger Platz 1, 13353, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Volkmar Falk
- Deutsches Herzzentrum der Charité (DHZC), Department of Cardiothoracic and Vascular Surgery, Augustenburger Platz 1, 13353, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany
- German Center for Cardiovascular Research (DHZK), Partner Site Berlin, Berlin, Germany
- Translational Cardiovascular Technologies, Institute of Translational Medicine, Department of Health Sciences and Technology, Swiss Federal Institute of Technology (ETH), Zurich, Switzerland
| | - Semih Buz
- Deutsches Herzzentrum der Charité (DHZC), Department of Cardiothoracic and Vascular Surgery, Augustenburger Platz 1, 13353, Berlin, Germany.
- Charité - Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany.
- German Center for Cardiovascular Research (DHZK), Partner Site Berlin, Berlin, Germany.
| |
Collapse
|
5
|
Bonacchi M, Cabrucci F, Bacchi B, Haranal M, Gelsomino S, Ramlawi B, Dokollari A. Editorial: Novel insights into aortic arch repair. Front Cardiovasc Med 2022; 9:1087952. [PMID: 36582737 PMCID: PMC9793074 DOI: 10.3389/fcvm.2022.1087952] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 11/14/2022] [Indexed: 12/15/2022] Open
Affiliation(s)
- Massimo Bonacchi
- Cardiac Surgery F.U., Experimental and Clinical Medicine Department, University of Florence, Florence, Italy,*Correspondence: Massimo Bonacchi
| | - Francesco Cabrucci
- Cardiac Surgery F.U., Experimental and Clinical Medicine Department, University of Florence, Florence, Italy
| | - Beatrice Bacchi
- Cardiac Surgery F.U., Experimental and Clinical Medicine Department, University of Florence, Florence, Italy
| | - Maruti Haranal
- Department of Cardiac Surgery, U. N. Mehta Institute of Cardiology and Research, Ahmedabad, India
| | - Sandro Gelsomino
- Department of Cardiac Surgery, Carom School for Cardiovascular Diseases, Maastricht University, Maastricht, Netherlands
| | - Basel Ramlawi
- Department of Cardiac Surgery Research, Lankenau Institute for Medical Research, Main Line Health, Wynnewood, PA, United States
| | - Aleksander Dokollari
- Department of Cardiac Surgery Research, Lankenau Institute for Medical Research, Main Line Health, Wynnewood, PA, United States
| |
Collapse
|
6
|
Shukuzawa K, Fujii T, Sumi M, Kozaki J, Umezu M, Ohki T, Iwasaki K. Gap distribution mapping to visualize regions associated with type 1 endoleak in a fenestrated thoracic stent graft. EUROPEAN JOURNAL OF CARDIO-THORACIC SURGERY : OFFICIAL JOURNAL OF THE EUROPEAN ASSOCIATION FOR CARDIO-THORACIC SURGERY 2022; 62:6649731. [PMID: 35876861 PMCID: PMC9319607 DOI: 10.1093/ejcts/ezac361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 06/01/2022] [Indexed: 11/14/2022]
Affiliation(s)
- Kota Shukuzawa
- Cooperative Major in Advanced Biomedical Sciences, Joint Graduate School of Tokyo Women's Medical University and Waseda University, Tokyo, Japan.,Division of Vascular Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Tomoya Fujii
- Department of Integrative Bioscience and Biomedical Engineering, Graduate School of Advanced Science and Engineering, Waseda University, Tokyo, Japan
| | - Makoto Sumi
- Department of Vascular Surgery, Saitama Cardiovascular and Respiratory Center, Saitama, Japan
| | - Junya Kozaki
- Department of Integrative Bioscience and Biomedical Engineering, Graduate School of Advanced Science and Engineering, Waseda University, Tokyo, Japan
| | - Mitsuo Umezu
- Cooperative Major in Advanced Biomedical Sciences, Joint Graduate School of Tokyo Women's Medical University and Waseda University, Tokyo, Japan.,Department of Integrative Bioscience and Biomedical Engineering, Graduate School of Advanced Science and Engineering, Waseda University, Tokyo, Japan.,Department of Modern Mechanical Engineering, School of Creative Science and Engineering, Waseda University, Tokyo, Japan
| | - Takao Ohki
- Division of Vascular Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Kiyotaka Iwasaki
- Cooperative Major in Advanced Biomedical Sciences, Joint Graduate School of Tokyo Women's Medical University and Waseda University, Tokyo, Japan.,Department of Integrative Bioscience and Biomedical Engineering, Graduate School of Advanced Science and Engineering, Waseda University, Tokyo, Japan.,Department of Modern Mechanical Engineering, School of Creative Science and Engineering, Waseda University, Tokyo, Japan
| |
Collapse
|
7
|
Xu X, Wang D, Hou N, Zhou H, Li J, Tian L. Thoracic Endovascular Aortic Repair for Aberrant Subclavian Artery and Stanford Type B Aortic Intramural Hematoma. Front Surg 2022; 8:813970. [PMID: 35223970 PMCID: PMC8878622 DOI: 10.3389/fsurg.2021.813970] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 12/28/2021] [Indexed: 11/18/2022] Open
Abstract
Objectives To evaluate the in-hospital and later outcomes of thoracic endovascular aortic repair (TEVAR) for type B intramural hematoma (TBIMH) combined with an aberrant subclavian artery (aSCA). Methods In the period from January 2014 to December 2020, 12 patients diagnosed with TBIMH combined with aSCA and treated by TEVAR were enrolled in this retrospective cohort study, including 11 patients with the aberrant right subclavian artery (ARSA) and 1 with an aberrant left subclavian artery (ALSA). A handmade fenestrated stent-graft or chimney stent or hybrid repair was performed when the proximal landing zone was not enough. Results The mean age of all the patients was 59.2 ± 7.6 years, and 66.7% of patients were men. There were 4 patients with Kommerell's diverticulum (KD). The procedures in all 12 patients were technically successful. There was one case each of postoperative delirium, renal impairment, and type IV endoleak after TEVAR. During follow-up, 1 patient died of acute pancreatitis 7 months after TEVAR. The overall survival at 1, 3, and 5 years for the patients was 90.9, 90.9, and 90.9%, respectively. KD was excluded in 2 patients, and the handmade fenestrated stent-graft was applied in the other 2 patients to preserve the blood flow of the aSCA. No neurological complications developed and no progression of KD was observed during the follow-up. Conclusion Thoracic endovascular aortic repair for patients with aSCA and TBIMH is promising. When KD was combined, we could exclude KD or preserve the blood flow of aSCA with regular follow-up for the diverticulum according to the size of the KD.
Collapse
Affiliation(s)
- Xia Xu
- Department of Cardiothoracic and Vascular Surgery, Tongji Medical College, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Daoquan Wang
- Department of Cardiothoracic and Vascular Surgery, Tongji Medical College, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Ningxin Hou
- Department of Cardiothoracic and Vascular Surgery, Tongji Medical College, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Hongmin Zhou
- Department of Cardiothoracic and Vascular Surgery, Tongji Medical College, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Jun Li
- Department of Cardiothoracic and Vascular Surgery, Tongji Medical College, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Liang Tian
- Department of Neurosurgery, Taikang Tongji (Wuhan) Hospital, Wuhan, China
| |
Collapse
|
8
|
Le Huu A, Preventza O. Endovascular repair of acute type B thoracic aortic dissection. Ann Cardiothorac Surg 2021; 10:793-800. [PMID: 34926184 DOI: 10.21037/acs-2021-taes-26] [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: 09/22/2021] [Accepted: 10/24/2021] [Indexed: 11/06/2022]
Abstract
Approximately one-third of patients with acute Stanford type B or DeBakey type III aortic dissection (TBAD) will develop complications, including persistent symptoms, malperfusion, enlarging aneurysms and impending rupture. In these cases, TBAD becomes a surgical emergency that requires endovascular intervention to complement the medical therapy. The immediate goal of endovascular therapy is to reestablish flow to the true lumen, stabilize the aneurysm and prevent rupture. Long-term goals are the remodeling of the descending thoracic aorta and the prevention of further surgeries in the thoracoabdominal aorta. In this report, we describe our step-by-step endovascular approach to TBAD repair.
Collapse
Affiliation(s)
- Alice Le Huu
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Ourania Preventza
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA.,Section of Adult Cardiac Surgery, Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas, USA
| |
Collapse
|
9
|
Hybrid Surgery to Manage Aortic Arch Pathology. ACTA ACUST UNITED AC 2021; 57:medicina57090909. [PMID: 34577832 PMCID: PMC8471267 DOI: 10.3390/medicina57090909] [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: 07/21/2021] [Revised: 08/25/2021] [Accepted: 08/26/2021] [Indexed: 11/29/2022]
Abstract
Background and Objectives: Aortic arch disease is still a high-risk surgical challenge despite major advances both in surgical and anesthesiological management. A combined surgical and endovascular approach has been proposed for aortic arch disease treatment to avoid hypothermia and circulatory arrest in high-risk patients. Materials and Methods: Between June 2004 and June 2021, 112 patients were referred to our department for aortic arch surgery; 38 (33.9%) patients underwent supra-aortic debranching and endovascular treatment. Of these, 21 (55%) patients underwent type I aortic arch hybrid debranching procedure and in 17 (45%) patients a type II aortic arch hybrid debranching procedure was performed. None of the patients were emergent. Results: No intra-operative deaths were recorded. In the type I aortic arch hybrid debranching patients’ group, one patient died at home waiting the endovascular step, one developed ascending aortic dissection and another one developed a pseudoaneurysm at the site of the debranching at follow-up. In the type II aortic arch hybrid debranching patients’ group, left carotid artery branch closure was detected at follow-up in one patient. Thirty day/in-hospital rates of adverse neurological events for both the surgical and endovascular procedures were 3% for minor stroke, with no permanent neurological deficit and 0% for permanent paraplegia/paraparesis. In 100% of the cases, the endovascular step succeeded and the type Ia endoleak rate was 0%. Conclusions: Hybrid arch surgery is a valuable option for aortic arch aneurysm treatment in patients with high surgical risk. The choice of aortic arch debranching between type I or type II is crucial and depends on anatomic and clinical patient characteristics. Further larger scale studies are needed to better define the advantages of these techniques.
Collapse
|
10
|
Seguchi R, Kiuchi R, Horikawa T, Tarui T, Sanada J, Ohtake H, Watanabe G. Novel Brain Protection Method for Zone 0 Endovascular Aortic Repair with Selective Cerebral Perfusion. Ann Vasc Dis 2021; 14:153-158. [PMID: 34239641 PMCID: PMC8241544 DOI: 10.3400/avd.oa.21-00025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 04/15/2021] [Indexed: 11/19/2022] Open
Abstract
Objective: Zone 0 thoracic endovascular aortic repair (TEVAR) is associated with a high incidence of cerebral infarction mostly due to the embolic shower of a plaque from the aortic arch when the stent graft brushes against the aortic wall. Thus, it is important to develop a method for protecting the brain from such embolism. We report the outcomes of Zone 0 TEVAR with a novel brain protection method using selective cerebral perfusion under extracorporeal membrane oxygenation (ECMO). Materials and Methods: Two T-shaped grafts with ringed expanded polytetrafluoroethylene (ePTFE) were created using an 8-mm-ringed ePTFE anastomosed end-to-side with a 7-mm-ringed ePTFE. Carotid–carotid bypass and axillo-axillary bypass were established using these grafts. ECMO was connected to the grafts and the femoral vein. Bilateral carotid and axillary arteries were blocked, and cerebral perfusion was selectively maintained using ECMO. Total endovascular Zone 0 TEVAR was performed. The patency of brachiocephalic artery was maintained using the chimney or in situ fenestration technique. Results: Since August 2016, seven patients with aortic arch aneurysms underwent the procedure. The mortality rate was 0%. No neurological complications developed. Conclusion: This brain protection method using selective cerebral perfusion under ECMO is a safe method for Zone 0 TEVAR.
Collapse
Affiliation(s)
- Ryuta Seguchi
- Department of Cardiovascular Surgery, NewHeart Watanabe Institute, Tokyo, Japan
| | - Ryuta Kiuchi
- Department of Cardiovascular Surgery, NewHeart Watanabe Institute, Tokyo, Japan
| | - Takafumi Horikawa
- Department of Cardiovascular Surgery, NewHeart Watanabe Institute, Tokyo, Japan
| | - Tatsuya Tarui
- Department of Cardiovascular Surgery, NewHeart Watanabe Institute, Tokyo, Japan
| | - Junichiro Sanada
- Department of Vascular Surgery, Ageo Central General Hospital, Ageo, Saitama, Japan
| | - Hiroshi Ohtake
- Department of Vascular Surgery, Ageo Central General Hospital, Ageo, Saitama, Japan
| | - Go Watanabe
- Department of Cardiovascular Surgery, NewHeart Watanabe Institute, Tokyo, Japan
| |
Collapse
|
11
|
Pietersen LC, van der Meer RW, Alders DJC, van Schaik J, Eefting D, van Rijswijk CSP. Partial Right Atrial Inflow Occlusion for Transient Systemic Hypotension During Deployment of Thoracic Stentgrafts. Cardiovasc Intervent Radiol 2021; 44:1116-1120. [PMID: 33709270 PMCID: PMC8189963 DOI: 10.1007/s00270-020-02758-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 12/23/2020] [Indexed: 11/28/2022]
Abstract
Purpose Temporary balloon occlusion of the inferior vena cava to lower cardiac output is a relatively infrequently used technique to induce controlled systemic hypotension. In this technical note, we describe the feasibility, reliability, and safety of partial occlusion of right atrial inflow and the effect on systemic blood pressure during the deployment of a thoracic stentgraft. Materials and Methods Twenty consecutive patients undergoing thoracic endovascular aortic repair, with proximal landing in zone 0–3 of the thoracic aorta, were prospectively included. Right atrial inflow occlusion was performed with a compliant occlusion balloon. Results Median time to reach a mean arterial pressure of 50 mmHg was 43 s. Median recovery time of blood pressure was 42 s. Conclusion Partial right atrial inflow occlusion with an occlusion balloon is feasible with reliable results and without procedure-related complications.
Collapse
Affiliation(s)
- L C Pietersen
- Department of Interventional Radiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands.
| | - R W van der Meer
- Department of Interventional Radiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - D J C Alders
- Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands
| | - J van Schaik
- Department of Vascular Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - D Eefting
- Department of Vascular Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - C S P van Rijswijk
- Department of Interventional Radiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| |
Collapse
|
12
|
Tortuosity of the Descending Thoracic Aorta in Patients with Aneurysm and Type B Dissection. World J Surg 2020; 44:1323-1330. [PMID: 31873803 DOI: 10.1007/s00268-019-05328-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE Tortuosity in the descending thoracic aorta (DTA) comes with aging and increases the risk of endoleaks after TEVAR. With this report, we would like to define and classify tortuosity in the DTA of patients with thoracic aortic disease. METHODS Retrospective case-control study of two hundred seven patients, comparing sixty-nine controls without aortic disease (CG), to sixty-nine patients with descending thoracic aortic aneurysm (AG) and sixty-nine patients with type B aortic dissection (DG). 3Mensio Vascular software was used to analyze CTA scans and collect the following measurements; tortuosity index, curvature ratio and the maximum tortuosity of the DTA. The DTA was divided into four equal zones. The maximum tortuosity was divided into three groups: low (<30°), moderate (30°-60°) and high tortuosity (>60°). RESULTS Compared to the CG, tortuosity was more pronounced in the DG, and even more in the AG, evidenced by the tortuosity index (1.11 vs. 1.20 vs. 1.31; p < 0.001), curvature ratio (1.00 vs. 1.01 vs. 1.03; p < 0.001), maximum tortuosity in degrees (28.17 vs. 33.29 vs. 43.83; p < 0.001) and group of tortuosity (p < 0.001). The maximum tortuosity was further distal for the DG and AG, evidenced by the zone of maximum tortuosity (4A vs. 4B vs. 4B; p < 0.001). CONCLUSION This study shows that tortuosity in the DTA is more prominent in diseased aortas, especially in aneurysmal disease. This phenomenon needs to be taken into account during planning of TEVAR to prevent stent graft-related complications and to obtain positive long-term outcome.
Collapse
|
13
|
Zhu C, Piao H, Wang Y, Li B, Zhang Y, Xu J, Wang T, Zhu Z, Xu R, Li D, Liu K. A New Aortic Arch Inclusion Technique with Frozen Elephant Trunk for Aortic Arch Aneurysm Treatment. Int Heart J 2020; 61:1229-1235. [PMID: 33116020 DOI: 10.1536/ihj.20-069] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Various surgical techniques have been proposed for treating aortic arch aneurysm (AAA); however, the optimal treatment has not been well defined. This study introduces a new aortic arch inclusion technique with frozen elephant trunk (FET) for AAA treatment.A retrospective analysis was performed among 22 patients for AAA surgical treatment between March 2010 and March 2019. Patients were classified into Z1, Z2, and Z3 groups based on the origins of aneurysms. A stent graft with a 10 cm stented graft and 5-9 cm proximal vascular prosthesis was released into the descending thoracic aorta as FET through an incision in the aortic arch. The proximal vascular prosthesis was retracted into the aortic arch, trimmed to expose the orifices of the brachiocephalic vessels, and sutured inside the aortic arch using the inclusion technique. The proximal sealing location of the vascular graft was tailored to cover the origins of aneurysms.There was no 30-day mortality. No patient had postoperative stroke or paraplegia. Complete aneurysm thrombosis was achieved in all patients. One patient died of severe respiratory tract stenosis 3 months postoperatively. All other 21 patients were alive during 53.3 ± 36.5-month follow-up. Computed tomography angiography was obtained in 15 patients during follow-up. Endoleak was observed in one patient, and the other 14 patients were free from aneurysm-related or graft-related complications during follow-up.The aortic arch inclusion technique with FET provides an alternative technique in treating AAA with satisfactory mid-term follow-up results. A larger patient population with long-term follow-up results is warranted.
Collapse
Affiliation(s)
- Cuilin Zhu
- Department of Cardiovascular Surgery, The Second Hospital of Jilin University
| | - Hulin Piao
- Department of Cardiovascular Surgery, The Second Hospital of Jilin University
| | - Yong Wang
- Department of Cardiovascular Surgery, The Second Hospital of Jilin University
| | - Bo Li
- Department of Cardiovascular Surgery, The Second Hospital of Jilin University
| | - Yixin Zhang
- Department of Cardiovascular Surgery, The Second Hospital of Jilin University
| | - Jinyu Xu
- Department of Cardiovascular Surgery, The Second Hospital of Jilin University
| | - Tiance Wang
- Department of Cardiovascular Surgery, The Second Hospital of Jilin University
| | - Zhicheng Zhu
- Department of Cardiovascular Surgery, The Second Hospital of Jilin University
| | - Rihao Xu
- Department of Cardiovascular Surgery, The Second Hospital of Jilin University
| | - Dan Li
- Department of Cardiovascular Surgery, The Second Hospital of Jilin University
| | - Kexiang Liu
- Department of Cardiovascular Surgery, The Second Hospital of Jilin University
| |
Collapse
|
14
|
Alhaizaey A, Aljabri B, Alghamdi M, AlAhmari A, Abulyazied A, Asiry M, Al-Omran M. Delayed Aortic Stent Collapse in Blunt Traumatic Aortic Injury Repair. AORTA : OFFICIAL JOURNAL OF THE AORTIC INSTITUTE AT YALE-NEW HAVEN HOSPITAL 2020; 7:129-136. [PMID: 32018308 PMCID: PMC7000265 DOI: 10.1055/s-0039-3401022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background
Endovascular stent grafting has emerged as an option to treat traumatic aorta injuries with reported significantly low mortality and morbidity. Stent collapse is one of the complications that can occur in this type of treatment. The aim of this article is to analyze the expected cause of stent collapse and to draw attention to the importance of the surveillance follow-up, as this phenomenon may occur late postdeployment.
Methods
A retrospectively collected dataset from the two highest volume trauma centers in Saudi Arabia was analyzed between April 2007 and October 2012. A total of 66 patients received stent grafts for traumatic aortic injury and were included in the study. We apply Ishimaru's anatomical aortic arch zones and Benjamin's aortic injury grading systems. There were 35 patients with aortic injury at zone 2, 26 patients in zone 3, and 5 patients in zone 4. About 96% (63) of the injuries were grades 2 and 3, including large intimal flap or aortic wall pseudoaneurysm with change in wall contour. The technical success rate, as defined by complete exclusion of lesions without leaks, stroke, arm ischemia or stent-related complications, was 90%.
Results
Proximal stent collapse occurred in 4.5% of patients (3 of 66 inserted stents) during follow-up of 4 to 8 years (mean, 6 years). Patients with stent collapse tended to have an acute aortic arch angle with long-intraluminal stent lip, when compared with patients with noncollapsed stents. Intraluminal lip protrusion more than 10-mm increased collapse (
p
< 0.001). Stent-grafts sizes larger than 28 mm also demonstrated a higher collapse rate (
p
< 0.001).
Conclusions
The risk of stent collapse appears related to poor apposition of the stent due to severe aortic arch angulation in young patients and to large stent sizes (>28 mm). Such age groups may have more anatomical and aortic size changes during the growth. Clinical and radiological surveillance is essential in follow-up after stent-graft treatment for traumatic aortic injury.
Collapse
Affiliation(s)
- Abdullah Alhaizaey
- Division of Vascular Surgery, King Khalid University, Aseer Central Hospital, Abha, Saudi Arabia
| | - Badr Aljabri
- Division of Vascular Surgery, King Khalid University, Aseer Central Hospital, Abha, Saudi Arabia
| | - Musaad Alghamdi
- Division of Vascular Surgery, King Khalid University, Aseer Central Hospital, Abha, Saudi Arabia
| | - Ali AlAhmari
- Division of Vascular Surgery, King Khalid University, Aseer Central Hospital, Abha, Saudi Arabia
| | - Ahmed Abulyazied
- Division of Vascular Surgery, King Khalid University, Aseer Central Hospital, Abha, Saudi Arabia
| | - Mohammed Asiry
- Division of Vascular Surgery, King Khalid University, Aseer Central Hospital, Abha, Saudi Arabia
| | - Mohammed Al-Omran
- Division of Vascular Surgery, King Khalid University, Aseer Central Hospital, Abha, Saudi Arabia
| |
Collapse
|
15
|
Belvroy VM, de Beaufort HW, van Herwaarden JA, Bismuth J, Moll FL, Trimarchi S. Tortuosity of the descending thoracic aorta: Normal values by age. PLoS One 2019; 14:e0215549. [PMID: 31013307 PMCID: PMC6478292 DOI: 10.1371/journal.pone.0215549] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 04/03/2019] [Indexed: 11/19/2022] Open
Abstract
Background Aging changes the aorta in length, tortuosity and diameter. This is relevant in thoracic endovascular aortic repair (TEVAR) and in the long term follow up. Methods and results Two groups of hundred patients < 65 years and hundred patients ≥ 65 years, with no vascular diseases were made. Thin cut CT scans were analyzed with 3Mensio Vascular software and the following measurements were collected; tortuosity index, curvature ratio, maximum tortuosity in degrees and the level of vertebrae of the maximum tortuosity. The descending thoracic aorta (DTA) was analyzed and was divided into four zones of equal length. Subjects were divided into three groups based on their maximum tortuosity value: low (< 30°), moderate (30° – 60°) and high (> 60°). A linear regression model was built to test the effect of age and gender on tortuosity. Tortuosity was more pronounced in the ≥ 65 compared to the < 65 group (tortuosity index: 1.05 vs. 1.14, respectively; p < 0.001), curvature ratio (1.00 vs. 1.01; p < 0.001), maximum tortuosity (22.24 vs. 27.26; p < 0.001), and group of angulation (low vs. low; p < 0.001). Additionally, the location of maximum tortuosity was further distal for the ≥ 65 group (level of vertebrae; 5.00 vs. 5.00; p < 0.001), and zone of maximum tortuosity (4A vs. 4A; p < 0.001). There was no significant difference between male and female subjects. Conclusion Normal DTA tortuosity increases with age. This is important to understand natural aging and for TEVAR planning and follow-up.
Collapse
Affiliation(s)
- Viony M. Belvroy
- Thoracic Aortic Research Center, IRCCS Policlinico San Donato, San Donato Milanese, Italy
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, Netherlands
- Houston Methodist DeBakey Heart & Vascular Center, Houston, Texas, United States of America
- * E-mail:
| | - Hector W.L. de Beaufort
- Thoracic Aortic Research Center, IRCCS Policlinico San Donato, San Donato Milanese, Italy
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, Netherlands
| | | | - Jean Bismuth
- Houston Methodist DeBakey Heart & Vascular Center, Houston, Texas, United States of America
| | - Frans L. Moll
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, Netherlands
| | - Santi Trimarchi
- Department of Health and Community Sciences, University of Milan, Milan, Italy
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico Milan, Milan, Italy
| |
Collapse
|
16
|
Son SA, Hahm MH, Kim YE, Kim GJ. Fracture of the Bare Spring of a Thoracic Endograft for Type A Aortic Dissection: A Case Report. Vasc Specialist Int 2019; 35:39-43. [PMID: 30993107 PMCID: PMC6453602 DOI: 10.5758/vsi.2019.35.1.39] [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] [Indexed: 11/20/2022] Open
Abstract
Retrograde type A aortic dissection (RTAD) following thoracic endovascular aortic repair is a devastating complication associated with high mortality rates. In particular, a deployed endograft in a bird-beak formation in an acute curve of the aortic arch can induce injury to the fragile aortic wall, with the subsequent development of RTAD. Here, we describe an extremely rare case of RTAD caused by fracture of the bare spring of the thoracic endograft for type A aortic dissection.
Collapse
Affiliation(s)
- Shin-Ah Son
- Department of Thoracic and Cardiovascular Surgery, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Myong Hun Hahm
- Department of Radiology, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Young Eun Kim
- Department of Thoracic and Cardiovascular Surgery, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Gun-Jik Kim
- Department of Thoracic and Cardiovascular Surgery, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| |
Collapse
|
17
|
Predictive Numerical Simulations of Double Branch Stent-Graft Deployment in an Aortic Arch Aneurysm. Ann Biomed Eng 2019; 47:1051-1062. [PMID: 30706308 DOI: 10.1007/s10439-019-02215-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 01/18/2019] [Indexed: 01/04/2023]
Abstract
Total endovascular repair of the aortic arch represents a promising option for patients ineligible to open surgery. Custom-made design of stent-grafts (SG), such as the Terumo Aortic® RelayBranch device (DB), requires complex preoperative measures. Accurate SG deployment is required to avoid intraoperative or postoperative complications, which is extremely challenging in the aortic arch. In that context, our aim is to develop a computational tool able to predict SG deployment in such highly complex situations. A patient-specific case is performed with complete deployment of the DB and its bridging stents in an aneurysmal aortic arch. Deviations of our simulation predictions from actual stent positions are estimated based on post-operative scan and a sensitivity analysis is performed to assess the effects of material parameters. Results show a very good agreement between simulations and post-operative scan, with especially a torsion effect, which is successfully reproduced by our simulation. Relative diameter, transverse and longitudinal deviations are of 3.2 ± 4.0%, 2.6 ± 2.9 mm and 5.2 ± 3.5 mm respectively. Our numerical simulations show their ability to successfully predict the DB deployment in complex anatomy. The results emphasize the potential of computational simulations to assist practitioners in planning and performing complex and secure interventions.
Collapse
|
18
|
Goebel N, Nagib R, Salehi-Gilani S, Ahad S, Albert M, Ursulescu A, Franke UFW. One-stage hybrid aortic repair using the frozen elephant trunk in acute DeBakey type I aortic dissection. J Thorac Dis 2018; 10:4195-4203. [PMID: 30174864 DOI: 10.21037/jtd.2018.06.148] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Background The extent of emergent surgery for acute DeBakey type I aortic dissection is discussed controversial. The frozen elephant trunk (FET) technique in addition to ascending and arch repair promotes aortic remodelling in the descending aorta and thus may provide superior long-term results in terms of less secondary re-interventions and reduced mortality linked to the downstream aorta. Methods Between October 2009 and December 2016, a total of 72 patients underwent emergent hybrid aortic repair using the FET for acute DeBakey type I aortic dissection at our centre. Data were analysed from our prospectively collected database and clinical and imaging mid-term follow-up was obtained. Results Implant success was 98.6% with an overall 30-day-mortality of 15.3%. New postoperative stroke was seen in 2.8%, new spinal cord injury in 4.2%. In follow-up (mean 37.8±21.2 months) cumulative survival was 75.0% with freedom from distal reintervention in 96.7% and aortic remodelling rate in the descending aorta in 96.5%. Conclusions Hybrid aortic repair using the FET in acute DeBakey type I aortic dissection does not elevate the perioperative risk of mortality and provides excellent aortic remodelling with low distal re-intervention rate in mid-term follow-up.
Collapse
Affiliation(s)
- Nora Goebel
- Department of Cardiovascular Surgery, Robert-Bosch-Hospital, Stuttgart, Germany
| | - Ragi Nagib
- Department of Cardiovascular Surgery, Robert-Bosch-Hospital, Stuttgart, Germany
| | | | - Samir Ahad
- Department of Cardiovascular Surgery, Robert-Bosch-Hospital, Stuttgart, Germany
| | - Marc Albert
- Department of Cardiovascular Surgery, Robert-Bosch-Hospital, Stuttgart, Germany
| | - Adrian Ursulescu
- Department of Cardiovascular Surgery, Robert-Bosch-Hospital, Stuttgart, Germany
| | - Ulrich F W Franke
- Department of Cardiovascular Surgery, Robert-Bosch-Hospital, Stuttgart, Germany
| |
Collapse
|
19
|
Xiang Y, Huang B, Zhao J, Hu H, Yuan D, Yang Y. The strategies and outcomes of left subclavian artery revascularization during thoracic endovascular repair for type B aortic dissection. Sci Rep 2018; 8:9289. [PMID: 29915242 PMCID: PMC6006358 DOI: 10.1038/s41598-018-27588-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Accepted: 06/05/2018] [Indexed: 02/05/2023] Open
Abstract
This study was to analyze the outcomes of left subclavian artery (LSA) revascularization during thoracic endovascular repair (TEVAR) for type B aortic dissections (TBAD). From 2011 to 2017, TBAD patients who underwent LSA revascularization during TEVAR were enrolled. Technical success, endoleaks, mortality, complication, reintervention, and patency of target vessels were analyzed. 38 patients were included, 14 underwent carotid-subclavian bypass (CSB), and 24 underwent chimney graft (CG) implantation. Technical success rates were 92.9% and 100% in CSB and CG group. Eleven immediate type I endoleak (EL-I) was detected, including one from CSB group and ten from CG group. Three immediate type II endoleak (EL-II) was detected in CSB group. Perioperative complications showed no difference, but CSB group had longer intensive care unit (ICU) stay time. Median follow-up time was 26.2 months, and overall mortality was 14.3% and 0% in each group. Three EL-I and one EL-II underwent reintervention. All the LSA showed good patency, except one suffered from CG collapse. Both CSB and CG were feasible strategies to preserve the antegrade blood flow of LSA, and each strategy had its advantages and disadvantages. Based on our current experience, we preferred CG for high-risk patients. However, the evidence was still not strong enough, further well-designed studies are necessary to identify the criteria for LSA revascularization strategy during TEVAR.
Collapse
Affiliation(s)
- Yuwei Xiang
- Department of Vascular Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Bin Huang
- Department of Vascular Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Jichun Zhao
- Department of Vascular Surgery, West China Hospital, Sichuan University, Chengdu, China.
| | - Hankui Hu
- Department of Vascular Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Ding Yuan
- Department of Vascular Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Yi Yang
- Department of Vascular Surgery, West China Hospital, Sichuan University, Chengdu, China
| |
Collapse
|
20
|
Joo HC, Youn YN, Ko YG, Choi D, Won JY, Lee DY, Yoo KJ. Comparison of open surgical versus hybrid endovascular repair for descending thoracic aortic aneurysms with distal arch involvement. J Thorac Dis 2018; 10:3548-3557. [PMID: 30069352 DOI: 10.21037/jtd.2018.05.127] [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] [Indexed: 11/06/2022]
Abstract
Background Our aim was to compare the efficacies of conventional open thoracotomy and hybrid endovascular technique in patients with descending thoracic aortic aneurysms involving the distal arch. Methods Between January 2005 and December 2015, 125 consecutive patients with descending aneurysms involving distal arch underwent open repair via thoracotomy (n=79) or zone 1/2 hybrid endovascular repair (n=46). Surgeries entailing total arch replacement by elephant trunk technique (with sternotomy) and Zone 0 hybrid arch repairs were excluded. Early and late outcomes were compared using propensity scores and inverse-probability-of-treatment weighting (IPTW). Results In-hospital mortality rates for open repair (10.1%) and hybrid repair (6.5%) did not differ significantly (P=0.49). Major adverse outcomes included stroke (11.4% vs. 8.7%), paraplegia (2.5% vs. 0.0%) and lung complications (19.0% vs. 6.5%). Once adjusted by IPTW, hospital mortality risk for conventional open repair (OR =4.396; P=0.086) tended to be higher, and there was significant risk of lung complications (OR =4.372; P=0.025). However, both techniques were similar in terms of 30-day mortality (OR =2.745; P=0.257), stroke (OR =2.134; P=0.217), paraplegia (OR =3.639; P=0.407), and midterm survival (OR =1.05; P=0.90). Freedom from reintervention at 10 years was significantly better for open repair (85.2%±7.1%) compared with the hybrid approach (46.3%±11.0%; OR =0.13; P<0.01). Conclusions Hybrid arch repair conferred a significantly lower incidence of pulmonary complications, without benefitting perioperative mortality and stroke. However, open repair proved more reliable, showing greater durability. Long-term investigations are needed to confirm the viability and safety of hybrid repair as an alternative treatment in this setting.
Collapse
Affiliation(s)
- Hyun-Chel Joo
- Division of Cardiovascular Surgery, Department of Thoracic and Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Young-Nam Youn
- Division of Cardiovascular Surgery, Department of Thoracic and Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Young-Guk Ko
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Donghoon Choi
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jong Yun Won
- Division of Radiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Do Yun Lee
- Division of Radiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Kyung-Jong Yoo
- Division of Cardiovascular Surgery, Department of Thoracic and Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| |
Collapse
|
21
|
van Bakel TM, Romarowski RM, Morganti S, van Herwaarden JA, Moll FL, de Beaufort HW, Marrocco-Trischitta MM, Secchi F, Conti M, Auricchio F, Trimarchi S. Blood Flow after Endovascular Repair in the Aortic Arch: A Computational Analysis. AORTA (STAMFORD, CONN.) 2018; 6:81-87. [PMID: 30795032 PMCID: PMC6386644 DOI: 10.1055/s-0039-1683771] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Accepted: 11/05/2018] [Indexed: 01/26/2023]
Abstract
BACKGROUND The benefits of thoracic endovascular aortic repair (TEVAR) have encouraged stent graft deployment more proximally in the aortic arch. This study quantifies the hemodynamic impact of TEVAR in proximal landing zone 2 on the thoracic aorta and the proximal supra-aortic branches. METHODS Patients treated with TEVAR in proximal landing zone 2 having available preoperative and 30-day postoperative computer tomography angiography and phase-contrast magnetic resonance imaging data were retrospectively selected. Blood flow was studied using patient-specific computational fluid dynamics simulations. RESULTS Four patients were included. Following TEVAR in proximal landing zone 2, the mean flow in the left common carotid artery (LCCA) increased almost threefold, from 0.21 (0.12-0.41) L/min to 0.61 (0.24-1.08) L/min (+294%). The surface area of the LCCA had not yet increased commensurately and therefore maximum flow velocity in the LCCA increased from 44.9 (27.0-89.3) cm/s to 72.6 (40.8-135.0) cm/s (+62%). One of the patients presented with Type Ib endoleak at 1-year follow-up. The displacement force in this patient measured 32.1 N and was directed dorsocranial, perpendicular to the distal sealing zone. There was a linear correlation between the surface area of the stent graft and the resulting displacement force (p = 0.04). CONCLUSION TEVAR in proximal landing zone 2 alters blood flow in the supra-aortic branches, resulting in increased flow with high flow velocities in the LCCA. High displacement forces were calculated and related to stent graft migration and Type I endoleak during 1-year follow-up.
Collapse
Affiliation(s)
- Theodorus M. van Bakel
- Thoracic Aortic Research Center, IRCCS—Policlinico San Donato, University of Milan, Milan, Italy
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Rodrigo M. Romarowski
- Thoracic Aortic Research Center, IRCCS—Policlinico San Donato, University of Milan, Milan, Italy
- Department of Civil Engineering and Architecture, University of Pavia, Pavia, Italy
| | - Simone Morganti
- Department of Civil Engineering and Architecture, University of Pavia, Pavia, Italy
| | | | - Frans L. Moll
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Hector W. de Beaufort
- Thoracic Aortic Research Center, IRCCS—Policlinico San Donato, University of Milan, Milan, Italy
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Francesco Secchi
- Department of Radiology, IRCCS—Policlinico San Donato, San Donato Milanese, Italy
| | - Michele Conti
- Department of Civil Engineering and Architecture, University of Pavia, Pavia, Italy
| | - Ferdinando Auricchio
- Department of Civil Engineering and Architecture, University of Pavia, Pavia, Italy
| | - Santi Trimarchi
- Thoracic Aortic Research Center, IRCCS—Policlinico San Donato, University of Milan, Milan, Italy
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
| |
Collapse
|
22
|
Makaloski V, Tsilimparis N, Rohlffs F, Heidemann F, Debus ES, Kölbel T. Endovascular total arch replacement techniques and early results. Ann Cardiothorac Surg 2018; 7:380-388. [PMID: 30155417 DOI: 10.21037/acs.2018.04.02] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
During the last 20 years, a clear shift has been observed towards thoracic endovascular aortic repair for different aortic pathologies. However, total endovascular repair of the aortic arch remains technically demanding. Simultaneous perfusion of all supra-aortic arteries without longer cerebral ischemia time, whilst trying to avoid cerebral embolization, labels endovascular aortic arch repair with highest level of technical difficulty and surgical expertise. The aim of this article is to present an overview of the current technical options for endovascular aortic arch repair and their early results. Currently, early results are reported from four endovascular arch replacement techniques: hybrid repair, total endovascular approach, chimney grafts and in-situ fenestration. The early results of these different arch replacement techniques are promising, especially the total arch replacement with custom-made fenestrated or branched stent-grafts. Long-term results are unknown, and larger series results and comparative studies are needed to determine safety and efficacy.
Collapse
Affiliation(s)
- Vladimir Makaloski
- Department of Vascular Medicine, German Aortic Center, University Heart Center Hamburg-Eppendorf, Hamburg, Germany
| | - Nikolaos Tsilimparis
- Department of Vascular Medicine, German Aortic Center, University Heart Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fiona Rohlffs
- Department of Vascular Medicine, German Aortic Center, University Heart Center Hamburg-Eppendorf, Hamburg, Germany
| | - Franziska Heidemann
- Department of Vascular Medicine, German Aortic Center, University Heart Center Hamburg-Eppendorf, Hamburg, Germany
| | - Eike Sebastian Debus
- Department of Vascular Medicine, German Aortic Center, University Heart Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tilo Kölbel
- Department of Vascular Medicine, German Aortic Center, University Heart Center Hamburg-Eppendorf, Hamburg, Germany
| |
Collapse
|
23
|
Preventza O, Tan CW, Orozco-Sevilla V, Euhus CJ, Coselli JS. Zone zero hybrid arch exclusion versus open total arch replacement. Ann Cardiothorac Surg 2018; 7:372-379. [PMID: 30155416 DOI: 10.21037/acs.2018.04.03] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Open total aortic arch replacement is one of the most technically demanding operations in cardiothoracic surgery, requiring operator expertise and intraoperative and postoperative teamwork. Despite current advancements in the field of open aortic surgery with regard to intraoperative brain protection and postoperative care, the morbidity and mortality associated with open total arch operations varies. Endovascular and hybrid procedures involving the use of zone 0 as a landing zone allow fair comparison between open total arch and hybrid operations. Hybrid procedures involving all of the other landing zones [1-4] should not be compared with open total arch replacement, as the extent of the pathology is different.
Collapse
Affiliation(s)
- Ourania Preventza
- Department of Cardiovascular Surgery, Texas Heart Institute, Houston, TX, USA.,Division of Cardiothoracic Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Corinne W Tan
- Division of Cardiothoracic Surgery, Baylor College of Medicine, Houston, TX, USA
| | | | - Caleb J Euhus
- Division of Cardiothoracic Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Joseph S Coselli
- Department of Cardiovascular Surgery, Texas Heart Institute, Houston, TX, USA.,Division of Cardiothoracic Surgery, Baylor College of Medicine, Houston, TX, USA
| |
Collapse
|
24
|
Chen Y, Zhang S, Liu L, Lu Q, Zhang T, Jing Z. Retrograde Type A Aortic Dissection After Thoracic Endovascular Aortic Repair: A Systematic Review and Meta-Analysis. J Am Heart Assoc 2017; 6:JAHA.116.004649. [PMID: 28939705 PMCID: PMC5634245 DOI: 10.1161/jaha.116.004649] [Citation(s) in RCA: 128] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Retrograde type A aortic dissection (RTAD) is a potentially lethal complication after thoracic endovascular aortic repair (TEVAR). However, data are limited regarding the development of RTAD post‐TEVAR. This systematic review aims to define the incidence, mortality, and potential risk factors of RTAD post‐TEVAR. Methods and Results Multiple electronic searches were performed. Fifty publications with a total of 8969 patients were analyzed. Pooled estimates for incidence and mortality of RTAD were 2.5% (95% confidence interval [CI], 2.0–3.1) and 37.1% (95% CI, 23.7–51.6), respectively. Metaregression analysis evidenced that RTAD rate was associated with hypertension (P=0.043), history of vascular surgery (P=0.042), and American Surgical Association (P=0.044). The relative risk of RTAD was 1.81 (95% CI, 1.04–3.14) for acute dissection (relative to chronic dissection) and 5.33 (95% CI, 2.70–10.51) for aortic dissection (relative to a degenerative aneurysm). Incidence of RTAD was significantly different in patients with proximal bare stent and nonbare stent endografts (relative risk [RR]=2.06; 95% CI, 1.22–3.50). RTAD occurrence rate in zone 0 was higher than other landing zones. Conclusions The pooled RTAD rate after TEVAR was calculated at 2.5% with a high mortality rate (37.1%). Incidence of RTAD is significantly more frequent in patients treated for dissection than those with an aneurysm (especially for acute dissection), and when the proximal bare stent was used. Rate of RTAD after TEVAR varied significantly according to the proximal Ishimaru landing zone. The more‐experienced centers tend to have lower RTAD incidences.
Collapse
Affiliation(s)
- Yanqing Chen
- Division of Vascular Surgery, Changhai Hospital, Shanghai, China.,Military Institute of Vascular Disease, The First Affiliated Hospital of the Second Military Medical University, Shanghai, China
| | - Simeng Zhang
- Division of Vascular Surgery, Changhai Hospital, Shanghai, China.,Military Institute of Vascular Disease, The First Affiliated Hospital of the Second Military Medical University, Shanghai, China
| | - Lei Liu
- Division of Vascular Surgery, Changhai Hospital, Shanghai, China.,Military Institute of Vascular Disease, The First Affiliated Hospital of the Second Military Medical University, Shanghai, China
| | - Qingsheng Lu
- Division of Vascular Surgery, Changhai Hospital, Shanghai, China .,Military Institute of Vascular Disease, The First Affiliated Hospital of the Second Military Medical University, Shanghai, China
| | - Tianyi Zhang
- Department of statistics, The Second Military Medical University, Shanghai, China
| | - Zaiping Jing
- Division of Vascular Surgery, Changhai Hospital, Shanghai, China .,Military Institute of Vascular Disease, The First Affiliated Hospital of the Second Military Medical University, Shanghai, China
| |
Collapse
|
25
|
Voskresensky I, Scali ST, Feezor RJ, Fatima J, Giles KA, Tricarico R, Berceli SA, Beck AW. Outcomes of thoracic endovascular aortic repair using aortic arch chimney stents in high-risk patients. J Vasc Surg 2017; 66:9-20.e3. [PMID: 28216358 DOI: 10.1016/j.jvs.2016.11.063] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Accepted: 11/29/2016] [Indexed: 12/17/2022]
Abstract
BACKGROUND Aortic arch disease is a challenging clinical problem, especially in high-risk patients, in whom open repair can have morbidity and mortality rates of 30% to 40% and 2% to 20%, respectively. Aortic arch chimney (AAC) stents used during thoracic endovascular aortic repair (TEVAR) are a less invasive treatment strategy than open repair, but the current literature is inconclusive about the role of this technology. The focus of this analysis is on our experience with TEVAR and AAC stents. METHODS All TEVAR procedures performed from 2002 to 2015 were reviewed to identify those with AAC stents. Primary end points were technical success and 30-day and 1-year mortality. Secondary end points included complications, reintervention, and endoleak. Technical success was defined as a patient's surviving the index operation with deployment of the AAC stent at the intended treatment zone with no evidence of type I or type III endoleak on initial postoperative imaging. The Kaplan-Meier method was used to estimate survival. RESULTS Twenty-seven patients (age, 69 ± 12 years; male, 70%) were identified, and all were described as being at prohibitive risk for open repair by the treating team. Relevant comorbidity rates were as follows: coronary artery disease/myocardial infarction, 59%; oxygen-dependent emphysema, 30%; preoperative creatinine concentration >1.8 mg/dL, 19%; and congestive heart failure, 15%. Presentations included elective (67%; n = 18), symptomatic (26%; n = 7), and ruptured (7%; n = 2). Eleven patients (41%) had prior endovascular or open arch/descending thoracic repair. Indications were degenerative aneurysm (49%), chronic residual type A dissection with aneurysm (15%), type Ia endoleak after TEVAR (11%), postsurgical pseudoaneurysm (11%), penetrating ulcer (7%), and acute type B dissection (7%). Thirty-two brachiocephalic vessels were treated: innominate (n = 7), left common carotid artery (LCCA; n = 24), and left subclavian artery (n = 1). Five patients (19%) had simultaneous innominate-LCCA chimneys. Brachiocephalic chimney stents were planned in 75% (n = 24), with the remainder placed for either LCCA or innominate artery encroachment (n = 8). Overall technical success was 89% (one intraoperative death, two persistent type Ia endoleaks in follow-up). The 30-day mortality was 4% (n = 1; intraoperative death of a patient with a ruptured arch aneurysm), and median length of stay was 6 (interquartile range, 4-9) days. Seven (26%) patients experienced a major complication (stroke, three [all with unplanned brachiocephalic chimney]; respiratory failure, three; and death, one). Nine (33%) patients underwent aorta-related reintervention, and no chimney occlusion events occurred during follow-up (median follow-up, 9 [interquartile range, 1-23] months). The 1-year and 3-year survival is estimated to be 88% ± 6% and 69% ± 9%, respectively. CONCLUSIONS TEVAR with AAC can be performed with high technical success and acceptable morbidity and mortality in high-risk patients. Unplanned AAC placement during TEVAR results in an elevated stroke risk, which may be related to the branch vessel coverage necessitating AAC placement. Acceptable midterm survival can be anticipated, but aorta-related reintervention is not uncommon, and diligent follow-up is needed.
Collapse
Affiliation(s)
- Igor Voskresensky
- Division of Vascular Surgery and Endovascular Therapy, University of Florida College of Medicine, Gainesville, Fla
| | - Salvatore T Scali
- Division of Vascular Surgery and Endovascular Therapy, University of Florida College of Medicine, Gainesville, Fla.
| | - Robert J Feezor
- Division of Vascular Surgery and Endovascular Therapy, University of Florida College of Medicine, Gainesville, Fla
| | - Javairiah Fatima
- Division of Vascular Surgery and Endovascular Therapy, University of Florida College of Medicine, Gainesville, Fla
| | - Kristina A Giles
- Division of Vascular Surgery and Endovascular Therapy, University of Florida College of Medicine, Gainesville, Fla
| | - Rosamaria Tricarico
- Division of Vascular Surgery and Endovascular Therapy, University of Florida College of Medicine, Gainesville, Fla
| | - Scott A Berceli
- Division of Vascular Surgery and Endovascular Therapy, University of Florida College of Medicine, Gainesville, Fla
| | - Adam W Beck
- Division of Vascular Surgery and Endovascular Therapy, University of Florida College of Medicine, Gainesville, Fla
| |
Collapse
|
26
|
Alonso Pérez M, Llaneza Coto JM, Del Castro Madrazo JA, Fernández Prendes C, González Gay M, Zanabili Al-Sibbai A. Debranching aortic surgery. J Thorac Dis 2017; 9:S465-S477. [PMID: 28616343 DOI: 10.21037/jtd.2017.03.87] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Conventional open surgery still remains as the gold standard of care for aortic arch and thoracoabdominal pathology. In centers of excellence, open repair of the arch has been performed with 5% immediate mortality and a low rate of complications; however overall mortality rates are around 15%, being up to 40% of all patients rejected for treatment due to their age or comorbidities. For thoracoabdominal aortic pathology, data reported from centers of excellence show immediate mortality rates from 5% to 19%, spinal cord ischemia from 2.7% to 13.2%, and renal failure needing dialysis from 4.6% to 5.6%. For these reasons, different alternatives that use endovascular techniques, including debranching procedures, have been developed. The reported results for hybrid debranching procedures are controversial and difficult to interpret because series are retrospective, heterogenic and including a small number of patients. Clearly, an important selection bias exists: debranching procedures are performed in elderly patients with more comorbidities and with thoracoabdominal aortic aneurysms that have more complex and extensive disease. Considering this fact, debranching procedures still remain a useful alternative: for aortic arch pathology debranching techniques can avoid or reduce the time of extracorporeal circulation (ECC) or cardiac arrest which may be beneficial in high-risk patients that otherwise would be rejected for treatment. And compared to pure endovascular techniques, they can be used in emergency cases with applicability in a wide range of anatomies. For thoracoabdominal aortic aneurysms, they are mainly useful when other lesser invasive endovascular options are not feasible due to anatomical limitations or when they are not available in cases where delaying the intervention is not an option.
Collapse
Affiliation(s)
- Manuel Alonso Pérez
- Vascular Surgery Department, Hospital Universitario Central de Asturias, Oviedo, Spain
| | | | | | | | | | | |
Collapse
|
27
|
Serra R, de Franciscis S, Grande R, Butrico L, Perri P, Indolfi C, Mastroroberto P. Endovascular repair for acute traumatic transection of the descending thoracic aorta: experience of a single centre with a 12-years follow up. J Cardiothorac Surg 2015; 10:171. [PMID: 26590963 PMCID: PMC4655082 DOI: 10.1186/s13019-015-0388-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Accepted: 11/18/2015] [Indexed: 11/24/2022] Open
Abstract
Background Most blunt aortic injuries occur in the proximal proximal descending aorta causing acute transection of this vessel. Generally, surgical repair of the ruptured segment of aorta is associated with high rates of morbidity and mortality and in this view endovascular treatment seems to be a valid and safer alternative. Aim of this article is to review our experience with endovascular approach for the treatment of acute traumatic rupture of descending thoracic aorta. Methods From April 2002 to November 2014, 11 patients (9 males and 2 females) were referred to our Department with a diagnosis of acute transection of thoracic aorta. Following preoperative Computed Tomography (CT) evaluation, thoracic endovascular aortic repair (TEVAR) with left subclavian artery coverage was performed. Follow-up consisted clinical and instrumental (CT, Duplex ultrasound) controls at discharge, 1, 3 and 6 months and yearly thereafter. Results At 12-year follow up, the overall survival for the entire patients cohort was 100 %, no major or minor neurological complications and no episode of left arm claudication occurred. Cardiovascular, respiratory and bleeding complications, in the early period, was represented by minor, non fatal events. No stent graft failure, collapse, leak or distal migration were detected at CT scan during the entire follow up period. Conclusions According to our experience, despite the small number of patient population, TEVAR procedure with with left subclavian artery coverage, performed in emergency settings, seems to provide excellent long term results. Trials registration The protocol was registered at a public trials registry, www.clinicaltrials.gov (trial identifier NCT02376998).
Collapse
Affiliation(s)
- Raffaele Serra
- Interuniversity Center of Phlebolymphology (CIFL). International Research and Educational Program in Clinical and Experimental Biotechnology. Headquarters: University Magna Graecia of Catanzaro, Viale Europa, Catanzaro, 88100, Italy. .,Department of Medical and Surgical Sciences, University Magna Graecia of Catanzaro, Viale Europa, Catanzaro, Germaneto, 88100, Italy.
| | - Stefano de Franciscis
- Interuniversity Center of Phlebolymphology (CIFL). International Research and Educational Program in Clinical and Experimental Biotechnology. Headquarters: University Magna Graecia of Catanzaro, Viale Europa, Catanzaro, 88100, Italy. .,Department of Medical and Surgical Sciences, University Magna Graecia of Catanzaro, Viale Europa, Catanzaro, Germaneto, 88100, Italy.
| | - Raffaele Grande
- Department of Medical and Surgical Sciences, University Magna Graecia of Catanzaro, Viale Europa, Catanzaro, Germaneto, 88100, Italy.
| | - Lucia Butrico
- Department of Medical and Surgical Sciences, University Magna Graecia of Catanzaro, Viale Europa, Catanzaro, Germaneto, 88100, Italy.
| | - Paolo Perri
- Department of Medical and Surgical Sciences, University Magna Graecia of Catanzaro, Viale Europa, Catanzaro, Germaneto, 88100, Italy.
| | - Ciro Indolfi
- Department of Medical and Surgical Sciences, University Magna Graecia of Catanzaro, Viale Europa, Catanzaro, Germaneto, 88100, Italy.
| | - Pasquale Mastroroberto
- Department of Experimental and Clinical Medicine, University Magna Graecia of Catanzaro, Viale Europa, Catanzaro, 88100, Italy.
| |
Collapse
|
28
|
Benrashid E, Wang H, Keenan JE, Andersen ND, Meza JM, McCann RL, Hughes GC. Evolving practice pattern changes and outcomes in the era of hybrid aortic arch repair. J Vasc Surg 2015; 63:323-31. [PMID: 26518097 DOI: 10.1016/j.jvs.2015.09.004] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2015] [Accepted: 09/14/2015] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The role of hybrid repair in the management of aortic arch pathology, and long-term outcomes with these techniques, remains uncertain. We report a decade of experience with hybrid arch repair (HAR) and assess institutional practice patterns with regard to the use of hybrid and open techniques. METHODS Hybrid and open total and distal arch procedures performed between July 2005 and January 2015 were identified from a prospectively maintained, institutional aortic surgery database. Perioperative morbidity and mortality, freedom from reintervention, and long-term survival were calculated. Hybrid and open procedural volumes over the study period were assessed to evaluate for potential practice pattern changes. RESULTS During the study period 148 consecutive procedures were performed for repair of transverse and distal aortic arch pathology, including 101 hybrid repairs and 47 open total or distal arch repairs. Patients in the hybrid repair group were significantly older with a greater incidence of chronic kidney disease, peripheral vascular disease, and chronic lung disease. Perioperative mortality and outcomes were not significantly different between the hybrid and open groups, aside from decreased median length of stay after hybrid repair. Need for subsequent reintervention was significantly greater after hybrid repair. Unadjusted long-term survival was superior after open repair (70% 5-year survival open vs 47% hybrid; P = .03), although aorta-specific survival was similar (98% 5-year aorta-specific survival open vs 93% hybrid; P = .59). Institutional use of HAR decreased over the final 3 years of the study, with an associated increased use of open total or distal arch repairs. This was primarily the result of decreased use of native zone 0 hybrid procedures. Concurrent with this apparent increased stringency around patient selection for HAR, perioperative morbidity and mortality was reduced, including avoidance of retrograde type A dissection. CONCLUSIONS HAR remains a viable option for higher-risk patients with transverse arch pathology with perioperative outcomes and long-term aorta-specific survival similar to open repair, albeit at a cost of increased reintervention. This observational single-institution study would suggest decreased use in more recent years in favor of open repair due to avoidance of native zone 0 hybrid procedures. This decline in the institutional use of native zone 0 hybrid repairs was associated with improved perioperative outcomes.
Collapse
Affiliation(s)
- Ehsan Benrashid
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Hanghang Wang
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Jeffrey E Keenan
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Nicholas D Andersen
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - James M Meza
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Richard L McCann
- Division of Vascular Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - G Chad Hughes
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC.
| |
Collapse
|
29
|
Reimer P, Vosshenrich R, Storck M. [Acute aortic diseases. Diagnostic imaging and therapy]. Radiologe 2015; 55:803-15, quiz 816. [PMID: 26336960 DOI: 10.1007/s00117-015-0010-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Diagnostic imaging is crucial in the work-up of acute aortic diseases. Current imaging algorithms enable radiologists differentiating the various entities with subsequent clinically relevant treatment options. Within this educational overview we focus on non-traumatic acute aortic disease. Recent developments of cross sectional imaging are summarized. As for acute aortic disease, we discuss dissections, intramural hematoma, penetrating aortic ulcer, and aortitis. Current treatment options are presented.
Collapse
Affiliation(s)
- P Reimer
- Institut für diagnostische und interventionelle Radiologie, Klinikum Karlsruhe, Moltkestraße 90, 79133, Karlsruhe, Deutschland.
| | - R Vosshenrich
- Praxis für moderne Schnittbild-Diagnostik, Bahnhofsallee 1d, 37081, Göttingen, Deutschland
| | - M Storck
- Klinik für Gefäß- und Thoraxchirurgie, Klinikum Karlsruhe, Moltkestraße 90, 79133, Karlsruhe, Deutschland
| |
Collapse
|
30
|
Matsuyama M, Nakamura K, Nagahama H, Nina K, Endou J, Kojima K, Nishimura M, Ishii H, Yokota A. Long-term results of endovascular repair for distal arch and descending thoracic aortic aneurysms treated by custom-made endografts: usefulness of fenestrated endografts. Ann Vasc Dis 2015; 7:383-92. [PMID: 25593623 DOI: 10.3400/avd.oa.14-00057] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Accepted: 08/14/2014] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVE We evaluated early and long-term results of atherosclerotic aneurysm repair with custom-made endografts. MATERIALS AND METHODS Eighty-one consecutive patients underwent thoracic endovascular aortic repair with custom-made endografts. Fenestrated grafts were used in 37 patients (45.7%) to maintain blood flow of the neck and a landing zone for as long as possible for distal arch or proximal descending aneurysms. The rates of perioperative mortality, stroke, paraplegia, and primary endoleaks were assessed to evaluate in-hospital safety. The rates of endoleak development, survival, and freedom from aortic-related death were assessed to evaluate long-term efficiency. RESULTS Twenty-four patients (29.6%) underwent urgent operations, and 38 (46.9%) underwent distal arch or proximal descending aortic aneurysm repair. There was one case (1.2%) of in-hospital mortality and no cases of stroke. Permanent spinal injury occurred in one patient (1.2%). Early and late endoleaks occurred in one and 16 patients, respectively. The actuarial survival rates were 88.9%, 64.9%, and 51.7% at 1, 5, and 10 years, respectively. The actuarial rates of freedom from endoleaks were 90.1%, 81.3%, and 68.6% at 1, 5, and 10 years, respectively. CONCLUSION Early results of custom-made endografts were excellent, and fenestrated endografts were safe for distal arch and proximal descending aortic aneurysms.
Collapse
Affiliation(s)
- Masakazu Matsuyama
- Department of Cardiovascular, Thoracic and General Surgery, University of Miyazaki, Miyazaki, Miyazaki, Japan
| | - Kunihide Nakamura
- Department of Cardiovascular, Thoracic and General Surgery, University of Miyazaki, Miyazaki, Miyazaki, Japan
| | - Hiroyuki Nagahama
- Department of Cardiovascular, Thoracic and General Surgery, University of Miyazaki, Miyazaki, Miyazaki, Japan
| | - Katsuhiko Nina
- Department of Cardiovascular Surgery, Miyazaki Prefectural Nobeoka Hospital, Nobeoka, Miyazaki, Japan
| | - Jouji Endou
- Department of Cardiovascular, Thoracic and General Surgery, University of Miyazaki, Miyazaki, Miyazaki, Japan
| | - Kazushi Kojima
- Department of Cardiovascular Surgery, Miyazaki Prefectural Nobeoka Hospital, Nobeoka, Miyazaki, Japan
| | - Masanori Nishimura
- Department of Cardiovascular, Thoracic and General Surgery, University of Miyazaki, Miyazaki, Miyazaki, Japan
| | - Hirohito Ishii
- Department of Cardiovascular, Thoracic and General Surgery, University of Miyazaki, Miyazaki, Miyazaki, Japan
| | - Atsuko Yokota
- Department of Cardiovascular Surgery, Miyazaki Prefectural Nobeoka Hospital, Nobeoka, Miyazaki, Japan
| |
Collapse
|
31
|
Lhommet P, Espitalier F, Merlini T, Marchand E, Aupart M, Martinez R. Tolerance of rapid right ventricular pacing during thoracic endovascular aortic repair. Ann Vasc Surg 2015; 29:578-85. [PMID: 25595106 DOI: 10.1016/j.avsg.2014.10.023] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Revised: 08/15/2014] [Accepted: 10/05/2014] [Indexed: 11/19/2022]
Abstract
BACKGROUND The objective of this retrospective study was to evaluate the tolerance of rapid right ventricular pacing (RRVP) compared with that of the traditional methods of hypotension used during thoracic endovascular aortic repair (TEVAR). METHODS From January 2002 to December 2012, we retrospectively included all the patients treated with TEVAR by comparing the 2 groups: patients operated with RRVP (RRVP+) and those operated without RRVP (RRVP-). The characteristics of the population and the procedures were recorded. The rates of complications were compared up to 1 year. RESULTS Sixty-one patients were operated. Treated pathologies were multiple with 19 aneurysms, 14 false aneurysms, 12 isthmic ruptures, 11 dissections, 3 coarctations, and 2 endoleaks. Twenty-four patients were RRVP+ and 37 patients were RRVP-. Mortality rates at 1 month in groups RRVP+ and RRVP- were of 0% and 2.7%, respectively (P = 1), and reintervention rates were 0% and 13.5%, respectively (P = 0.15). Three peroperative rhythm disorders (12.5%) were observed in the RRVP+ group including 2 ventricular fibrillations and 1 atrial fibrillation, both reduced without complications. One pacemaker was implanted for atrioventricular block in the RRVP- group. In the RRVP+ group, 83.3% of the patients presented a rise in troponin Ic (TnI) >0.04 ng/mL in 72 hours compared with 40.5% of the patients in the RRVP- group (P = 0.0013), with a spontaneously favorable evolution. No coronary syndrome was observed at 1 year with a mortality rate of 10.8% in the RRVP- group vs. 0% in the RRVP+ (P = 0.15). CONCLUSIONS In spite of a frequent moderate rise of TnI at the time of RRVP, this technique does not present more complications at 1 year than the use of a chemical hypotension. It thus seems an interesting alternative for selected patients, in trained teams.
Collapse
Affiliation(s)
- Pierre Lhommet
- Department of Thoracic and Cardiovascular Surgery, University Hospital of Tours, Tours, France.
| | - Fabien Espitalier
- Department of Thoracic and Cardiovascular Surgery, University Hospital of Tours, Tours, France
| | - Thierry Merlini
- Department of Thoracic and Cardiovascular Surgery, University Hospital of Tours, Tours, France
| | - Etienne Marchand
- Department of Thoracic and Cardiovascular Surgery, University Hospital of Tours, Tours, France
| | - Michel Aupart
- Department of Thoracic and Cardiovascular Surgery, University Hospital of Tours, Tours, France
| | - Robert Martinez
- Department of Thoracic and Cardiovascular Surgery, University Hospital of Tours, Tours, France
| |
Collapse
|
32
|
Kacila M, Vranic H, Straus S. Extensive Operation as One of the Solution for Patients with the Insufficient Proximal Landing Zone for TEVAR in Aortic Dissection - short term results. Acta Inform Med 2014; 22:356-9. [PMID: 25684839 PMCID: PMC4315638 DOI: 10.5455/aim.2014.22.356-359] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2014] [Accepted: 11/22/2014] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE In our study we wanted to showed the safety, feasibility, efficacy and way how to solve the problems of endovascular repair for aortic dissection with insufficient proximal Landing Zone. METHODS The clinical data of all the patients with insufficient proximal Landing Zone (PLZ) for endovascular repair for aortic aneurism and dissection Stanford type B for the period from October 2013 to June 2014 was prospectively reviewed. According to the classification proposed by Mitchell et al, aortic Zone 0 was involved in 3 cases, Zone 1 in 1 case, Zone 2 in 9 cases and Zone 3 in 6 cases (19 patients in total). A hybrid surgical procedure of supraortic debranching and revascularization, with direct anastomosed truncus brachiocephalicus and left common carotid artery, were performed to obtain an adequate aortic PLZ. Revascularization of the left subclavian artery was carried out on the patient with dissection Stanford type B and short PLZ 2. RESULTS There was no significant difference of risk factors between Zone 0, Zone 1, and Zone 2 (Table 1.), but the length of the PLZ significantly differed between groups (p<0.01) and there is no significant difference in technical and clinical success rate among the groups. CONCLUSION The procedure of extending insufficient PLZ for endovascular repair for aortic arch pathology is feasible and relatively safe. The TEVAR applicability in such aortic disorders could be extended.
Collapse
Affiliation(s)
- Mirsad Kacila
- University Clinical Center University of Sarajevo, Institute for Heart Disease, Sarajevo, Bosnia and Herzegovina
| | - Haris Vranic
- University Clinical Center University of Sarajevo, Institute for Heart Disease, Sarajevo, Bosnia and Herzegovina
| | - Slavenka Straus
- University Clinical Center University of Sarajevo, Institute for Heart Disease, Sarajevo, Bosnia and Herzegovina
| |
Collapse
|
33
|
Abstract
The incidence and operations of thoracic and thoracoabdominal aortic aneurysms have significantly increased. The indications for repair are considered to be a diameter of 6 cm or more and 5.5 cm for patient groups with increased risk of rupture. Complex open surgical repair is associated with significant mortality and complication rates. Total or hybrid endovascular repair seems to reduce early postoperative complications and mortality. The endovascular approach has evolved to be a good and predominant alternative to open repair of these aneurysms for older and high-risk patients as well as for aneurysms with optimal morphological suitability. Notwithstanding, at present a complete paradigm shift from open to endovascular repair for all patients, especially those with complex aneurysms, cannot yet be established.
Collapse
Affiliation(s)
- J Zanow
- Klinik für Allgemein-, Viszeral- und Gefäßchirurgie, Universitätsklinikum Jena, Erlanger Allee 101, 07740, Jena, Deutschland,
| | | |
Collapse
|
34
|
Andersen ND, Keenan JE, Ganapathi AM, Gaca JG, McCann RL, Hughes GC. Current management and outcome of chronic type B aortic dissection: results with open and endovascular repair since the advent of thoracic endografting. Ann Cardiothorac Surg 2014; 3:264-74. [PMID: 24967165 DOI: 10.3978/j.issn.2225-319x.2014.05.07] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Accepted: 05/20/2014] [Indexed: 11/14/2022]
Abstract
BACKGROUND Thoracic endovascular aortic repair (TEVAR) has become the preferred treatment for chronic type B aortic dissection (CTBAD) at our institution. However, it remains incapable of treating all patients with CTBAD. The present study aims to review our contemporary results with open and endovascular CTBAD repairs since the advent of thoracic endografting. METHODS The records of all patients undergoing index repair of CTBAD (chronic DeBakey type IIIA, IIIB and repaired type I) at our institution between June 2005 and December 2013, were retrospectively reviewed. RESULTS A total of 107 patients underwent CTBAD repair, of whom 70% (n=75) underwent endovascular-based procedures [44 TEVAR, 27 hybrid arch and four hybrid thoracoabdominal aortic aneurysm (TAAA) repair] and 30% (n=32) underwent open procedures (nine open descending and 23 open TAAA). Connective tissue disease (CTD), prior aortic surgery and DeBakey dissection type were strongly associated with the choice of operation. The rates of stroke, paraplegia and operative mortality following endovascular-based repairs were 0%, 0% and 4% (n=3), respectively. Adverse neurologic events were higher following open repair, and rates of stroke, paraplegia, and operative mortality were 16% (n=5), 9% (n=3), and 6% (n=2), respectively. However, 1- and 5-year survival rates were similar for endovascular-based repairs (86% and 65%, respectively), and open repairs (88% and 79%, respectively). Over a median follow-up interval of 34 months, the rate of descending aortic reintervention was 24% (n=18) following endovascular-based repairs and 0% following open repairs (P=0.001). Forty-four percent (n=8) of descending aortic reinterventions were required to treat stent graft complications (five endoleak, two stent graft collapse and one stent graft-induced new entry tear) and the remainder were required to treat metachronous pathology (n=2) or progressive aneurysmal disease related to persistent distal fenestrations (n=8). CONCLUSIONS Endovascular repair of CTBAD was associated with excellent procedural and survival outcomes, but at the expense of further reinterventions. Open repair remains relevant for patients who are not candidates for endovascular repair and was associated with higher procedural morbidity but similar overall survival and fewer reinterventions.
Collapse
Affiliation(s)
- Nicholas D Andersen
- 1 Division of Cardiovascular and Thoracic Surgery, 2 Division of Vascular Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Jeffrey E Keenan
- 1 Division of Cardiovascular and Thoracic Surgery, 2 Division of Vascular Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Asvin M Ganapathi
- 1 Division of Cardiovascular and Thoracic Surgery, 2 Division of Vascular Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Jeffrey G Gaca
- 1 Division of Cardiovascular and Thoracic Surgery, 2 Division of Vascular Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Richard L McCann
- 1 Division of Cardiovascular and Thoracic Surgery, 2 Division of Vascular Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - G Chad Hughes
- 1 Division of Cardiovascular and Thoracic Surgery, 2 Division of Vascular Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| |
Collapse
|
35
|
Early outcomes of extra-thoracic debranching thoracic endovascular aortic repair for distal aortic arch disease. J Artif Organs 2014; 17:236-42. [DOI: 10.1007/s10047-014-0774-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2013] [Accepted: 05/19/2014] [Indexed: 10/25/2022]
|
36
|
Dzsinich C, Vaszily M, Vallus G, Berek P, Barta L, Dzsinich M, Darabos G, Nyiri G, Szentpétery L, Pataki T, Nagy G. [Penetrating atheromatous ulcer of the thoracic aorta. Treatment options]. Orv Hetil 2014; 155:461-8. [PMID: 24631934 DOI: 10.1556/oh.2014.29846] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTIONS Atherosclerosis is a generalized degenerative disease of arteries. A rare manifestation of that is the penetrating atheromatous aortic ulceration of the aortic wall which may be complicated by subintimal hematoma, dissection, false aneurysm and rupture (acute aortic syndrome). AIM The aim of the authors was to analyse their experience with this rare disease. METHOD In the department of the authors 10,212 patients underwent surgery for cardiovascular diseases. Among these, 18 patients were diagnosed with penetrating atheromatous aortic ulceration located in the thoracic aorta (ascending aorta 2, aortic arch 8, descending aorta 6 and thoracoabdominal aorta 2 patients). Severe comorbidities were present in the majority of patients. RESULTS Depending on the localisation the authors used various treatment options such as open surgery (4 patients), hybrid techniques (7 patients) and pure endografting (7 patients). One patient died on postoperative day 3. Two patients had late complications due to endoleaks treated successfully by open surgery. CONCLUSIONS The authors conclude that when this dangerous condition detected in time, a wide variety of open, hybrid and endovascular methods can be applied with good results.
Collapse
Affiliation(s)
- Csaba Dzsinich
- MH Egészségügyi Központ Szív-, Ér- és Mellkas-Sebészeti Osztály Budapest Róbert Károly krt. 44. 1133
| | - Miklós Vaszily
- MH Egészségügyi Központ Szív-, Ér- és Mellkas-Sebészeti Osztály Budapest Róbert Károly krt. 44. 1133
| | - Gábor Vallus
- MH Egészségügyi Központ Szív-, Ér- és Mellkas-Sebészeti Osztály Budapest Róbert Károly krt. 44. 1133
| | - Péter Berek
- MH Egészségügyi Központ Szív-, Ér- és Mellkas-Sebészeti Osztály Budapest Róbert Károly krt. 44. 1133
| | - László Barta
- MH Egészségügyi Központ Szív-, Ér- és Mellkas-Sebészeti Osztály Budapest Róbert Károly krt. 44. 1133
| | - Máté Dzsinich
- MH Egészségügyi Központ Szív-, Ér- és Mellkas-Sebészeti Osztály Budapest Róbert Károly krt. 44. 1133
| | - Gábor Darabos
- MH Egészségügyi Központ Szív-, Ér- és Mellkas-Sebészeti Osztály Budapest Róbert Károly krt. 44. 1133
| | - Gabriella Nyiri
- MH Egészségügyi Központ Szív-, Ér- és Mellkas-Sebészeti Osztály Budapest Róbert Károly krt. 44. 1133
| | - László Szentpétery
- MH Egészségügyi Központ Szív-, Ér- és Mellkas-Sebészeti Osztály Budapest Róbert Károly krt. 44. 1133
| | - Tibor Pataki
- MH Egészségügyi Központ Szív-, Ér- és Mellkas-Sebészeti Osztály Budapest Róbert Károly krt. 44. 1133
| | - Gabriella Nagy
- MH Egészségügyi Központ Szív-, Ér- és Mellkas-Sebészeti Osztály Budapest Róbert Károly krt. 44. 1133
| |
Collapse
|
37
|
Lachat M, Mayer D, Pfammatter T, Criado FJ, Rancic Z, Larzon T, Veith FJ, Pecoraro F. Periscope Endograft Technique to Revascularize the Left Subclavian Artery During Thoracic Endovascular Aortic Repair. J Endovasc Ther 2013; 20:728-34. [DOI: 10.1583/13-4884r.1] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
|
38
|
Kong JH, Baek KS, Kwun WH, Kim YH, Kim DS, Kim SW. Two-stage endovascular repair for concurrent penetrating atherosclerotic ulcers of the thoracic and abdominal aorta. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2013; 46:365-8. [PMID: 24175273 PMCID: PMC3810560 DOI: 10.5090/kjtcs.2013.46.5.365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/08/2012] [Revised: 05/14/2013] [Accepted: 05/20/2013] [Indexed: 11/16/2022]
Abstract
We report a case of concurrent saccular aneurysms caused by a penetrating atherosclerotic ulcer of the thoracic and abdominal aorta that were successfully treated by staged endovascular repair. Even though surgical open repair or endovascular repair is the treatment option, use of endovascular repair is now accepted as an alternative treatment to surgery in selected patients. To prevent contrast medium-induced nephropathy and spinal cord ischemia caused by a simultaneous endovascular procedure, a saccular aneurysm of the descending thoracic aorta was excluded by stent graft, followed by the placement of a bifurcated stent graft in the infrarenal abdominal aorta one month later.
Collapse
Affiliation(s)
- Joon Hyuk Kong
- Department of Thoracic and Cardiovascular Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Korea
| | | | | | | | | | | |
Collapse
|
39
|
Andersen ND, Williams JB, Hanna JM, Shah AA, McCann RL, Hughes GC. Results with an algorithmic approach to hybrid repair of the aortic arch. J Vasc Surg 2012. [PMID: 23186868 DOI: 10.1016/j.jvs.2012.09.039] [Citation(s) in RCA: 90] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Hybrid repair of the transverse aortic arch may allow for aortic arch repair with reduced morbidity in patients who are suboptimal candidates for conventional open surgery. We present our results with an algorithmic approach to hybrid arch repair, based on the extent of aortic disease and patient comorbidities. METHODS Between August 2005 and January 2012, 87 patients underwent hybrid arch repair by three principal procedures: zone 1 endograft coverage with extra-anatomic left carotid revascularization (zone 1; n = 19), zone 0 endograft coverage with aortic arch debranching (zone 0; n = 48), or total arch replacement with staged stented elephant trunk completion (stented elephant trunk; n = 20). RESULTS The mean patient age was 64 years, and the mean expected in-hospital mortality rate was 16.3% as calculated by the EuroSCORE II. Of operations, 22% (n = 19) were nonelective. Sternotomy, cardiopulmonary bypass, and deep hypothermic circulatory arrest were required in 78% (n = 68), 45% (n = 39), and 31% (n = 27) of patients to allow for total arch replacement, arch debranching, or other concomitant cardiac procedures, including ascending with or without hemiarch replacement in 17% (n = 8) of patients undergoing zone 0 repair. All stented elephant trunk procedures (n = 20) and 19% (n = 9) of zone 0 procedures were staged, with 41% (n = 12) of patients undergoing staged repair during a single hospitalization. The 30-day/in-hospital rates of stroke and permanent paraplegia or paraparesis were 4.6% (n = 4) and 1.2% (n = 1). Of 27 patients with native ascending aorta zone 0 proximal landing zone, three (11.1%) experienced retrograde type A dissection after endograft placement. The overall in-hospital mortality rate was 5.7% (n = 5); however, 30-day/in-hospital mortality increased to 14.9% (n = 13) owing to eight 30-day out-of-hospital deaths. Native ascending aorta zone 0 endograft placement was found to be the only univariate predictor of 30-day in-hospital mortality (odds ratio, 4.63; 95% confidence interval, 1.35-15.89; P = .02). Over a mean follow-up period of 28.5 ± 22.2 months, 13% (n = 11) of patients required reintervention for type 1A (n = 4), type 2 (n = 6), or type 3 (n = 1) endoleak. Kaplan-Meier estimates of survival at 1 year, 3 years, and 5 years were 73%, 60%, and 51%. CONCLUSIONS Hybrid aortic arch repair can be tailored to patient anatomy and comorbid status to allow complete repair of aortic pathology, frequently in a single stage, with acceptable outcomes. However, endograft placement in the native ascending aorta is associated with high rates of retrograde type A dissection and 30-day/in-hospital mortality and should be approached with caution.
Collapse
Affiliation(s)
- Nicholas D Andersen
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | | | | | | | | | | |
Collapse
|
40
|
Canaud L, Demaria R, Joyeux F, Hireche K, Berthet JP, D’Annoville T, Marty-Ané C, Alric P. Endoluminal Treatment of Dissecting Aortic Arch Aneurysm After Surgical Treatment of Acute Type A Dissection. Ann Vasc Surg 2012; 26:715-9. [DOI: 10.1016/j.avsg.2011.11.035] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2010] [Revised: 06/18/2011] [Accepted: 11/26/2011] [Indexed: 10/28/2022]
|
41
|
Alric P, Canaud L, Branchereau P, Marty-Ane C. Traitement endovasculaire des anévrismes de l’aorte thoracique descendante. ACTA ACUST UNITED AC 2012. [DOI: 10.1016/s0246-0459(12)43886-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
|
42
|
Ferrero E, Ferri M, Viazzo A, Robaldo A, Zingarelli E, Sansone F, Casabona R, Nessi F. Is total debranching a safe procedure for extensive aortic-arch disease? A single experience of 27 cases. Eur J Cardiothorac Surg 2012; 41:177-82. [PMID: 21820909 DOI: 10.1016/j.ejcts.2011.05.058] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Thoracic, arch, and proximal descending thoracic aorta diseases are still considered an enormous challenge. The hybrid approach developed in recent years (supra-aortic trunks debranching and thoracic endovascular repair aortic repair; TEVAR) may improve the morbidity and mortality of the population at risk. The aim of this study was to analyze retrospectively our experience in the hybrid treatment of aortic-arch aneurysms and dissections. METHOD We carried out a retrospective review of 27 patients who required a surgical debranching of the supra-aortic trunks and a TEVAR in the management of the aortic arch and proximal descending thoracic aortic disease. The aortic lesions included 18 degenerative arch-aortic aneurysms, four complicated aortic dissections, two subclavian artery aneurysms, and three penetrating atherosclerotic ulcers. Technical success was achieved in all patients. RESULTS The 30-day mortality rate was 11.1% (3/27). Mean follow-up was 16.7 months (range, 1-56), and the survival rate was 77.8%. The endoleaks' rate was 3.7% (1/27), due to a stent-graft migration. CONCLUSION Hybrid approaches may represent an alternative option in the treatment of complex aortic lesions involving the arch and the proximal descending thoracic aorta in high-risk patients and emergency cases. However, the promising early results need to be confirmed by longer follow-up and larger comparative series.
Collapse
Affiliation(s)
- Emanuele Ferrero
- Vascular and Endovascular Surgery Unit, Mauriziano Umberto I Hospital, Largo Turati 62, 10128 Turin, Italy.
| | | | | | | | | | | | | | | |
Collapse
|
43
|
Stanley BM, Mylankal KJ, Tibballs J, Bond R, Hartley D. Branch thoracic stent graft repair for arch aneurysm. ANZ J Surg 2012; 82:348-51. [DOI: 10.1111/j.1445-2197.2012.06024.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
44
|
Retrograde ascending aortic dissection as an early complication of thoracic endovascular aortic repair. J Vasc Surg 2012; 55:1255-62. [PMID: 22265798 DOI: 10.1016/j.jvs.2011.11.063] [Citation(s) in RCA: 109] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2011] [Revised: 09/22/2011] [Accepted: 11/12/2011] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Retrograde ascending aortic dissection (rAAD) is a potential complication of thoracic endovascular aortic repair (TEVAR), yet little data exist regarding its occurrence. This study examines the incidence, etiology, and outcome of this event. METHODS A prospective institutional database was used to identify cases of acute rAAD following TEVAR from a cohort of 309 consecutive procedures from March 2005 (date of initial Food and Drug Administration approval) to September 2010. The database was analyzed for the complication of rAAD as well as relevant patient and operative variables. RESULTS The incidence of rAAD was 1.9% (6/309); all cases occurred with proximal landing zone in the ascending aorta and/or arch (zones 0-2). All were identified in the perioperative period (range, 0-6 days) with 33% (2/6) 30-day/in-hospital mortality. Eighty-three percent (5/6) underwent emergent repair; one patient died without repair. rAAD patients were similar to the non-rAAD group (n = 303) across pertinent variables, including age, gender, race, and device size (all P > .1). rAAD incidence by aortic pathology was 1.0% (2/200) for aneurysm, 4.4% (4/91) for dissection, and 0% (0/18) for transection; P = .08. rAAD incidence by device was TAG (Gore) 1.0% (2/205), Talent (Medtronic) 4.7% (2/43), and Zenith TX2 (Cook) 3.6% (2/55). rAAD incidence was observed to be higher among patients with an ascending aortic diameter ≥ 4.0 cm (4.8% vs 0.9% for ascending diameter <4.0 cm); P = .047. Incidence was also higher with proximal landing zone in the native ascending aorta (zone 0) 6.9% (2/29) versus 1.4% for all others (4/280); P = .101. For patients with dissection pathology and an ascending aortic diameter ≥ 4.0 cm, 11% (3/28) suffered rAAD; with the combination of native ascending aorta (zone 0) landing zone measuring ≥ 4.0 cm, the incidence was 25% (2/8). Definitive diagnosis was by computed tomography angiography (n = 1), intraoperative transesophageal echocardiography (n = 3), intraoperative arteriography (n = 1), or postmortem autopsy (n = 1). CONCLUSIONS rAAD is a lethal early complication of TEVAR, which may be more common when treating dissection, with devices utilizing proximal bare springs or barbs for fixation, with native zone 0 proximal landing zone and with ascending aortic diameter ≥ 4 cm. Combinations of these risk factors may be particularly high risk. Intraoperative imaging assessment of the ascending aorta should be conducted following TEVAR to avoid under-recognition. National database reporting of this complication is needed to ensure safety and proper application of emerging TEVAR technology.
Collapse
|
45
|
Valente T, Rossi G, Lassandro F, Rea G, Marino M, Dialetto G, Muto R, Scaglione M. Unusual complications of endovascular repair of the thoracic aorta: MDCT findings. Radiol Med 2012; 117:831-54. [PMID: 22228128 DOI: 10.1007/s11547-011-0771-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2011] [Accepted: 06/20/2011] [Indexed: 11/26/2022]
Abstract
With the development of minimally invasive surgical techniques, endovascular stent-graft placement has become an accepted and widely used alternative to the traditional surgical repair of aortic disease and is gaining acceptance as the treatment of choice. Many studies show that endovascular stent-graft therapy is safe and effective, although complications related to this treatment are also recognised. Although the incidence of major complication is low, neurological sequelae remain the major concern of endovascular repair. With growing experience, however, the spectrum of mid- and long-term complications has broadened to include potentially disastrous events, other than paraplegia or stroke, that require diligent surveillance. Three-dimensional data sets acquired quickly by multidetector computed tomography (MDCT) allow multiplanar reformations and 3D viewing, as well as quantitative assessment of vessel lumens, walls and surroundings. Although a large portion of radiologists will not be involved in the actual endograft deployment, many will be involved in the interpretation of postprocedural surveillance studies. Accordingly, the goal of this report is to summarise our experience with the presentation, diagnostic approach, management and outcomes of these unusual, but potentially catastrophic, postendovascular aortic repair complications to highlight their significance and increase familiarity with them among the imaging community. Increasing awareness of these complications may facilitate rapid diagnosis and/or triage and treatment.
Collapse
Affiliation(s)
- T Valente
- Dipartimento di Diagnostica per Immagini, Servizio di Radiologia, A.O.R.N. Monaldi, 80131, Napoli, Italy
| | | | | | | | | | | | | | | |
Collapse
|
46
|
Elephant trunk procedure 27 years after Borst: what remains and what is new? Eur J Cardiothorac Surg 2011; 40:1-11. [PMID: 21388822 DOI: 10.1016/j.ejcts.2011.01.062] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2010] [Revised: 01/24/2011] [Accepted: 01/27/2011] [Indexed: 11/21/2022] Open
|
47
|
Ueda T, Fleischmann D, Dake MD, Rubin GD, Sze DY. Incomplete endograft apposition to the aortic arch: bird-beak configuration increases risk of endoleak formation after thoracic endovascular aortic repair. Radiology 2010; 255:645-52. [PMID: 20413775 DOI: 10.1148/radiol.10091468] [Citation(s) in RCA: 131] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To determine the clinical importance of the bird-beak configuration after thoracic endovascular aortic repair (TEVAR). MATERIALS AND METHODS The institutional review board approved this retrospective study and waived the requirement to obtain informed consent from patients. Sixty-four patients (40 men, 24 women; mean age, 64 years) who underwent TEVAR were evaluated. The treated diseases included dissection (n = 29), degenerative aneurysm (n = 13), acute traumatic transection (n = 8), pseudoaneurysm (n = 4), penetrating aortic ulcer (n = 6), intramural hematoma (n = 2), and mycotic aneurysm (n = 2). Bird-beak configuration, defined as the incomplete apposition of the proximal endograft with a wedge-shaped gap between the device and the aortic wall, was assessed with postprocedural CT angiography. The presence and length of the bird-beak configuration were compared with the formation of endoleaks and adverse clinical events. RESULTS Endoleaks were detected in 26 (40%) of the 64 patients, including 14 with type Ia endoleak formation, one with type Ib endoleak formation, six with type II endoleak formation (from the left subclavian artery), two with type IIo endoleak formation (from other arteries), and three with type III endoleak formation. Bird-beak configuration was observed in 28 (44%) of 64 patients and correlated significantly with the risk of developing a type Ia or IIa endoleak (P < .01). Mean bird-beak length was significantly longer (P < .01) in patients with a type Ia or II endoleak (mean length, 14.3 and 13.9 mm, respectively) than in patients without endoleaks (mean length, 8.4 mm). Adverse events included early aortic-related death in three patients, additional treatment for endoleak in eight patients, and stent-graft collapse or infolding in six patients. CONCLUSION Detection of bird-beak configuration is helpful in the prediction of adverse clinical events after TEVAR.
Collapse
Affiliation(s)
- Takuya Ueda
- Department of Radiology, Stanford University School of Medicine, 300 Pasteur Dr, Room S-072, Stanford, CA 94305, USA.
| | | | | | | | | |
Collapse
|
48
|
Criado FJ. Mapping the Aorta: A New Look at Vascular Anatomy in the Era of Endograft Repair. J Endovasc Ther 2010; 17:68-72. [DOI: 10.1583/09-2967.1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
|
49
|
Yuan L, Feng X, Jing Z. Endovascular Repair of a Thoracic Arch Aneurysm With a Fenestrated Stent-Graft. J Endovasc Ther 2008; 15:539-43. [DOI: 10.1583/07-2111.1] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
|
50
|
Canaud L, Alric P, Laurent M, Baum TP, Branchereau P, Marty-Ané CH, Berthet JP. Proximal Fixation of Thoracic Stent-Grafts as a Function of Oversizing and Increasing Aortic Arch Angulation in Human Cadaveric Aortas. J Endovasc Ther 2008; 15:326-34. [DOI: 10.1583/08-2425.1] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
|