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Eggebrecht H, Thompson M, Rousseau H, Czerny M, Lönn L, Mehta RH, Erbel R. Retrograde Ascending Aortic Dissection During or After Thoracic Aortic Stent Graft Placement. Circulation 2009; 120:S276-81. [PMID: 19752379 DOI: 10.1161/circulationaha.108.835926] [Citation(s) in RCA: 247] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Single-center reports have identified retrograde ascending aortic dissection (rAAD) as a potentially lethal complication of thoracic endovascular aortic repair (TEVAR).
Methods and Results—
Between 1995 and 2008, 28 centers participating in the European Registry on Endovascular Aortic Repair Complications reported a total of 63 rAAD cases (incidence, 1.33%; 95% CI, 0.75 to 2.40). Eighty-one percent of patients underwent TEVAR for acute (n=26, 54%) or chronic type B dissection (n=13, 27%). Stent grafts with proximal bare springs were used in majority of patients (83%). Only 7 (15%) patients had intraoperative rAAD, with the remaining occurring during the index hospitalization (n=10, 21%) and during follow-up (n=31, 64%). Presenting symptoms included acute chest pain (n=16, 33%), syncope (n=12, 25%), and sudden death (n=9, 19%) whereas one fourth of patients were asymptomatic (n=12, 25%). Most patients underwent emergency (n=25) or elective (n=5) surgical repair. Outcome was fatal in 20 of 48 patients (42%). Causes of rAAD included the stent graft itself (60%), manipulation of guide wires/sheaths (15%), and progression of underlying aortic disease (15%).
Conclusions—
The incidence of rAAD was low (1.33%) in the present analysis with high mortality (42%). Patients undergoing TEVAR for type B dissection appeared to be most prone for the occurrence of rAAD. This complication occurred not only during the index hospitalization but after discharge up to 1050 days after TEVAR. Importantly, the majority of rAAD cases were associated with the use of proximal bare spring stent grafts with direct evidence of stent graft–induced injury at surgery or necropsy in half of the patients.
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Affiliation(s)
- Holger Eggebrecht
- From the Department of Cardiology (H.E., R.E.), West-German Heart Center Essen, University of Duisburg-Essen, Essen, Germany; the Department of Vascular Surgery (M.T.), St George’s Vascular Institute, St George’s Hospital NHS Trust, London, United Kingdom; the Department of Radiology (H.R.), Centre Hospitalier Universitaire, Hopital de Rangueil, Toulouse, France; the Department of Cardiothoracic Surgery (M.C.), University of Vienna Medical School, Vienna, Austria; the Department of Interventional
| | - Matt Thompson
- From the Department of Cardiology (H.E., R.E.), West-German Heart Center Essen, University of Duisburg-Essen, Essen, Germany; the Department of Vascular Surgery (M.T.), St George’s Vascular Institute, St George’s Hospital NHS Trust, London, United Kingdom; the Department of Radiology (H.R.), Centre Hospitalier Universitaire, Hopital de Rangueil, Toulouse, France; the Department of Cardiothoracic Surgery (M.C.), University of Vienna Medical School, Vienna, Austria; the Department of Interventional
| | - Hervé Rousseau
- From the Department of Cardiology (H.E., R.E.), West-German Heart Center Essen, University of Duisburg-Essen, Essen, Germany; the Department of Vascular Surgery (M.T.), St George’s Vascular Institute, St George’s Hospital NHS Trust, London, United Kingdom; the Department of Radiology (H.R.), Centre Hospitalier Universitaire, Hopital de Rangueil, Toulouse, France; the Department of Cardiothoracic Surgery (M.C.), University of Vienna Medical School, Vienna, Austria; the Department of Interventional
| | - Martin Czerny
- From the Department of Cardiology (H.E., R.E.), West-German Heart Center Essen, University of Duisburg-Essen, Essen, Germany; the Department of Vascular Surgery (M.T.), St George’s Vascular Institute, St George’s Hospital NHS Trust, London, United Kingdom; the Department of Radiology (H.R.), Centre Hospitalier Universitaire, Hopital de Rangueil, Toulouse, France; the Department of Cardiothoracic Surgery (M.C.), University of Vienna Medical School, Vienna, Austria; the Department of Interventional
| | - Lars Lönn
- From the Department of Cardiology (H.E., R.E.), West-German Heart Center Essen, University of Duisburg-Essen, Essen, Germany; the Department of Vascular Surgery (M.T.), St George’s Vascular Institute, St George’s Hospital NHS Trust, London, United Kingdom; the Department of Radiology (H.R.), Centre Hospitalier Universitaire, Hopital de Rangueil, Toulouse, France; the Department of Cardiothoracic Surgery (M.C.), University of Vienna Medical School, Vienna, Austria; the Department of Interventional
| | - Rajendra H. Mehta
- From the Department of Cardiology (H.E., R.E.), West-German Heart Center Essen, University of Duisburg-Essen, Essen, Germany; the Department of Vascular Surgery (M.T.), St George’s Vascular Institute, St George’s Hospital NHS Trust, London, United Kingdom; the Department of Radiology (H.R.), Centre Hospitalier Universitaire, Hopital de Rangueil, Toulouse, France; the Department of Cardiothoracic Surgery (M.C.), University of Vienna Medical School, Vienna, Austria; the Department of Interventional
| | - Raimund Erbel
- From the Department of Cardiology (H.E., R.E.), West-German Heart Center Essen, University of Duisburg-Essen, Essen, Germany; the Department of Vascular Surgery (M.T.), St George’s Vascular Institute, St George’s Hospital NHS Trust, London, United Kingdom; the Department of Radiology (H.R.), Centre Hospitalier Universitaire, Hopital de Rangueil, Toulouse, France; the Department of Cardiothoracic Surgery (M.C.), University of Vienna Medical School, Vienna, Austria; the Department of Interventional
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Eriksson JW, Jansson PA, Carlberg B, Hägg A, Kurland L, Svensson MK, Ahlström H, Ström C, Lönn L, Öjbrandt K, Johansson L, Lind L. Hydrochlorothiazide, but not Candesartan, Aggravates Insulin Resistance and Causes Visceral and Hepatic Fat Accumulation. Hypertension 2008; 52:1030-7. [DOI: 10.1161/hypertensionaha.108.119404] [Citation(s) in RCA: 103] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Treatment with angiotensin II receptor blockers is associated with lower risk for the development of type 2 diabetes mellitus compared with thiazide diuretics. The Mechanisms for the Diabetes Preventing Effect of Candesartan Study addressed insulin action and secretion and body fat distribution after treatment with candesartan, hydrochlorothiazide, and placebo. Twenty-six nondiabetic, abdominally obese, hypertensive patients were included in a multicenter 3-way crossover trial, and 22 completers (by predefined criteria; 10 men and 12 women) were included in the analyses. They underwent 12-week treatment periods with candesartan (C; 16 to 32 mg), hydrochlorothiazide (H; 25 to 50 mg), and placebo (P), respectively, and the treatment order was randomly assigned and double blinded. Intravenous glucose tolerance tests and euglycemic hyperinsulinemic (56 mU/m
2
per minute) clamps were performed. Intrahepatic and intramyocellular and extramyocellular lipid content and subcutaneous and visceral abdominal adipose tissue were measured using proton magnetic resonance spectroscopy and MRI. Insulin sensitivity (M-value) was reduced following H versus C and P (6.07±2.05, 6.63±2.04, and 6.90±2.10 mg/kg of body weight per minute, mean±SD;
P
≤0.01). Liver fat content was higher (
P
<0.05) following H than both P and C. The subcutaneous to visceral abdominal adipose tissue ratio was reduced following H versus C and P (
P
<0.01). Glycosylated hemoglobin, alanine aminotransferase, aspartate aminotransferase, and high-sensitivity C-reactive protein levels were higher (
P
<0.05) after H, but not C, versus P. There were no changes in body fat, intramyocellular lipid, extramyocellular lipid, or first-phase insulin secretion. Blood pressure was reduced similarly by C and H versus P. In conclusion, visceral fat redistribution, liver fat accumulation, low-grade inflammation, and aggravated insulin resistance were demonstrated after hydrochlorothiazide but not candesartan treatment. These findings can partly explain the diabetogenic potential of thiazides.
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Affiliation(s)
- Jan W. Eriksson
- From the Departments of Medicine (J.W.E., B.C., M.K.S., K.O.) and Radiology (C.S.), Umeå University Hospital, Umeå, Sweden; Departments of Medicine (J.W.E., P-A.J., M.K.S.) and Radiology (L. Lönn), Sahlgrenska University Hospital, Gothenburg, Sweden; Departments of Medicine (A.H., L.K., L. Lind) and Radiology (H.A., L.J.), Uppsala University Hospital, Uppsala, Sweden; AstraZeneca R&D (J.W.E., L.J.), Mölndal, Sweden; and the Faculty of Health Sciences (L. Lönn), Rigshospitalet Umeå,
| | - Per-Anders Jansson
- From the Departments of Medicine (J.W.E., B.C., M.K.S., K.O.) and Radiology (C.S.), Umeå University Hospital, Umeå, Sweden; Departments of Medicine (J.W.E., P-A.J., M.K.S.) and Radiology (L. Lönn), Sahlgrenska University Hospital, Gothenburg, Sweden; Departments of Medicine (A.H., L.K., L. Lind) and Radiology (H.A., L.J.), Uppsala University Hospital, Uppsala, Sweden; AstraZeneca R&D (J.W.E., L.J.), Mölndal, Sweden; and the Faculty of Health Sciences (L. Lönn), Rigshospitalet Umeå,
| | - Bo Carlberg
- From the Departments of Medicine (J.W.E., B.C., M.K.S., K.O.) and Radiology (C.S.), Umeå University Hospital, Umeå, Sweden; Departments of Medicine (J.W.E., P-A.J., M.K.S.) and Radiology (L. Lönn), Sahlgrenska University Hospital, Gothenburg, Sweden; Departments of Medicine (A.H., L.K., L. Lind) and Radiology (H.A., L.J.), Uppsala University Hospital, Uppsala, Sweden; AstraZeneca R&D (J.W.E., L.J.), Mölndal, Sweden; and the Faculty of Health Sciences (L. Lönn), Rigshospitalet Umeå,
| | - Anders Hägg
- From the Departments of Medicine (J.W.E., B.C., M.K.S., K.O.) and Radiology (C.S.), Umeå University Hospital, Umeå, Sweden; Departments of Medicine (J.W.E., P-A.J., M.K.S.) and Radiology (L. Lönn), Sahlgrenska University Hospital, Gothenburg, Sweden; Departments of Medicine (A.H., L.K., L. Lind) and Radiology (H.A., L.J.), Uppsala University Hospital, Uppsala, Sweden; AstraZeneca R&D (J.W.E., L.J.), Mölndal, Sweden; and the Faculty of Health Sciences (L. Lönn), Rigshospitalet Umeå,
| | - Lisa Kurland
- From the Departments of Medicine (J.W.E., B.C., M.K.S., K.O.) and Radiology (C.S.), Umeå University Hospital, Umeå, Sweden; Departments of Medicine (J.W.E., P-A.J., M.K.S.) and Radiology (L. Lönn), Sahlgrenska University Hospital, Gothenburg, Sweden; Departments of Medicine (A.H., L.K., L. Lind) and Radiology (H.A., L.J.), Uppsala University Hospital, Uppsala, Sweden; AstraZeneca R&D (J.W.E., L.J.), Mölndal, Sweden; and the Faculty of Health Sciences (L. Lönn), Rigshospitalet Umeå,
| | - Maria K. Svensson
- From the Departments of Medicine (J.W.E., B.C., M.K.S., K.O.) and Radiology (C.S.), Umeå University Hospital, Umeå, Sweden; Departments of Medicine (J.W.E., P-A.J., M.K.S.) and Radiology (L. Lönn), Sahlgrenska University Hospital, Gothenburg, Sweden; Departments of Medicine (A.H., L.K., L. Lind) and Radiology (H.A., L.J.), Uppsala University Hospital, Uppsala, Sweden; AstraZeneca R&D (J.W.E., L.J.), Mölndal, Sweden; and the Faculty of Health Sciences (L. Lönn), Rigshospitalet Umeå,
| | - Håkan Ahlström
- From the Departments of Medicine (J.W.E., B.C., M.K.S., K.O.) and Radiology (C.S.), Umeå University Hospital, Umeå, Sweden; Departments of Medicine (J.W.E., P-A.J., M.K.S.) and Radiology (L. Lönn), Sahlgrenska University Hospital, Gothenburg, Sweden; Departments of Medicine (A.H., L.K., L. Lind) and Radiology (H.A., L.J.), Uppsala University Hospital, Uppsala, Sweden; AstraZeneca R&D (J.W.E., L.J.), Mölndal, Sweden; and the Faculty of Health Sciences (L. Lönn), Rigshospitalet Umeå,
| | - Conny Ström
- From the Departments of Medicine (J.W.E., B.C., M.K.S., K.O.) and Radiology (C.S.), Umeå University Hospital, Umeå, Sweden; Departments of Medicine (J.W.E., P-A.J., M.K.S.) and Radiology (L. Lönn), Sahlgrenska University Hospital, Gothenburg, Sweden; Departments of Medicine (A.H., L.K., L. Lind) and Radiology (H.A., L.J.), Uppsala University Hospital, Uppsala, Sweden; AstraZeneca R&D (J.W.E., L.J.), Mölndal, Sweden; and the Faculty of Health Sciences (L. Lönn), Rigshospitalet Umeå,
| | - Lars Lönn
- From the Departments of Medicine (J.W.E., B.C., M.K.S., K.O.) and Radiology (C.S.), Umeå University Hospital, Umeå, Sweden; Departments of Medicine (J.W.E., P-A.J., M.K.S.) and Radiology (L. Lönn), Sahlgrenska University Hospital, Gothenburg, Sweden; Departments of Medicine (A.H., L.K., L. Lind) and Radiology (H.A., L.J.), Uppsala University Hospital, Uppsala, Sweden; AstraZeneca R&D (J.W.E., L.J.), Mölndal, Sweden; and the Faculty of Health Sciences (L. Lönn), Rigshospitalet Umeå,
| | - Kristina Öjbrandt
- From the Departments of Medicine (J.W.E., B.C., M.K.S., K.O.) and Radiology (C.S.), Umeå University Hospital, Umeå, Sweden; Departments of Medicine (J.W.E., P-A.J., M.K.S.) and Radiology (L. Lönn), Sahlgrenska University Hospital, Gothenburg, Sweden; Departments of Medicine (A.H., L.K., L. Lind) and Radiology (H.A., L.J.), Uppsala University Hospital, Uppsala, Sweden; AstraZeneca R&D (J.W.E., L.J.), Mölndal, Sweden; and the Faculty of Health Sciences (L. Lönn), Rigshospitalet Umeå,
| | - Lars Johansson
- From the Departments of Medicine (J.W.E., B.C., M.K.S., K.O.) and Radiology (C.S.), Umeå University Hospital, Umeå, Sweden; Departments of Medicine (J.W.E., P-A.J., M.K.S.) and Radiology (L. Lönn), Sahlgrenska University Hospital, Gothenburg, Sweden; Departments of Medicine (A.H., L.K., L. Lind) and Radiology (H.A., L.J.), Uppsala University Hospital, Uppsala, Sweden; AstraZeneca R&D (J.W.E., L.J.), Mölndal, Sweden; and the Faculty of Health Sciences (L. Lönn), Rigshospitalet Umeå,
| | - Lars Lind
- From the Departments of Medicine (J.W.E., B.C., M.K.S., K.O.) and Radiology (C.S.), Umeå University Hospital, Umeå, Sweden; Departments of Medicine (J.W.E., P-A.J., M.K.S.) and Radiology (L. Lönn), Sahlgrenska University Hospital, Gothenburg, Sweden; Departments of Medicine (A.H., L.K., L. Lind) and Radiology (H.A., L.J.), Uppsala University Hospital, Uppsala, Sweden; AstraZeneca R&D (J.W.E., L.J.), Mölndal, Sweden; and the Faculty of Health Sciences (L. Lönn), Rigshospitalet Umeå,
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