1
|
Antonello M, Spertino A, Rodinò G, Tarantini G. Emergent In Situ Fenestration in the Ascending Aorta for the Endovascular Repair of a Large Pseudoaneurysm: A Technical Note. J Endovasc Ther 2024; 31:366-370. [PMID: 36214426 DOI: 10.1177/15266028221125587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE The purpose of this article is to describe an emergent in situ fenestration (ISF) technique in the ascending aorta for the endovascular repair of a large pseudoaneurysm using a trans-septal needle device through direct right common carotid artery access, in a patient with left ventricular assist device (LVAD). TECHNIQUE We performed, in a multidisciplinary team-work approach, an emergent ISF to correct the displacement of a physician-modified thoracic endograft released in the ascending aorta to correct a large anastomotic pseudoaneurysm in a patient who underwent ascending aorta replacement and subsequent LVAD implantation. We used a trans-septal needle device inserted through a direct access to the right carotid artery and performed an ISF to restore the patency of the outflow ostium of the LVAD. Window was then completed and stabilized with a nitinol balloon expandable covered stent graft obtaining an effective exclusion of the anastomotic aortic aneurism and the regular patency of the LVAD outflow graft with no signs of leaks. CONCLUSIONS Multidisciplinary teamwork approach can be crucial in challenging procedures where an alternative approach may lead to problem solving. The ISF technique may be a valid option to adopt in emergency cases in which no other technical solutions are suitable. CLINICAL IMPACT The endovascular approach has become more and more frequent for the treatment of vascular pathologies, getting increasingly refined and complex. Thereby the chance of incurring intraprocedural troubles has grown and bailout strategies should always be present. In situ fenestration is a technique to be aware of and that could help you recover from difficult situations. We report a possible rescue maneuver that can be applied also in arduous anatomies such as the ascending aorta. Moreover, we would like to highlight the importance of a multidisciplinary working environment that can enrich our everyday practice accomplishing effective and unexpected solutions.
Collapse
Affiliation(s)
- Michele Antonello
- Vascular and Endovascular Surgery Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Andrea Spertino
- Vascular and Endovascular Surgery Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Giulio Rodinò
- Interventional Cardiology Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Giuseppe Tarantini
- Interventional Cardiology Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| |
Collapse
|
2
|
Kedwai BJ, Geiger JT, Lehane DJ, Newhall KA, Pitcher GS, Stoner MC, Mix DS. Early Financial Outcomes of Physician Modified Endograft Programs are Dictated by Device Cost. J Surg Res 2024; 299:17-25. [PMID: 38688237 DOI: 10.1016/j.jss.2024.04.003] [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: 09/12/2023] [Revised: 02/13/2024] [Accepted: 04/04/2024] [Indexed: 05/02/2024]
Abstract
INTRODUCTION Physician-modified endografts (PMEGs) have been used for repair of thoracoabdominal aortic aneurysms (TAAAs) for 2 decades with good outcomes but limited financial data. This study compared the financial and clinical outcomes of PMEGs to the Cook Zenith-Fenestrated (ZFEN) graft and open surgical repair (OSR). METHODS A retrospective review of financial and clinical data was performed for all patients who underwent endovascular or OSR of juxtarenal aortic aneurysms and TAAAs from January 2018 to December 2022 at an academic medical center. Clinical presentation, demographics, operative details, and outcomes were reviewed. Financial data was obtained through the institution's finance department. The primary end point was contribution margin (CM). RESULTS Thirty patients met inclusion criteria, consisting of twelve PMEG, seven ZFEN, and eleven open repairs. PMEG repairs had a total CM of -$110,000 compared to $18,000 for ZFEN and $290,000 for OSR. Aortic and branch artery implants were major cost-drivers for endovascular procedures. Extent II TAAA repairs were the costliest PMEG procedure, with a total device cost of $59,000 per case. PMEG repairs had 30-d and 1-y mortality rates of 8.3% which was not significantly different from ZFEN (0.0%, P = 0.46; 0.0%, P = 0.46) or OSR (9.1%, P = 0.95; 18%, P = 0.51). Average intensive care unit and hospital stay after PMEG repairs were comparable to ZFEN and shorter than OSR. CONCLUSIONS Our study suggests that PMEG repairs yield a negative CM. To make these cases financially viable for hospital systems, device costs will need to be reduced or reimbursement rates increased by approximately $8800.
Collapse
Affiliation(s)
- Baqir J Kedwai
- Division of Vascular Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Joshua T Geiger
- Division of Vascular Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Daniel J Lehane
- Division of Vascular Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Karina A Newhall
- Division of Vascular Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Grayson S Pitcher
- Division of Vascular Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Michael C Stoner
- Division of Vascular Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Doran S Mix
- Division of Vascular Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, New York.
| |
Collapse
|
3
|
Vervoort D, An KR, Deng MX, Elbatarny M, Fremes SE, Ouzounian M, Tarola C. The Call for the "Interventional/Hybrid" Aortic Surgeon: Open, Endovascular, and Hybrid Therapies of the Aortic Arch. Can J Cardiol 2024; 40:478-495. [PMID: 38052303 DOI: 10.1016/j.cjca.2023.11.038] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 11/29/2023] [Accepted: 11/29/2023] [Indexed: 12/07/2023] Open
Abstract
Aortic arch pathology is relatively rare but potentially highly fatal and associated with considerable comorbidity. Operative mortality and complication rates have improved over time but remain high. In response, aortic arch surgery is one of the most rapidly evolving areas of cardiac surgery in terms of surgical volume and improved outcomes. Moreover, there has been a surge in novel devices and techniques, many of which have been developed by or codeveloped with vascular surgeons and interventional radiologists. Nevertheless, the extent of arch surgery, the choice of nadir temperature, cannulation, and perfusion strategies, and the use of open, endovascular, or hybrid options vary according to country, centre, and surgeon. In this review article, we provide a technical overview of the surgical, total endovascular, and hybrid repair options for aortic arch pathology through historical developments and contemporary results. We highlight key information for surgeons, cardiologists, and trainees to understand the management of patients with aortic arch pathology. We conclude by discussing training paradigms, the role of aortic teams, and gaps in knowledge, arguing for the need for wire skills for the future "interventional aortic surgeon" and increased research into techniques and novel devices to continue improving outcomes for aortic arch surgery.
Collapse
Affiliation(s)
- Dominique Vervoort
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Kevin R An
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Mimi X Deng
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Malak Elbatarny
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Stephen E Fremes
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada; Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada.
| | - Maral Ouzounian
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada; Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Christopher Tarola
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada; Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
4
|
Vervoort D, Tarola C, Chung JCY, Crawford SA, Lindsay TF, Fremes SE. Aortic Arch Innovation: Branching Out By Branching In? Can J Cardiol 2024:S0828-282X(24)00188-0. [PMID: 38430958 DOI: 10.1016/j.cjca.2024.02.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 02/26/2024] [Indexed: 03/05/2024] Open
Affiliation(s)
- Dominique Vervoort
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Christopher Tarola
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada; Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Jennifer C Y Chung
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada; Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, Ontario, Canada
| | - Sean A Crawford
- Division of Vascular Surgery, Peter Munk Cardiac Centre Toronto General Hospital, Toronto, Ontario, Canada
| | - Thomas F Lindsay
- Division of Vascular Surgery, Peter Munk Cardiac Centre Toronto General Hospital, Toronto, Ontario, Canada
| | - Stephen E Fremes
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada; Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
| |
Collapse
|
5
|
Han SM, DiBartolomeo AD, Pyun AJ, Maithel S, Patel S, Fleischman F. Use of Iliac Branch Endoprosthesis to Rescue Inadvertent False Lumen Deployment of the Innominate Branch Stent During Physician-Modified Fenestrated-Branched Aortic Arch Repair. Vasc Endovascular Surg 2024; 58:193-199. [PMID: 37473451 DOI: 10.1177/15385744231191216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/22/2023]
Abstract
A 70-year-old male with a history of 3 prior median sternotomies and on anticoagulation presented with acute chest and back pain associated with a pseudoaneurysm of the ascending and aortic arch in the setting of residual dissection involving the innominate, proximal right carotid, and subclavian arteries. A physician-modified triple vessel fenestrated-branched arch endograft was deployed. The innominate branch stent was deployed from the right carotid cut down, while the left carotid and left subclavian branch stents were placed from a femoral approach. Postoperatively, the innominate branch was found to be deployed in the false lumen of the dissected native innominate artery, leading to continued pressurization of the pseudoaneurysm. This was rescued by placing a Gore Iliac Branch Endoprosthesis (IBE) into the innominate branch through a temporary conduit sewn to the right carotid artery with a right subclavian branch placed via a brachial artery cut down into the internal iliac gate. The use of IBE allowed branch stent extension past the dissected native vessels. The patient had an uneventful recovery without neurologic complications. At 3-month follow-up, the patient remains well with an excluded pseudoaneurysm, and patent bifurcated innominate, bilateral carotid, and subclavian artery branches. A Gore IBE can be utilized in a dissected innominate artery to create an innominate branch device during fenestrated-branched endovascular arch repair.
Collapse
Affiliation(s)
- Sukgu M Han
- Division of Vascular Surgery and Endovascular Therapy, Keck Medical Center of University of Southern California, Los Angeles, CA, USA
| | - Alexander D DiBartolomeo
- Division of Vascular Surgery and Endovascular Therapy, Keck Medical Center of University of Southern California, Los Angeles, CA, USA
| | - Alyssa J Pyun
- Division of Vascular Surgery and Endovascular Therapy, Keck Medical Center of University of Southern California, Los Angeles, CA, USA
| | - Shelley Maithel
- Division of Vascular Surgery and Endovascular Therapy, Keck Medical Center of University of Southern California, Los Angeles, CA, USA
| | - Sanjeet Patel
- Division of Cardiothoracic Surgery, Keck Medical Center of University of Southern California, Los Angeles, CA, USA
| | - Fernando Fleischman
- Division of Cardiothoracic Surgery, Keck Medical Center of University of Southern California, Los Angeles, CA, USA
| |
Collapse
|
6
|
DiBartolomeo AD, Ding L, Weaver FA, Han SM, Magee GA. Risk of Stroke with Thoracic Endovascular Aortic Repair of the Aortic Arch. Ann Vasc Surg 2023; 97:37-48. [PMID: 37121336 DOI: 10.1016/j.avsg.2023.04.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 04/17/2023] [Accepted: 04/18/2023] [Indexed: 05/02/2023]
Abstract
BACKGROUND Thoracic endovascular aortic repair (TEVAR) involving the aortic arch is increasingly being performed and novel endografts have been developed for this procedure, but the association of stroke and relative risk of procedural techniques remains unclear. This study evaluates the procedural risk factors for stroke and mortality with zone 0-2 TEVAR. METHODS The Society for Vascular Surgery Vascular Quality Initiative registry was queried for patients who underwent TEVAR with proximal landing in zone 0-2 from 2013 to 2022. Emergent and ruptured cases were excluded. Primary exposure variables included proximal seal zone (0-2) and branch vessel revascularization technique: open debranching/bypass, total endovascular incorporation, or combination (at least 1 branch open and 1 branch endovascular). The primary outcome was perioperative inhospital stroke and the secondary outcome was inhospital mortality. Univariable and multivariable regression analyses were performed. RESULTS In total, 4,355 cases were analyzed with 350 in zone 0 (8%), 513 in zone 1 (12%), and 3,492 in zone 2 (80%). For zone 0, 1, and 2, the stroke rates were 11.1%, 5.3% and 4.7% (P < 0.0001) and inhospital mortality rates were 6.9%, 5.3% and 3.5% (P = 0.002), respectively. Branch vessel revascularization technique was associated with stroke in zone 0 with a 3-fold higher stroke rate for total endovascular incorporation of branches compared to combination and open techniques (P = 0.002). On multivariable analysis, zone 0 was independently associated with a greater than 2-fold increased odds of stroke compared to zone 2 (95% CI 1.4-3.2, P = 0.0008). CONCLUSIONS Stroke rate was 2-3 times higher for zone 0 TEVAR compared to zones 1 and 2. Within zone 0, total endovascular branch incorporation was associated with a 3-fold higher stroke rate than open and combination techniques. Future device design modifications and novel endovascular strategies for stroke prevention are required to make total endovascular repair of the aortic arch an acceptable alternative to combination and open debranching/bypass techniques.
Collapse
Affiliation(s)
- Alexander D DiBartolomeo
- Division of Vascular Surgery and Endovascular Therapy, Keck Medical Center of University of Southern California, Los Angeles, CA
| | - Li Ding
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Fred A Weaver
- Division of Vascular Surgery and Endovascular Therapy, Keck Medical Center of University of Southern California, Los Angeles, CA
| | - Sukgu M Han
- Division of Vascular Surgery and Endovascular Therapy, Keck Medical Center of University of Southern California, Los Angeles, CA
| | - Gregory A Magee
- Division of Vascular Surgery and Endovascular Therapy, Keck Medical Center of University of Southern California, Los Angeles, CA.
| |
Collapse
|
7
|
Wen Q, Wu G, Ji Y, Yang G, Zhang Y, Li W, Du X, Li X, Zhou M. Physician-Modified Endografts for the Treatment of Thoracic Aortic Pathologies Involving the Aortic Arch. J Endovasc Ther 2023:15266028231207023. [PMID: 37902431 DOI: 10.1177/15266028231207023] [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: 10/31/2023]
Abstract
OBJECTIVE This study aimed to evaluate the outcomes of physician-modified endografts (PMEGs) for the treatment of thoracic aortic pathologies involving the aortic arch. METHODS A retrospective single-center study was performed on consecutive patients with thoracic aortic pathologies treated by PMEGs between February 2018 and May 2022. Data on baseline characteristics, operative procedure, and follow-up information were collected. The endpoints included technical success, complications, mortality, overall survival, re-intervention, and target vessel instability. RESULTS This study comprised 173 patients (mean age=58±13, range=28-83, 148 men) with thoracic aortic pathologies, including 44 thoracic aortic aneurysms, 113 aortic dissections (9 type A, 4 residual type A, 75 type B, 32 non-A non-B), 3 aortic intramural hematomas, and 13 penetrating aortic ulcers. Thirty-five of the patients had PMEGs with 3 fenestrations, 32 had 2 fenestrations, and 106 had 1 single fenestration. Technical success was 98% (170/173), and the 30-day mortality was 2% (3/173). Perioperative complications included stroke (n=3, 2%), retrograde type A dissection (RTAD; n=3, 2%) and renal injury (n=3, 2%). Seven deaths (4%) were noted during a median follow-up of 11 (range=1-52) months. Eleven cases of re-intervention were stent-related. There were 5 type Ia endoleaks (3%), 2 type III endoleaks (1%) from the innominate artery (IA), and 3 type Ic endoleaks (2%) from the left subclavian arteries. One case of IA stent-graft (SG) stenosis was noted because of mural thrombus. Estimate rates of overall survival, freedom from secondary intervention, and freedom from target vessel instability at 2 years were 93.4% (95% confidence interval [CI]=88.7%-98.1%), 80.7% (95% CI=73.3%-88.1%), and 89.0% (95% CI=80.4%-97.6%), respectively. CONCLUSIONS Physician-modified endografts showed promising immediate therapeutic results in the treatment of thoracic aortic pathologies involving the aortic arch. Our study demonstrates that the technique is feasible and produces acceptable results. Long-term outcomes are required for further refinement of this technical approach to confirm technical success and durability over time as a valuable option for endovascular aortic arch repair in specialized centers. CLINICAL IMPACT Our short- and mid-term outcomes of physician-modified endografts in 173 patients showed promising results compared to other branched/fenestrated techniques and backed up the endovascular repair of the aortic arch. Meanwhile, the technical expertise pointed out in our manuscript, including preloaded guidewire, diameter-reducing wire and inner mini-cuffs, provided reference and technical guidance for our peers. Most importantly, it demonstrated that the PMEG, as a device whose components were all commercially available, might be a better option for emergency surgery and for centers who had no access to custom-made devices.
Collapse
Affiliation(s)
- Qinshu Wen
- Department of Vascular Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Guangyan Wu
- Department of Vascular Surgery, Medical School of Southeast University, Nanjing Drum Tower Hospital, Nanjing, China
| | - Ye Ji
- Department of Vascular Surgery, Nanjing Drum Tower Hospital Clinical College of Nanjing University of Chinese Medicine, Nanjing, China
| | - Guangmin Yang
- Department of Vascular Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Yepeng Zhang
- Department of Vascular Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Wendong Li
- Department of Vascular Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Xiaolong Du
- Department of Vascular Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Xiaoqiang Li
- Department of Vascular Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Min Zhou
- Department of Vascular Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
- Department of Vascular Surgery, Medical School of Southeast University, Nanjing Drum Tower Hospital, Nanjing, China
- Department of Vascular Surgery, Nanjing Drum Tower Hospital Clinical College of Nanjing University of Chinese Medicine, Nanjing, China
| |
Collapse
|
8
|
Mei F, Sun J, Wang K, Guan W, Huang M, Fan J, Li Y. Physician-Modified Endovascular Graft for Left Subclavian Artery Fenestration during Thoracic Endovascular Aortic Repair. Ann Vasc Surg 2023; 95:14-22. [PMID: 37121338 DOI: 10.1016/j.avsg.2023.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 03/31/2023] [Accepted: 04/14/2023] [Indexed: 05/02/2023]
Abstract
BACKGROUND This study aimed to evaluate the safety and efficacy of physician-modified endovascular graft for preservation of left subclavian artery during thoracic endovascular aortic repair. METHODS From June 2019 to October 2022, 66 patients with a variety of thoracic aortic pathologies were treated with thoracic endovascular aortic repair using physician-modified endovascular graft left subclavian artery fenestration to achieve adequate proximal landing zone. The details of surgical techniques were described. The perioperative morbidity, mortality, and the outcomes of mid-term follow-up were analyzed. RESULTS Of the 66 patients (men: women, 53:13; age, 55.18 [55.18 ± 10.62] years), 53 (80.30%) presented with type B aortic dissection, 10 (15.15%) with thoracic penetrating aortic ulcer, 2 (3.03%) with thoracic aortic aneurysm, and 1 (1.52%) with left subclavian artery aneurysm. All of them underwent thoracic endovascular aortic repair using physician-modified endovascular graft left subclavian artery fenestration on the sterile back table. The technique success rate was 96.97% (n = 64). Total operation time was 92 min (interquartile range, 86-118), graft modification time was 19 min (interquartile range, 17-21), fluoroscopy time was 49 min (interquartile range, 41-62), and contrast agent dosage was 165 mL (interquartile range, 155-185). 30-day perioperative morbidities were 3 (4.55%) strokes, 1 (1.52%) retrograde type A aortic dissection, 1 (1.52%) aortic intimal intussusception, 1 (1.52%) left arm ischemia, and 3 (4.55%) type Ia endoleaks. Postoperative 30-day mortality and reintervention rates were 1.52% and 4.55%, respectively. Among the 63 patients included in the follow-up of 17 months (interquartile range, 7.75-18.25), the primary patency of left subclavian artery fenestration stents was 100%. Late complications were 1 (1.59%) distal stent graft-induced new entry and 1 (1.59%) death due to retrograde type A aortic dissection during the follow-up. The stent graft-induced new entry patient was observed with stable false lumen. CONCLUSIONS Thoracic endovascular aortic repair with physician-modified endovascular graft for left subclavian artery revascularization is a safe, feasible, and efficacious technique associated with high success rate. Further study is needed for long-term outcome investigation.
Collapse
Affiliation(s)
- Fei Mei
- Department of Vascular Surgery, Yichang Central People's Hospital, The First College of Medical Science, China Three Gorges University, Hubei, China.
| | - Jianfeng Sun
- Department of Vascular Surgery, Yichang Central People's Hospital, The First College of Medical Science, China Three Gorges University, Hubei, China.
| | - Kewei Wang
- Department of Vascular Surgery, Yichang Central People's Hospital, The First College of Medical Science, China Three Gorges University, Hubei, China
| | - Wenfei Guan
- Department of Vascular Surgery, Yichang Central People's Hospital, The First College of Medical Science, China Three Gorges University, Hubei, China
| | - Mingkui Huang
- Department of Vascular Surgery, Yichang Central People's Hospital, The First College of Medical Science, China Three Gorges University, Hubei, China
| | - Jiawei Fan
- Department of Vascular Surgery, Yichang Central People's Hospital, The First College of Medical Science, China Three Gorges University, Hubei, China
| | - Yu Li
- Department of Vascular Surgery, Yichang Central People's Hospital, The First College of Medical Science, China Three Gorges University, Hubei, China
| |
Collapse
|
9
|
Peterss S, Stana J, Rantner B, Buech J, Radner C, Konstantinou N, Hagl C, Pichlmaier M, Tsilimparis N. Expert opinion: How to treat type IA endoleakage. Asian Cardiovasc Thorac Ann 2023; 31:604-614. [PMID: 36740844 DOI: 10.1177/02184923231154742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Type Ia endoleaks due to failed sealing or loss of landing zone and the adequate management thereof remain crucial for long-term therapeutic success following TEVAR. This expert opinion summarizes our institutional experience with endovascular, open surgical, and hybrid techniques in the context of recent scientific publications. The rapid turnover of technical innovations, but most importantly outcome data demonstrate the requirement for increasingly patient-tailored treatment strategies and the need for specialized aortic centers. The latter should offer a complete range of treatment options, an adequate perioperative management, and the highest level of multidisciplinary expertise.
Collapse
Affiliation(s)
- Sven Peterss
- University Aortic Centre Munich, LMU University Hospital, Munich, Germany
- Department of Cardiac Surgery, LMU University Hospital, Munich, Germany
| | - Jan Stana
- University Aortic Centre Munich, LMU University Hospital, Munich, Germany
- Department of Vascular and Endovascular Surgery, LMU University Hospital, Munich, Germany
| | - Barbara Rantner
- University Aortic Centre Munich, LMU University Hospital, Munich, Germany
- Department of Vascular and Endovascular Surgery, LMU University Hospital, Munich, Germany
| | - Joscha Buech
- University Aortic Centre Munich, LMU University Hospital, Munich, Germany
- Department of Cardiac Surgery, LMU University Hospital, Munich, Germany
- DZHK (German Centre for Cardiovascular Research), Partner site Munich Heart Alliance, Munich, Germany
| | - Caroline Radner
- University Aortic Centre Munich, LMU University Hospital, Munich, Germany
- Department of Cardiac Surgery, LMU University Hospital, Munich, Germany
- DZHK (German Centre for Cardiovascular Research), Partner site Munich Heart Alliance, Munich, Germany
| | - Nikolaos Konstantinou
- University Aortic Centre Munich, LMU University Hospital, Munich, Germany
- Department of Vascular and Endovascular Surgery, LMU University Hospital, Munich, Germany
| | - Christian Hagl
- University Aortic Centre Munich, LMU University Hospital, Munich, Germany
- Department of Cardiac Surgery, LMU University Hospital, Munich, Germany
- DZHK (German Centre for Cardiovascular Research), Partner site Munich Heart Alliance, Munich, Germany
| | - Maximilian Pichlmaier
- University Aortic Centre Munich, LMU University Hospital, Munich, Germany
- Department of Cardiac Surgery, LMU University Hospital, Munich, Germany
| | - Nikolaos Tsilimparis
- University Aortic Centre Munich, LMU University Hospital, Munich, Germany
- Department of Vascular and Endovascular Surgery, LMU University Hospital, Munich, Germany
| |
Collapse
|
10
|
Qiu C, Li Z, Dai X, Lu X, Lu Q, Li X, Zhou W, Guo P, Pan J, Li D, Wu Z, Zhang H. Technical details of thoracic endovascular aortic repair with fenestrations for thoracic aortic pathologies involving the aortic arch: A Chinese expert consensus. Front Cardiovasc Med 2022; 9:1056229. [PMID: 36606283 PMCID: PMC9807668 DOI: 10.3389/fcvm.2022.1056229] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 11/18/2022] [Indexed: 12/24/2022] Open
Abstract
Thoracic aortic pathologies involving the aortic arch are a great challenge for vascular surgeons. Maintaining the patency of supra-aortic branches while excluding the aortic lesion remains difficult. Thoracic EndoVascular Aortic Repair (TEVAR) with fenestrations provides a feasible and effective approach for this type of disease. The devices needed in the procedure are off-the-shelf, with promising results reported in many medical centers. Up until now, there have been no guidelines focusing exclusively on the details of the TEVAR technique with fenestrations. Experts from China have discussed the technical parts of both in situ fenestrations (needle and laser) and fenestrations in vitro (direction inversion strategy and guidewire-assisted strategy), providing a technical reference to standardize the procedure and improve its results.
Collapse
Affiliation(s)
- Chenyang Qiu
- Department of Vascular Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Zhenjiang Li
- Department of Vascular Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Xiangchen Dai
- Department of Vascular Surgery, General Hospital, Tianjin Medical University, Tianjin, China
| | - Xinwu Lu
- Department of Vascular Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Qingsheng Lu
- Department of Vascular Surgery, The First Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Xiaoqiang Li
- Department of Vascular Surgery, Nanjing Drum Tower Hospital, Affiliated to Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Weimin Zhou
- Department of Vascular Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Pingfan Guo
- Department of Vascular Surgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Jun Pan
- Department of Vascular Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Donglin Li
- Department of Vascular Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Ziheng Wu
- Department of Vascular Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Hongkun Zhang
- Department of Vascular Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China,*Correspondence: Hongkun Zhang,
| |
Collapse
|
11
|
Chastant R, Belarbi A, Ozdemir BA, Alric P, Gandet T, Canaud L, Legend FIGUREABLE. Homemade fenestrated physician-modified stent-grafts for arch aortic degenerative aneurysms. J Vasc Surg 2022; 76:1133-1140.e2. [PMID: 35697312 DOI: 10.1016/j.jvs.2022.04.041] [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] [Received: 08/22/2021] [Revised: 02/06/2022] [Accepted: 04/05/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To evaluate early and medium-term outcomes of single and double fenestrated physician-modified endovascular grafts (PMEGs) for total endovascular degenerative aortic arch aneurysm repair. METHODS This single-center retrospective analysis of prospectively collected data included 52 patients, from August 2013 through January 2021, undergoing home-made fenestrated thoracic endovascular aortic repair (TEVAR) for degenerative aortic aneurysms. In all cases a distal smaller fenestration for the left subclavian artery (LSA) was fashioned and the only one stented. For double-fenestrated endograft a proximal larger fenestration that incorporated both the brachiocephalic trunk and left common carotid artery was added. RESULTS 52 patients with degenerative aortic arch aneurysms were treated. There were 36 men and the mean age was 75 ± 8 years. 31% treated with a single LSA fenestration, while 69% had a double-fenestrated TEVAR. 10% (n=5) were emergent procedures. Technical success was 100%. The median time requirement for stent graft modification was 22 ± 6 minutes. Thirty-day mortality was 2% (n=1). 5 patients (10%) had a cerebrovascular event including 2 transient ischemic attack, one minor stroke with full neurological recovery and 2 with sequelae. 2 patients (4%) experienced perioperative retrograde dissection during follow-up. No patient had a type I, type III or type II endoleak from the LSA. No patient required re-intervention. All supra-aortic trunks were patent. During a mean follow up of 18 ± 11 months, there were no conversion to open surgical repair, aortic rupture or paraplegia. CONCLUSIONS Single or double PMEG is a safe and suitable tool for the treatment of high morbidity pathology such as aortic arch degenerative aneurysm repair. This device can be used in elective and emergency patients.
Collapse
Affiliation(s)
- Robin Chastant
- Department of Thoracic and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France.
| | - Amin Belarbi
- Department of Thoracic and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France
| | - Baris Ata Ozdemir
- Department of Thoracic and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France; University of Bristol, Bristol, United Kingdom
| | - Pierre Alric
- Department of Thoracic and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France; PhyMedExp, Univ Montpellier, CNRS, INSERM, CHU Montpellier, Montpellier, France
| | - Thomas Gandet
- Department of Thoracic and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France; PhyMedExp, Univ Montpellier, CNRS, INSERM, CHU Montpellier, Montpellier, France
| | - Ludovic Canaud
- Department of Thoracic and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France; PhyMedExp, Univ Montpellier, CNRS, INSERM, CHU Montpellier, Montpellier, France.
| | | |
Collapse
|
12
|
MacGillivray TE, Gleason TG, Patel HJ, Aldea GS, Bavaria JE, Beaver TM, Chen EP, Czerny M, Estrera AL, Firestone S, Fischbein MP, Hughes GC, Hui DS, Kissoon K, Lawton JS, Pacini D, Reece TB, Roselli EE, Stulak J. The Society of Thoracic Surgeons/American Association for Thoracic Surgery clinical practice guidelines on the management of type B aortic dissection. J Thorac Cardiovasc Surg 2022; 163:1231-1249. [PMID: 35090765 DOI: 10.1016/j.jtcvs.2021.11.091] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 11/08/2021] [Indexed: 01/16/2023]
Affiliation(s)
| | - Thomas G Gleason
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, Md
| | - Himanshu J Patel
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
| | - Gabriel S Aldea
- Division of Cardiothoracic Surgery, University of Washington School of Medicine, Seattle, Wash
| | - Joseph E Bavaria
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Thomas M Beaver
- Division of Thoracic and Cardiovascular Surgery, University of Florida, Gainesville, Fla
| | - Edward P Chen
- Division of Cardiovascular and Thoracic Surgery, Duke University School of Medicine, Durham, NC
| | - Martin Czerny
- Department of Cardiovascular Surgery, University Heart Center Freiburg-Bad Krozingen, Freiburg, Germany
| | - Anthony L Estrera
- Department of Cardiothoracic and Vascular Surgery, The University of Texas Health Science Center at Houston and Memorial Hermann Hospital, Houston, Tex
| | | | - Michael P Fischbein
- Department of Cardiothoracic Surgery, Stanford University, School of Medicine, Stanford, Calif
| | - G Chad Hughes
- Division of Cardiovascular and Thoracic Surgery, Duke University School of Medicine, Durham, NC
| | - Dawn S Hui
- Department of Cardiothoracic Surgery, University of Texas Health Science Center at San Antonio, San Antonio, Tex
| | | | - Jennifer S Lawton
- Division of Cardiac Surgery, Johns Hopkins University, Baltimore, Md
| | - Davide Pacini
- Department of Cardiac Surgery, University of Bologna, Bologna, Italy
| | - T Brett Reece
- Department of Cardiothoracic Surgery, University of Colorado School of Medicine, Aurora, Colo
| | - Eric E Roselli
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - John Stulak
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| |
Collapse
|
13
|
MacGillivray TE, Gleason TG, Patel HJ, Aldea GS, Bavaria JE, Beaver TM, Chen EP, Czerny M, Estrera AL, Firestone S, Fischbein MP, Hughes GC, Hui DS, Kissoon K, Lawton JS, Pacini D, Reece TB, Roselli EE, Stulak J. The Society of Thoracic Surgeons/American Association for Thoracic Surgery Clinical Practice Guidelines on the Management of Type B Aortic Dissection. Ann Thorac Surg 2022; 113:1073-1092. [PMID: 35090687 DOI: 10.1016/j.athoracsur.2021.11.002] [Citation(s) in RCA: 41] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 11/08/2021] [Indexed: 02/07/2023]
Affiliation(s)
| | - Thomas G Gleason
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Himanshu J Patel
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Gabriel S Aldea
- Division of Cardiothoracic Surgery, University of Washington School of Medicine, Seattle, Washington
| | - Joseph E Bavaria
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Thomas M Beaver
- Division of Thoracic and Cardiovascular Surgery, University of Florida, Gainesville, Florida
| | - Edward P Chen
- Division of Cardiovascular and Thoracic Surgery, Duke University School of Medicine, Durham, North Carolina
| | - Martin Czerny
- Department of Cardiovascular Surgery, University Heart Center Freiburg-Bad Krozingen, Freiburg, Germany
| | - Anthony L Estrera
- Department of Cardiothoracic and Vascular Surgery, The University of Texas Health Science Center at Houston and Memorial Hermann Hospital, Houston, Texas
| | | | - Michael P Fischbein
- Department of Cardiothoracic Surgery, Stanford University, School of Medicine, Stanford, California
| | - G Chad Hughes
- Division of Cardiovascular and Thoracic Surgery, Duke University School of Medicine, Durham, North Carolina
| | - Dawn S Hui
- Department of Cardiothoracic Surgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | | | - Jennifer S Lawton
- Division of Cardiac Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Davide Pacini
- Department of Cardiac Surgery, University of Bologna, Bologna, Italy
| | - T Brett Reece
- Department of Cardiothoracic Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Eric E Roselli
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - John Stulak
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| |
Collapse
|
14
|
Asciutto G, Usai MV, Ibrahim A, Oberhuber A. Early experience with the Bolton Relay Pro/Plus for physician-modified fenestrated TEVAR. INT ANGIOL 2022; 41:105-109. [PMID: 35005873 DOI: 10.23736/s0392-9590.22.04745-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Thoracic endovascular aortic repair (TEVAR) can be challenging in cases involving the aortic arch and the visceral segment. We report our initial experience with fenestrated TEVAR (f-TEVAR) for thoracic aortic disease involving aortic branches using physician-modified stent grafts (PMSGs). MATERIALS AND METHODS Between February 2019 and November 2020 nine patients were treated with a PMSG. Indication to treatment were a symptomatic acute type B aortic dissection (TBAD) in three cases, a penetrating aortic ulcer in three cases (two in zone 3 and one in zone 6), one case of an endoleak type I A after TEVAR, a chronic TBAD after TEVAR in one case and one case of a contained rupture of a thoracoabdominal aneurysm in zone 3. Pre-, intra- and postoperative clinical data were recorded. RESULTS The median patient age was 65 (IQR 60.5-71) years, and 8 (89%) patients were men. Nine stent grafts (six Bolton Relay Plus and three Bolton Relay Pro, Terumo Aortic, Vascutek Ltd., Inchinnan, United Kingdom) were deployed. Small fenestrations (8 mm) were created on table, median duration for on table stent graft modifications was 20 minutes (13-22). The technical success rate was 100%. Median operative time was 188 (116-252) minutes. No major adverse events of any sort occurred during the first 30-day postoperatively. There were no type I or type III endoleaks at the end of the procedure, and no cases of spinal cord ischemia. Two access related complications occurred (22%). After a median of 12 (range 5-12) months all patients survived and all target vessels remained patent with one case of fenestration-related type I endoleak, which required open conversion. CONCLUSIONS The results of our initial experience with f-TEVAR using PMSGs with the Bolton Relay stentgraft for the treatment of aortic diseases are acceptable. These results should be confirmed on larger patient cohorts.
Collapse
Affiliation(s)
- Giuseppe Asciutto
- Department of Vascular and Endovascular Surgery, University Hospital Münster, Münster, Germany.,Section of Vascular Surgery, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Marco V Usai
- Department of Vascular and Endovascular Surgery, St. Franziskus Hospital Münster, Münster, Germany
| | - Abdulhakim Ibrahim
- Department of Vascular and Endovascular Surgery, University Hospital Münster, Münster, Germany -
| | - Alexander Oberhuber
- Department of Vascular and Endovascular Surgery, University Hospital Münster, Münster, Germany
| |
Collapse
|
15
|
Atkins MD, Lumsden AB. Parallel grafts and physician modified endografts for endovascular repair of the aortic arch. Ann Cardiothorac Surg 2022; 11:16-25. [PMID: 35211381 PMCID: PMC8807419 DOI: 10.21037/acs-2021-taes-171] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 10/27/2021] [Indexed: 10/31/2023]
Abstract
Aortic arch aneurysms are a challenging clinical problem especially in high-risk patients. Open aortic arch replacement, even in the best of centers, carries significant risk of stroke or death in this high-risk population. Many high-risk patients are deemed inoperable and not offered repair. Branched and fenestrated thoracic endografts are currently undergoing clinical trials in the United States but are not yet commercially available. Many elderly and frail patients have significant brachiocephalic occlusive disease or anatomy excluding them for consideration for such clinical trials. These patients also present with acute aortic syndromes requiring urgent or emergent repair and are unable to participate in clinical trials due to the time required to have such devices available. Alternative endovascular therapies, including parallel stent grafts (including Chimneys, Snorkels and Periscopes) and physician modified thoracic endografts, have been used to treat such high-risk patients combined with commercially available thoracic endovascular aneurysm repair (TEVAR) devices. This paper aims to review the techniques and current reported outcomes from parallel stent grafts and physician modified devices used to treat high risk patients undergoing repair for aortic arch pathologies.
Collapse
Affiliation(s)
- Marvin D Atkins
- Houston Methodist Hospital and Houston Methodist DeBakey Cardiovascular Surgery Associates, Houston, TX, USA
| | - Alan B Lumsden
- Houston Methodist Hospital and Houston Methodist DeBakey Cardiovascular Surgery Associates, Houston, TX, USA
| |
Collapse
|
16
|
Sonawane BS, Pavithran S, Sivakumar K. Endovascular Treatment of Acquired Atheromatous Postsubclavian Aortic Coarctation. Tex Heart Inst J 2021; 48:475126. [PMID: 34902023 DOI: 10.14503/thij-20-7270] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Coral reef aorta is a rare calcifying obstructive disease that involves the thoracoabdominal aorta. Similar presentations in the postsubclavian aorta may result in acquired atheromatous aortic coarctation leading to systemic hypertension and heart failure. The associated calcification makes surgical anatomic or extraanatomic bypass and thromboendarterectomy challenging. Extensive circumferential calcification often precludes endovascular intervention. We present the case of a 25-year-old man with an acquired atheromatous coarctation of the postsubclavian aorta who underwent successful endovascular treatment with use of a balloon-expandable covered stent.
Collapse
Affiliation(s)
- Bhushan S Sonawane
- Department of Cardiology, Institute of Cardiovascular Diseases, Madras Medical Mission, Chennai, India
| | - Sreeja Pavithran
- Department of Cardiology, Institute of Cardiovascular Diseases, Madras Medical Mission, Chennai, India
| | - Kothandam Sivakumar
- Department of Cardiology, Institute of Cardiovascular Diseases, Madras Medical Mission, Chennai, India
| |
Collapse
|