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Sultan S, Acharya Y, Chua Vi Long K, Hatem M, Hezima M, Veerasingham D, Soliman O, Hynes N. Management of acute aortic syndrome with evolving individualized precision medicine solutions: Lessons learned over two decades and literature review. Front Surg 2023; 10:1157457. [PMID: 37065997 PMCID: PMC10097442 DOI: 10.3389/fsurg.2023.1157457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 03/15/2023] [Indexed: 03/30/2023] Open
Abstract
BackgroundThoracoabdominal acute aortic syndrome is associated with high morbidity and mortality. We aim to scrutinize our evolving strategies for acute aortic syndrome (AAS) management using minimally invasive and adaptive surgical techniques over two decades.MethodsThis is a longitudinal observational study at our tertiary vascular centre from 2002 to 2021. Out of 22,349 aortic referrals, we performed 1,555 aortic interventions over twenty years. Amongst 96 presented with symptomatic aortic thoracic pathology, 71 patients had AAS. Our primary endpoint is combined aneurysm-related and cardiovascular-related mortality.ResultsThere were 43 males and 28 females (5 Traumatic Aortic Transection (TAT), 8 Acute Aortic Intramural Hematoma (IMH), 27 Symptomatic Aortic Dissection (SAD) and 31 Thoracic Aortic Aneurysm (TAA) post-SAD) with a mean age of 69. All the patients with AAS received optimal medical therapy (OMT), but TAT patients underwent emergency thoracic endovascular aortic repair (TEVAR). Fifty-eight patients had an aortic dissection, of which 31 developed TAA. These 31 patients with SAD and TAA received OMT initially and interval surgical intervention with TEVAR or sTaged hybrId sinGle lumEn Reconstruction (TIGER). To increase our landing area, we performed a left subclavian chimney graft with TEVAR in twelve patients. The average follow-up duration was 78.2 months, and eleven patients (15.5%) had combined aneurysm and cardiovascular-related mortality. Twenty-six percentage of the patients developed endoleaks (EL), of which 15% required re-intervention for type II and III. Four patients who had paraplegia (5.7%) and developed renal failure died. None of our patients had a stroke or bowel ischaemia. Twenty patients had OMT, eight of these were patients with acute aortic hematoma, and all eight died within 30 days of presentation.ConclusionAcute aortic hematoma is a sinister finding, which must be closely monitored, and consideration is given to early intervention. Paraplegia and renal failure result in an increased mortality rate. TIGER technique with interval TEVAR has salvaged complex situations in young patients. Left subclavian chimney increases our landing area and abolishes SINE. Our experience shows that minimally invasive techniques could be a viable option for AAS.
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Affiliation(s)
- Sherif Sultan
- Western Vascular Institute, Department of Vascular and Endovascular Surgery, University Hospital Galway, University of Galway, Galway, Ireland
- Department of Vascular Surgery and Endovascular Surgery, Galway Clinic, Royal College of Surgeons in Ireland and University of Galway, Galway Affiliated Hospital, Doughiska, Ireland
- CORRIB-CURAM-Vascular Group, University of Galway, Galway, Ireland
- Correspondence: Sherif Sultan
| | - Yogesh Acharya
- Western Vascular Institute, Department of Vascular and Endovascular Surgery, University Hospital Galway, University of Galway, Galway, Ireland
- Department of Vascular Surgery and Endovascular Surgery, Galway Clinic, Royal College of Surgeons in Ireland and University of Galway, Galway Affiliated Hospital, Doughiska, Ireland
| | - Keegan Chua Vi Long
- Western Vascular Institute, Department of Vascular and Endovascular Surgery, University Hospital Galway, University of Galway, Galway, Ireland
| | - Mohamed Hatem
- Western Vascular Institute, Department of Vascular and Endovascular Surgery, University Hospital Galway, University of Galway, Galway, Ireland
| | - Mohieldin Hezima
- Western Vascular Institute, Department of Vascular and Endovascular Surgery, University Hospital Galway, University of Galway, Galway, Ireland
| | - David Veerasingham
- Department of Cardiothoracic Surgery, University Hospital Galway, University of Galway, Galway, Ireland
| | - Osama Soliman
- CORRIB-CURAM-Vascular Group, University of Galway, Galway, Ireland
| | - Niamh Hynes
- Department of Vascular Surgery and Endovascular Surgery, Galway Clinic, Royal College of Surgeons in Ireland and University of Galway, Galway Affiliated Hospital, Doughiska, Ireland
- CORRIB-CURAM-Vascular Group, University of Galway, Galway, Ireland
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DEZZANI EO. SARS-CoV-2 infection and cardiovascular disease. GAZZETTA MEDICA ITALIANA ARCHIVIO PER LE SCIENZE MEDICHE 2022. [DOI: 10.23736/s0393-3660.22.04901-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Sultan S, Acharya Y, Soliman O, Parodi JC, Hynes N. TEVAR and EVAR, the unknown knowns of the cardiovascular hemodynamics; and the immediate and long-term consequences of fabric material on major adverse clinical outcome. Front Surg 2022; 9:940304. [PMID: 36111231 PMCID: PMC9468223 DOI: 10.3389/fsurg.2022.940304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 08/11/2022] [Indexed: 11/29/2022] Open
Abstract
This review discusses the impact of endovascular aneurysm repair on cardiovascular (CV) hemodynamics and the role of stent-graft material, i.e., polytetrafluoroethylene (PTFE) vs. polyester in post-procedural outcomes. Endovascular aneurysm repair has been widely employed in the last decades for thoracic and abdominal aneurysm repair. However, aortic endografts are stiff and alter the native flow hemodynamics. This failure to simulate the native aorta could lead to added strain on the heart, manifesting as increased left ventricular strain, higher pulse pressure, and congestive heart failure later. This could result in adverse CV outcomes. Also, evidence is mounting to support the implication of stent-graft materials, i.e., PTFE vs. polyester, in adverse post-procedural outcomes. However, there is an absence of level one evidence. Therefore, the only way forward is to plan and perform a randomised controlled trial to demonstrate the alterations in the CV hemodynamics in the short and long run and compare the available stent-graft materials regarding procedural and clinical outcomes. We believe the best solution, for now, would be to reduce the stented length of the aorta. At the same time, in the longer term, encourage continuous improvement in stent-graft materials and design.
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Affiliation(s)
- Sherif Sultan
- Department of Vascular and Endovascular Surgery, Western Vascular Institute, University Hospital Galway, National University of Ireland, Galway, Ireland
- Galway Clinic, Doughiska, Royal College of Surgeons in Ireland and the National University of Ireland, Galway Affiliated Hospital, Galway, Ireland
- CÚRAM-CORRIB-Vascular Group, National University of Ireland, Galway, Ireland
- Correspondence: Sherif Sultan ,
| | - Yogesh Acharya
- Department of Vascular and Endovascular Surgery, Western Vascular Institute, University Hospital Galway, National University of Ireland, Galway, Ireland
- Galway Clinic, Doughiska, Royal College of Surgeons in Ireland and the National University of Ireland, Galway Affiliated Hospital, Galway, Ireland
| | - Osama Soliman
- CÚRAM-CORRIB-Vascular Group, National University of Ireland, Galway, Ireland
| | - Juan Carlos Parodi
- Department of Vascular Surgery and Biomedical Engineering Department, University of Buenos Aires, Buenos Aires, Argentina
| | - Niamh Hynes
- CÚRAM-CORRIB-Vascular Group, National University of Ireland, Galway, Ireland
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Sultan S, Acharya Y, Hazima M, Salahat H, Parodi JC, Hynes N. Combined thoracic endovascular aortic repair and endovascular aneurysm repair and the long-term consequences of altered cardiovascular haemodynamics on morbidity and mortality: case series and literature review. EUROPEAN HEART JOURNAL-CASE REPORTS 2021; 5:ytab339. [PMID: 34622129 PMCID: PMC8493011 DOI: 10.1093/ehjcr/ytab339] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 05/18/2021] [Accepted: 08/13/2021] [Indexed: 11/14/2022]
Abstract
Background Thoracic and abdominal aortic stent grafts are firmer and more rigid than the native aorta. Aortic implanted devices have been implicated in the development of acute systolic hypertension, elevated pulse pressure, and reduced coronary perfusion. Case summary We report four cases of staged thoracic endovascular aortic repair (TEVAR) and then endovascular aneurysm repair (EVAR). All patients had TEVAR first for thoracic aortic aneurysm and later on developed infra-renal abdominal aortic aneurysm (AAA) that required EVAR. There were three males and one female with a median age of 74.5 years (range 67.5-78.5). None of the patients developed aortic-related major clinical adverse effects or required any aortic intervention during their follow-up. However, within 2 years, all patients developed symptomatic left ventricular hypertrophy with diastolic dysfunction. All patients had bilateral lower limb oedema, with on and off chest pain and shortness of breath (SOB), necessitating coronary angiograms, which showed no evidence of coronary artery disease. Three patients died from cardiovascular-related morbidities, and the fourth patient is still complaining of SOB despite a normal coronary angiogram. Discussion Aortic-endograft compliance mismatch is an invisible enemy, with troubling consequences for the aorta proximal and distal to the endograft. Aortic stiffness due to vascular endograft could lead to cardiovascular adverse events, even in the absence of direct aortic-related complications. After combined TEVAR and EVAR, the compliance mismatch and elasticity loss are even more pronounced than with TEVAR alone, which necessitates patient monitoring for the development of cardiovascular complications.
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Affiliation(s)
- Sherif Sultan
- Western Vascular Institute, Department of Vascular and Endovascular Surgery, University Hospital Galway, National University of Ireland, Newcastle Road, Galway H91 YR71, Ireland.,Department of Vascular and Endovascular Surgery, Galway Clinic, Doughiska, Royal College of Surgeons in Ireland and the National University of Ireland, Galway Affiliated Hospital, Ireland
| | - Yogesh Acharya
- Western Vascular Institute, Department of Vascular and Endovascular Surgery, University Hospital Galway, National University of Ireland, Newcastle Road, Galway H91 YR71, Ireland.,Department of Vascular and Endovascular Surgery, Galway Clinic, Doughiska, Royal College of Surgeons in Ireland and the National University of Ireland, Galway Affiliated Hospital, Ireland
| | - Mohiey Hazima
- Western Vascular Institute, Department of Vascular and Endovascular Surgery, University Hospital Galway, National University of Ireland, Newcastle Road, Galway H91 YR71, Ireland
| | - Hiba Salahat
- Department of Vascular and Endovascular Surgery, Galway Clinic, Doughiska, Royal College of Surgeons in Ireland and the National University of Ireland, Galway Affiliated Hospital, Ireland
| | - Juan Carlos Parodi
- Department of Vascular Surgery and Biomedical Engineering Department, Alma mater, University of Buenos Aires, Wake Forest University, Washington University in St. Louis, and Trinidad Hospital, Buenos Aires, Argentina
| | - Niamh Hynes
- Department of Vascular and Endovascular Surgery, Galway Clinic, Doughiska, Royal College of Surgeons in Ireland and the National University of Ireland, Galway Affiliated Hospital, Ireland
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Concannon J, Moerman KM, Hynes N, Sultan S, McGarry JP. Influence of shape-memory stent grafts on local aortic compliance. Biomech Model Mechanobiol 2021; 20:2373-2392. [PMID: 34541627 PMCID: PMC8595172 DOI: 10.1007/s10237-021-01514-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 08/18/2021] [Indexed: 12/19/2022]
Abstract
The effect of repair techniques on the biomechanics of the aorta is poorly understood, resulting in significant levels of postoperative complications for patients worldwide. This study presents a computational analysis of the influence of Nitinol-based devices on the biomechanical performance of a healthy patient-specific human aorta. Simulations reveal that Nitinol stent-grafts stretch the artery wall so that collagen is stretched to a straightened high-stiffness configuration. The high-compliance regime (HCR) associated with low diastolic lumen pressure is eliminated, and the artery operates in a low-compliance regime (LCR) throughout the entire cardiac cycle. The slope of the lumen pressure–area curve for the LCR post-implantation is almost identical to that of the native vessel during systole. This negligible change from the native LCR slope occurs because the stent-graft increases its diameter from the crimped configuration during deployment so that it reaches a low-stiffness unloading plateau. The effective radial stiffness of the implant along this unloading plateau is negligible compared to the stiffness of the artery wall. Provided the Nitinol device unloads sufficiently during deployment to the unloading plateau, the degree of oversizing has a negligible effect on the pressure–area response of the vessel, as each device exerts approximately the same radial force, the slope of which is negligible compared to the LCR slope of the native artery. We show that 10% oversizing based on the observed diastolic diameter in the mid descending thoracic aorta results in a complete loss of contact between the device and the wall during systole, which could lead to an endoleak and stent migration. 20% oversizing reaches the Dacron enforced area limit (DEAL) during the pulse pressure and results in an effective zero-compliance in the later portion of systole.
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Affiliation(s)
- J Concannon
- Biomedical Engineering, College of Engineering and Informatics, National University of Ireland, Galway, Ireland
| | - K M Moerman
- Biomedical Engineering, College of Engineering and Informatics, National University of Ireland, Galway, Ireland
| | - N Hynes
- Western Vascular Institute, National University of Ireland Galway, Galway, Ireland
| | - S Sultan
- Western Vascular Institute, National University of Ireland Galway, Galway, Ireland
| | - J P McGarry
- Biomedical Engineering, College of Engineering and Informatics, National University of Ireland, Galway, Ireland.
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Sultan S, Parodi J, Acharya Y, Hynes N. Why Are Medical Device Multinationals Choking Disruptive Technology and Killing Innovation? Challenges to Innovation in Medical Device Technology. J Endovasc Ther 2021; 28:367-372. [PMID: 33511910 DOI: 10.1177/1526602821989356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Sherif Sultan
- Department of Vascular and Endovascular Surgery, Western Vascular Institute, University Hospital Galway, National University of Ireland, Galway, Ireland.,Department of Vascular Surgery and Endovascular Surgery, Galway Clinic, Affiliated Hospital of the Royal College of Surgeons in Ireland and the National University of Ireland, Doughiska Galway, Ireland
| | - Juan Parodi
- Department of Vascular Surgery and Biomedical Engineering Department, Alma Mater, University of Buenos Aires, and Trinidad Hospital, San Isidro, Buenos Aires, Argentina.,Wake Forest University, Winston-Salem, NC, USA.,Washington University in St Louis, St Louis, MO, USA
| | - Yogesh Acharya
- Department of Vascular and Endovascular Surgery, Western Vascular Institute, University Hospital Galway, National University of Ireland, Galway, Ireland.,Department of Vascular Surgery and Endovascular Surgery, Galway Clinic, Affiliated Hospital of the Royal College of Surgeons in Ireland and the National University of Ireland, Doughiska Galway, Ireland
| | - Niamh Hynes
- Department of Vascular Surgery and Endovascular Surgery, Galway Clinic, Affiliated Hospital of the Royal College of Surgeons in Ireland and the National University of Ireland, Doughiska Galway, Ireland
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Sultan S, Acharya Y, Hynes N. Commentary: When Promising Innovators Lack Strategic Vision: The Concept of Flow Modulation in Aortic Dissection. J Endovasc Ther 2020; 28:32-35. [DOI: 10.1177/1526602820954450] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Sherif Sultan
- Western Vascular Institute, Department of Vascular and Endovascular Surgery, University Hospital Galway, National University of Ireland, Galway, Ireland
- Department of Vascular and Endovascular Surgery, Galway Clinic, Doughiska, Royal College of Surgeons in Ireland, and National University of Ireland, Galway Affiliated Hospital, Galway, Ireland
| | - Yogesh Acharya
- Western Vascular Institute, Department of Vascular and Endovascular Surgery, University Hospital Galway, National University of Ireland, Galway, Ireland
- Department of Vascular and Endovascular Surgery, Galway Clinic, Doughiska, Royal College of Surgeons in Ireland, and National University of Ireland, Galway Affiliated Hospital, Galway, Ireland
| | - Niamh Hynes
- Department of Vascular and Endovascular Surgery, Galway Clinic, Doughiska, Royal College of Surgeons in Ireland, and National University of Ireland, Galway Affiliated Hospital, Galway, Ireland
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