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Nordkamp S, van Rees JM, van den Berg K, Mens DM, Creemers DMJ, Peulen HMU, Creemers GJ, Nieuwenhuijzen GAP, Tolenaar JL, Bloemen JG, Rothbarth J, Rutten HJT, Verhoef C, Burger JWA. Locally recurrent rectal cancer: oncological outcomes of neoadjuvant chemoradiotherapy with or without induction chemotherapy. Br J Surg 2023; 110:1637-1640. [PMID: 37406084 DOI: 10.1093/bjs/znad214] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 05/18/2023] [Accepted: 05/21/2023] [Indexed: 07/07/2023]
Affiliation(s)
- Stefi Nordkamp
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
- GROW School for Oncology and Reproduction, Maastricht University, Maastricht, the Netherlands
| | - Jan M van Rees
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Kim van den Berg
- GROW School for Oncology and Reproduction, Maastricht University, Maastricht, the Netherlands
- Department of Medical Oncology, Catharina Hospital, Eindhoven, the Netherlands
| | - David M Mens
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Davy M J Creemers
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - Heike M U Peulen
- Department of Radiation Oncology, Catharina Hospital, Eindhoven, the Netherlands
| | - Geert-Jan Creemers
- Department of Medical Oncology, Catharina Hospital, Eindhoven, the Netherlands
| | | | - Jip L Tolenaar
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - Johanne G Bloemen
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - Joost Rothbarth
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Harm J T Rutten
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
- GROW School for Oncology and Reproduction, Maastricht University, Maastricht, the Netherlands
| | - Cornelis Verhoef
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
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Ketelaers SHJ, Jacobs A, van der Linden CMJ, Nieuwenhuijzen GAP, Tolenaar JL, Rutten HJT, Burger JWA, Bloemen JG. An evaluation of postoperative outcomes and treatment changes after frailty screening and geriatric assessment and management in a cohort of older patients with colorectal cancer. J Geriatr Oncol 2023; 14:101647. [PMID: 37862736 DOI: 10.1016/j.jgo.2023.101647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Revised: 07/23/2023] [Accepted: 10/10/2023] [Indexed: 10/22/2023]
Abstract
INTRODUCTION Adequate patient selection is crucial within the treatment of older patients with colorectal cancer (CRC). While previous studies report increased morbidity and mortality in older patients screened positive for frailty, improvements in the perioperative care and postoperative outcomes have raised the question of whether older patients screened positive for frailty still face worse outcomes. This study aimed to investigate the postoperative outcomes of older patients with CRC screened positive for frailty, and to evaluate changes in treatment after frailty screening and geriatric assessment. MATERIALS AND METHODS Patients ≥70 years with primary CRC who underwent frailty screening between 1 January 2019 and 31 October 2021 were included. Frailty screening was performed by the Geriatric-8 (G8) screening tool. If the G8 indicated frailty (G8 ≤ 14), patients were referred for a comprehensive geriatric assessment (CGA). Postoperative outcomes and changes in treatment based on frailty screening and CGA were evaluated. RESULTS A total of 170 patients were included, of whom 74 (43.5%) screened positive for frailty (G8 ≤ 14). Based on the CGA, the initially proposed treatment plan was altered to a less intensive regimen in five (8.9%) patients, and to a more intensive regimen in one (1.8%) patient. Surgery was performed in 87.8% of patients with G8 ≤ 14 and 96.9% of patients with G8 > 14 (p = 0.03). Overall postoperative complications were similar between patients with G8 ≤ 14 and G8 > 14 (46.2% vs. 47.3%, p = 0.89). Postoperative delirium was observed in 7.7% of patients with G8 ≤ 14 and 1.1% of patients with G8 > 14 (p = 0.08). No differences in 30-day mortality (1.1% vs. 1.5%, p > 0.99) or one-year and two-year survival rates were observed (log rank, p = 0.26). DISCUSSION Although patients screened positive for frailty underwent CRC surgery less often, those considered eligible for surgery can safely undergo CRC resection within current clinical care pathways, without increased morbidity and mortality. Efforts to optimise perioperative care and minimise the risk of postoperative complications, in particular delirium, seem warranted. A multidisciplinary onco-geriatric pathway may support tailored decision-making in patients at risk of frailty.
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Affiliation(s)
- Stijn H J Ketelaers
- Department of Surgery, Catharina Hospital, PO Box 1350, 5602 ZA Eindhoven, the Netherlands.
| | - Anne Jacobs
- Department of Gerontology and Geriatrics, Catharina Hospital, PO Box 1350, 5602 ZA Eindhoven, the Netherlands
| | - Carolien M J van der Linden
- Department of Gerontology and Geriatrics, Catharina Hospital, PO Box 1350, 5602 ZA Eindhoven, the Netherlands
| | | | - Jip L Tolenaar
- Department of Surgery, Catharina Hospital, PO Box 1350, 5602 ZA Eindhoven, the Netherlands
| | - Harm J T Rutten
- Department of Surgery, Catharina Hospital, PO Box 1350, 5602 ZA Eindhoven, the Netherlands; Department of GROW, School for Oncology & Reproduction, Maastricht University, Maastricht, the Netherlands
| | - Jacobus W A Burger
- Department of Surgery, Catharina Hospital, PO Box 1350, 5602 ZA Eindhoven, the Netherlands
| | - Johanne G Bloemen
- Department of Surgery, Catharina Hospital, PO Box 1350, 5602 ZA Eindhoven, the Netherlands
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Nordkamp S, Creemers DMJ, Glazemakers S, Ketelaers SHJ, Scholten HJ, van de Calseijde S, Nieuwenhuijzen GAP, Tolenaar JL, Crezee HW, Rutten HJT, Burger JWA, Bloemen JG. Implementation of an Enhanced Recovery after Surgery Protocol in Advanced and Recurrent Rectal Cancer Patients after beyond Total Mesorectal Excision Surgery: A Feasibility Study. Cancers (Basel) 2023; 15:4523. [PMID: 37760492 PMCID: PMC10526990 DOI: 10.3390/cancers15184523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 09/06/2023] [Accepted: 09/07/2023] [Indexed: 09/29/2023] Open
Abstract
INTRODUCTION The implementation of an Enhanced Recovery After Surgery (ERAS) protocol in patients with locally advanced rectal cancer (LARC) and locally recurrent rectal cancer (LRRC) has been deemed unfeasible until now because of the heterogeneity of this disease and low caseloads. Since evidence and experience with ERAS principles in colorectal cancer care are increasing, a modified ERAS protocol for this specific group has been developed. The aim of this study is to evaluate the implementation of a tailored ERAS protocol for patients with LARC or LRRC, requiring beyond total mesorectal excision (bTME) surgery. METHODS Patients who underwent a bTME for LARC or LRRC between October 2021 and December 2022 were prospectively studied. All patients were treated in accordance with the ERAS LARRC protocol, which consisted of 39 ERAS care elements specifically developed for patients with LARC and LRRC. One of the most important adaptations of this protocol was the anaesthesia procedure, which involved the use of total intravenous anaesthesia with intravenous (iv) lidocaine, iv methadone, and iv ketamine instead of epidural anaesthesia. The outcomes showed compliance with ERAS care elements, complications, length of stay, and functional recovery. A follow-up was performed at 30 and 90 days post-surgery. RESULTS Seventy-two patients were selected, all of whom underwent bTME for either LARC (54.2%) or LRRC (45.8%). Total compliance with the adjusted ERAS protocol was 73.6%. Major complications were present in 12 patients (16.7%), and the median length of hospital stay was 9 days (IQR 6.0-14.0). Patients who received multimodal anaesthesia (75.0%) stayed in the hospital for a median of 7.0 days (IQR 6.8-15.5). These patients received fewer opioids on the first three postoperative days than patients who received epidural analgesia (p < 0.001). CONCLUSIONS The implementation of the ERAS LARRC protocol seemed successful according to its compliance rate of >70%. Its complication rate was substantially reduced in comparison with the literature. Multimodal anaesthesia is feasible in beyond TME surgery with promising effects on recovery after surgery.
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Affiliation(s)
- Stefi Nordkamp
- Department of Surgery, Catharina Hospital, 5623 EJ Eindhoven, The Netherlands (G.A.P.N.)
- Department of GROW, School for Oncology and Reproduction, Maastricht University, 6229 ER Maastricht, The Netherlands
| | - Davy M. J. Creemers
- Department of Surgery, Catharina Hospital, 5623 EJ Eindhoven, The Netherlands (G.A.P.N.)
| | - Sofie Glazemakers
- Department of Surgery, Catharina Hospital, 5623 EJ Eindhoven, The Netherlands (G.A.P.N.)
| | - Stijn H. J. Ketelaers
- Department of Surgery, Catharina Hospital, 5623 EJ Eindhoven, The Netherlands (G.A.P.N.)
| | - Harm J. Scholten
- Department of Anaesthesiology, Catharina Hospital, 5623 EJ Eindhoven, The Netherlands
| | | | | | - Jip L. Tolenaar
- Department of Surgery, Catharina Hospital, 5623 EJ Eindhoven, The Netherlands (G.A.P.N.)
| | - Hendi W. Crezee
- Department of Surgery, Catharina Hospital, 5623 EJ Eindhoven, The Netherlands (G.A.P.N.)
| | - Harm J. T. Rutten
- Department of Surgery, Catharina Hospital, 5623 EJ Eindhoven, The Netherlands (G.A.P.N.)
- Department of GROW, School for Oncology and Reproduction, Maastricht University, 6229 ER Maastricht, The Netherlands
| | - Jacobus W. A. Burger
- Department of Surgery, Catharina Hospital, 5623 EJ Eindhoven, The Netherlands (G.A.P.N.)
| | - Johanne G. Bloemen
- Department of Surgery, Catharina Hospital, 5623 EJ Eindhoven, The Netherlands (G.A.P.N.)
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Nordkamp S, Piqeur F, van den Berg K, Tolenaar JL, van Hellemond IEG, Creemers GJ, Roef M, van Lijnschoten G, Cnossen JS, Nieuwenhuijzen GAP, Bloemen JG, Coolen L, Nederend J, Peulen HMU, Rutten HJT, Burger JWA. Locally recurrent rectal cancer: Oncological outcomes for patients with a pathological complete response after neoadjuvant therapy. Br J Surg 2023:7181206. [PMID: 37243705 DOI: 10.1093/bjs/znad094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 03/11/2023] [Accepted: 03/21/2023] [Indexed: 05/29/2023]
Abstract
BACKGROUND For patients with locally recurrent rectal cancer, it is an ongoing pursuit to establish factors predicting or improving oncological outcomes. In locally advanced rectal cancer, a pCR appears to be associated with improved outcomes. The aim of this retrospective cohort study was to compare the oncological outcomes of patients with locally recurrent rectal cancer with and without a pCR. METHODS Patients who underwent neoadjuvant treatment and surgery for locally recurrent rectal cancer with curative intent between January 2004 and June 2020 at a tertiary referral hospital were analysed. Primary outcomes included overall survival, disease-free survival, metastasis-free survival, and local re-recurrence-free survival, stratified according to whether the patient had a pCR. RESULTS Of a total of 345 patients, 51 (14.8 per cent) had a pCR. Median follow-up was 36 (i.q.r. 16-60) months. The 3-year overall survival rate was 77 per cent for patients with a pCR and 51.1 per cent for those without (P < 0.001). The 3-year disease-free survival rate was 56 per cent for patients with a pCR and 26.1 per cent for those without (P < 0.001). The 3-year local re-recurrence-free survival rate was 82 and 44 per cent respectively (P < 0.001). Surgical procedures (for example soft tissue, sacrum, and urogenital organ resections) and postoperative complications were comparable between patients with and without a pCR. CONCLUSION This study showed that patients with a pCR have superior oncological outcomes to those without a pCR. It may therefore be safe to consider a watch-and-wait approach in highly selected patients, potentially improving quality of life by omitting extensive surgical procedures without compromising oncological outcomes.
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Affiliation(s)
- Stefi Nordkamp
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
- Faculty of Health, Medicine and Life Sciences, GROW School for Oncology and Reproduction, Maastricht University, Maastricht, the Netherlands
| | - Floor Piqeur
- Department of Radiation Oncology, Catharina Hospital, Eindhoven, the Netherlands
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Kim van den Berg
- Department of Medical Oncology, Catharina Hospital, Eindhoven, the Netherlands
| | - Jip L Tolenaar
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | | | - Geert-Jan Creemers
- Department of Medical Oncology, Catharina Hospital, Eindhoven, the Netherlands
| | - Mark Roef
- Department of Nuclear Medicine, Catharina Hospital, Eindhoven, the Netherlands
| | | | - Jeltsje S Cnossen
- Department of Radiation Oncology, Catharina Hospital, Eindhoven, the Netherlands
| | | | - Johanne G Bloemen
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - Liën Coolen
- Department of Radiology, Catharina Hospital, Eindhoven, the Netherlands
| | - Joost Nederend
- Department of Radiology, Catharina Hospital, Eindhoven, the Netherlands
| | - Heike M U Peulen
- Department of Radiation Oncology, Catharina Hospital, Eindhoven, the Netherlands
| | - Harm J T Rutten
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
- Faculty of Health, Medicine and Life Sciences, GROW School for Oncology and Reproduction, Maastricht University, Maastricht, the Netherlands
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Ketelaers SHJ, Jacobs A, van der Linden CMJ, Nieuwenhuijzen GAP, Tolenaar JL, Rutten HJT, Burger JWA, Bloemen JG. The influence of geriatric screening and evaluation on the treatment decisions and postoperative outcomes in vulnerable elderly colorectal cancer patients. European Journal of Surgical Oncology 2023. [DOI: 10.1016/j.ejso.2022.11.118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
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Ketelaers SHJ, Jacobs A, Verrijssen ASE, Cnossen JS, van Hellemond IEG, Creemers GJM, Schreuder RM, Scholten HJ, Tolenaar JL, Bloemen JG, Rutten HJT, Burger JWA. A Multidisciplinary Approach for the Personalised Non-Operative Management of Elderly and Frail Rectal Cancer Patients Unable to Undergo TME Surgery. Cancers (Basel) 2022; 14:2368. [PMID: 35625976 PMCID: PMC9139821 DOI: 10.3390/cancers14102368] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 05/05/2022] [Accepted: 05/09/2022] [Indexed: 02/07/2023] Open
Abstract
Despite it being the optimal curative approach, elderly and frail rectal cancer patients may not be able to undergo a total mesorectal excision. Frequently, no treatment is offered at all and the natural course of the disease is allowed to unfold. These patients are at risk for developing debilitating symptoms that impair quality of life and require palliative treatment. Recent advancements in non-operative treatment modalities have enhanced the toolbox of alternative treatment strategies in patients unable to undergo surgery. Therefore, a proposed strategy is to aim for the maximal non-operative treatment, in an effort to avoid the onset of debilitating symptoms, improve quality of life, and prolong survival. The complexity of treating elderly and frail patients requires a patient-centred approach to personalise treatment. The main challenge is to optimise the balance between local control of disease, patient preferences, and the burden of treatment. A comprehensive geriatric assessment is a crucial element within the multidisciplinary dialogue. Since limited knowledge is available on the optimal non-operative treatment strategy, these patients should be treated by dedicated multidisciplinary rectal cancer experts with special interest in the elderly and frail. The aim of this narrative review was to discuss a multidisciplinary patient-centred treatment approach and provide a practical suggestion of a successfully implemented clinical care pathway.
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Affiliation(s)
- Stijn H. J. Ketelaers
- Department of Surgery, Catharina Hospital, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands; (J.L.T.); (J.G.B.); (H.J.T.R.); (J.W.A.B.)
| | - Anne Jacobs
- Department of Gerontology and Geriatrics, Catharina Hospital, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands;
| | - An-Sofie E. Verrijssen
- Department of Radiation Oncology, Catharina Hospital, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands; (A.-S.E.V.); (J.S.C.)
| | - Jeltsje S. Cnossen
- Department of Radiation Oncology, Catharina Hospital, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands; (A.-S.E.V.); (J.S.C.)
| | - Irene E. G. van Hellemond
- Department of Medical Oncology, Catharina Hospital, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands; (I.E.G.v.H.); (G.-J.M.C.)
| | - Geert-Jan M. Creemers
- Department of Medical Oncology, Catharina Hospital, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands; (I.E.G.v.H.); (G.-J.M.C.)
| | - Ramon-Michel Schreuder
- Department of Gastroenterology, Catharina Hospital, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands;
| | - Harm J. Scholten
- Department of Anaesthesiology, Catharina Hospital, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands;
| | - Jip L. Tolenaar
- Department of Surgery, Catharina Hospital, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands; (J.L.T.); (J.G.B.); (H.J.T.R.); (J.W.A.B.)
| | - Johanne G. Bloemen
- Department of Surgery, Catharina Hospital, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands; (J.L.T.); (J.G.B.); (H.J.T.R.); (J.W.A.B.)
| | - Harm J. T. Rutten
- Department of Surgery, Catharina Hospital, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands; (J.L.T.); (J.G.B.); (H.J.T.R.); (J.W.A.B.)
- GROW, School for Oncology and Reproduction, Maastricht University, P.O. Box 616, 6200 MD Maastricht, The Netherlands
| | - Jacobus W. A. Burger
- Department of Surgery, Catharina Hospital, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands; (J.L.T.); (J.G.B.); (H.J.T.R.); (J.W.A.B.)
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Trimarchi S, de Beaufort HWL, Tolenaar JL, Bavaria JE, Desai ND, Di Eusanio M, Di Bartolomeo R, Peterson MD, Ehrlich M, Evangelista A, Montgomery DG, Myrmel T, Hughes GC, Appoo JJ, De Vincentiis C, Yan TD, Nienaber CA, Isselbacher EM, Deeb GM, Gleason TG, Patel HJ, Sundt TM, Eagle KA. Acute aortic dissections with entry tear in the arch: A report from the International Registry of Acute Aortic Dissection. J Thorac Cardiovasc Surg 2019; 157:66-73. [PMID: 30396735 DOI: 10.1016/j.jtcvs.2018.07.101] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 07/03/2018] [Accepted: 07/19/2018] [Indexed: 01/12/2023]
Abstract
OBJECTIVE To analyze presentation, management, and outcomes of acute aortic dissections with proximal entry tear in the arch. METHODS Patients enrolled in the International Registry of Acute Aortic Dissection and entry tear in the arch were classified into 2 groups: arch A (retrograde extension into the ascending aorta with or without antegrade extension) and arch B (only antegrade extension into the descending aorta or further distally). Presentation, management, and in-hospital outcomes of the 2 groups were compared. RESULTS The arch A (n = 228) and arch B (n = 140) groups were similar concerning the presence of any preoperative complication (68.4% vs 60.0%; P = .115), but the types of complication were different. Arch A presented more commonly with shock, neurologic complications, cardiac tamponade, and grade 3 or 4 aortic valve insufficiency and less frequently with refractory hypertension, visceral ischemia, extension of dissection, and aortic rupture. Management for both groups were open surgery (77.6% vs 18.6%; P < .001), endovascular treatment (3.5% vs 25.0%; P < .001), and medical management (16.2% vs 51.4%; P < .001). Overall in-hospital mortality was similar (16.7% vs 19.3%; P = .574), but mortality tended to be lower in the arch A group after open surgery (15.3% vs 30.8%; P = .090), and higher after endovascular (25.0% vs 14.3%; P = .597) or medical treatment (24.3% vs 13.9%; P = .191), although the differences were not significant. CONCLUSIONS Acute aortic dissection patients with primary entry tear in the arch are currently managed by a patient-specific approach. In choosing the management type of these patients, it may be advisable to stratify them based on retrograde or only antegrade extension of the dissection.
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Affiliation(s)
- Santi Trimarchi
- Thoracic Aortic Research Center, IRCCS Policlinico San Donato, San Donato Milanese, Italy; Department of Scienze Biomediche per la Salute, University of Milan, Milan, Italy.
| | - Hector W L de Beaufort
- Thoracic Aortic Research Center, IRCCS Policlinico San Donato, San Donato Milanese, Italy
| | - Jip L Tolenaar
- Thoracic Aortic Research Center, IRCCS Policlinico San Donato, San Donato Milanese, Italy
| | - Joseph E Bavaria
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Nimesh D Desai
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Marco Di Eusanio
- Department of Cardiac Surgery, Ospedali Riuniti di Ancona, Ancona, Italy
| | - Roberto Di Bartolomeo
- Department of Cardiac Surgery, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Mark D Peterson
- Division of Cardiac Surgery, St Michael's Hospital, Toronto, Ontario, Canada
| | - Marek Ehrlich
- Department of Cardiothoracic Surgery, University of Vienna, Vienna, Austria
| | - Arturo Evangelista
- Department of Cardiology, Hospital General Universitari Vall d'Hebron, Barcelona, Spain
| | - Daniel G Montgomery
- Department of Medicine, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Mich
| | - Truls Myrmel
- Department of Thoracic and Cardiovascular Surgery, University of Tromsø, Tromsø, Norway
| | - G Chad Hughes
- Department of Surgery, Duke University Medical Center, Durham, NC
| | - Jehangir J Appoo
- Division of Cardiac Surgery, Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Carlo De Vincentiis
- Thoracic Aortic Research Center, IRCCS Policlinico San Donato, San Donato Milanese, Italy
| | - Tristan D Yan
- Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, University of Sydney, Sydney, Australia
| | - Christoph A Nienaber
- Cardiology and Aortic Centre, Royal Brompton Hospital, Royal Brompton & Harefield NHS Trust, Imperial College London, London, United Kingdom
| | - Eric M Isselbacher
- Thoracic Aortic Center and Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, Mass
| | - G Michael Deeb
- Department of Cardiac Surgery, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Mich
| | - Thomas G Gleason
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pa
| | - Himanshu J Patel
- Department of Cardiac Surgery, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Mich
| | - Thoralf M Sundt
- Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Mass
| | - Kim A Eagle
- Department of Medicine, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Mich
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Froehlich W, Tolenaar JL, Harris KM, Strauss C, Sundt TM, Tsai TT, Peterson MD, Evangelista A, Montgomery DG, Kline-Rogers E, Nienaber CA, Froehlich JB, Isselbacher EM, Eagle KA, Trimarchi S. Delay from Diagnosis to Surgery in Transferred Type A Aortic Dissection. Am J Med 2018; 131:300-306. [PMID: 29180025 DOI: 10.1016/j.amjmed.2017.11.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Revised: 11/06/2017] [Accepted: 11/06/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVES The purpose of this research is to analyze factors associated with delays to surgical management of Type A acute aortic dissection patients. METHODS Time from diagnosis to surgery and associated factors were evaluated in 1880 surgically managed Type A dissection patients enrolled in the International Registry of Acute Aortic Dissection. RESULTS The majority of patients were transferred (75.7% vs 24.3%). Patients who were transferred had a median delay from diagnosis to surgery of 4.0 hours (interquartile range 2.5-7.2 hours), compared with 2.3 hours (interquartile range 1.1-4.2 hours; P < .001) in nontransferred patients. Among patients who were transferred, those with worst-ever, posterior, or tearing chest pain those with severe complications, and those receiving transthoracic echocardiogram prior to a transesophageal echocardiogram or as the only echocardiogram were treated more quickly. Those undergoing magnetic resonance imaging, or who had prior cardiac surgery, had longer delays to surgery. Among nontransferred patients, those with coma were treated more quickly. In both groups, patients presenting with emergent conditions such as cardiac tamponade, hypotension, or shock had more rapid treatment. Among transferred patients, surviving patients had longer delays (4.1 [2.6-7.8] hours vs 3.3 [2.0-6.0] hours, P = .001). Overall mortality did not differ between patients who were transferred vs not (19.3% vs 21.1%, P = .416). CONCLUSION Simply being transferred added significantly to the delay to surgery for Type A acute aortic dissection patients, but a number of factors affected its extent. Overall, signs and symptoms leading to a definitive diagnosis or indicating immediate life threat reduced time to surgery, while factors suggesting other diagnoses correlated with delays.
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Affiliation(s)
| | - Jip L Tolenaar
- Thoracic Aortic Research Center, IRCCS Policlinico San Donato, Milan, Italy
| | - Kevin M Harris
- Cardiovascular Division, Minneapolis Heart Institute, Minn
| | - Craig Strauss
- Cardiovascular Division, Minneapolis Heart Institute, Minn
| | - Thoralf M Sundt
- Thoracic Aortic Center, Massachusetts General Hospital, Boston
| | - Thomas T Tsai
- Cardiology Department, University of Colorado Hospital, Denver
| | - Mark D Peterson
- Division of Cardiac Surgery, St. Michael's Hospital, Toronto, ON, Canada
| | - Arturo Evangelista
- Servei de Cardiologia, Hospital General Universitari Vall d'Hebron, Barcelona, Spain
| | | | | | - Christoph A Nienaber
- Cardiology and Aortic Centre, The Royal Brompton & Harefield NHS Trust, London, UK
| | | | | | - Kim A Eagle
- Cardiovascular Center, University of Michigan, Ann Arbor
| | - Santi Trimarchi
- Thoracic Aortic Research Center, IRCCS Policlinico San Donato, Milan, Italy.
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Nauta FJ, Tolenaar JL, Patel HJ, Appoo JJ, Tsai TT, Desai ND, Montgomery DG, Mussa FF, Upchurch GR, Fattori R, Hughes GC, Nienaber CA, Isselbacher EM, Eagle KA, Trimarchi S. Impact of Retrograde Arch Extension in Acute Type B Aortic Dissection on Management and Outcomes. Ann Thorac Surg 2016; 102:2036-2043. [DOI: 10.1016/j.athoracsur.2016.05.013] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Revised: 04/27/2016] [Accepted: 05/02/2016] [Indexed: 11/26/2022]
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10
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Tolenaar JL, DE Vries JP. Towards an entirely endovascular aortic world. J Cardiovasc Surg (Torino) 2016; 57:683-685. [PMID: 27332678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Affiliation(s)
- Jip L Tolenaar
- Department of Vascular Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands -
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11
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Derbel B, Mialhe C, Tolenaar JL, Dreyfus G. Complex Iatrogenic Dissection Complicating Thoracic Endovascular Aneurysm Repair. Ann Vasc Surg 2015; 29:1659.e13-20. [DOI: 10.1016/j.avsg.2015.06.079] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Revised: 06/22/2015] [Accepted: 06/23/2015] [Indexed: 11/30/2022]
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12
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Nauta FJH, Conti M, Kamman AV, van Bogerijen GHW, Tolenaar JL, Auricchio F, Figueroa CA, van Herwaarden JA, Moll FL, Trimarchi S. Biomechanical Changes After Thoracic Endovascular Aortic Repair in Type B Dissection. J Endovasc Ther 2015; 22:918-33. [DOI: 10.1177/1526602815608848] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Thoracic endovascular aortic repair (TEVAR) has evolved into an established treatment option for type B aortic dissection (TBAD) since it was first introduced 2 decades ago. Morbidity and mortality have decreased due to the minimally invasive character of TEVAR, with adequate stabilization of the dissection, restoration of true lumen perfusion, and subsequent positive aortic remodeling. However, several studies have reported severe setbacks of this technique. Indeed, little is known about the biomechanical behavior of implanted thoracic stent-grafts and the impact on the vascular system. This study sought to systematically review the performance and behavior of implanted thoracic stent-grafts and related biomechanical aortic changes in TBAD patients in order to update current knowledge and future perspectives.
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Affiliation(s)
- Foeke J. H. Nauta
- Thoracic Aortic Research Center, Policlinico San Donato IRCCS, University of Milan, Italy
- Departments of Surgery and Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
- Department of Vascular Surgery, University Medical Center Utrecht, the Netherlands
| | - Michele Conti
- Department of Civil Engineering and Architecture, University of Pavia, Italy
| | - Arnoud V. Kamman
- Thoracic Aortic Research Center, Policlinico San Donato IRCCS, University of Milan, Italy
- Departments of Surgery and Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
- Department of Vascular Surgery, University Medical Center Utrecht, the Netherlands
| | | | - Jip L. Tolenaar
- Department of General Surgery, St. Antonius Hospital, Nieuwegein, the Netherlands
| | | | - C. Alberto Figueroa
- Departments of Surgery and Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
| | | | - Frans L. Moll
- Department of Vascular Surgery, University Medical Center Utrecht, the Netherlands
| | - Santi Trimarchi
- Thoracic Aortic Research Center, Policlinico San Donato IRCCS, University of Milan, Italy
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Abstract
PURPOSE To demonstrate explantation of the Nellix Endovascular Aneurysm Sealing (EVAS) System in the setting of infection. CASE REPORTS Two male patients, 71 and 83 years old, underwent Nellix implantation for asymptomatic infrarenal aortic aneurysms measuring 5.1 and 6.3 cm, respectively. Each developed late infections at 8 and 4 months post EVAS, respectively. The first patient experienced aneurysm rupture after medical therapy failed; the Nellix endosystem was explanted in an uneventful procedure. The second patient developed an aortoduodenal fistula, which was sutured before the Nellix device was removed without complications. The patient died 3 months later, presumably due to ongoing infection. CONCLUSION The need to explant a Nellix EVAS System due to graft infection is a straightforward procedure compared to the removal of a conventional endograft with suprarenal fixation. It requires only temporary suprarenal clamping. The devices can be easily removed due to the lack of penetrating components and without damage to the aortic segment needed to create an anastomosis.
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Affiliation(s)
- Jip L Tolenaar
- Department of Vascular Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
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van Rappard JRM, Tolenaar JL, Smits AB, Go PMNYH. Spinal epidural abscess and meningitis following short-term epidural catheterisation for postoperative analgaesia. BMJ Case Rep 2015; 2015:bcr-2015-210867. [PMID: 26294360 DOI: 10.1136/bcr-2015-210867] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
We present a case of a patient with a spinal epidural abscess (SEA) and meningitis following short-term epidural catheterisation for postoperative pain relief after a laparoscopic sigmoid resection. On the fifth postoperative day, 2 days after removal of the epidural catheter, the patient developed high fever, leucocytosis and elevated C reactive protein. Blood cultures showed a methicillin-sensitive Staphylococcus aureus infection. A photon emission tomography scan revealed increased activity of the spinal canal, suggesting S. aureus meningitis. A gadolinium-enhanced MRI showed a SEA that was localised at the epidural catheter insertion site. Conservative management with intravenous flucloxacillin was initiated, as no neurological deficits were seen. At last follow-up, 8 weeks postoperatively, the patient showed complete recovery.
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Affiliation(s)
| | - Jip L Tolenaar
- Department of Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Anke B Smits
- Department of Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Peter M N Y H Go
- Department of Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
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15
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16
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Derbel B, Tolenaar JL, Trimarchi S. Use of Chimney graft after accidental coverage of the left common carotid artery in TEVAR procedure. Tunis Med 2014; 92:756-759. [PMID: 25879602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
BACKGROUND Thoracic endovascular aneurysm repair (TEVAR) is currently the therapy of first choice for most thoracic aortic disease. Because aortic stent grafts are placed in the vicinity of aortic side branches, unintentional coverage of these arteries may occur. CASE REPORT We report a case of a 69-year-old male with an asymptomatic penetrating ulcer of the aortic arch, based at the origin of the left subclavian artery. Due to his medical story, we decided to perform an endovascular procedure with placement of a stent graft in the left hemi-ach wit previous left common carotid subclavian bypass. During the deployment of the aortic stent graft, the proximal margin of the stent graft displaced, inadvertly covering the origin of the left common carotid artery. As a bail out procedure, we successfully revascularized the left common carotid artery with the use of the chimney technique. CONCLUSION Endovascular treatment of aortic disease has gained popularity over the last decade. Despite increasing experience, these procedures remain technically challenging. Unintentional coverage of main aortic side branches during TEVAR is a serious complication, which requires immediate intervention. The chimney technique offers a minimal invasive procedure in such case, with promising results.
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van Bogerijen GHW, Auricchio F, Conti M, Lefieux A, Reali A, Veneziani A, Tolenaar JL, Moll FL, Rampoldi V, Trimarchi S. Aortic Hemodynamics After Thoracic Endovascular Aortic Repair, With Particular Attention to the Bird-Beak Configuration. J Endovasc Ther 2014; 21:791-802. [DOI: 10.1583/14-4778mr.1] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Tolenaar JL, Eagle KA, Jonker FHW, Moll FL, Elefteriades JA, Trimarchi S. Partial thrombosis of the false lumen influences aortic growth in type B dissection. Ann Cardiothorac Surg 2014; 3:275-7. [PMID: 24967166 DOI: 10.3978/j.issn.2225-319x.2014.04.01] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2014] [Accepted: 03/27/2014] [Indexed: 11/14/2022]
Affiliation(s)
- Jip L Tolenaar
- 1 Thoracic Aortic Research Center, Policlinico San Donato IRCCS, Milan, Italy ; 2 Department of Vascular Surgery, University Medical Center Utrecht, the Netherlands ; 3 Cardiovascular Center, University of Michigan, Ann Arbor, MI, USA ; 4 Section of Vascular Surgery, Maasstad Hospital Rotterdam, the Netherlands ; 5 Aortic Institute, Yale University, New Haven, CT, USA
| | - Kim A Eagle
- 1 Thoracic Aortic Research Center, Policlinico San Donato IRCCS, Milan, Italy ; 2 Department of Vascular Surgery, University Medical Center Utrecht, the Netherlands ; 3 Cardiovascular Center, University of Michigan, Ann Arbor, MI, USA ; 4 Section of Vascular Surgery, Maasstad Hospital Rotterdam, the Netherlands ; 5 Aortic Institute, Yale University, New Haven, CT, USA
| | - Frederik H W Jonker
- 1 Thoracic Aortic Research Center, Policlinico San Donato IRCCS, Milan, Italy ; 2 Department of Vascular Surgery, University Medical Center Utrecht, the Netherlands ; 3 Cardiovascular Center, University of Michigan, Ann Arbor, MI, USA ; 4 Section of Vascular Surgery, Maasstad Hospital Rotterdam, the Netherlands ; 5 Aortic Institute, Yale University, New Haven, CT, USA
| | - Frans L Moll
- 1 Thoracic Aortic Research Center, Policlinico San Donato IRCCS, Milan, Italy ; 2 Department of Vascular Surgery, University Medical Center Utrecht, the Netherlands ; 3 Cardiovascular Center, University of Michigan, Ann Arbor, MI, USA ; 4 Section of Vascular Surgery, Maasstad Hospital Rotterdam, the Netherlands ; 5 Aortic Institute, Yale University, New Haven, CT, USA
| | - John A Elefteriades
- 1 Thoracic Aortic Research Center, Policlinico San Donato IRCCS, Milan, Italy ; 2 Department of Vascular Surgery, University Medical Center Utrecht, the Netherlands ; 3 Cardiovascular Center, University of Michigan, Ann Arbor, MI, USA ; 4 Section of Vascular Surgery, Maasstad Hospital Rotterdam, the Netherlands ; 5 Aortic Institute, Yale University, New Haven, CT, USA
| | - Santi Trimarchi
- 1 Thoracic Aortic Research Center, Policlinico San Donato IRCCS, Milan, Italy ; 2 Department of Vascular Surgery, University Medical Center Utrecht, the Netherlands ; 3 Cardiovascular Center, University of Michigan, Ann Arbor, MI, USA ; 4 Section of Vascular Surgery, Maasstad Hospital Rotterdam, the Netherlands ; 5 Aortic Institute, Yale University, New Haven, CT, USA
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Tolenaar JL, Kern JA, Jonker FHW, Cherry KJ, Tracci MC, Angle JF, Sabri S, Trimarchi S, Strider D, Alaiwaidi G, Upchurch GR. Predictors of false lumen thrombosis in type B aortic dissection treated with TEVAR. Ann Cardiothorac Surg 2014; 3:255-63. [PMID: 24967164 DOI: 10.3978/j.issn.2225-319x.2014.05.17] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Accepted: 05/28/2014] [Indexed: 11/14/2022]
Abstract
BACKGROUND Thoracic endovascular aortic repair (TEVAR) offers a less invasive treatment option in type B aortic dissection (TBAD) patients and its value has been demonstrated in acute and chronic dissection patients. Total false lumen thrombosis (FLT) is associated with better long-term outcome in these patients, however, this is not obtained in all patients. The purpose of this study was to investigate predictors of FLT. METHODS We retrospectively investigated patients who underwent TEVAR for a type B dissection in a large referral center between 2005 and 2012. All patients with a CT angiogram (CTA) obtained preoperatively, postoperatively and after one year of follow-up were selected for analysis. Volume measurements and several morphologic characteristics were analyzed for all scans using Aquarius iNtuition software (TeraRecon, San Mateo, Calif, USA). Multivariate logistic regression analyses were used to study the influence of these characteristics on FLT. RESULTS Of 132 patients that received TEVAR for an aortic dissection, 43 patients (mean age, 60.3±14.2; 30 male) met our inclusion criteria, of whom 16 (37%) developed full FLT after 1 yr of follow-up. Multivariate logistic regression showed that side branch involvement [odds ratio (OR), 0.03; 95% confidence interval (CI), 0.00-0.92; P=0.045] and a total patent false lumen (FL) at presentation (OR, 0.01; 95% CI, 0.00-0.58; P=0.027) were associated with decreased complete FLT. Volumetric data showed significantly more reduction of the thoracic false lumen in FLT patients compared with non-FLT (-52.3% vs. -32.4%; P=0.043) and also a tendency of less volume increase in the abdominal segment (-5.0±37.5 vs. 21.8±44.3; P=0.052). CONCLUSIONS Patients admitted with type B dissection and branch vessel involvement or a patent entry tear after TEVAR are less likely to develop FLT and aortic remodeling during follow-up. These findings suggest that these patients may require a more extensive procedure and more intensive follow-up to prevent long-term complications.
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Affiliation(s)
- Jip L Tolenaar
- 1 Department of Surgery, University of Virginia, Charlottesville, VA, USA ; 2 Thoracic Aorta Research Center, Policlinico San Donato IRCCS, Milan, Italy ; 3 Department of Surgery, Maasstad ziekenhuis, Rotterdam, The Netherlands
| | - John A Kern
- 1 Department of Surgery, University of Virginia, Charlottesville, VA, USA ; 2 Thoracic Aorta Research Center, Policlinico San Donato IRCCS, Milan, Italy ; 3 Department of Surgery, Maasstad ziekenhuis, Rotterdam, The Netherlands
| | - Frederik H W Jonker
- 1 Department of Surgery, University of Virginia, Charlottesville, VA, USA ; 2 Thoracic Aorta Research Center, Policlinico San Donato IRCCS, Milan, Italy ; 3 Department of Surgery, Maasstad ziekenhuis, Rotterdam, The Netherlands
| | - Kenneth J Cherry
- 1 Department of Surgery, University of Virginia, Charlottesville, VA, USA ; 2 Thoracic Aorta Research Center, Policlinico San Donato IRCCS, Milan, Italy ; 3 Department of Surgery, Maasstad ziekenhuis, Rotterdam, The Netherlands
| | - Megan C Tracci
- 1 Department of Surgery, University of Virginia, Charlottesville, VA, USA ; 2 Thoracic Aorta Research Center, Policlinico San Donato IRCCS, Milan, Italy ; 3 Department of Surgery, Maasstad ziekenhuis, Rotterdam, The Netherlands
| | - John F Angle
- 1 Department of Surgery, University of Virginia, Charlottesville, VA, USA ; 2 Thoracic Aorta Research Center, Policlinico San Donato IRCCS, Milan, Italy ; 3 Department of Surgery, Maasstad ziekenhuis, Rotterdam, The Netherlands
| | - Saher Sabri
- 1 Department of Surgery, University of Virginia, Charlottesville, VA, USA ; 2 Thoracic Aorta Research Center, Policlinico San Donato IRCCS, Milan, Italy ; 3 Department of Surgery, Maasstad ziekenhuis, Rotterdam, The Netherlands
| | - Santi Trimarchi
- 1 Department of Surgery, University of Virginia, Charlottesville, VA, USA ; 2 Thoracic Aorta Research Center, Policlinico San Donato IRCCS, Milan, Italy ; 3 Department of Surgery, Maasstad ziekenhuis, Rotterdam, The Netherlands
| | - David Strider
- 1 Department of Surgery, University of Virginia, Charlottesville, VA, USA ; 2 Thoracic Aorta Research Center, Policlinico San Donato IRCCS, Milan, Italy ; 3 Department of Surgery, Maasstad ziekenhuis, Rotterdam, The Netherlands
| | - Gorav Alaiwaidi
- 1 Department of Surgery, University of Virginia, Charlottesville, VA, USA ; 2 Thoracic Aorta Research Center, Policlinico San Donato IRCCS, Milan, Italy ; 3 Department of Surgery, Maasstad ziekenhuis, Rotterdam, The Netherlands
| | - Gilbert R Upchurch
- 1 Department of Surgery, University of Virginia, Charlottesville, VA, USA ; 2 Thoracic Aorta Research Center, Policlinico San Donato IRCCS, Milan, Italy ; 3 Department of Surgery, Maasstad ziekenhuis, Rotterdam, The Netherlands
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20
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Trimarchi S, Jonker FHW, van Bogerijen GHW, Tolenaar JL, Moll FL, Czerny M, Patel HJ. Predicting aortic enlargement in type B aortic dissection. Ann Cardiothorac Surg 2014; 3:285-91. [PMID: 24967168 DOI: 10.3978/j.issn.2225-319x.2014.05.01] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2014] [Accepted: 05/12/2014] [Indexed: 11/14/2022]
Abstract
Patients with uncomplicated acute type B aortic dissection (ABAD) can generally be treated with conservative medical management. However, these patients may develop aortic enlargement during follow-up, with the risk of rupture. Several predictors have been studied in recent years to identify ABAD patients at high risk of aortic enlargement, who may benefit from early surgical or endovascular intervention. This study reviewed and summarized the current available literature on prognostic variables related to aortic enlargement during follow-up in uncomplicated ABAD patients. It revealed multiple factors affecting aortic expansion including demographic, clinical, pharmacologic and radiologic variables. Such predictors may be used to identify those ABAD patients at higher risk for aortic enlargement who may benefit from closer radiologic surveillance or early endovascular intervention. This approach deserves even more consideration because a significant number of patients develop aneurysmal degeneration along the dissected segments during follow-up, and may lose the opportunity for endovascular treatment if not identified at an early stage.
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Affiliation(s)
- Santi Trimarchi
- 1 Thoracic Aortic Research Center, Policlinico San Donato IRCCS, University of Milan, Milan, Italy ; 2 Department of Surgery, Maasstad Hospital, Rotterdam, The Netherlands ; 3 The Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands ; 4 Department of Cardiac Surgery, University of Michigan Cardiovascular Center, Ann Arbor, MI, USA ; 5 Department of Cardiothoracic Surgery, University of Zurich, Switzerland
| | - Frederik H W Jonker
- 1 Thoracic Aortic Research Center, Policlinico San Donato IRCCS, University of Milan, Milan, Italy ; 2 Department of Surgery, Maasstad Hospital, Rotterdam, The Netherlands ; 3 The Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands ; 4 Department of Cardiac Surgery, University of Michigan Cardiovascular Center, Ann Arbor, MI, USA ; 5 Department of Cardiothoracic Surgery, University of Zurich, Switzerland
| | - Guido H W van Bogerijen
- 1 Thoracic Aortic Research Center, Policlinico San Donato IRCCS, University of Milan, Milan, Italy ; 2 Department of Surgery, Maasstad Hospital, Rotterdam, The Netherlands ; 3 The Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands ; 4 Department of Cardiac Surgery, University of Michigan Cardiovascular Center, Ann Arbor, MI, USA ; 5 Department of Cardiothoracic Surgery, University of Zurich, Switzerland
| | - Jip L Tolenaar
- 1 Thoracic Aortic Research Center, Policlinico San Donato IRCCS, University of Milan, Milan, Italy ; 2 Department of Surgery, Maasstad Hospital, Rotterdam, The Netherlands ; 3 The Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands ; 4 Department of Cardiac Surgery, University of Michigan Cardiovascular Center, Ann Arbor, MI, USA ; 5 Department of Cardiothoracic Surgery, University of Zurich, Switzerland
| | - Frans L Moll
- 1 Thoracic Aortic Research Center, Policlinico San Donato IRCCS, University of Milan, Milan, Italy ; 2 Department of Surgery, Maasstad Hospital, Rotterdam, The Netherlands ; 3 The Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands ; 4 Department of Cardiac Surgery, University of Michigan Cardiovascular Center, Ann Arbor, MI, USA ; 5 Department of Cardiothoracic Surgery, University of Zurich, Switzerland
| | - Martin Czerny
- 1 Thoracic Aortic Research Center, Policlinico San Donato IRCCS, University of Milan, Milan, Italy ; 2 Department of Surgery, Maasstad Hospital, Rotterdam, The Netherlands ; 3 The Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands ; 4 Department of Cardiac Surgery, University of Michigan Cardiovascular Center, Ann Arbor, MI, USA ; 5 Department of Cardiothoracic Surgery, University of Zurich, Switzerland
| | - Himanshu J Patel
- 1 Thoracic Aortic Research Center, Policlinico San Donato IRCCS, University of Milan, Milan, Italy ; 2 Department of Surgery, Maasstad Hospital, Rotterdam, The Netherlands ; 3 The Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands ; 4 Department of Cardiac Surgery, University of Michigan Cardiovascular Center, Ann Arbor, MI, USA ; 5 Department of Cardiothoracic Surgery, University of Zurich, Switzerland
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21
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van Bogerijen GH, Tolenaar JL, Rampoldi V, Moll FL, van Herwaarden JA, Jonker FH, Eagle KA, Trimarchi S. Predictors of aortic growth in uncomplicated type B aortic dissection. J Vasc Surg 2014; 59:1134-43. [DOI: 10.1016/j.jvs.2014.01.042] [Citation(s) in RCA: 81] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2013] [Revised: 01/10/2014] [Accepted: 01/19/2014] [Indexed: 10/25/2022]
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Tolenaar JL, Jonker FH, Moll FL, van Herwaarden J, Morasch MD, Makaroun MS, Trimarchi S. Influence of Oversizing on Outcome in Thoracic Endovascular Aortic Repair. J Endovasc Ther 2013; 20:738-45. [DOI: 10.1583/13-4388mr.1] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Tolenaar JL, van Herwaarden JA, Verhagen H, Moll FL, Muhs BE, Trimarchi S. Importance of entry tears in Type B aortic dissection prognosis. Ann Cardiothorac Surg 2013; 2:631-2. [PMID: 24109572 DOI: 10.3978/j.issn.2225-319x.2013.09.05] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2013] [Accepted: 09/06/2013] [Indexed: 11/14/2022]
Affiliation(s)
- Jip L Tolenaar
- Thoracic Aortic Research Center, Policlinico San Donato IRCCS, Milan, Italy
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van Bogerijen GH, Tolenaar JL, Conti M, Auricchio F, Secchi F, Sardanelli F, Moll FL, van Herwaarden JA, Rampoldi V, Trimarchi S. Contemporary Role of Computational Analysis in Endovascular Treatment for Thoracic Aortic Disease. Aorta (Stamford) 2013; 1:171-181. [PMID: 26798690 PMCID: PMC4682739 DOI: 10.12945/j.aorta.2013.13-003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/14/2013] [Accepted: 07/12/2013] [Indexed: 06/05/2023]
Abstract
In the past decade, thoracic endovascular aortic repair (TEVAR) has become the primary treatment option in descending aneurysm and dissection. The clinical outcome of this minimally invasive technique is strictly related to an appropriate patient/stent graft selection, hemodynamic interactions, and operator skills. In this context, a quantitative assessment of the biomechanical stress induced in the aortic wall due to the stent graft may support the planning of the procedure. Different techniques of medical imaging, like computed tomography or magnetic resonance imaging, can be used to evaluate dynamics in the thoracic aorta. Such information can also be combined with dedicated patient-specific computer-based simulations, to provide a further insight into the biomechanical aspects. In clinical practice, computational analysis might show the development of aortic disease, such as the aortic wall segments which experience higher stress in places where rupture and dissection may occur. In aortic dissections, the intimal tear is usually located at the level of the sino-tubular junction and/or at the origin of the left subclavian artery. Besides, computational models may potentially be used preoperatively to predict stent graft behavior, virtually testing the optimal stent graft sizing, deployment, and conformability, in order to provide the best endovascular treatment. The present study reviews the current literature regarding the use of computational tools for TEVAR biomechanics, highlighting their potential clinical applications.
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Affiliation(s)
- Guido H.W. van Bogerijen
- Thoracic Aortic Research Center, Policlinico San Donato IRCCS, University of Milan, Milan, Italy
| | - Jip L. Tolenaar
- Thoracic Aortic Research Center, Policlinico San Donato IRCCS, University of Milan, Milan, Italy
| | - Michele Conti
- Department of Civil Engineering and Architecture, Structural Mechanics Division, University of Pavia, Pavia, Italy
| | - Ferdinando Auricchio
- Department of Civil Engineering and Architecture, Structural Mechanics Division, University of Pavia, Pavia, Italy
| | - Francesco Secchi
- Department of Radiology, Policlinico San Donato IRCCS, University of Milan, Milan, Italy; and
| | - Francesco Sardanelli
- Department of Radiology, Policlinico San Donato IRCCS, University of Milan, Milan, Italy; and
| | - Frans L. Moll
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Vincenzo Rampoldi
- Thoracic Aortic Research Center, Policlinico San Donato IRCCS, University of Milan, Milan, Italy
| | - Santi Trimarchi
- Thoracic Aortic Research Center, Policlinico San Donato IRCCS, University of Milan, Milan, Italy
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Tolenaar JL, van Keulen JW, Trimarchi S, Jonker FH, van Herwaarden JA, Verhagen HJ, Moll FL, Muhs BE. Number of Entry Tears Is Associated With Aortic Growth in Type B Dissections. Ann Thorac Surg 2013; 96:39-42. [DOI: 10.1016/j.athoracsur.2013.03.087] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2013] [Revised: 03/28/2013] [Accepted: 03/28/2013] [Indexed: 11/28/2022]
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Tolenaar JL, Hutchison SJ, Montgomery D, O'Gara P, Fattori R, Pyeritz RE, Pape L, Suzuki T, Evangelista A, Moll FL, Rampoldi V, Isselbacher EM, Nienaber CA, Eagle KA, Trimarchi S. Painless Type B Aortic Dissection: Insights From the International Registry of Acute Aortic Dissection. Aorta (Stamford) 2013; 1:96-101. [PMID: 26798680 DOI: 10.12945/j.aorta.2013.13-014] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/06/2013] [Accepted: 06/03/2013] [Indexed: 11/18/2022]
Abstract
INTRODUCTION The classical presentation of a patient with Type B acute aortic dissection (TBAAD) is characterized by severe chest, back, or abdominal pain, ripping or tearing in nature. However, some patients present with painless acute aortic dissection, which can lead to a delay in diagnosis and treatment. We utilized the International Registry on Acute Aortic Dissections (IRAD) database to study these patients. METHODS We analyzed 43 painless TBAAD patients enrolled in the database between January 1996 and July 2012. The differences in presentation, diagnostics, management, and outcome were compared with patients presenting with painful TBAAD. RESULTS Among the 1162 TBAAD patients enrolled in IRAD, 43 patients presented with painless TBAAD (3.7%). The mean age of patients with painless TBAAD was significantly higher than normal TBAAD patients (69.2 versus 63.3 years, P = 0.020). The presence of atherosclerosis (46.4% versus 30.1%, P = 0.022), diabetes (17.9% versus 7.5%; P = 0.018), and other aortic diseases (8.6% versus 2.3%, P= 0.051), such as prior aortic aneurysm (31% versus 18.8% P = 0.049) was more common in these patients. Median delay time between presentation and diagnosis was longer in painless patients (median 34.0 versus 19.0 hours; P = 0.006). Dissection of iatrogenic origin (19.5% versus 1.3%; P < 0.001) was significantly more frequent in the painless group. The in-hospital mortality was 18.6% in the painless group, compared with an in-hospital mortality of 9.9% in the control group (P = 0.063). CONCLUSION Painless TBAAD is a relatively rare presentation (3.7%) of aortic dissection, and is often associated with a history of atherosclerosis, diabetes, prior aortic disease including aortic aneurysm, and an iatrogenic origin. We observed a trend for increased in-hospital mortality in painless TBAAD patients, which may be the result of a delay in diagnosis and management. Therefore, physicians should be aware of this relative rare presentation of TBAAD.
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Affiliation(s)
- Jip L Tolenaar
- Department of Cardiovascular Surgery, Policlinico San Donato IRCCS, Milan, Italy
| | | | - Dan Montgomery
- University of Michigan Health System, Ann Arbor, Michigan
| | | | | | - Reed E Pyeritz
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Linda Pape
- University of Massachusetts Hospital, Worcester, Massachusetts
| | - Toru Suzuki
- Department of Cardiology, University of Tokyo, Tokyo, Japan
| | | | - Frans L Moll
- University Medical Center Utrecht, Utrecht, The Netherlands
| | - Vincenzo Rampoldi
- Department of Cardiovascular Surgery, Policlinico San Donato IRCCS, Milan, Italy
| | | | | | - Kim A Eagle
- University of Michigan Health System, Ann Arbor, Michigan
| | - Santi Trimarchi
- Department of Cardiovascular Surgery, Policlinico San Donato IRCCS, Milan, Italy
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Tolenaar JL, Zandvoort HJA, Moll FL, van Herwaarden JA. Technical considerations and results of chimney grafts for the treatment of juxtarenal aneursyms. J Vasc Surg 2013; 58:607-15. [PMID: 23684412 DOI: 10.1016/j.jvs.2013.02.238] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2012] [Revised: 02/13/2013] [Accepted: 02/14/2013] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To present our initial experience and technical considerations for the use of chimney grafts in the treatment of patients that require endovascular aneurysm repair with aortic branch preservation. METHODS All patients treated with a chimney procedure between October 2009 and June 2011 were included in our analyses. Chimney procedures were only performed in patients that were unsuitable for open repair and without opportunity to use fenestrated grafts (because of unsuitable anatomy or emergency operation). Open brachial or axillary access was used to deploy covered chimney grafts in the target vessels, and subsequently, a stent graft was deployed via femoral cut-down access. RESULTS Thirteen patients (12 males; mean age, 77.2 ± 6.2 years; mean maximal diameter, 71.4 ± 10.2 mm) underwent a chimney procedure with the preservation of 22 aortic side branches. Primary technical success was 92.3% due to occlusion of one renal artery within 24 hours. Thirty-day mortality was 0%. Infrarenal mean neck length was 2.6 mm ± 3.2 mm (range, 0-8 mm) and could be extended to 27.3 mm ± 9.9 mm (range, 18-53 mm) by the use of chimney grafts. During follow-up (median, 10.8 months; interquartile range, 7.4-19.4), one patient died from complications from mesenteric ischemia based on a stenosis of the celiac trunk attributable to the bare stent of the stent graft, and one patient died from aneurysm rupture. Other complications included late occlusion of one renal artery and a type II endoleak, which was unsuccessfully treated with coil embolization and required laparotomy. If we disregard the ruptured patient who had an enormous increase of aneurysm diameter, mean aortic aneurysm diameter reduced from 70.7 ± 10.3 mm (range, 54-89 mm) to 66.7 ± 13.9 mm (range, 48-96 mm) during follow-up (P = .13). In three patients, the aneurysm diameter decreased by more than 5 mm and in two patients, the diameter increased by more than 5 mm. The aneurysm diameter remained stable in the other eight patients. CONCLUSIONS Until off-the-shelf fenestrated or branched stent grafts become available, the chimney procedure offers a minimally invasive treatment option in patients requiring aneurysm exclusion with side branch revascularization. Although long-term follow-up has to be awaited, the initial results show that chimney grafts can help to decrease or stabilize the aneurysm diameter in most patients, but aneurysm rupture was not prevented in all patients.
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Affiliation(s)
- Jip L Tolenaar
- Department of Vascular Surgery, University Medical Center, Utrecht, The Netherlands
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Froehlich WT, Tolenaar JL, Suzuki T, Masip AE, Braverman A, Pape L, Voehringer M, O'Gara P, Forteza A, Greason K, Steg P, Isselbacher E, Nienaber C, Eagle K, Trimarchi S. PREDICTORS OF DEATH IN TYPE B ACUTE AORTIC DISSECTION PATIENTS: AN ANALYSIS FROM THE INTERNATIONAL REGISTRY OF ACUTE AORTIC DISSECTION (IRAD). J Am Coll Cardiol 2013. [DOI: 10.1016/s0735-1097(13)61564-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Trimarchi S, Tolenaar JL, Jonker FH, Murray B, Tsai TT, Eagle KA, Rampoldi V, Verhagen HJ, van Herwaarden JA, Moll FL, Muhs BE, Elefteriades JA. Importance of false lumen thrombosis in type B aortic dissection prognosis. J Thorac Cardiovasc Surg 2013; 145:S208-12. [DOI: 10.1016/j.jtcvs.2012.11.048] [Citation(s) in RCA: 121] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2012] [Revised: 08/07/2012] [Accepted: 11/20/2012] [Indexed: 11/17/2022]
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Auricchio F, Conti M, Marconi S, Reali A, Tolenaar JL, Trimarchi S. Patient-specific aortic endografting simulation: from diagnosis to prediction. Comput Biol Med 2013; 43:386-94. [PMID: 23395199 DOI: 10.1016/j.compbiomed.2013.01.006] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2012] [Revised: 01/03/2013] [Accepted: 01/16/2013] [Indexed: 11/29/2022]
Abstract
Traditional surgical repair of ascending aortic pseudoaneurysm is complex, technically challenging, and associated with significant mortality. Although new minimally invasive procedures are rapidly arising thanks to the innovations in catheter-based technologies, the endovascular repair of the ascending aorta is still limited because of the related anatomical challenges. In this context, the integration of the clinical considerations with dedicated bioengineering analysis, combining the vascular features and the prosthesis design, might be helpful to plan the procedure and predict its outcome. Moving from such considerations, in the present study we describe the use of a custom-made stent-graft to perform a fully endovascular repair of an asymptomatic ascending aortic pseudoaneurysm in a patient, who was a poor candidate for open surgery. We also discuss the possible contribution of a dedicated medical images analysis and patient-specific simulation as support to procedure planning. In particular, we have compared the simulation prediction based on pre-operative images with post-operative outcomes. The agreement between the computer-based analysis and reality encourages the use of the proposed approach for a careful planning of the treatment strategy and for an appropriate patient selection, aimed at achieving successful outcomes for endovascular treatment of ascending aortic pseudoaneurysms as well as other aortic diseases.
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Affiliation(s)
- F Auricchio
- Department of Civil Engineering and Architecture, University of Pavia, Pavia, Italy
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Tolenaar JL, Harris KM, Upchurch GR, Rampoldi V, Evangelista A, Moll FL, Froehlich JB, di Eusanio M, Eagle K, Trimarchi S. Intramural Hematoma of the Descending Aorta: Differences and Similarities With Acute B Dissection. J Vasc Surg 2013. [DOI: 10.1016/j.jvs.2012.11.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Tolenaar JL, van Keulen JW, Trimarchi S, Muhs BE, Moll FL, van Herwaarden JA. The chimney graft, a systematic review. Ann Vasc Surg 2012; 26:1030-8. [PMID: 22498342 DOI: 10.1016/j.avsg.2011.11.029] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2011] [Revised: 11/30/2011] [Accepted: 11/30/2011] [Indexed: 01/09/2023]
Abstract
BACKGROUND Approximately 20% to 30% of the patients are considered not eligible for standard endovascular aneurysm repair because of aortic neck morphology. Most of these patients have an aortic neck situated in the vicinity of the aortic side branches, requiring extensive open surgery. The introduction of fenestrated and branched stent grafts has made endovascular branch preservation possible, but these procedures are time-consuming and expensive. The chimney procedure offers a readily available endovascular alternative for the treatment in patients with acute aneurysms and challenging anatomy. We conducted a systematic review to evaluate the short- and long-term results of the chimney procedure. METHODS A comprehensive literature search for studies describing the chimney procedure was performed using MEDLINE and Excerpta Medica Database. All articles were critically appraised and included, based on relevance, validity, and outcome measures. Patient characteristics, details of the surgical intervention, and short- and long-term outcomes were studied. RESULTS A total of 75 patients were included who underwent a chimney procedure for the preservation of a total of 96 branches. Used operating techniques differed considerably between all studies, with an overall technical success rate of 98.9%. Three perioperative deaths were reported, of which one patient died from intervention-related complication. The follow-up duration ranged from 2 days to 54 months. Late complications included three deaths, none of which was device or aneurysm related. Three chimney grafts occluded during follow-up, of which two required reintervention. CONCLUSION The chimney procedure appears as an acceptable alternative for patients in an emergency setting, although data regarding long-term follow-up are not yet available.
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Affiliation(s)
- Jip L Tolenaar
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
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Trimarchi S, Tolenaar JL, Tsai TT, Froehlich J, Pegorer M, Upchurch GR, Fattori R, Sundt TM, Isselbacher EM, Nienaber CA, Rampoldi V, Eagle KA. Influence of clinical presentation on the outcome of acute B aortic dissection: evidences from IRAD. J Cardiovasc Surg (Torino) 2012; 53:161-168. [PMID: 22456637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
AIM In-hospital outcome of acute type B dissection (ABAD) is strongly related to preoperative aortic conditions. In order to clarify the influence of the clinical presentation on the outcome, we analyzed the patients of the International Registry of Acute Aortic Dissection (IRAD). All patients affected by complicated ABAD, enrolled in the IRAD from 1996-2004, were included. Complications were defined as the presence of shock, periaortic hematoma, spinal cord ischemia, preoperative mesenteric ischemia/infarction, acute renal failure, limb ischemia, recurrent pain, refractory pain or refractory hypertension (group I). All other patients were categorized as uncomplicated (group II). A comprehensive analysis was performed of all clinical variables in relation to in-hospital outcome. RESULTS The overall in-hospital mortality among 550 patients was 12.4%. Mortality in group I (250 patients) was 20.0 %, compared to 6.1% in group II (300 patients) (P<0.001). Univariate predictors of ABAD complications were Marfan syndrome, abrupt onset of pain, migrating pain, any focal neurological deficits, need for higher number of diagnostic examinations and use of magnetic resonance and/or aortogram, abdominal vessels involvement at aortogram, larger descending aortic diameter, especially >6 cm, pleural effusion, and widened mediastinum on chest X-ray. Univariate predictors of a non complicated status were normal chest X-ray and medical management. In group I, in-hospital mortality following surgical and endovascular intervention were 28.6% and 10.1% (P=0.006), respectively. Independent predictors of overall in-hospital mortality included age >70 years, female gender, ECG showing ischemia, preoperative acute renal failure, preoperative limb ischemia, periaortic hematoma, and surgical management. The only independent variable protective for mortality was magnetic resonance as diagnostic test. CONCLUSION ABAD is a heterogeneous disease that produces dissimilar clinical subsets, each of which can have specific clinical signs, management and in-hospital results. In IRAD ABAD uncomplicated patients, medical therapy was associated with best hospital outcome, while endovascular interventions were associated with better results than surgery when invasive treatments were required. Although selection bias may be possible, and irrespective of treatments, knowledge of significant risk factors for mortality may contribute to a better management and a more defined risk-assessment in patients affected by ABAD.
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Affiliation(s)
- S Trimarchi
- Thoracic Aortic Research Center, Policlinico San Donato IRCCS, University of Milan, Milan, Italy.
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van Keulen JW, Moll FL, Vonken EJP, Tolenaar JL, Muhs BE, van Herwaarden JA. Pulsatility in the iliac artery is significant at several levels: implications for EVAR. J Endovasc Ther 2011; 18:199-204. [PMID: 21521060 DOI: 10.1583/10-3322.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
PURPOSE To evaluate the pulsatility of the iliac arteries and compare their distension at several levels that might influence preoperative stent-graft sizing and the long-term durability of stent-graft sealing and fixation. METHODS Preoperative dynamic computed tomographic angiography (CTA) scans of 30 patients (24 men; median age 75 years, range 60-85) with an abdominal aortic aneurysm and patent iliac arteries were included. The CTAs consisted of 8 images per heartbeat. Bilateral diameter and area changes per heartbeat were measured semi-automatically in the common iliac artery (CIA) at 3 levels: (A) 0.5 cm after the aortic bifurcation, (B) in the middle of the CIA, and (C) 0.5 cm proximal to the iliac bifurcation. Pulsatility was defined as the largest difference in area and average diameter change over 180 axes per heartbeat. Pulsatility at the 3 levels was compared, and the intraobserver variability of the method was calculated according to Bland and Altman. RESULTS The mean area increases in the CIAs at levels A, B, and C were 12.5% (16.3 mm²), 11.2% (13.6 mm²), and 9.6% (12.6 mm²), respectively, and the mean iliac diameter increases were 9.2% (1.1 mm), 8.5% (1.0 mm), and 8.1% (1.0 mm). The iliac distension was statistically significant at all levels. The iliac distension at level A was statistically significantly larger than the distension at level C. The intraobserver variability was 13.3 mm² for area and 0.6 mm for diameter measurements. CONCLUSION The pulsatility in the iliac arteries is statistically significant at several levels relevant to endovascular aneurysm repair. The distension of the iliac artery possibly decreases more distally, which might encourage the extension of stent-grafts to the internal iliac artery.
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Affiliation(s)
- Jasper W van Keulen
- Department of Vascular Surgery, University Medical Center Utrecht, The Netherlands
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Tolenaar JL, van Keulen JW, Vonken EJ, van Herwaarden JA, Moll FL, de Borst GJ. Fenestration of an Iatrogenic Aortic Dissection After Endovascular Aneurysm Repair. J Endovasc Ther 2011; 18:256-60. [DOI: 10.1583/10-3330.1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Tolenaar JL, van Keulen JW, Leijdekkers VJ, Vonken EJ, Moll FL, van Herwaarden JA. A ruptured aneurysm after stent graft puncture during computed tomography-guided thrombin injection. J Vasc Surg 2010; 52:1045-7. [DOI: 10.1016/j.jvs.2010.04.074] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2010] [Revised: 04/29/2010] [Accepted: 03/29/2010] [Indexed: 11/28/2022]
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van Keulen JW, Moll FL, Tolenaar JL, Verhagen HJ, van Herwaarden JA. Validation of a new standardized method to measure proximal aneurysm neck angulation. J Vasc Surg 2010; 51:821-8. [DOI: 10.1016/j.jvs.2009.10.114] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2009] [Revised: 10/20/2009] [Accepted: 10/21/2009] [Indexed: 10/19/2022]
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