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Hasan IS, Brown JA, Serna-Gallegos D, Aranda-Michel E, Yousef S, Wang Y, Sultan I. Association of Thoracic Aortic Aneurysm Versus Aortic Dissection on Outcomes After Thoracic Endovascular Aortic Repair. J Am Heart Assoc 2023; 12:e027641. [PMID: 36892050 PMCID: PMC10111510 DOI: 10.1161/jaha.122.027641] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/10/2023]
Abstract
Background Because thoracic endovascular aortic repair (TEVAR) has become the standard of care for complicated type B aortic dissection (TBAD) and descending thoracic aortic (DTA) aneurysm, it is important to understand outcomes and use of TEVAR across thoracic aortic pathologies. Methods and Results This was an observational study of patients with TBAD or DTA undergoing TEVAR from 2010 to 2018, using the Nationwide Readmissions Database. In-hospital mortality, postoperative complications, admission costs, and 30- and 90-day readmissions were compared between the groups. Mixed model logistic regression was used to identify variables associated with mortality. An estimated total of 12 824 patients underwent TEVAR nationally, of which 6043 had an indication of TBAD and 6781 of DTA. Patients with aneurysms were more likely to be older, women, have cardiovascular disease, and have chronic pulmonary disease compared with patients with TBAD. Weighted in-hospital mortality was higher for TBAD (8% [1054/12 711] versus 3% [433/14 407], P<0.001), compared with DTA, as were all postoperative complications. Patients with TBAD had a higher cost of care during their index admission (57.3 versus 38.8 × $1000, P<0.001), compared with DTA. The 30-day and 90-day weighted readmissions were more frequent for the TBAD group compared with DTA (20% [1867/12 711] and 30% [2924/12 711] versus 15% [1603/14 407] and 25% [2695/14 407], respectively, P<0.001). On multivariable adjustment, TBAD was independently associated with mortality (odds ratio, 2.06 [95% CI, 1.68-2.52]; P<0.001). Conclusions After TEVAR, patients who presented with TBAD had higher rates of postoperative complications, in-hospital mortality, and cost compared with DTA. The incidence of early readmission was substantial for patients undergoing TEVAR, faring worse for those undergoing TEVAR for TBAD as compared with DTA.
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Affiliation(s)
- Irsa S Hasan
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery University of Pittsburgh PA USA
| | - James A Brown
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery University of Pittsburgh PA USA
| | - Derek Serna-Gallegos
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery University of Pittsburgh PA USA
- Heart and Vascular Institute University of Pittsburgh Medical Center PA USA
| | - Edgar Aranda-Michel
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery University of Pittsburgh PA USA
| | - Sarah Yousef
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery University of Pittsburgh PA USA
| | - Yisi Wang
- Heart and Vascular Institute University of Pittsburgh Medical Center PA USA
| | - Ibrahim Sultan
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery University of Pittsburgh PA USA
- Heart and Vascular Institute University of Pittsburgh Medical Center PA USA
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Brown JA, Sultan I. Commentary: Delaying the inevitable? Interventions for medically managed, uncomplicated type B aortic dissection. J Thorac Cardiovasc Surg 2023; 165:966-969. [PMID: 33972114 DOI: 10.1016/j.jtcvs.2021.04.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 04/12/2021] [Accepted: 04/13/2021] [Indexed: 11/26/2022]
Affiliation(s)
- James A Brown
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - Ibrahim Sultan
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa.
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Watanabe S, Saito Y, Murata K, Kondo N, Minakawa M. Amplatzer Vascular Plug With Endologix AFX Lining for Visceral Re-Entry Closure in a Patient With Chronic Type B Aortic Dissection. J Endovasc Ther 2022:15266028221131450. [PMID: 36300538 DOI: 10.1177/15266028221131450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2024]
Abstract
PURPOSE To demonstrate the efficacy of a combination of Amplatzer vascular plug (AVP2) and Endologix AFX for a visceral entry closure. CASE REPORT A 70-year-old woman with treated chronic type B aortic dissection was seen to have sac enlargement. An isolated residual tear was observed at the origin of the celiac artery. A 12 mm AVP2 was successfully deployed for the entry closure. Angiography after the plug deployment still demonstrated residual flow to the false lumen. Hence, an Endologix AFX VELA proximal endograft was deployed, covering the AVP membrane and leaving no endoleak. CONCLUSION Deployment of a vascular plug with Endologix AFX lining was efficacious for securing complete closure of an entry tear at the origin of the celiac artery in our patient. CLINICAL IMPACT Vascular plugs are reported to be effective for closing small entries, although their effectiveness is limited when the entry site is not located on the flat intima, or in a high-flow situation. In the presented case, an isolated entry tear at the origin of the celiac artery was successfully closed with a vascular plug following Endologix AFX stent-graft lining of the true lumen.
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Affiliation(s)
- Shuto Watanabe
- Department of Thoracic and Cardiovascular Surgery, Hirosaki University School of Medicine, Hirosaki, Japan
| | - Yoshiaki Saito
- Department of Thoracic and Cardiovascular Surgery, Hirosaki University School of Medicine, Hirosaki, Japan
| | - Kenyu Murata
- Department of Thoracic and Cardiovascular Surgery, Hirosaki University School of Medicine, Hirosaki, Japan
| | - Norihiro Kondo
- Department of Thoracic and Cardiovascular Surgery, Hirosaki University School of Medicine, Hirosaki, Japan
| | - Masahito Minakawa
- Department of Thoracic and Cardiovascular Surgery, Hirosaki University School of Medicine, Hirosaki, Japan
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Yamane Y, Oshima S, Ishiko K, Okiyama M, Hirokami T, Hirai Y, Sakurai S, Ozaki K, Yoshimura K, Takahashi S, Yamamoto S. Descending thoracic aortic repair outcomes for chronic aortic dissection: a single-centre experience. Interact Cardiovasc Thorac Surg 2022; 35:6697888. [PMID: 36102809 PMCID: PMC9519091 DOI: 10.1093/icvts/ivac233] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 08/31/2022] [Accepted: 09/13/2022] [Indexed: 11/14/2022] Open
Affiliation(s)
- Yoshitaka Yamane
- Kawasaki Aortic Center, Kawasaki Saiwai Hospital , Kawasaki, Japan
| | - Susumu Oshima
- Kawasaki Aortic Center, Kawasaki Saiwai Hospital , Kawasaki, Japan
| | - Kazumasa Ishiko
- Kawasaki Aortic Center, Kawasaki Saiwai Hospital , Kawasaki, Japan
| | - Makoto Okiyama
- Kawasaki Aortic Center, Kawasaki Saiwai Hospital , Kawasaki, Japan
| | | | - Yuki Hirai
- Kawasaki Aortic Center, Kawasaki Saiwai Hospital , Kawasaki, Japan
| | - Shigeru Sakurai
- Kawasaki Aortic Center, Kawasaki Saiwai Hospital , Kawasaki, Japan
| | - Kensuke Ozaki
- Kawasaki Aortic Center, Kawasaki Saiwai Hospital , Kawasaki, Japan
| | - Kenichi Yoshimura
- Department of Biostatistics, Medical Center for Translational and Clinical Research, Hiroshima University Hospital , Hiroshima, Japan
| | - Shinya Takahashi
- Department of Surgery, Graduate School of Biomedical and Health Science, Hiroshima University , Hiroshima, Japan
| | - Shin Yamamoto
- Kawasaki Aortic Center, Kawasaki Saiwai Hospital , Kawasaki, Japan
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5
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Liu L, Yang Y. Nutritional Management Mode of Early Cardiac Rehabilitation in Patients with Stanford Type A Aortic Dissection. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2022; 2022:2124636. [PMID: 36035298 PMCID: PMC9410849 DOI: 10.1155/2022/2124636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 07/07/2022] [Accepted: 08/08/2022] [Indexed: 12/01/2022]
Abstract
Malnutrition and metabolic disorders are common problems faced by patients with Stanford type A aortic dissection after surgery. Some patients have dietary problems such as malnutrition, unbalanced diet, and poor eating habits before surgery. Therefore, the nutritional management of early heart health can improve the nutritional support for perioperative recovery, to improve the pertinence. Therefore, active nutritional support after surgery will help to change malnutrition and metabolism and is of great significance to postoperative recovery and quality of life. This paper is aimed at studying the nutritional management mode of early cardiac rehabilitation in patients with Stanford type A aortic dissection. Based on the analysis of the pathogenesis of aortic dissection and the diagnosis of aortic dissection, two groups of patients were given individualized nutritional management scheme and routine nutritional scheme, respectively, and the nutritional risk differences between the two groups under different schemes were compared. The results showed that there was a statistical difference between the two groups at discharge. The NRS-2002 score of 14 cases in the observation group was less than 3 after nutritional intervention, indicating that there was no nutritional risk at discharge.
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Affiliation(s)
- Lu Liu
- School of Public Health, Anhui Medical University, Hefei 230032, China
- Department of Cardiovascular Surgery, First Affiliated Hospital of University of Science and Technology of China/Anhui Provincial Hospital, Hefei 230001, China
| | - Yongjian Yang
- School of Public Health, Anhui Medical University, Hefei 230032, China
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Arnaoutakis GJ, Ogami T, Aranda-Michel E, Dai Y, Holmes R, Beaver TM, Serna-Gallegos D, Martin TD, Navid F, Yousef S, Sultan I. Misdiagnosis of Thoracic Aortic Emergencies Occurs Frequently Among Transfers to Aortic Referral Centers: An Analysis of Over 3700 Patients. J Am Heart Assoc 2022; 11:e025026. [PMID: 35766274 PMCID: PMC9333395 DOI: 10.1161/jaha.121.025026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Acute aortic syndromes may be prone to misdiagnosis by nonreferral aortic centers with less diagnostic experience. We evaluated regional variability in these misdiagnosis trends among patients transferred to different regional quaternary care centers with presumed acute aortic syndromes. Methods and Results Two institutional aortic center databases were retrospectively reviewed for emergency transfers in patients diagnosed with acute aortic dissection, intramural hematoma, penetrating aortic ulcer, thoracic aortic aneurysm, or aortic pseudoaneurysm between 2008 and 2020. Transferring diagnoses versus actual diagnoses were reviewed using physician notes and radiology reports. Misdiagnoses were confirmed by a board‐certified cardiothoracic surgeon. A total of 3772 inpatient transfers were identified, of which 1762 patients were classified as emergency transfers. The mean age was 64 years (58% male). Patients were transferred from 203 medical centers by ground (51%) or air (49%). Differences in transfer diagnosis and actual diagnosis were identified in 188 (10.7%) patients. Of those, incorrect classification of Type A versus B dissections was identified among 23%, and 30% of patients with a referring diagnosis of an acute aortic dissection did not have one. In addition, 14% transferred for contained/impending rupture did not have signs of rupture. All misdiagnoses were secondary to misinterpretation of imaging, with motion artifacts (n=32, 17%) and postsurgical changes (n=44, 23%) being common sources of diagnostic error. Conclusions Misdiagnosis of acute aortic syndromes commonly occurred in patients transferred to 2 separate large aortic referral centers. Although diagnostic accuracy may be improving, there are opportunities for improved physician awareness through standardized web‐based imaging education.
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Affiliation(s)
| | - Takuya Ogami
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery University of Pittsburgh Pittsburgh PA USA
| | - Edgar Aranda-Michel
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery University of Pittsburgh Pittsburgh PA USA
| | - Yancheng Dai
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery University of Pittsburgh Pittsburgh PA USA
| | | | | | - Derek Serna-Gallegos
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery University of Pittsburgh Pittsburgh PA USA.,Heart and Vascular Institute University of Pittsburgh Medical Center Pittsburgh PA
| | | | - Forozan Navid
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery University of Pittsburgh Pittsburgh PA USA.,Heart and Vascular Institute University of Pittsburgh Medical Center Pittsburgh PA
| | - Sarah Yousef
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery University of Pittsburgh Pittsburgh PA USA
| | - Ibrahim Sultan
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery University of Pittsburgh Pittsburgh PA USA.,Heart and Vascular Institute University of Pittsburgh Medical Center Pittsburgh PA
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7
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Blakeslee-Carter J, Potter HA, Banks CA, Passman M, Pearce B, McFarland G, Han SM, Scali S, Magee GA, Spangler E, Beck AW. Aortic Visceral Segment Instability is evident following Thoracic Endovascular Aortic Repair for Acute and Subacute Type B Aortic Dissection. J Vasc Surg 2022; 76:389-399.e1. [PMID: 35276262 PMCID: PMC9329185 DOI: 10.1016/j.jvs.2022.02.046] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 02/08/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Anatomic remodeling within the thoracic aorta following thoracic endovascular aortic repair (TEVAR) for type B aortic dissections (TBAD) has been well documented, but less is known about the response of the untreated visceral aorta. This study aims to investigate visceral aortic behavior following TEVAR for acute or subacute TBAD and identify associations with clinical outcomes. METHODS A multi-center retrospective review was performed of all imaging for all patients treated with TEVAR for acute (0-14 days) and subacute (14-90 days) non-traumatic TBAD between 2006-2020. Cohort was inclusive of uncomplicated, high-risk, and complicated (defined per SVS reporting guidelines) dissections. Centerline aortic measurements of the true and false lumen and total aortic diameter (TAD) were taken at standardized locations relative to aortic anatomy within each aortic zone (zones defined by SVS reporting guidelines). Diameter changes over time were evaluated using repeated measures mixed effects linear growth modeling. Visceral segment instability (VSI) was defined as any growth in TAD ≥ 5mm within aortic zones 5 through 9. RESULTS A total of 82 patients were identified. Median length of imaging follow-up was 2.1 years (IQR 3.9 years), with 15% of the cohort having follow-up longer than 5 years. VSI was present in 55% of the cohort, with an average maximal increase in TAD of 10.4±6.3 mm over a median follow-up of 2.1 years (IQR 3.9 years). Roughly a third of the cohort experienced rapid VSI (growth ≥5mm in first year), and 4.8% of the cohort developed a large para-visceral aneurysm aortic (TAD≥5cm) secondary to VSI. Linear growth modeling identified significant predictable growth in TAD across all visceral zones. Zones 7 had the highest rate of TAD dilation, with a fixed effect estimated rate of 1.3 mm per year (95%-CI 0.23-2.1, p=0.022). The preoperative factor most strongly associated with VSI was ≥6 cumulative number of zones dissected (OR 6.4, 95% OR 1.07-8.6, p=0.041). Odds for aortic reintervention were significantly increased in cases where VSI led to development of a para-visceral aortic aneurysm ≥5cm development (OR 3.7, 95%-CI 1.1-13, p=0.038). CONCLUSION VSI was identified in the majority of patients treated with TEVAR for management of acute and subacute TBAD. Preoperative anatomic features such as extent of dissection, rather than procedural details of graft coverage, may play a more significant role in VSI occurrence. Importantly, significant TAD growth occurred in all visceral segments. These results highlight the importance of lifelong surveillance following TEVAR, and identify a subset of patients that may be at increased risk for re-intervention.
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Affiliation(s)
- Juliet Blakeslee-Carter
- University of Alabama at Birmingham, Division of Vascular Surgery and Endovascular Therapy, Birmingham, AL
| | - Hellen A Potter
- University of Southern California, Division of Vascular Surgery and Endovascular Therapy, Los Angeles, CA
| | - Charles A Banks
- University of Alabama at Birmingham, Division of Vascular Surgery and Endovascular Therapy, Birmingham, AL
| | - Marc Passman
- University of Alabama at Birmingham, Division of Vascular Surgery and Endovascular Therapy, Birmingham, AL
| | - Benjamin Pearce
- University of Alabama at Birmingham, Division of Vascular Surgery and Endovascular Therapy, Birmingham, AL
| | - Graeme McFarland
- University of Alabama at Birmingham, Division of Vascular Surgery and Endovascular Therapy, Birmingham, AL
| | - Sukgu M Han
- University of Southern California, Division of Vascular Surgery and Endovascular Therapy, Los Angeles, CA
| | - Salvatore Scali
- University of Florida College of Medicine, Division of Vascular Surgery and Endovascular Therapy, Gainesville, FL
| | - Gregory A Magee
- University of Southern California, Division of Vascular Surgery and Endovascular Therapy, Los Angeles, CA
| | - Emily Spangler
- University of Alabama at Birmingham, Division of Vascular Surgery and Endovascular Therapy, Birmingham, AL
| | - Adam W Beck
- University of Alabama at Birmingham, Division of Vascular Surgery and Endovascular Therapy, Birmingham, AL.
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9
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Brown JA, Sultan I. Temporary TEVAR as a bridge to open aortic pseudoaneurysm repair. J Card Surg 2021; 36:1157-1158. [PMID: 33522618 DOI: 10.1111/jocs.15381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Accepted: 01/18/2021] [Indexed: 11/26/2022]
Affiliation(s)
- James A Brown
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ibrahim Sultan
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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10
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Tanaka A, Sandhu HK, Afifi RO, Miller CC, Ray A, Hassan M, Safi HJ, Estrera AL. Outcomes of open repairs of chronic distal aortic dissection anatomically amenable to endovascular repairs. J Thorac Cardiovasc Surg 2021; 161:36-43.e6. [PMID: 31699416 DOI: 10.1016/j.jtcvs.2019.09.083] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 09/12/2019] [Accepted: 09/15/2019] [Indexed: 01/17/2023]
Abstract
OBJECTIVE To review short-term outcomes and long-term survival and durability after open surgical repairs for chronic distal aortic dissections in patients whose anatomy was amenable to thoracic endovascular aortic repair (TEVAR). METHODS Between February 1991 and August 2017, we repaired chronic distal dissections in 697 patients. Of those patients, we enrolled 427 with anatomy amenable to TEVAR, which included 314 descending thoracic aortic aneurysms (DTAAs) and 105 extent I thoracoabdominal aortic aneurysms (TAAAs). One hundred eighty-five patients (44%) had a history of type A dissection, and 33 (7.9%) had a previous DTAA/TAAA repair. Variables were assessed with logistic regression for 30-day mortality and Cox regression for long-term mortality. Time-to-event analysis was performed using Kaplan-Meier methods. RESULTS Thirty-day mortality was 8.4% (n = 36). In all, 22 patients (5.2%) developed motor deficit (paraplegia/paraparesis), and 17 (4.0%) experienced stroke. Multivariable analysis identified low estimated glomerular filtration rate (eGFR; <60 mL/min/1.73 m2), previous DTAA/TAAA repair, and chronic obstructive pulmonary disease (COPD) as associated with 30-day mortality. Patients without all 3 risk factors had a 30-day mortality rate of 2.6%. During a median follow-up of 6.5 years, 160 patients died. The survival rate was 81% at 1 year and 61% at 10 years. Cox regression analysis identified preoperative aortic rupture, eGFR <60 mL/min/1.73 m2, previous DTAA/TAAA repair, COPD, and age >60 years as predictive of long-term mortality. Forty-five patients required subsequent aortic procedures, including 8 reinterventions to the treated segment. Freedom from any aortic procedures was 85% at 10 years, and aortic procedure-free survival was 45% at 10 years. Hereditary aortic disease was the sole predictor for any aortic interventions (hazard ratio, 3.2; P = .004). CONCLUSIONS Open surgical repair provided satisfactory low neurologic complication rates and durable repairs in chronic distal aortic dissection. Patients without low eGFR, redo, and COPD are the low-risk surgical candidates and may benefit from open surgical repair at centers with similar experience to ours. Patients with hereditary aortic disease warrant close surveillance.
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Affiliation(s)
- Akiko Tanaka
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston and Memorial Hermann Hospital, Houston, Tex
| | - Harleen K Sandhu
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston and Memorial Hermann Hospital, Houston, Tex
| | - Rana O Afifi
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston and Memorial Hermann Hospital, Houston, Tex
| | - Charles C Miller
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston and Memorial Hermann Hospital, Houston, Tex
| | - Amberly Ray
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston and Memorial Hermann Hospital, Houston, Tex
| | - Madiha Hassan
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston and Memorial Hermann Hospital, Houston, Tex
| | - Hazim J Safi
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston and Memorial Hermann Hospital, Houston, Tex
| | - Anthony L Estrera
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston and Memorial Hermann Hospital, Houston, Tex.
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11
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Yang G, Zhang M, Zhang Y, Du X, Qiao T, Li X, Zhou M. Endovascular Repair of Postdissection Aortic Aneurysms Using Physician-Modified Endografts. Ann Thorac Surg 2020; 112:1201-1208. [PMID: 33285129 DOI: 10.1016/j.athoracsur.2020.11.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 10/22/2020] [Accepted: 11/16/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND The purpose of this study was to report our experience and evaluate the technical and clinical outcomes of physician-modified endovascular aortic repair of chronic postdissection thoracoabdominal aortic aneurysms. METHODS A retrospective analysis of prospectively collected data of consecutive patients presenting with chronic postdissection aneurysms unfit for open surgery and treated by physician-modified stent grafts between January 2016 and December 2019 was conducted. Outcome data were collected retrospectively. Early outcomes included technical success, perioperative mortality, and major adverse events. Late outcomes included reintervention, false lumen thrombosis rate, aneurysm size regression, and survival. RESULTS Sixty-two patients (80.1% men with a mean age of 64 ± 9.9 years) were treated. The technical success was 98.3%. There was 1 (1.6%) death within 30 days. Perioperative major adverse events included respiratory failure (1.6%), spinal cord injury (0%), acute kidney injury (3.2%; 1 dialysis), bowel ischemia (1.6%), myocardial infarction (1.6%), and lower limb ischemia (1.6%). A reintervention was required in 6 (9.8%) patients. The false lumen thrombosis rates were 91.8% (n = 45 of 49) at 1-year follow-up. One patient died during follow-up from an aneurysm-related cause. The estimated overall survival rates were 98.4% and 96.8% at 6 months and 12 months, respectively. CONCLUSIONS The report confirmed the feasibility and safety of fenestrated and branched endovascular aortic repair in the setting of postdissection thoracoabdominal aortic aneurysms. Despite the associated perioperative risk and high probability of intended or unintended reintervention, the procedure could lead to favorable aortic remodeling.
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Affiliation(s)
- Guangmin Yang
- Department of Vascular Surgery, Drum Tower Hospital, School of Medicine, Nanjing University, Nanjing, Jiangsu, China
| | - Ming Zhang
- Department of Vascular Surgery, Drum Tower Hospital, School of Medicine, Nanjing University, Nanjing, Jiangsu, China
| | - Yepeng Zhang
- Department of Vascular Surgery, Drum Tower Hospital, School of Medicine, Nanjing University, Nanjing, Jiangsu, China
| | - Xiaolong Du
- Department of Vascular Surgery, Drum Tower Hospital, School of Medicine, Nanjing University, Nanjing, Jiangsu, China
| | - Tong Qiao
- Department of Vascular Surgery, Drum Tower Hospital, School of Medicine, Nanjing University, Nanjing, Jiangsu, China
| | - Xiaoqiang Li
- Department of Vascular Surgery, Drum Tower Hospital, School of Medicine, Nanjing University, Nanjing, Jiangsu, China
| | - Min Zhou
- Department of Vascular Surgery, Drum Tower Hospital, School of Medicine, Nanjing University, Nanjing, Jiangsu, China.
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12
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Stent Graft–Induced Entry Tear After Thoracic Endovascular Aortic Repair: It Happens More Often Than We Think. Ann Thorac Surg 2020; 110:1500-1501. [DOI: 10.1016/j.athoracsur.2020.02.080] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 02/29/2020] [Indexed: 11/23/2022]
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13
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Commentary: Blowing stuff up: Balloon fracture fenestration with thoracic endovascular aortic repair for chronic type B aortic dissection. J Thorac Cardiovasc Surg 2020; 164:11-12. [PMID: 33160611 DOI: 10.1016/j.jtcvs.2020.10.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 10/05/2020] [Accepted: 10/06/2020] [Indexed: 11/23/2022]
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14
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Arnaoutakis DJ, Khan TA, Scali ST, Neal D, Giles KA, Cooper MA, Beaver TM, Huber TS, Upchurch GR, Arnaoutakis GJ, Back MR. Remodeling, Reintervention, and Survival After Endovascular Repair of Chronic Type B Dissection. Ann Thorac Surg 2020; 111:1560-1569. [PMID: 32961141 DOI: 10.1016/j.athoracsur.2020.07.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 06/18/2020] [Accepted: 07/10/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND The efficacy of thoracic endovascular aortic repair (TEVAR) of chronic type B aortic dissection (cTBAD) is controversial. Only limited evidence describes temporal anatomic changes after TEVAR for cTBAD and their relationship to outcomes. We sought to investigate early aortic remodeling events after TEVAR for cTBAD with thoracic aneurysm and determine the association with reintervention and survival. METHODS Records from 95 cTBAD patients undergoing TEVAR from 2005 to 2017 were reviewed. Using 3-dimensional centerline analysis, anatomic phenotyping of the thoracoabdominal aorta was performed. Reverse aortic remodeling (RAR) was defined by a ≥5-mm reduction in maximal thoracic aortic diameter. Kaplan-Meier analysis estimated freedom from reintervention and survival. RESULTS Visceral segment dissection involvement was present in 89% of patients (n = 85), and the mean preoperative thoracic diameter was 63 mm (SD, 10). Complete thoracic false lumen thrombosis occurred in 71% of patients (n = 67), whereas abdominal false lumen thrombosis was documented in 60% (n = 57) by 6 months. RAR occurred in 41%. Aortic reintervention rate was 39% (n = 37). The 1- and 3-year freedom from reintervention was significantly higher in subjects experiencing early RAR (log-rank P = .02), but reintervention did not impact overall survival (log-rank P = .9). Similarly, overall survival was similar between patients with or without RAR (log-rank P = .4). CONCLUSIONS Early RAR is associated with decreased rates of reintervention; however, overall survival is not impacted by these changes. TEVAR for cTBAD results in a high rate of reintervention, which mandates vigilant surveillance protocols.
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Affiliation(s)
- Dean J Arnaoutakis
- Division of Vascular Surgery and Endovascular Therapy, University of Florida College of Medicine, Gainesville, Florida.
| | - Tabassum A Khan
- Division of Vascular Surgery and Endovascular Therapy, University of Florida College of Medicine, Gainesville, Florida
| | - Salvatore T Scali
- Division of Vascular Surgery and Endovascular Therapy, University of Florida College of Medicine, Gainesville, Florida
| | - Dan Neal
- Division of Vascular Surgery and Endovascular Therapy, University of Florida College of Medicine, Gainesville, Florida
| | - Kristina A Giles
- Division of Vascular Surgery and Endovascular Therapy, University of Florida College of Medicine, Gainesville, Florida
| | - Michol A Cooper
- Division of Vascular Surgery and Endovascular Therapy, University of Florida College of Medicine, Gainesville, Florida
| | - Thomas M Beaver
- Division of Thoracic and Cardiovascular Surgery, University of Florida College of Medicine, Gainesville, Florida
| | - Thomas S Huber
- Division of Vascular Surgery and Endovascular Therapy, University of Florida College of Medicine, Gainesville, Florida
| | - Gilbert R Upchurch
- Division of Vascular Surgery and Endovascular Therapy, University of Florida College of Medicine, Gainesville, Florida
| | - George J Arnaoutakis
- Division of Thoracic and Cardiovascular Surgery, University of Florida College of Medicine, Gainesville, Florida
| | - Martin R Back
- Division of Vascular Surgery and Endovascular Therapy, University of Florida College of Medicine, Gainesville, Florida
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15
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The Number of Preoperative Abdominal False Lumen-perfused Small Branches Is Related to Abdominal Aortic Remodeling after Thoracic Endovascular Aortic Repair for Type B Aortic Dissection. Ann Vasc Surg 2020; 71:56-64. [PMID: 32949748 DOI: 10.1016/j.avsg.2020.09.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 09/02/2020] [Accepted: 09/06/2020] [Indexed: 01/16/2023]
Abstract
BACKGROUND Abdominal aortic enlargement (AAE) is a commonly seen complication after thoracic endovascular aortic repair (TEVAR) for type B aortic dissection (TBAD). This study assessed the relationship between preoperative abdominal false lumen-perfused small branches (pre-AFLSBs) and risk of AAE after TEVAR for TBAD extending through the abdominal aorta. METHODS One hundred and eighty-four patients with TBAD who had been treated by TEVAR at 4 hospitals in China were stratified in accordance with median pre-AFLSBs: ≤8 (group A) and >8 (group B). AAE was defined as ≥20% increase in abdominal total aortic volume, measured using imaging software featuring centerline analysis, on most recent postoperative computed tomography angiography relative to preoperative examination. Multivariable Cox proportional hazard regression was used to evaluate the relationship between the number of pre-AFLSBs and the risk of AAE after TEVAR. RESULTS At median 12.4 months imaging follow-up, AAE was present in 65 patients at higher cumulative rate (log-rank test P < 0.001) in group B, which had more frequent partially thrombosed or patent abdominal false lumen than group A at 6-12 months (P < 0.01) and 12-24 months (P = 0.03) of follow-up. In a multivariable Cox proportional hazard regression model, the number of pre-AFLSBs was independently associated with risk of AAE after TEVAR (hazard ratio [for one increase], 1.10; 95% confidence interval, 1.00-1.21; P = 0.04) after adjustment for age, gender, dissection chronicity, Society for Vascular Surgery risk score, preoperative maximum descending aortic diameter, false lumen status of the abdominal aorta, numbers of false lumen-perfused visceral arteries, abdominal intimal larger tears, and preoperative abdominal intimal small tears, and dissection length and descending aortic length ratio. CONCLUSIONS The number of pre-AFLSBs was positively associated with the risk of AAE after TEVAR for TBAD extending through the abdominal aorta.
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16
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Grimm JC, Szeto WY. Commentary: Managing the septum in chronic type B aortic dissections-power up the laser. J Thorac Cardiovasc Surg 2020; 164:460-461. [PMID: 33010882 DOI: 10.1016/j.jtcvs.2020.09.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 09/04/2020] [Accepted: 09/04/2020] [Indexed: 11/24/2022]
Affiliation(s)
- Joshua C Grimm
- Division of Cardiovascular Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pa
| | - Wilson Y Szeto
- Division of Cardiovascular Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pa.
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17
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Ueki C, Tsuneyoshi H. Late Aortic Expansion After Thoracic Endovascular Aortic Repair for Chronic DeBakey IIIb Dissection. Ann Thorac Surg 2020; 111:1271-1277. [PMID: 32882195 DOI: 10.1016/j.athoracsur.2020.06.070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 04/14/2020] [Accepted: 06/17/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND The efficacy of thoracic endovascular aortic repair (TEVAR) for chronic DeBakey IIIb aortic dissection is still under discussion. This study was performed to investigate the incidence of and risk factors for late aortic expansion after TEVAR for chronic DeBakey IIIb aortic dissection. METHODS From March 2014 to April 2019, a total of 35 patients with chronic DeBakey IIIb aortic dissection underwent TEVAR in our institution. Risk factors for aortic expansion events were examined by stepwise Cox regression analysis. Aortic expansion events were defined as reintervention for expansion or aortic expansion of greater than 5 mm. RESULTS No operative death occurred, and the 2-year survival rate was 96.8%. The 1- and 2-year rates of freedom from reintervention were 87.8% and 80.2%, respectively. During follow-up, 11 patients had late aortic expansion events (4 with expansion of the thoracic aorta and 7 with expansion of the abdominal aorta). The 1- and 2-year rates of freedom from aortic expansion were 87.8% and 68.7%, respectively. Significant risk factors for expansion events were aortic dilation at the celiac level (hazard ratio [HR], 1.11; P = .015), saccular aneurysm formation of the false lumen (HR, 5.08; P = .049), and high number of residual large reentries (>5 mm) (HR, 2.78; P = .027). CONCLUSIONS In patients undergoing TEVAR for chronic DeBakey IIIb aortic dissection, late aortic expansion in both the thoracic and abdominal aorta remains an important issue. Aggressive additional intervention should be considered for high-risk patients with residual large reentries and aortic dilation at the celiac level.
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Affiliation(s)
- Chikara Ueki
- Department of Cardiovascular Surgery, Shizuoka General Hospital, Shizuoka, Japan.
| | - Hiroshi Tsuneyoshi
- Department of Cardiovascular Surgery, Shizuoka General Hospital, Shizuoka, Japan
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18
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Hughes GC. TEVAR for Chronic Type B Dissection: Highlighting the Importance of Patient Selection, Adjunctive False Lumen Procedures, Speaking the Same Language, and Industry Collaboration. Ann Thorac Surg 2020; 111:501-502. [PMID: 32791061 DOI: 10.1016/j.athoracsur.2020.05.186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 05/29/2020] [Indexed: 10/23/2022]
Affiliation(s)
- G Chad Hughes
- Department of Surgery, Duke University Medical Center, Box 3051 DUMC, Durham, NC 27710.
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19
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Brown JA, Arnaoutakis GJ, Kilic A, Gleason TG, Aranda‐Michel E, Sultan I. Medical and surgical management of acute type B aortic intramural hematoma. J Card Surg 2020; 35:2324-2330. [DOI: 10.1111/jocs.14823] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- James A. Brown
- Division of Cardiac Surgery, Department of Cardiothoracic SurgeryUniversity of Pittsburgh Pittsburgh Pennsylvania
| | - George J. Arnaoutakis
- Division of Thoracic and Cardiovascular SurgeryUniversity of Florida Gainesville Florida
| | - Arman Kilic
- Division of Cardiac Surgery, Department of Cardiothoracic SurgeryUniversity of Pittsburgh Pittsburgh Pennsylvania
- Heart and Vascular InstituteUniversity of Pittsburgh Medical Center Pittsburgh Pennsylvania
| | - Thomas G. Gleason
- Division of Cardiac Surgery, Department of Cardiothoracic SurgeryUniversity of Pittsburgh Pittsburgh Pennsylvania
- Heart and Vascular InstituteUniversity of Pittsburgh Medical Center Pittsburgh Pennsylvania
| | - Edgar Aranda‐Michel
- Division of Cardiac Surgery, Department of Cardiothoracic SurgeryUniversity of Pittsburgh Pittsburgh Pennsylvania
| | - Ibrahim Sultan
- Division of Cardiac Surgery, Department of Cardiothoracic SurgeryUniversity of Pittsburgh Pittsburgh Pennsylvania
- Heart and Vascular InstituteUniversity of Pittsburgh Medical Center Pittsburgh Pennsylvania
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20
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Yamane Y, Katayama K, Furukawa T, Shimizu H, Okazaki T, Takasaki T, Kurosaki T, Takahashi S. Mid-Term Results of Frozen Elephant Trunk Technique for Chronic Aortic Dissection. Ann Vasc Dis 2020; 13:137-143. [PMID: 32595789 PMCID: PMC7315230 DOI: 10.3400/avd.oa.19-00131] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 02/03/2020] [Indexed: 12/19/2022] Open
Abstract
Objective: In this study, we report our experience using the frozen elephant trunk (FET) technique for chronic aortic dissection. Methods: Between January 2011 and December 2017, 15 patients underwent total arch replacement (TAR) with the FET technique for chronic aortic dissection (CAD). Results: Hospital mortality was 6.7% (n=1). No patients experienced spinal cord injury. Distal stent-induced new entry (dSINE) occurred in the early postoperative period in one patient. There were four unplanned additional operations to manage dSINE. Five patients suffered from dSINE, and aortoesophageal fistula developed in three of them. Short insertion length of the FET and large angle between the distal edge of the FET and the descending aorta were significantly more common in the dSINE group than in the non-dSINE group. The cumulative survival rates at 1, 3, and 5 years were 93.3%, 93.3%, and 66.4%, respectively. The cumulative aortic event-free rates at 1, 2, and 3 years were 85.7%, 77.1%, and 52.9%, respectively. Conclusion: The FET technique for CAD provided good early results. Short insertion length of the FET, however, can induce dSINE, which requires an additional operation at mid-term. Thus, surgical indication of the FET technique for CAD must be discussed.
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Affiliation(s)
- Yoshitaka Yamane
- Department of Cardiovascular Surgery, Hiroshima University Hospital, Hiroshima, Hiroshima, Japan
| | - Keijiro Katayama
- Department of Cardiovascular Surgery, Hiroshima University Hospital, Hiroshima, Hiroshima, Japan
| | - Tomokuni Furukawa
- Cardiovascular Center, Department of Cardiovascular Surgery, Akane-Foundation Tsuchiya General Hospital, Hiroshima, Hiroshima, Japan
| | - Haruna Shimizu
- Department of Cardiovascular Surgery, Hiroshima University Hospital, Hiroshima, Hiroshima, Japan
| | - Takanobu Okazaki
- Department of Cardiovascular Surgery, Hiroshima University Hospital, Hiroshima, Hiroshima, Japan
| | - Taiichi Takasaki
- Department of Cardiovascular Surgery, Hiroshima University Hospital, Hiroshima, Hiroshima, Japan
| | - Tatsuya Kurosaki
- Department of Cardiovascular Surgery, Hiroshima University Hospital, Hiroshima, Hiroshima, Japan
| | - Shinya Takahashi
- Department of Cardiovascular Surgery, Hiroshima University Hospital, Hiroshima, Hiroshima, Japan
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21
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Tsagakis K, Pacini D, Grabenwöger M, Borger MA, Goebel N, Hemmer W, Laranjeira Santos A, Sioris T, Widenka K, Risteski P, Mascaro J, Rudez I, Zierer A, Mestres CA, Ruhparwar A, Di Bartolomeo R, Jakob H. Results of frozen elephant trunk from the international E-vita Open registry. Ann Cardiothorac Surg 2020; 9:178-188. [PMID: 32551250 DOI: 10.21037/acs-2020-fet-25] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Over the years, frozen elephant trunk (FET) has become the treatment of choice for multisegmental thoracic aortic disease. This multicenter study presents the evolution of FET results using the E-vita Open hybrid graft with respect to institutional experience and time. Methods The data of International E-vita Open registry were studied according to the institutional experience of the participating centers (high- versus low-volume centers) and according to the evolution of FET treatment during time (1st period, 2005-2011 versus 2nd period, 2012-2018). Overall, 1,165 patients were enrolled in the study with a wide variety of multisegmental thoracic aortic pathologies and aortic emergencies. Participating centers determined their own surgical protocol. Results The overall 30-day mortality was 12%. Short- and long-term survival were higher in high- versus low-volume centers (P=0.048 and P=0.013, respectively). In the 2nd time period, cerebral complications were reduced significantly (P=0.015). Incidence of permanent spinal cord-related symptoms was reduced to 3% in the 2nd time period, but did not reach statistical significance. Hypothermic circulatory arrest time (P<0.001) and incidence of postoperative temporary renal replacement therapy (P=0.008) were significantly reduced in the 2nd time period. Ten-year survival and freedom from aortic-related death rates were 46.6% and 85.7%, respectively, for the entire group. The freedom from distal aortic re-interventions for a new or progressive residual aortic disease was 76.0%. Conclusions Evolution of FET arch repair techniques with the E-vita Open graft and increasing institutional experience were associated with improved results. Progression of residual aortic disease makes close follow-up with aortic imaging mandatory in such patients.
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Affiliation(s)
- Konstantinos Tsagakis
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center Essen, University Hospital of Essen, Essen, Germany
| | - Davide Pacini
- Department of Cardiac Surgery, S. Orsola Hospital, University of Bologna, Bologna, Italy
| | - Martin Grabenwöger
- Department of Cardiovascular Surgery, Hospital Hietzing, Vienna, Austria
| | - Michael A Borger
- Department of Cardiac Surgery, Leipzig Heart Center, University of Leipzig, Leipzig, Germany
| | - Nora Goebel
- Department of Cardiac and Vascular Surgery, Robert Bosch Hospital, Stuttgart, Germany
| | - Wolfgang Hemmer
- Department of Cardiac Surgery, Sana Cardiac Surgery Stuttgart GmbH, Stuttgart, Germany
| | | | - Thanos Sioris
- Tampere University Hospital Heart Center, Tampere, Finland
| | | | - Petar Risteski
- Department of Thoracic and Cardiovascular Surgery, University Hospital Frankfurt am Main, Frankfurt am Main, Germany
| | - Jorge Mascaro
- Department of Cardiothoracic Surgery, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
| | - Igor Rudez
- Department of Cardiac and Transplant Surgery, University Hospital Dubrava, Zagreb, Croatia
| | - Andreas Zierer
- Department of Thoracic and Cardiovascular Surgery, Faculty of Medicine, Kepler University Hospital Linz, Johannes Kepler University Linz, Linz, Austria
| | - Carlos A Mestres
- Department of Cardio Vascular Surgery, Hospital Clinico, University of Barcelona, Barcelona, Spain.,Department of Cardiovascular Surgery, University Hospital Zürich, Zürich, Switzerland
| | - Arjang Ruhparwar
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center Essen, University Hospital of Essen, Essen, Germany
| | - Roberto Di Bartolomeo
- Department of Cardiac Surgery, S. Orsola Hospital, University of Bologna, Bologna, Italy
| | - Heinz Jakob
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center Essen, University Hospital of Essen, Essen, Germany
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22
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Oishi Y, Yamashita Y, Kimura S, Sonoda H, Matsuyama S, Ushijima T, Fujita S, Tatewaki H, Tanoue Y, Shiose A. Preoperative distal aortic diameter is a significant predictor of late aorta-related events after endovascular repair for chronic type B aortic dissection. Gen Thorac Cardiovasc Surg 2020; 68:1086-1093. [PMID: 32078136 DOI: 10.1007/s11748-020-01318-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Accepted: 02/06/2020] [Indexed: 10/25/2022]
Abstract
OBJECTIVES Long-term therapeutic effects of thoracic endovascular aortic repair (TEVAR) for chronic type B aortic dissection remain controversial. This study aimed to evaluate the possible predictors of late aortic rupture and re-interventions after TEVAR. METHODS We retrospectively reviewed the operative outcomes of 40 patients who underwent TEVAR for chronic type B aortic dissection at Kyushu University Hospital. During a mean follow-up period of 39.2 months, we assessed aortic morphology via computed tomography and then employed a multivariable Cox regression analysis in an attempt to identify the predictors of late aorta-related events. RESULTS The early success rate of TEVAR was 100%. During the follow-up, however, three patients died from aortic rupture. Eight patients required aortic re-intervention, including thoraco-abdominal aortic graft replacement, repeated TEVAR, total arch replacement and EVAR. Multivariable Cox regression analysis revealed that the preoperative maximum distal aortic diameter was a significant predictor of late aorta-related events. The cutoff value of the distal aortic diameter was 40 mm. Freedom from aorta-related events was 94.6% at 1 year and 78.3% at 3 years. The survival rate was not significantly different despite the re-intervention. CONCLUSIONS TEVAR is an effective treatment for chronic type B dissection, with acceptable mid-term results. The preoperative distal aortic diameter is a significant risk factor for late aorta-related events. When the maximum distal aortic diameter is ≥ 40 mm, a therapeutic strategy should be developed taking into consideration the possible need for aortic re-intervention.
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Affiliation(s)
- Yasuhisa Oishi
- Department of Cardiovascular Surgery, Faculty of Medicine, Kyushu University Graduate School of Medicine, 3-1-1 Maidashi, Higashi, Fukuoka, 812-8552, Japan.
| | - Yoshiyuki Yamashita
- Department of Cardiovascular Surgery, Faculty of Medicine, Kyushu University Graduate School of Medicine, 3-1-1 Maidashi, Higashi, Fukuoka, 812-8552, Japan
| | - Satoshi Kimura
- Department of Cardiovascular Surgery, Faculty of Medicine, Kyushu University Graduate School of Medicine, 3-1-1 Maidashi, Higashi, Fukuoka, 812-8552, Japan
| | - Hiromichi Sonoda
- Department of Cardiovascular Surgery, Faculty of Medicine, Kyushu University Graduate School of Medicine, 3-1-1 Maidashi, Higashi, Fukuoka, 812-8552, Japan
| | - Sho Matsuyama
- Department of Cardiovascular Surgery, Faculty of Medicine, Kyushu University Graduate School of Medicine, 3-1-1 Maidashi, Higashi, Fukuoka, 812-8552, Japan
| | - Tomoki Ushijima
- Department of Cardiovascular Surgery, Faculty of Medicine, Kyushu University Graduate School of Medicine, 3-1-1 Maidashi, Higashi, Fukuoka, 812-8552, Japan
| | - Satoshi Fujita
- Department of Cardiovascular Surgery, Faculty of Medicine, Kyushu University Graduate School of Medicine, 3-1-1 Maidashi, Higashi, Fukuoka, 812-8552, Japan
| | - Hideki Tatewaki
- Department of Cardiovascular Surgery, Faculty of Medicine, Kyushu University Graduate School of Medicine, 3-1-1 Maidashi, Higashi, Fukuoka, 812-8552, Japan
| | - Yoshihisa Tanoue
- Department of Cardiovascular Surgery, Faculty of Medicine, Kyushu University Graduate School of Medicine, 3-1-1 Maidashi, Higashi, Fukuoka, 812-8552, Japan
| | - Akira Shiose
- Department of Cardiovascular Surgery, Faculty of Medicine, Kyushu University Graduate School of Medicine, 3-1-1 Maidashi, Higashi, Fukuoka, 812-8552, Japan
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23
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Xue Y, Ge Y, Ge X, Miao J, Fan W, Rong D, Liu F, Liu X, Guo W. Association Between Extent of Stent-Graft Coverage and Thoracic Aortic Remodeling After Endovascular Repair of Type B Aortic Dissection. J Endovasc Ther 2020; 27:211-220. [PMID: 32026762 DOI: 10.1177/1526602820904164] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Purpose: To examine the association between the extent of stent-graft coverage and thoracic aortic expansion after thoracic endovascular aortic repair (TEVAR) for type B aortic dissection. Materials and Methods: A retrospective analysis was conducted of 201 patients (mean age 52.4±11.5 years; 178 men) with acute (135, 67.2%) or chronic (66, 32.8%) type B aortic dissection who underwent TEVAR at 4 medical centers. The mean stent-graft length was 157.1±33.3 mm. The percentage of stented descending aorta (PSDA) represented the extent of stent-graft coverage. After using restricted cubic smoothing spline plots to confirm the roughly linear relationship between PSDA and the risk of thoracic aortic expansion, patients were stratified into 2 groups on the median PSDA: the lower group (≤31.3%) and the higher group (>31.3%). Thoracic aortic expansion was defined as a ≥20% increase in the total thoracic aortic volume on the most recent postoperative computed tomography angiography scan compared with the preoperative measurement. The Kaplan-Meier method was used to estimate the cumulative freedom from thoracic aortic expansion after TEVAR; estimates are given with the 95% confidence interval (CI). A multivariable Cox proportional hazards model was used to analyze any independent association of the PSDA as a continuous or categorical variable with the risk of thoracic aortic expansion; results are presented as the hazard ratio (HR) and 95% CI. Results: No patients developed symptoms of spinal cord ischemia during hospitalization. Over a median 12.4 months of imaging follow-up, 34 (16.9%) patients developed thoracic aortic expansion. The estimate of freedom from thoracic aortic expansion at 12 months for the overall PSDA was 84.0% (95% CI 77.8% to 88.6%); between the groups, the freedom from thoracic aortic expansion estimate for the PSDA ≤31.3% group was significantly lower than in the higher group (p=0.032). Regression analysis showed no significant association between the risk of thoracic aortic expansion and the PSDA as a continuous variable (HR 0.97, 95% CI 0.91 to 1.03, p=0.288); however, analyzing the PSDA as a categorical variable indicated a significantly lower risk of thoracic aortic expansion for the PSDA >31.3% group (HR 0.46, 95% CI 0.22 to 0.95, p=0.036) after adjusting for a variety of demographic and anatomical characteristics. Conclusion: More extensive stent-graft coverage appears to improve thoracic aortic remodeling after TEVAR. However, the clinician should balance the benefit of extensive stent-graft coverage and its related risk of spinal cord ischemia.
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Affiliation(s)
- Yan Xue
- Department of Vascular and Endovascular Surgery, First Medical Center of Chinese PLA General Hospital, Beijing, China
- Research Platform for Minimally Invasive Cardiovascular Surgery, Beijing Key Laboratory, Beijing, China
| | - Yangyang Ge
- Department of Vascular and Endovascular Surgery, First Medical Center of Chinese PLA General Hospital, Beijing, China
- Research Platform for Minimally Invasive Cardiovascular Surgery, Beijing Key Laboratory, Beijing, China
| | - Xiaohu Ge
- Department of Vascular Surgery, People’s Hospital of Xinjiang Uygur Autonomous Region, Urumchi, China
| | - Jianhang Miao
- Department of General Surgery, Zhongshan People’s Hospital, Zhongshan, China
| | - Weidong Fan
- Department of Cardiology, Henan Provincial Chest Hospital, Zhengzhou, China
| | - Dan Rong
- Department of Vascular and Endovascular Surgery, First Medical Center of Chinese PLA General Hospital, Beijing, China
- Research Platform for Minimally Invasive Cardiovascular Surgery, Beijing Key Laboratory, Beijing, China
| | - Feng Liu
- Department of Vascular and Endovascular Surgery, First Medical Center of Chinese PLA General Hospital, Beijing, China
- Research Platform for Minimally Invasive Cardiovascular Surgery, Beijing Key Laboratory, Beijing, China
| | - Xiaoping Liu
- Department of Vascular and Endovascular Surgery, First Medical Center of Chinese PLA General Hospital, Beijing, China
- Research Platform for Minimally Invasive Cardiovascular Surgery, Beijing Key Laboratory, Beijing, China
| | - Wei Guo
- Department of Vascular and Endovascular Surgery, First Medical Center of Chinese PLA General Hospital, Beijing, China
- Research Platform for Minimally Invasive Cardiovascular Surgery, Beijing Key Laboratory, Beijing, China
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24
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Open Descending and Thoracoabdominal Aortic Repairs in Patients Younger Than 50 Years Old. Ann Thorac Surg 2019; 108:693-699. [DOI: 10.1016/j.athoracsur.2019.03.058] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2018] [Revised: 03/05/2019] [Accepted: 03/18/2019] [Indexed: 11/22/2022]
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25
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Outcomes After Thoracic Endovascular Aortic Repair With Overstenting of the Left Subclavian Artery. Ann Thorac Surg 2019; 107:1372-1379. [DOI: 10.1016/j.athoracsur.2018.10.051] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Revised: 09/25/2018] [Accepted: 10/16/2018] [Indexed: 11/17/2022]
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26
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Aranda-Michel E, Kilic A, Gleason TG, Bianco V, Sultan I. Diagnostic dilemma in prosthetic valve endocarditis: Computed tomography to the rescue. J Card Surg 2019; 34:208-210. [PMID: 30803027 DOI: 10.1111/jocs.14001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 01/24/2019] [Accepted: 02/05/2019] [Indexed: 12/01/2022]
Abstract
A 58-year-old man with multiple myeloma, prior bioprosthetic valve, spinal hardware and multiple episodes of Corynebacterium amycolatum bacteremia was found to have a well-seated valve without vegetations, paravalvular leak, abscess or degeneration over a period of 6 months on five separate transesophageal echocardiographic studies. Computed tomography angiography was performed which revealed vegetation at the level of the left ventricular outflow tract. Reoperative sternotomy and interrogation of the valve confirmed a 1.5-cm vegetation with the same bacterium. The patient underwent a redo aortic valve replacement and recovered without any complications. He has been asymptomatic and culture negative on surveillance.
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Affiliation(s)
- Edgar Aranda-Michel
- Department of Cardiothoracic Surgery, Division of Cardiac Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Arman Kilic
- Department of Cardiothoracic Surgery, Division of Cardiac Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania.,Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Thomas G Gleason
- Department of Cardiothoracic Surgery, Division of Cardiac Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania.,Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Valentino Bianco
- Department of Cardiothoracic Surgery, Division of Cardiac Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Ibrahim Sultan
- Department of Cardiothoracic Surgery, Division of Cardiac Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania.,Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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27
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Sultan I, Dufendach K, Kilic A, Bianco V, Trivedi D, Althouse AD, Thoma F, Navid F, Gleason TG. Bare Metal Stent Use in Type B Aortic Dissection May Offer Positive Remodeling for the Distal Aorta. Ann Thorac Surg 2018; 106:1364-1370. [DOI: 10.1016/j.athoracsur.2018.06.042] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Revised: 05/07/2018] [Accepted: 06/13/2018] [Indexed: 10/28/2022]
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28
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Bianco V, Kilic A, Gleason TG, Arnaoutakis GJ, Sultan I. Management of thoracic aortic graft infections. J Card Surg 2018; 33:658-665. [DOI: 10.1111/jocs.13792] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Valentino Bianco
- Division of Cardiac Surgery; Department of Cardiothoracic Surgery, University of Pittsburgh; Pittsburgh Pennsylvania
| | - Arman Kilic
- Division of Cardiac Surgery; Department of Cardiothoracic Surgery, University of Pittsburgh; Pittsburgh Pennsylvania
- Heart and Vascular Institute; University of Pittsburgh Medical Center; Pittsburgh Pennsylvania
| | - Thomas G. Gleason
- Division of Cardiac Surgery; Department of Cardiothoracic Surgery, University of Pittsburgh; Pittsburgh Pennsylvania
- Heart and Vascular Institute; University of Pittsburgh Medical Center; Pittsburgh Pennsylvania
| | - George J. Arnaoutakis
- Division of Thoracic and Cardiovascular Surgery; University of Florida; Gainesville Florida
| | - Ibrahim Sultan
- Division of Cardiac Surgery; Department of Cardiothoracic Surgery, University of Pittsburgh; Pittsburgh Pennsylvania
- Heart and Vascular Institute; University of Pittsburgh Medical Center; Pittsburgh Pennsylvania
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