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Mylonas KS, Zoupas I, Tasoudis PT, Vitkos E, Stavridis GT, Avgerinos DV. Endovascular Treatment of Type A Aortic Dissection: A Systematic Review and Meta-Analysis Using Reconstructed Time-to-Event Data. J Clin Med 2023; 12:7051. [PMID: 38002665 PMCID: PMC10672308 DOI: 10.3390/jcm12227051] [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: 10/11/2023] [Revised: 10/31/2023] [Accepted: 11/07/2023] [Indexed: 11/26/2023] Open
Abstract
OBJECTIVE The undisputed gold standard of treatment for type A aortic dissections (TAAD) is open surgery. Anecdotal reports have assessed thoracic endovascular aortic repair (TEVAR) as a last resort for highly selected candidates. The present study aims to evaluate endovascular outcomes in TAAD patients who are unsuitable for open surgery whilst having TEVAR-compatible aortic anatomy. METHODS A PRISMA-compliant systematic search of the PubMed, Scopus, and Cochrane databases was performed up to 19 May 2022. Time-to-event data were reconstructed using Kaplan-Meier curves from the source literature. RESULTS In 20 eligible studies, 311 patients underwent TEVAR for acute, subacute, or chronic TAAD. Mean age at the time of the operation was 60.70 ± 8.00 years and 75.48% (95% Confidence Interval [CI], 60.33-88.46%) of the included patients were males. Mean operative time was 169.40 ± 30.70 min. Overall, 0.44% (95% CI, 0.00-4.83%) of the cases were converted to salvage open surgery. Technical failure, stroke, and endoleaks occurred in 0.22%, 0.1%, and 8.52% of the cohort, respectively. Thirty-day postoperative complication rate was 7.08% (95% CI, 1.52-14.97%), whereas late complications developed in 16.89% (95% CI, 7.75-27.88%) of the patients. One-, three-, and five-year survival rates were estimated at 87.15%, 82.52% and 82.31%, respectively. Reintervention was required in 8.38% of the cohort over a mean follow-up of 32.40 ± 24.40 months. CONCLUSIONS TEVAR seems to be feasible in highly selected patients with TAAD who cannot tolerate open surgery. Overcoming technical limitations and acquiring long-term data are warranted to safely define the place of endovascular treatment in the armamentarium of TAAD repair.
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Affiliation(s)
- Konstantinos S. Mylonas
- Department of Cardiac Surgery, Onassis Cardiac Surgery Center, 176 74 Athens, Greece; (K.S.M.)
- School of Medicine, National and Kapodistrian University of Athens, Mikras Asias Str. 75, 115 27 Athens, Greece
| | - Ioannis Zoupas
- School of Medicine, National and Kapodistrian University of Athens, Mikras Asias Str. 75, 115 27 Athens, Greece
- Surgery Working Group, Society of Junior Doctors, 151 23 Athens, Greece;
| | | | - Evangelos Vitkos
- Department of General Surgery, General Hospital of Katerini, 601 00 Katerini, Greece
| | - George T. Stavridis
- Department of Cardiac Surgery, Onassis Cardiac Surgery Center, 176 74 Athens, Greece; (K.S.M.)
| | - Dimitrios V. Avgerinos
- Department of Cardiac Surgery, Onassis Cardiac Surgery Center, 176 74 Athens, Greece; (K.S.M.)
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Lin JP, Zhang H, Shang T, Jin BX, Yao YX. Thoracic endovascular aortic repair of an anastomosis pseudoaneurysm after the Bentall procedure assisted by rapid ventricular pacing: A case report. Heliyon 2023; 9:e16833. [PMID: 37303570 PMCID: PMC10250794 DOI: 10.1016/j.heliyon.2023.e16833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 05/24/2023] [Accepted: 05/30/2023] [Indexed: 06/13/2023] Open
Abstract
Background Although commonly used for the treatment of descending aortic dissection, endovascular repair is challenging for ascending aortic pseudoaneurysms. Rapid ventricular pacing (RVP), a method that temporarily impedes cardiac output by stopping ventricular activity, heralds potential benefits for thoracic endovascular aortic repair (TEVAR) during precision landing. Recently, we successfully treated an anastomosis pseudoaneurysm after the Bentall procedure using TEVAR assisted by RVP. Case report A 69-year-old male was admitted to our hospital with a ascending aortic anastomosis pseudoaneurysm. He had undergone a Bentall procedure and a coronary artery bypass grafting nine years prior. After extensive consultation, the decision was made to perform TEVAR with the assistance of RVP. After a covered stent graft was delivered to the precise location of the ascending aorta, RVP was performed at a frequency of 180 beats/min with a pacemaker. When a flattened arterial blood wave of <50 mmHg was observed, the stent graft was released precisely between the opening of the coronary graft and innominate artery. Angiography revealed the presence of an endoleak; therefore, a set of interlock coils were packed into the aneurysm. Subsequent angiography showed intact blood flow in the aorta, superior arch branches, and coronary graft vessels. The patient recovered uneventfully after the procedure. He was discharged six days later and was doing well at the eight-month follow-up. Conclusion The case indicates that TEVAR assisted by RVP is a promising combination for ascending aortic pseudoaneurysm in selected patients.
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Affiliation(s)
- Jia-Piao Lin
- Department of Anesthesia, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, People's Republic of China
| | - Hui Zhang
- Department of Anesthesia, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, People's Republic of China
| | - Tao Shang
- Department of Vascular Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, People's Republic of China
| | - Bing-Xin Jin
- Department of Anesthesia, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, People's Republic of China
| | - Yong-Xing Yao
- Department of Anesthesia, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, People's Republic of China
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Yen Y, Chen Y, Kao PH, Lin C. Zone 0 thoracic endovascular aortic repair in high risk patients: A retrospective case series. Catheter Cardiovasc Interv 2022; 100:787-794. [DOI: 10.1002/ccd.30356] [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: 02/21/2022] [Revised: 06/02/2022] [Accepted: 07/28/2022] [Indexed: 11/08/2022]
Affiliation(s)
- Yu‐Tong Yen
- Division of Cardiovascular Surgery, Department of Surgery Shin Kong Wu Ho‐Su Memorial Hospital Taipei City Taiwan
| | - Yen‐Yang Chen
- Division of Cardiovascular Surgery, Department of Surgery Shin Kong Wu Ho‐Su Memorial Hospital Taipei City Taiwan
| | - Patrick Hung‐Ju Kao
- Division of Cardiovascular Surgery, Department of Surgery Shin Kong Wu Ho‐Su Memorial Hospital Taipei City Taiwan
| | - Chia‐Hsun Lin
- Division of Cardiovascular Surgery, Department of Surgery Shin Kong Wu Ho‐Su Memorial Hospital Taipei City Taiwan
- School of Medicine Fu‐Jen Catholic University New Taipei City Taiwan
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Waterford SD, Ghoreishi M, Toursavadkohi S, Taylor BS. The 10 Commandments of Aortic Arch Endovascular Repair. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2022; 17:266-272. [PMID: 35997683 DOI: 10.1177/15569845221116864] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Stephen D Waterford
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center Hamot, Erie, PA, USA
| | - Mehrdad Ghoreishi
- Division of Cardiac Surgery, 12264University of Maryland School of Medicine, Baltimore, MD, USA
| | - Shahab Toursavadkohi
- Division of Vascular Surgery, 12264University of Maryland School of Medicine, Baltimore, MD, USA
| | - Bradley S Taylor
- Division of Cardiac Surgery, 12264University of Maryland School of Medicine, Baltimore, MD, USA
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Sibinga Mulder BG, van Strijen MJ, Heijmen RH. Unexpected, complete recovery after emergent thoracic endovascular aortic repair for inoperable type A aortic dissection. J Vasc Surg Cases Innov Tech 2022; 8:167-170. [PMID: 35391994 PMCID: PMC8980558 DOI: 10.1016/j.jvscit.2022.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 01/31/2022] [Indexed: 11/17/2022] Open
Affiliation(s)
- Babs G. Sibinga Mulder
- Department of Cardiothoracic Surgery, St. Antonius Hospital, Nieuwegein, the Netherlands
| | | | - Robin H. Heijmen
- Department of Cardiothoracic Surgery, St. Antonius Hospital, Nieuwegein, the Netherlands
- Correspondence: Robin H. Heijmen, PhD, MD, Department of Cardiothoracic Surgery, Koekoekslaan 1, 3435 CM, Nieuwegein, the Netherlands
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Roselli EE, Atkins MD, Brinkman W, Coselli J, Desai N, Estrera A, Johnston DR, Patel H, Preventza O, Vargo PR, Fleischman F, Taylor BS, Reardon MJ. ARISE: First-In-Human Evaluation of a Novel Stent Graft to Treat Ascending Aortic Dissection. J Endovasc Ther 2022:15266028221095018. [PMID: 35587698 DOI: 10.1177/15266028221095018] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND Operative mortality for type A aortic dissection is still 10-20% at centers of excellence. Additionally, 10-20% are not considered as viable candidates for open surgical repair and not offered life-saving emergency surgery. ARISE is a multicenter investigation evaluating the novel GORE® Ascending Stent Graft (ASG; Flagstaff, AZ). OBJECTIVE The purpose of this study is to assess early feasibility of using these investigational devices to treat ascending aortic dissection. METHODS This a prospective, multicenter, non-randomized, single-arm study that enrolls patients at high surgical risk with appropriate anatomical requirements based on computed tomography imaging at 7 of 9 US sites. Devices are delivered transfemorally under fluoroscopic guidance. Primary endpoint is all-cause mortality at 30 days. Secondary endpoints include major adverse cardiovascular and cerebrovascular events (MACCE) at 30 days, 6 months, and 12 months. RESULTS Nineteen patients were enrolled with a mean age of 75.7 years (range 47-91) and 11 (57.9%) were female. Ten (52.6%) had DeBakey type I disease, and the rest were type II. Sixteen (84.2%) of the patients were acute. Patients were treated with safe access, (7/19 (36.8%) percutaneous, 10/19 (52.6%) transfemoral, 2/19 (10.5%) iliac conduit), delivery, and deployment completed in all cases. Median procedure time was 154 mins (range 52-392) and median contrast used was 111 mL (range 75-200). MACCE at 30 days occurred in 5 patients including mortality 3/19 (15.8%), disabling stroke in 1/19 (5.3%), and myocardial infarction in 1/19 (5.3%). CONCLUSION Results from the ARISE early feasibility study of a specific ascending stent graft device to treat ascending aortic dissection are promising.
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Affiliation(s)
- Eric E Roselli
- Department of Thoracic and Cardiovascular Surgery, Aortic Center, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | | | | | | | - Nimesh Desai
- University of Pennsylvania, Philadelphia, PA, USA
| | | | - Douglas R Johnston
- Department of Thoracic and Cardiovascular Surgery, Aortic Center, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Himanshu Patel
- University of Michigan Frankel Cardiovascular Center, Ann Arbor, MI, USA
| | | | - Patrick R Vargo
- Department of Thoracic and Cardiovascular Surgery, Aortic Center, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
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Nomura Y, Koide Y, Kawasaki R, Murakami H. Endovascular Repair for Ascending Aortic Graft Side Branch Pseudoaneurysm: A Report of Two Cases. EJVES Vasc Forum 2022; 55:48-51. [PMID: 35515008 PMCID: PMC9062449 DOI: 10.1016/j.ejvsvf.2022.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 03/13/2022] [Accepted: 03/28/2022] [Indexed: 11/26/2022] Open
Abstract
Introduction A pseudoaneurysm arising from the side branch of the prosthesis, following ascending aortic replacement, is extremely rare. Re-intervention usually involves open surgery, replacement of the ascending aorta, or ligation of the side branch. Redo surgery with an additional sternotomy carries the risk of cardiac and vascular injuries, and endovascular treatment can reduce such adverse events. Report This study describes the successful thoracic endovascular aortic repair (TEVAR) of two cases of pseudoaneurysms arising from the side branch after ascending aortic replacement. Case 1 involved a 79 year old man who underwent ascending aortic replacement and omentopexy for a ruptured tuberculous aortic aneurysm 13 years ago. The pseudoaneurysm was mushroom shaped with a 30 mm protrusion. Case 2 involved an 83 year old man who underwent ascending aortic replacement for Stanford type A acute aortic dissection 11 years ago. The pseudoaneurysm was rod shaped with a 27 mm protrusion. In both cases, the pseudoaneurysm arising from the side branch was not noted on computed tomography (CT) until one year earlier and was first identified at a routine follow up examination. The pseudoaneurysms required surgical repair because of the risk of rupture; however, TEVAR was selected considering the risks of redo surgery and the patients' ages. It was performed via a femoral artery approach without adverse events using a commercially available thoracic aortic device. Post-operative CT scan showed complete exclusion of the pseudoaneurysm. Discussion Although TEVAR is usually not indicated for ascending aortic pathologies, if there is an anatomical indication and a compatible stent graft, TEVAR for the ascending aorta should be the first choice in patients who are inoperable, at high risk and undergoing redo surgery.
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Affiliation(s)
- Yoshikatsu Nomura
- Department of Cardiovascular Surgery, Hyogo Brain and Heart Centre at Himeji, Hyogo, Japan
| | - Yutaka Koide
- Department of Radiology, Hyogo Brain and Heart Centre at Himeji, Hyogo, Japan
| | - Ryota Kawasaki
- Department of Radiology, Hyogo Brain and Heart Centre at Himeji, Hyogo, Japan
| | - Hirohisa Murakami
- Department of Cardiovascular Surgery, Hyogo Brain and Heart Centre at Himeji, Hyogo, Japan
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Kikuchi Y, Kunioka S, Shirasaka T, Kamiya H. Combination of a vascular plug and coiling to treat an ascending aortic pseudoaneurysm following aortic surgery. JTCVS Tech 2022; 12:12-14. [PMID: 35403020 PMCID: PMC8987380 DOI: 10.1016/j.xjtc.2022.01.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 01/12/2022] [Indexed: 11/30/2022] Open
Affiliation(s)
| | | | - Tomonori Shirasaka
- Address for reprints: Tomonori Shirasaka, MD, PhD, Department of Cardiovascular Surgery, Asahikawa Medical University, 1-1-1, Higashi 2 jo, Midorigaoka, Asahikawa, Hokkaido 078-8510, Japan.
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Marquis KM, Naeem M, Rajput MZ, Raptis DA, Steinbrecher KL, Ohman JW, Bhalla S, Raptis CA. CT of Postoperative Repair of the Ascending Aorta and Aortic Arch. Radiographics 2021; 41:1300-1320. [PMID: 34415808 DOI: 10.1148/rg.2021210026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
While many of the classic open surgical repairs are still used to repair the ascending aorta, management of the aortic arch has become more complex via implementation of newer open surgical and endovascular techniques. Furthermore, techniques are often combined in novel repairs or to allow extended anatomic coverage. As such, a framework that rests on understanding the expected postoperative appearance is necessary for the diagnostic radiologist to best interpret CT studies in these patients. After reviewing the imaging appearances of the common components used in proximal aortic repair, the authors present a structured approach that focuses on the key relevant questions that diagnostic radiologists should consider when interpreting CT studies in these patients. For repair of the ascending aorta, this includes determining whether the aortic valve has been repaired, whether the sinuses of Valsalva have been repaired, and how the coronary arteries were managed, when necessary. In repairs that involve the aortic arch, the relevant considerations relate to management of the arch vessels and the distal extent of the repair. In focusing on these questions, the diagnostic radiologist will be able to identify and describe the vast majority of repairs. Understanding these questions will also facilitate improved understanding of novel repairs, which often use these basic building blocks. Finally, complications-which typically involve infection, noninfectious repair breakdown, hemorrhage, problems with endografts, or disease of the remaining adjacent aorta-will be identifiable as deviations from the expected postoperative appearance. Online supplemental material is available for this article. ©RSNA, 2021.
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Affiliation(s)
- Kaitlin M Marquis
- From the Mallinckrodt Institute of Radiology (K.M.M., M.N., M.Z.R., D.A.R., K.L.S., S.B., C.A.R.) and Department of Surgery (J.W.O.), Washington University School of Medicine, 510 S Kingshighway Blvd, St Louis, MO 63110
| | - Muhammad Naeem
- From the Mallinckrodt Institute of Radiology (K.M.M., M.N., M.Z.R., D.A.R., K.L.S., S.B., C.A.R.) and Department of Surgery (J.W.O.), Washington University School of Medicine, 510 S Kingshighway Blvd, St Louis, MO 63110
| | - Mohamed Zak Rajput
- From the Mallinckrodt Institute of Radiology (K.M.M., M.N., M.Z.R., D.A.R., K.L.S., S.B., C.A.R.) and Department of Surgery (J.W.O.), Washington University School of Medicine, 510 S Kingshighway Blvd, St Louis, MO 63110
| | - Demetrios A Raptis
- From the Mallinckrodt Institute of Radiology (K.M.M., M.N., M.Z.R., D.A.R., K.L.S., S.B., C.A.R.) and Department of Surgery (J.W.O.), Washington University School of Medicine, 510 S Kingshighway Blvd, St Louis, MO 63110
| | - Kacie L Steinbrecher
- From the Mallinckrodt Institute of Radiology (K.M.M., M.N., M.Z.R., D.A.R., K.L.S., S.B., C.A.R.) and Department of Surgery (J.W.O.), Washington University School of Medicine, 510 S Kingshighway Blvd, St Louis, MO 63110
| | - J Westley Ohman
- From the Mallinckrodt Institute of Radiology (K.M.M., M.N., M.Z.R., D.A.R., K.L.S., S.B., C.A.R.) and Department of Surgery (J.W.O.), Washington University School of Medicine, 510 S Kingshighway Blvd, St Louis, MO 63110
| | - Sanjeev Bhalla
- From the Mallinckrodt Institute of Radiology (K.M.M., M.N., M.Z.R., D.A.R., K.L.S., S.B., C.A.R.) and Department of Surgery (J.W.O.), Washington University School of Medicine, 510 S Kingshighway Blvd, St Louis, MO 63110
| | - Constantine A Raptis
- From the Mallinckrodt Institute of Radiology (K.M.M., M.N., M.Z.R., D.A.R., K.L.S., S.B., C.A.R.) and Department of Surgery (J.W.O.), Washington University School of Medicine, 510 S Kingshighway Blvd, St Louis, MO 63110
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Prasad NK, Boyajian G, Gupta A, Hall M, Toursavadkouhi S, Ghoreishi M, Taylor BS. Transcarotid Approach for Ascending Aortic Endovascular Repair. Ann Thorac Surg 2021; 112:e17-e19. [DOI: 10.1016/j.athoracsur.2020.10.063] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 10/21/2020] [Indexed: 10/22/2022]
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Hauck SR, Kupferthaler A, Stelzmüller M, Eilenberg W, Ehrlich M, Neumayer C, Wolf F, Loewe C, Funovics MA. Endovascular Stent-Graft Repair of the Ascending Aorta: Assessment of a Specific Novel Stent-Graft Design in Phantom, Cadaveric, and Clinical Application. Cardiovasc Intervent Radiol 2021; 44:1448-1455. [PMID: 34180002 PMCID: PMC8382630 DOI: 10.1007/s00270-021-02859-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 04/24/2021] [Indexed: 11/24/2022]
Abstract
Purpose To test a stent-graft specifically designed for the ascending aorta in phantom, cadaver, and clinical application, and to measure deployment accuracy to overcome limitations of existing devices. Methods A stent-graft has been designed with support wires to fixate the apices toward the inner curvature, thereby eliminating the forward movement of the proximal end which can happen with circumferential tip capture systems. The device was deployed in three aortic phantoms, and in four cadavers, deployment precision was measured. Subsequently, the device was implanted in a patient to exclude a pseudoaneurysm originating from the distal anastomosis after ascending aortic replacement. Results The stent-grafts were successfully deployed in all phantoms and cadavers. Deployment accuracy of the proximal end of the stent-graft was within 1 mm proximally and 14 mm distally to the intended landing zone on the inner curvature, and 2–8 mm distal to the intended landing zone on the outer curvature. In clinical application, the pseudoaneurysm could be successfully excluded without complications. Conclusion The novel stent-graft design promises accurate placement in the ascending aorta. The differential deployment of the apices at the inner and outer curvatures allows deployment perpendicular to the aortic axis. Level of Evidence No level of evidence.
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Affiliation(s)
- Sven R Hauck
- Cardiovascular and Interventional Radiology, Department of Bioimaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Alexander Kupferthaler
- Cardiovascular and Interventional Radiology, Department of Bioimaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria.,Department of Diagnostic and Interventional Radiology, Ordensklinikum Linz, Linz, Austria
| | - Marlies Stelzmüller
- Department of Cardiothoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Wolf Eilenberg
- Department of Vascular Surgery, Medical University of Vienna, Vienna, Austria
| | - Marek Ehrlich
- Department of Cardiothoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Christoph Neumayer
- Department of Vascular Surgery, Medical University of Vienna, Vienna, Austria
| | - Florian Wolf
- Cardiovascular and Interventional Radiology, Department of Bioimaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Christian Loewe
- Cardiovascular and Interventional Radiology, Department of Bioimaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Martin A Funovics
- Cardiovascular and Interventional Radiology, Department of Bioimaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria.
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Grewal A, Odonkor P, Ghoreishi M, Deshpande SP. Anesthetic Considerations in Endovascular Repair of the Ascending Aorta. J Cardiothorac Vasc Anesth 2021; 35:3085-3097. [PMID: 34059437 DOI: 10.1053/j.jvca.2021.04.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Revised: 04/10/2021] [Accepted: 04/14/2021] [Indexed: 11/11/2022]
Abstract
Since the first endovascular aortic repair in 1990, endovascular devices and the indications for their use have significantly grown. Considerable progress has been made in endovascular devices and techniques, such that endovascular repair is now considered first-line treatment for patients with descending aortic disease. However, for patients with ascending aortic disease, open surgical repair with cardiopulmonary bypass and hypothermic cardiac arrest was the only option until recently. Although the outcomes for open surgical repair of the ascending aorta have improved over the years, approximately 30% of patients with an emergent surgical indication, such as type A aortic dissection, are considered to be too high risk for open repair. For these patients, endovascular repair of the ascending aorta offers a life-saving procedure. The ascending aorta is regarded as the final frontier for endovascular therapy. Endovascular repair of it has posed a formidable challenge thus far, due to its unique anatomy, hemodynamic forces, and lack of an appropriate stent-graft designed specifically for the ascending aorta. Although currently there are no comprehensive data from randomized clinical trials, there are several case series and case reports that have shown favorable outcomes. Improvements in available devices soon will drive an exponential increase in the number of patients undergoing endovascular ascending aortic repair. In this review, the authors discuss multiple aspects of endovascular ascending aortic repair including the unique surgical and anesthetic considerations, the devices used, and the available outcomes data, and future directions are also explored.
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Affiliation(s)
- Ashanpreet Grewal
- Department of Anesthesiology, Division of Cardiothoracic Anesthesiology, University of Maryland School of Medicine, Baltimore, MD.
| | - Patrick Odonkor
- Department of Anesthesiology, Division of Cardiothoracic Anesthesiology, University of Maryland School of Medicine, Baltimore, MD
| | - Mehrdad Ghoreishi
- Department of Surgery, Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Seema P Deshpande
- Department of Anesthesiology, Division of Cardiothoracic Anesthesiology, University of Maryland School of Medicine, Baltimore, MD
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13
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De Freitas S, Rossi MJ, Abramowitz SD, Fatima J, Kiguchi MM, Vallabhaneni R, Walsh SR, Woo EY. Systematic review and meta-analysis of endovascular interventions for Stanford type A aortic dissection. J Vasc Surg 2021; 74:1721-1731.e4. [PMID: 33592292 DOI: 10.1016/j.jvs.2021.01.054] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 01/14/2021] [Indexed: 10/22/2022]
Abstract
OBJECTIVE The standard surgical approach to Stanford type A aortic dissection is open repair. However, up to one in four patients will be declined surgery because of prohibitive risk. Patients who are treated nonoperatively have an unacceptably high mortality. Endovascular repair of the ascending aorta is emerging as an alternative treatment for a select group of patients. The reported rates of technical success, mortality, stroke, and reintervention have varied. The objective of the study was to systematically report outcomes for acute type A dissections repaired using an endovascular approach. METHODS The systematic review and meta-analysis was conducted in accordance with the PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines. We performed online literature database searches through April 2020. The demographic and procedural characteristics of the individual studies were tabulated. Data on technical success, short-term mortality, stroke, and reintervention were extracted and underwent meta-analysis using a random effects model. RESULTS Fourteen studies with 80 cases of aortic dissection (55 acute and 25 subacute) were included in the final analysis. A wide variation was found in technique and device design across the studies. The outcomes rates were estimated at 17% (95% confidence interval [CI], 10%-26%) for mortality, 15% (95% CI, 8%-23%) for technical failure, 11% (95% CI, 6%-19%) for stroke and 18% (95% CI, 9%-31%) for reintervention. The mean Downs and Black quality assessment score was 13.9 ± 3.2. CONCLUSION The technique for endovascular repair of type A aortic dissection is feasible and reproducible. The results of our meta-analysis demonstrate an acceptable safety profile for inoperable patients who otherwise would have an extremely poor prognosis. Data from clinical trials are required before the technique can be introduced into routine clinical practice.
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Affiliation(s)
- Simon De Freitas
- MedStar Heart and Vascular Institute, MedStar Washington Hospital Center, Washington, DC.
| | - Matthew J Rossi
- MedStar Heart and Vascular Institute, MedStar Washington Hospital Center, Washington, DC
| | - Steven D Abramowitz
- MedStar Heart and Vascular Institute, MedStar Washington Hospital Center, Washington, DC
| | - Javairiah Fatima
- MedStar Heart and Vascular Institute, MedStar Washington Hospital Center, Washington, DC
| | - Misaki M Kiguchi
- MedStar Heart and Vascular Institute, MedStar Washington Hospital Center, Washington, DC
| | | | - Stewart R Walsh
- Lambe Institute for Translational Research, National University of Ireland Galway, Galway, Ireland
| | - Edward Y Woo
- MedStar Heart and Vascular Institute, MedStar Washington Hospital Center, Washington, DC
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Ahmed Y, Houben IB, Figueroa CA, Burris NS, Williams DM, Moll FL, Patel HJ, van Herwaarden JA. Endovascular ascending aortic repair in type A dissection: A systematic review. J Card Surg 2021; 36:268-279. [PMID: 33169411 PMCID: PMC8463007 DOI: 10.1111/jocs.15192] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 09/01/2020] [Accepted: 09/08/2020] [Indexed: 11/27/2022]
Abstract
PURPOSE Up to 10% of acute type A aortic dissection (TAAD) patients are deemed unfit for open surgical repair, exposing these patients to high mortality rates. In recent years, thoracic endovascular aortic repair has proven to be a promising alternative treatment modality in specific cases. This study presents a comprehensive overview of the current state of catheter-based interventions in the setting of primary TAAD. METHODS A literature search was conducted, using MEDLINE and PubMed databases according to PRISMA guidelines, updated until January 2020. Articles were selected if they reported on the endovascular repair of DeBakey Type I and II aortic dissections. The exclusion criteria were retrograde type A dissection, hybrid procedures, and combined outcome reporting of mixed aortic pathologies (e.g., pseudoaneurysm and intramural hematoma). RESULTS A total of 31 articles, out of which 19 were case reports and 12 case series, describing a total of 92 patients, were included. The median follow-up was 6 months for case reports and the average follow-up was 14 months for case series. Overall technical success was 95.6% and 30-day mortality of 9%. Stroke and early endoleak rates were 6% and 18%, respectively. Reintervention was required in 14 patients (15%). CONCLUSION This review not only demonstrates that endovascular repair in the setting of isolated TAAD is feasible with acceptable outcomes at short-term follow-up, but also underlines a lack of mid-late outcomes and reporting consistency. Studies with longer follow-up and careful consideration of patient selection are required before endovascular interventions can be widely introduced.
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Affiliation(s)
- Yunus Ahmed
- Department of Vascular Surgery, Utrecht University Medical Center, Utrecht, The Netherlands
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Ignas B. Houben
- Department of Vascular Surgery, Utrecht University Medical Center, Utrecht, The Netherlands
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - C. Alberto Figueroa
- Departments of Surgery & Biomedical Engineering, University of Michigan, Ann Arbor, Michigan, USA
| | - Nicholas S. Burris
- Department of Radiology, University of Michigan, Ann Arbor, Michigan, USA
| | - David M. Williams
- Department of Radiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Frans L. Moll
- Department of Vascular Surgery, Utrecht University Medical Center, Utrecht, The Netherlands
| | - Himanshu J. Patel
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan, USA
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15
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Eid-Lidt G, Vega Servín S, Farjat Pasos JI, Ramírez Marroquín S, Criales Vera SA, Gaspar Hernández J. Acute Aortic Syndrome of Ascending Thoracic Aorta: Transcarotid Percutaneous Exclusion of a Ruptured Pseudoaneurysm. JACC Case Rep 2020; 2:2414-2418. [PMID: 34317184 PMCID: PMC8305088 DOI: 10.1016/j.jaccas.2020.09.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 08/09/2020] [Accepted: 09/04/2020] [Indexed: 11/16/2022]
Abstract
Treatment of ascending aorta disease is surgical; however, some series have evaluated the effectiveness of endovascular treatment. We report the case of a patient with a ruptured pseudoaneurysm who underwent endovascular repair via the left common carotid artery. The clinical and neurological evolution was satisfactory during the in-hospital follow-up. (Level of Difficulty: Intermediate.).
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Affiliation(s)
- Guering Eid-Lidt
- Department of Interventional Cardiology, Ignacio Chavez National Institute of Cardiology, Mexico City, Mexico
| | - Said Vega Servín
- Department of Interventional Cardiology, Ignacio Chavez National Institute of Cardiology, Mexico City, Mexico
| | - Julio Iván Farjat Pasos
- Department of Interventional Cardiology, Ignacio Chavez National Institute of Cardiology, Mexico City, Mexico
| | - Samuel Ramírez Marroquín
- Department of Cardiovascular Surgery, Ignacio Chavez National Institute of Cardiology, Mexico City, Mexico
| | | | - Jorge Gaspar Hernández
- Department of Interventional Cardiology, Ignacio Chavez National Institute of Cardiology, Mexico City, Mexico
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16
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Mazzeffi M, Ghoreishi M, Alejo D, Fonner CE, Tanaka K, Abernathy JH, Whitman G, Salenger R, Lawton J, Ad N, Brown J, Gammie J, Taylor B. Clinical Practice Variation and Outcomes for Stanford Type A Aortic Dissection Repair Surgery in Maryland: Report from a Statewide Quality Initiative. AORTA : OFFICIAL JOURNAL OF THE AORTIC INSTITUTE AT YALE-NEW HAVEN HOSPITAL 2020; 8:66-73. [PMID: 33152787 PMCID: PMC7644293 DOI: 10.1055/s-0040-1714121] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Background
Stanford Type A aortic dissection repair surgery is associated with high mortality and clinical practice remains variable among hospitals. Few studies have examined statewide practice variation.
Methods
Patients who had Stanford Type A aortic dissection repair surgery in Maryland between July 1, 2014 and June 30, 2018 were identified using the Maryland Cardiac Surgery Quality Initiative (MCSQI) database. Patient demographics, comorbidities, surgery details, and outcomes were compared between hospitals. We also explored the impact of arterial cannulation site and brain protection technique on outcome.
Results
A total of 233 patients were included from eight hospitals during the study period. Seventy-six percent of surgeries were done in two high-volume hospitals (≥10 cases per year), while the remaining 24% were done in low-volume hospitals. Operative mortality was 12.0% and varied between 0 and 25.0% depending on the hospital. Variables that differed significantly between hospitals included patient age, the percentage of patients in shock, left ventricular ejection fraction, creatinine level, arterial cannulation site, brain protection technique, tobacco use, and intraoperative blood transfusion. The percentage of patients who underwent aortic valve repair or replacement procedures differed significantly between hospitals (
p
< 0.001), although the prevalence of moderate-to-severe aortic insufficiency was not significantly different (
p
= 0.14). There were no significant differences in clinical outcomes including mortality, renal failure, stroke, or gastrointestinal complications between hospitals or based on arterial cannulation site (all
p
> 0.05). Patients who had aortic cross-clamping or endovascualr repair had more embolic strokes when compared with patients who had hypothermic circulatory arrest (
p
= 0.03).
Conclusion
There remains considerable practice variation in Stanford Type A aortic dissection repair surgery within Maryland including some modifiable factors such as intraoperative blood transfusion, arterial cannulation site, and brain protection technique. Continued efforts are needed within MCSQI and nationally to evaluate and employ the best practices for patients having acute aortic dissection repair surgery.
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Affiliation(s)
- Michael Mazzeffi
- Department of Anesthesiology, University of Maryland, Baltimore, Maryland
| | - Mehrdad Ghoreishi
- Division of Cardiothoracic Surgery, Department of Surgery, University of Maryland, Baltimore, Maryland
| | - Diane Alejo
- Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Clifford E Fonner
- Division of Cardiothoracic Surgery, Maryland Cardiac Surgery Quality Initiative Inc., Baltimore, Maryland
| | - Kenichi Tanaka
- Department of Anesthesiology, University of Maryland, Baltimore, Maryland
| | - James H Abernathy
- Department of Anesthesiology, Johns Hopkins University, Baltimore, Maryland
| | - Glenn Whitman
- Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Rawn Salenger
- Department of Cardiothoracic surgery, St. Joseph Medical Center, Towson, Maryland
| | - Jennifer Lawton
- Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Niv Ad
- Department of Cardiothoracic Surgery, Washington Adventist Hospital, Takoma Park, Maryland
| | - James Brown
- Department of Surgery, University of Maryland, Capital Region Health, Cheverly, Maryland
| | - James Gammie
- Division of Cardiothoracic Surgery, Department of Surgery, University of Maryland, Baltimore, Maryland
| | - Bradley Taylor
- Division of Cardiothoracic Surgery, Department of Surgery, University of Maryland, Baltimore, Maryland
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17
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Successful Endovascular Repair of an Aortobronchial Fistula due to Takayasu Arteritis. Ann Vasc Surg 2020; 71:533.e7-533.e10. [PMID: 32949744 DOI: 10.1016/j.avsg.2020.08.152] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 08/04/2020] [Accepted: 08/27/2020] [Indexed: 11/22/2022]
Abstract
Endovascular approaches to treating a diseased ascending aorta are challenging. We report the use of an endovascular occlusion device for successful closure of a ruptured penetrating atherosclerotic ulcer of an ascending aorta. A 47-year-old female patient with Takayasu arteritis complained of a worsening hemoptysis. She had a history of Bentall procedure for a sinus of Valsalva aneurysm and redo surgery for a ruptured penetrating atherosclerotic ulcer close to the distal anastomosis. She developed methicillin-resistant Staphylococcus aureus (MRSA) mediastinitis after the second procedure and required negative pressure wound therapy. Computed tomographic angiography revealed recurrence of a ruptured penetrating aortic ulcer and an aortobronchial fistula. Because of the high risk of redo sternotomy after MRSA mediastinitis, we used an endovascular occlusion device to achieve successful percutaneous closure. The patient was discharged without any complications. Postoperative computed tomography scans showed that the endovascular device was positioned without migration and that complete thrombosis of the penetrating atherosclerotic ulcer was achieved. This is the first report on endovascular repair of a ruptured penetrating atherosclerotic ulcer of the ascending aorta in Takayasu arteritis.
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18
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Nikol S, Mathias K, Olinic DM, Blinc A, Espinola-Klein C. Aneurysms and dissections - What is new in the literature of 2019/2020 - a European Society of Vascular Medicine annual review. VASA 2020; 49:1-36. [PMID: 32856993 DOI: 10.1024/0301-1526/a000865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
More than 6,000 publications were found in PubMed concerning aneurysms and dissections, including those Epub ahead of print in 2019, printed in 2020. Among those publications 327 were selected and considered of particular interest.
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Affiliation(s)
- Sigrid Nikol
- Department of Angiology, ASKLEPIOS Klinik St. Georg, Hamburg, Germany.,University of Münster, Germany
| | - Klaus Mathias
- World Federation for Interventional Stroke Treatment (WIST), Hamburg, Germany
| | - Dan Mircea Olinic
- Medical Clinic No. 1, University of Medicine and Pharmacy and Interventional Cardiology Department, Emergency Hospital, Cluj-Napoca, Romania
| | - Aleš Blinc
- Department of Vascular Diseases, University Medical Centre Ljubljana, Slovenia.,Faculty of Medicine, University of Ljubljana, Slovenia
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19
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Spadaccio C, Hu H, Li C, Qiao Z, Ge Y, Tie Z, Zhu J, Moon MR, Danton M, Sun L, Gaudino MF. Thoracic aortic surgery: status and upcoming novelties. Minerva Cardioangiol 2020; 68:518-531. [PMID: 32319269 DOI: 10.23736/s0026-4725.20.05263-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Several novel technological developments and surgical approaches have characterized the field of aortic surgery in the recent decade. The progressive introduction of endovascular procedures, minimally invasive surgical techniques and hybrid approaches have changed the practice in aortic surgery and generated new trends and questions. Also, the advancements in the manufacturing of tissue engineered vascular grafts as substitutes for aortic replacements are enlightening new avenues in the treatment of aortic disease. This review will provide an overview of the current novel perspectives, debates and trends in major thoracic aortic surgery.
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Affiliation(s)
- Cristiano Spadaccio
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK - .,Department of Cardiac Surgery, Golden Jubilee National Hospital, Glasgow, UK - .,Department of Cardiovascular Surgery, Beijing Aortic Disease Centre, Beijing Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing Engineering Research Centre for Vascular Prostheses, Capital Medical University, Beijing, China -
| | - Haiou Hu
- Department of Cardiovascular Surgery, Beijing Aortic Disease Centre, Beijing Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing Engineering Research Centre for Vascular Prostheses, Capital Medical University, Beijing, China
| | - Chengnan Li
- Department of Cardiovascular Surgery, Beijing Aortic Disease Centre, Beijing Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing Engineering Research Centre for Vascular Prostheses, Capital Medical University, Beijing, China
| | - Zhiyu Qiao
- Department of Cardiovascular Surgery, Beijing Aortic Disease Centre, Beijing Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing Engineering Research Centre for Vascular Prostheses, Capital Medical University, Beijing, China
| | - Yipeng Ge
- Department of Cardiovascular Surgery, Beijing Aortic Disease Centre, Beijing Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing Engineering Research Centre for Vascular Prostheses, Capital Medical University, Beijing, China
| | - Zheng Tie
- Department of Cardiovascular Surgery, Beijing Aortic Disease Centre, Beijing Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing Engineering Research Centre for Vascular Prostheses, Capital Medical University, Beijing, China
| | - Junming Zhu
- Department of Cardiovascular Surgery, Beijing Aortic Disease Centre, Beijing Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing Engineering Research Centre for Vascular Prostheses, Capital Medical University, Beijing, China
| | - Marc R Moon
- School of Medicine, Washington University, St Louis, MI, USA
| | - Mark Danton
- Department of Cardiac Surgery, Scottish Pediatric Cardiac Services, Royal Hospital for Children, Glasgow, UK
| | - Lizhong Sun
- Department of Cardiovascular Surgery, Beijing Aortic Disease Centre, Beijing Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing Engineering Research Centre for Vascular Prostheses, Capital Medical University, Beijing, China
| | - Mario F Gaudino
- Department of Cardiothoracic Surgery Weill Cornell Medicine, New York-Presbyterian Hospital, New York, NY, USA
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