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Kupferthaler A, Hauck SR, Schwarz M, Kern M, Deinsberger J, Dachs TM, Neumayer C, Stelzmüller ME, Ehrlich M, Loewe C, Funovics MA. Endovascular Repair of Penetrating Thoracic Aortic Ulcers Using Tubular Stent Grafts Versus Stent Grafts With a Proximal Scallop. J Endovasc Ther 2024; 31:821-830. [PMID: 36680393 DOI: 10.1177/15266028221149919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
PURPOSE In penetrating aortic ulcers (PAUs), limited data support tubular thoracic endovascular aortic repair (TEVAR) as a viable treatment option. For treatment of more proximal PAUs, hybrid approaches and-more recently-scalloped TEVAR (scTEVAR) have been advocated. Outcomes of scTEVAR specifically for PAUs have not yet been reported. This study reports long-term outcomes for tubular and scTEVAR in PAUs and compares the safety profile in both cohorts regarding the significantly more proximal landing zone (LZ) for scTEVAR. MATERIALS AND METHODS This single-center retrospective cohort study includes all nonacute patients treated for complicated PAU with scTEVAR and tubular TEVAR. Patient and PAU characteristics as well as procedural success, complication and reintervention rates, and all-cause and aortic mortality were analyzed. RESULTS Of 212 TEVAR procedures reviewed, 21 patients with tubular TEVAR and 19 patients with scTEVAR were included. Patient and PAU characteristics were similar, and LZ was significantly more proximal in the scTEVAR cohort (p=0.0001), with similar number and types of supra-aortic revascularization procedures. Clinical success was reached in all 40 patients (100%), and reintervention rate was 2/21 (9.5%) and 1/19 (5.3%), respectively. Over the mean follow-up of 63 (TEVAR) and 53 (scTEVAR) months, clinical success was stable in all patients with one (abdominal) aortic-related mortality in the scTEVAR cohort. CONCLUSION Treatment of complicated PAUs with TEVAR as well as scTEVAR provides excellent and similar clinical success, stability of clinical success, and aortic survival with acceptable complication and reintervention rates. Scalloped TEVAR safely lengthens the proximal sealing zone to address more proximal pathologies. CLINICAL IMPACT Treatment of asymptomatic complicated penetrating aortic ulcers (PAUs) with thoracic endovascular aortic repair (TEVAR) provides excellent clinical success and acceptable complication and reintervention rates. More patients become amenable to endovascular treatment by including scalloped TEVAR (scTEVAR) as a means to safely lengthen the proximal sealing zone to address more proximal pathologies.
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Affiliation(s)
- Alexander Kupferthaler
- Division of Cardiovascular and Interventional Radiology, Department of Biomedical Imaging and Image-guided Therapy, Vienna General Hospital, Medical University of Vienna, Vienna, Austria
- Department of Diagnostic and Interventional Radiology, Ordensklinikum Linz, Linz, Austria
- Medical Faculty, Johannes Kepler University Linz, Linz, Austria
| | - Sven R Hauck
- Division of Cardiovascular and Interventional Radiology, Department of Biomedical Imaging and Image-guided Therapy, Vienna General Hospital, Medical University of Vienna, Vienna, Austria
| | - Michael Schwarz
- Division of Cardiovascular and Interventional Radiology, Department of Biomedical Imaging and Image-guided Therapy, Vienna General Hospital, Medical University of Vienna, Vienna, Austria
- Institute of Medical Radiology, Diagnostic, Intervention, University Hospital St. Pölten, Karl Landsteiner University of Health Sciences, St. Pölten, Austria
| | - Maximilian Kern
- Department of Radiology, Klinik Floridsdorf, Vienna, Austria
| | - Julia Deinsberger
- Department of Dermatology, Medical University of Vienna, Vienna, Austria
| | - Theresa-Marie Dachs
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Christoph Neumayer
- Division of Vascular Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | | | - Marek Ehrlich
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Christian Loewe
- Division of Cardiovascular and Interventional Radiology, Department of Biomedical Imaging and Image-guided Therapy, Vienna General Hospital, Medical University of Vienna, Vienna, Austria
| | - Martin A Funovics
- Division of Cardiovascular and Interventional Radiology, Department of Biomedical Imaging and Image-guided Therapy, Vienna General Hospital, Medical University of Vienna, Vienna, Austria
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Gallitto E, Faggioli G, Spath P, Ancetti S, Pini R, Logiacco A, Palermo S, Gargiulo M. Midterm results of complicated penetrating abdominal aortic ulcer treated by aortobi-iliac endograft and embolization. J Vasc Surg 2023; 77:106-113.e2. [PMID: 35944729 DOI: 10.1016/j.jvs.2022.07.181] [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: 05/07/2022] [Revised: 07/10/2022] [Accepted: 07/28/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND Penetrating aortic ulcer (PAU) is determined by atherosclerotic degeneration of the tunica media with disruption of the intima. Usually it is detected in the thoracic aorta, with few series describing an abdominal location. The aim of the study was to report early and late outcomes of the endovascular repair of complicated infrarenal abdominal PAU (a-PAU) by aortobi-iliac endograft and embolization. METHODS Data from all complicated a-PAU submitted to endovascular repair by aortobi-iliac endograft (Cook-Zenith Alpha) between 2016 and 2021 (February) were analyzed. The a-PAU coil embolization was performed to decrease the risk of persistent type II endoleak whenever possible. Complicated a-PAU were defined according with the presence of symptoms, aortic rupture, or saccular or pseudo-aneurysm. Technical success, 30-day morbidity and mortality, and reinterventions were assessed as early outcomes. Survival, endoleaks, and freedom from reinterventions were evaluated during follow-up. RESULTS Of 1153 endovascular aortic procedures, 45 cases (4%) of complicated a-PAU were identified. Fourteen cases (31%) were managed in urgent setting (symptoms, n = 10 [22%]; shock, n = 4 [9%]). The median diameter of a-PAU was 49 mm (interquartile range, 14 mm). Thirteen patients (29%) had severe femoral or iliac access (angle >90°, circumferential calcification [>50%], hemodynamic iliac stenosis or obstruction, an external iliac artery diameter of less than 7 mm, or a previous femoral surgical graft). The a-PAU embolization was performed in 30 cases (67%). Technical success was achieved in all patients. Postoperative cardiac, pulmonary and renal morbidity occurred in one (2%), two (4%), and eight (18%) patients, respectively. Two patients (4%) required reintervention within 30 days for access related complications. The 30-day mortality was 2%. At a median follow-up of 24 months (interquartile range, 18 months), no type I or III endoleaks, iliac leg occlusion, or graft infection occurred and no patient required late reinterventions; the 36-month survival rate was 72%. No a-PAU enlarged or ruptured during follow-up. CONCLUSIONS Endovascular repair of complicated a-PAU by a low-profile aortobi-iliac endograft and embolization is safe and effective. Excellent technical results are reported even in challenging anatomic features. Midterm clinical results are satisfactory in terms of aortic-related complications or mortality, freedom from reintervention, and survival.
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Affiliation(s)
- Enrico Gallitto
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, IRCCS Sant'Orsola-Malpighi Hospital, Bologna, Italy.
| | - Gianluca Faggioli
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, IRCCS Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - Paolo Spath
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, IRCCS Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - Stefano Ancetti
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, IRCCS Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - Rodolfo Pini
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, IRCCS Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - Antonino Logiacco
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, IRCCS Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - Sergio Palermo
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, IRCCS Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - Mauro Gargiulo
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, IRCCS Sant'Orsola-Malpighi Hospital, Bologna, Italy
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Mandigers TJ, Lomazzi C, Domanin M, Piffaretti G, van Herwaarden JA, Trimarchi S. Vascular Access Challenges in Thoracic Endovascular Aortic Repair: A Literature Review. Ann Vasc Surg 2022. [PMID: 37534575 DOI: 10.1016/j.avsg.2022.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND This review aims to comprehensively summarize access challenges in thoracic endovascular aortic repair (TEVAR) by describing vascular access routes, associated risks, outcomes, and complications. METHODS A literature search was conducted utilizing the PubMed (Medline), Scopus, and Web of Science databases. Qualitative and quantitative data from selected studies are extracted and discussed according to available standards for narrative reviews. RESULTS In total, there were 109 eligible studies based on predefined inclusion- and exclusion criteria. There were 39 original articles or reviews and 57 case series or case reports. This article summarizes the evidence from these studies and discusses traditional retrograde access routes and techniques for TEVAR via a femoral or iliac route, with or without the use of conduits. Next, alternative antegrade access routes and techniques via a brachial, axillary, carotid, ascending aorta, transapical, transcaval, or another route are discussed. Vascular access complications are presented with specific attention to the importance of gender and alternative antegrade access routes. CONCLUSIONS Multiple access routes and techniques are currently available to overcome access challenges associated with TEVAR, based on low grade evidence from heterogeneous studies. Future research that compares different access routes and techniques might help in the development of a tailored access protocol for specific patients with challenging TEVAR access.
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Wang S, Liu D, Li Y, Gao B. Transthoracic minimally invasive closure for the treatment of arch penetrating aortic ulcer: a case report. J Cardiothorac Surg 2021; 16:285. [PMID: 34627316 PMCID: PMC8501624 DOI: 10.1186/s13019-021-01659-9] [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: 12/08/2020] [Accepted: 09/19/2021] [Indexed: 11/24/2022] Open
Abstract
Penetrating aortic ulcer (PAU) is one of the three subtypes of acute aortic syndrome. PAUs occur at any point throughout the aorta, most commonly in the descending thoracic aorta and less frequently in the aortic arch. Open surgical repair and total/hybrid endovascular repair are currently available to treat aortic arch PAUs. Herein, we present a patient with aortic arch PAU who underwent transthoracic minimally invasive closure, which is a novel method for the treatment of PAU. We describe a 52-year old Asian man who presented with sudden chest and back pain for 8 h. Computed tomography angiography showed that the PAU occurred in the aortic arch and had a diameter of 16 mm and a depth of 6 mm. The opening was successfully closed via transthoracic minimally invasive closure with an atrial septal defect occluder.
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Affiliation(s)
- Shixiong Wang
- Department of Cardiac Surgery, Lanzhou University Second Hospital, No. 82 Cuiyingmen, Lanzhou, 730030, Gansu, People's Republic of China
| | - Debin Liu
- Department of Cardiac Surgery, Lanzhou University Second Hospital, No. 82 Cuiyingmen, Lanzhou, 730030, Gansu, People's Republic of China
| | - Yongnan Li
- Department of Cardiac Surgery, Lanzhou University Second Hospital, No. 82 Cuiyingmen, Lanzhou, 730030, Gansu, People's Republic of China
| | - Bingren Gao
- Department of Cardiac Surgery, Lanzhou University Second Hospital, No. 82 Cuiyingmen, Lanzhou, 730030, Gansu, People's Republic of China.
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Kreibich M, Kremer J, Vötsch A, Berger T, Farag M, Winkler A, Siepe M, Karck M, Beyersdorf F, Rylski B, Czerny M, Gottardi R. Multicentre experience with the frozen elephant trunk technique to treat penetrating aortic ulcers involving the aortic arch. Eur J Cardiothorac Surg 2021; 59:1238-1244. [PMID: 33517361 DOI: 10.1093/ejcts/ezaa480] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 11/12/2020] [Accepted: 11/30/2020] [Indexed: 01/16/2023] Open
Abstract
OBJECTIVES Our goal was to evaluate the use of the frozen elephant trunk (FET) technique for the treatment of penetrating aortic ulcers involving the aortic arch. METHODS Between January 2008 and January 2020, a total of 34 patients had the FET technique at 3 aortic centres. The indication for the FET technique was unsuitability for thoracic endovascular aortic repair due to the lack of a sufficient proximal landing zone even after supra-aortic rerouting (subclavian transposition, double transposition), ectasia of the ascending aorta/aortic arch (>40 mm) and/or a shaggy proximal thoracic aorta. RESULTS Additional cardiac procedures were performed in 14 patients (41%), and the beating heart technique was used in 7 patients (21%). Perioperative mortality was 18% (n = 6); 3 of these patients had a major stroke (9%). No case of spinal cord ischaemia was observed, and 2 patients (6%) developed a non-disabling stroke. After a median follow-up of 7 (first quartile: 1; third quartile 29) months, 2 patients (6%) died (1 of malignant disease and 1 of an unclear cause); 10 additional aortic interventions in all aortic segments (29%; endovascular: n = 8 [24%] and conventional surgical: n = 2 [6%]) were performed in 8 patients. CONCLUSIONS The FET technique is a good treatment option for patients with penetrating aortic ulcers involving the aortic arch unsuitable for thoracic endovascular aortic repair. However, the high obliterative atherosclerotic load in these patients is accompanied by an un-neglectable risk of perioperative neurological injury. Concomitant cardiac surgical procedures are frequently needed. Patients commonly require secondary aortic procedures in all aortic segments, emphasizing the need for thorough primary conceptual planning and stringent follow-up.
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Affiliation(s)
- Maximilian Kreibich
- Department of Cardiovascular Surgery, Heart Centre Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Jamila Kremer
- Department of Cardiac Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Andreas Vötsch
- Department of Cardiac Surgery, Paracelsus Medical University, Salzburg, Austria
| | - Tim Berger
- Department of Cardiovascular Surgery, Heart Centre Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Mina Farag
- Department of Cardiac Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Andreas Winkler
- Department of Cardiac Surgery, Paracelsus Medical University, Salzburg, Austria
| | - Matthias Siepe
- Department of Cardiovascular Surgery, Heart Centre Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Matthias Karck
- Department of Cardiac Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Friedhelm Beyersdorf
- Department of Cardiovascular Surgery, Heart Centre Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Bartosz Rylski
- Department of Cardiovascular Surgery, Heart Centre Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Martin Czerny
- Department of Cardiovascular Surgery, Heart Centre Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Roman Gottardi
- Department of Cardiac Surgery, Paracelsus Medical University, Salzburg, Austria
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Czerny M, Berger T, Kondov S, Siepe M, Saint Lebes B, Mokrane F, Rousseau H, Lescan M, Schlensak C, Andic M, Hazenberg C, Bloemert-Tuin T, Braithwaite S, van Herwaarden J, Hyhlik-Dürr A, Gosslau Y, Pedro LM, Amorim P, Kuratani T, Cheng S, Heijmen R, van der Weijde E, Pleban E, Szopiński P, Rylski B. Results of endovascular aortic arch repair using the Relay Branch system. Eur J Cardiothorac Surg 2021; 60:662-668. [PMID: 33956958 DOI: 10.1093/ejcts/ezab160] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 02/10/2021] [Accepted: 02/14/2021] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVES Our goal was to evaluate results of endovascular aortic arch repair using the Relay Branch system. METHODS Forty-three patients with thoracic aortic pathology involving the aortic arch have been treated with the Relay Branch system (Terumo Aortic, Sunrise, FL, USA) in 10 centres. We assessed in-hospital mortality, neurological injury, treatment success according to current reporting standards and the need for secondary interventions. In addition, outcome was analysed according to the underlying pathology: non-dissective disease versus residual aortic dissection (RAD) (defined as remaining dissection after previous type A repair, chronic type B aortic dissections). RESULTS In-hospital mortality was 9% (0% in patients with RAD). Disabling stroke occurred in 7% (0% in patients with RAD); non-disabling stroke occurred in 19% (7% in patients with RAD). Early type IA and B endoleak formation occurred in 4%. Median follow-up was 16 ± 18 months. During the follow-up period, 23% of the patients died. Aortic-related deaths were low (3% in patients with RAD). CONCLUSIONS The results of endovascular aortic arch repair using the Relay Branch system in a selected patient population with regard to technical success are good. In-hospital mortality is acceptable, the number of disabling strokes is low and technical success is high. Non-disabling stroke is a major concern, and every effort has to be taken to reduce this to a minimum. The best outcome is seen in patients with underlying RAD. Finally, more data are needed.
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Affiliation(s)
- Martin Czerny
- Department of Cardiovascular Surgery, University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany
| | - Tim Berger
- Department of Cardiovascular Surgery, University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany
| | - Stoyan Kondov
- Department of Cardiovascular Surgery, University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany
| | - Matthias Siepe
- Department of Cardiovascular Surgery, University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany
| | | | | | | | - Mario Lescan
- Department of Cardio-Thoracic and Vascular Surgery, University of Tübingen, Germany
| | - Christian Schlensak
- Department of Cardio-Thoracic and Vascular Surgery, University of Tübingen, Germany
| | - Mateja Andic
- Department of Cardio-Thoracic and Vascular Surgery, University of Tübingen, Germany
| | - Constatijn Hazenberg
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, Netherlands
| | | | - Sue Braithwaite
- Department of Anesthesiology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Joost van Herwaarden
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, Netherlands
| | | | - Yvonne Gosslau
- Department of Vascular Surgery, University Clinic Augsburg, Germany
| | - Luís Mendes Pedro
- Department of Vascular Surgery, Hospital de Santa Maria, Lisbon, Portugal
| | - Pedro Amorim
- Department of Vascular Surgery, Hospital de Santa Maria, Lisbon, Portugal
| | - Toru Kuratani
- Department of Minimally Invasive Cardiovascular Medicine, Osaka University, Osaka, Japan
| | - Stephen Cheng
- Division of Vascular Surgery, University of Hong Kong, Hong Kong
| | - Robin Heijmen
- Department of Cardiothoracic Surgery, St. Antonius Hospital, Nieuwegein, Netherlands
| | - Emma van der Weijde
- Department of Cardiothoracic Surgery, St. Antonius Hospital, Nieuwegein, Netherlands
| | - Eliza Pleban
- Department of Vascular Surgery, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | - Piotr Szopiński
- Department of Vascular Surgery, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | - Bartosz Rylski
- Department of Cardiovascular Surgery, University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany
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Ren C, Wang S, Sun L, Xu S, Lai Y. Analysis of clinical outcomes of one-staged hybrid procedure without thoracotomy for aorta lesion involving distal aortic arch. J Card Surg 2021; 36:1313-1319. [PMID: 33522664 DOI: 10.1111/jocs.15391] [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: 11/05/2020] [Revised: 01/16/2021] [Accepted: 01/18/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND This study aimed to evaluate the clinical outcomes of one-staged hybrid procedure for aortic lesions involving the distal aortic arch. METHODS We retrospectively studied 99 consecutive patients who underwent the hybrid procedure (thoracic endovascular aortic repair combined with supra-arch branch vessel bypass) in our center between April 2009 and January 2020 for lesions involving the distal aortic arch. RESULTS Median age was 64.0 (57.0-69.0) years, and 83 (83.8%) patients were male. There were five deaths in the perioperative period (three due to cerebral infarction and two due to intimal rupture). During the median follow-up of 41.0 months, 20 patients died, three had endoleak, one had a newly formed intimal tear, and two had femoral artery pseudoaneurysm. The 5- and 10-year survival rates of the total population were 72.2% and 48.8%, respectively. Additionally, there was no difference in the 5-year survival rate among the four groups according to different pathologies (Type B aortic dissection, aortic ulcer, aortic aneurysm, aortic pseudoaneurysm: 74.7%, 78.2%, 61.1%, and 75.5%, respectively, p = .58). Furthermore, there was no difference in the 5- and 10-year survival rates between the two groups according to the different bypass methods (right axillary artery [RAA]-left axillary artery [LAA] vs. RAA-LAA-left common carotid artery: 74.1% vs. 68.9%, p = .38). CONCLUSIONS Although one-staged hybrid procedure has fewer complications in high-risk patients with lesions involving the distal aortic arch, the long-term survival rate is not optimistic.
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Affiliation(s)
- Changwei Ren
- Department of Cardiovascular Surgery Center, Beijing Anzhen Hospital, Beijing Institute of Heart, Lung, and Blood Vascular Diseases, Capital Medical University, Beijing, China
| | - Shengwei Wang
- Department of Cardiovascular Surgery Center, Beijing Anzhen Hospital, Beijing Institute of Heart, Lung, and Blood Vascular Diseases, Capital Medical University, Beijing, China
| | - Lizhong Sun
- Department of Cardiovascular Surgery Center, Beijing Anzhen Hospital, Beijing Institute of Heart, Lung, and Blood Vascular Diseases, Capital Medical University, Beijing, China
| | - Shangdong Xu
- Department of Cardiovascular Surgery Center, Beijing Anzhen Hospital, Beijing Institute of Heart, Lung, and Blood Vascular Diseases, Capital Medical University, Beijing, China
| | - Yongqiang Lai
- Department of Cardiovascular Surgery Center, Beijing Anzhen Hospital, Beijing Institute of Heart, Lung, and Blood Vascular Diseases, Capital Medical University, Beijing, China
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Thoracic endovascular aortic repair for symptomatic penetrating aortic ulcers and intramural hematomas is associated with poor outcomes. J Vasc Surg 2020; 74:63-70.e1. [PMID: 33340703 DOI: 10.1016/j.jvs.2020.11.045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Accepted: 11/19/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND The natural history of penetrating aortic ulcers (PAUs) and intramural hematomas (IMHs) of the aorta has not been well described. Although repair is warranted for rupture, unremitting chest pain, or growth, no threshold has been established for treating those found incidentally. Thoracic endovascular aortic repair (TEVAR) offers an attractive approach for treating these pathologic entities. However, the periprocedural and postoperative outcomes have not been well defined. METHODS Patients aged ≥18 years identified in the Vascular Quality Initiative database who had undergone TEVAR for PAUs and/or IMHs from January 2011 to February 2020 were included. We identified 1042 patients, of whom 809 had follow-up data available. The patient demographics and comorbidities were analyzed to identify the risk factors for major adverse events (MAEs) and postoperative and late mortality. RESULTS The cohort was 54.8% female, and 69.9% were former smokers, with a mean age of 71.1 years. Comorbidities were prevalent, with 57.8% classified as having American Society of Anesthesiologists class 4. Of the 1042 patients, 89.8% had hypertension, 28.3% chronic obstructive pulmonary disease, 17.9% coronary artery disease, and 12.2% congestive heart failure. Patients were predominately symptomatic (74%), and 44.5% had undergone nonelective repair. The MAE incidence was 17%. The independent predictors of MAEs were a history of coronary artery disease, nonwhite race, emergent procedural indication, ruptured presentation, and deployment of two or more endografts. In-hospital mortality was 4.3%. Of the index hospitalization mortalities, 73% were treatment related. For the 809 patients with follow-up (mean, 25.1 ± 19 months), the all-cause mortality was 10.6%. The predictors of late mortality during follow-up included age >70 years, ruptured presentation, and a history of chronic obstructive pulmonary disease and end-stage renal disease. A subset analysis comparing symptomatic (74%) vs asymptomatic (26%) patients demonstrated that the former were frequently women (58.2% vs 45.3%; P < .001), with a greater incidence of MAEs (20.6% vs 6.9%; P < .001), including higher in-hospital reintervention rates (5.9% vs 1.5%; P = .002) and mortality (5.6% vs 0.7%; log-rank P = .015), and a prolonged length of stay (6.9 vs 3.7 days; P < .0001), despite similar procedural risks. During follow-up, late mortality was greater in the symptomatic cohort (12.2% vs 6.5%; log-rank P = .025), with all treatment-related mortalities limited to the symptomatic group. CONCLUSIONS We found significantly greater morbidity and mortality in symptomatic patients undergoing repair compared with asymptomatic patients, despite similar baseline characteristics. Asymptomatic patients treated with TEVAR had no treatment-related mortality during follow-up, with the overall prognosis largely dependent on preexisting comorbidities. These findings, in conjunction with increasing evidence highlighting the risk of disease progression and attendant morbidity associated with these aortic entities, suggest a need for natural history studies and definitive guidelines on the elective repair of IMHs and PAUs.
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Silverberg D, Bar-Dayan A, Rimon U, Raskin D, Fefer P, Halak M. The Jailed Coiling Technique for the Treatment of Penetrating Ulcers and Saccular Aneurysms of the Aortic Arch. Vasc Endovascular Surg 2020; 54:423-429. [PMID: 32323631 DOI: 10.1177/1538574420921282] [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: 11/15/2022]
Abstract
OBJECTIVE To evaluate the technical success and short-term outcome of patients with penetrating aortic ulcers (PAUs) and saccular aneurysms (SAs) of the aortic arch treated with the jailed coiling technique. METHODS A retrospective review of 9 patients (mean age 70 years, 9 males) treated for PAUs and SAs of the aortic arch between 2018 and 2019 at our institution. Treatment included thoracic endovascular aneurysm repair (TEVAR) with a short (1cm) proximal landing zone, followed by coiling of aneurysm through a jailed extraluminal catheter. RESULTS All 9 patients underwent TEVAR followed by jailed coiling of the lumen of the aneurysms. Debranching of supra-aortic vessels was performed in 4 patients in order to create a proximal landing zone of at least 10 mm. Technical success was achieved in all cases. Coils were placed accurately within the aneurysm lumen in all patients. No distal embolization occurred. One patient expired in the perioperative period from a cardiac event. No patient developed spinal cord ischemia or stroke in the perioperative period. Mean follow-up was 10 months (range 3-18). On follow-up imaging, complete thrombosis of the aneurysm lumen was seen in all patients. None experienced enlargement of ulcer dimensions and none required reintervention. CONCLUSION PAUs and SAs of the aortic arch with a very short landing zone can be treated successfully by jailed coiling of the aneurysm and TEVAR. The procedure is technically feasible and can be performed with minimal morbidity. Long-term durability of the repair needs to be determined.
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Affiliation(s)
- Daniel Silverberg
- Department of Vascular Surgery, The Chaim Sheba Medical Center, Tel Hashomer, The Sackler School of Medicine, Tel Aviv, Israel
| | - Avner Bar-Dayan
- Department of Vascular Surgery, The Chaim Sheba Medical Center, Tel Hashomer, The Sackler School of Medicine, Tel Aviv, Israel
| | - Uri Rimon
- Division of Interventional Radiology, The Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Daniel Raskin
- Division of Diagnostic Imaging, The Chaim Sheba Medical Center, Tel Hashomer, The Sackler School of Medicine, Tel Aviv, Israel
| | - Paul Fefer
- Leviev Cardiovascular Institute, The Chaim Sheba Medical Center, Tel Hashomer, The Sackler School of Medicine, Tel Aviv, Israel
| | - Moshe Halak
- Department of Vascular Surgery, The Chaim Sheba Medical Center, Tel Hashomer, The Sackler School of Medicine, Tel Aviv, Israel
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