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Thoracic Endovascular Aortic Repair (TEVAR) First in Patients with Lower Limb Ischemia in Complicated Type B Aortic Dissection: Clinical Outcome and Morphology. J Clin Med 2022; 11:jcm11144154. [PMID: 35887918 PMCID: PMC9320233 DOI: 10.3390/jcm11144154] [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: 06/18/2022] [Revised: 07/03/2022] [Accepted: 07/15/2022] [Indexed: 11/17/2022] Open
Abstract
Acute Type B aortic dissection (TBAD) can cause organ malperfusion, e.g., lower limb ischemia (LLI). Thoracic endovascular aortic repair (TEVAR) represents the standard treatment for complicated TBAD; however, with respect to LLI, data is scant. The aim of this study was to investigate clinical and morphological outcomes in patients with complicated TBAD and LLI managed with a "TEVAR-first" policy. Between March 1997 and December 2021, 731 TEVAR-procedures were performed, including 106 TBAD-cases. Cases with TBAD + LLI were included in this retrospective analysis. Study endpoints were morphological/clinical success of TEVAR, regarding aortic and extremity-related outcome, including extremity-related adjunct procedures (erAP) during a median FU of 28.68 months. A total of 20/106 TBAD-cases (18.8%, 32-82 years, 7 women) presented with acute LLI (12/20 Rutherford class IIb/III). In 15/20 cases, true lumen-collapse (TLC) was present below the aortic bifurcation. In 16/20 cases, TEVAR alone resolved LLI. In the remaining four cases, erAP was necessary. A morphological analysis showed a relation between lower starting point and lesser extent of TLC and TEVAR success. No extremity-related reinterventions and only one major amputation was needed. The data strongly suggest that aTEVAR-first-strategy for treating TBAD with LLI is reasonable. Morphological parameters might be of importance to anticipate the failure of TEVAR alone.
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Liisberg M, Baudier F, Akgül C, Lindholt JS. Long-term Thoracic Endovascular Repair follow-up from 1999-2019 - a Single-Center Experience. Ann Vasc Surg 2022; 86:399-407. [PMID: 35460855 DOI: 10.1016/j.avsg.2022.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 02/22/2022] [Accepted: 04/06/2022] [Indexed: 11/01/2022]
Abstract
INTRODUCTION Thoracic endovascular aortic repair (TEVAR) was introduced in the early 1990's, and long-term follow-up studies are warranted in current guidelines. METHODS Patients undergoing TEVAR were consecutively included from 1999-2019. Thoracic aortic disease includes thoracic aortic aneurysms, aortic dissection, traumatic rupture, penetrating aortic ulcer (PAU) and intramural hematoma (IMH). Our prospective database recorded baseline characteristics, endoleak or aneurysm growth and death. Patients were included at time of treatment and censored at death, or first reintervention depending on the analysis. Primary endpoint was all-cause death, secondary endpoint was reintervention. Survival and failure analysis were done using StataIC 16.0® and truncated at 15 years of follow-up. RESULTS 256 patients were included - 63% were men. Their mean age at intervention was 66.2 ± 14.5 years and they were followed for a mean of 5.2 ± 4.5 years. Indications for TEVAR were acute aortic syndrome 40.6%, chronic aortic disease 44.5%, and traumatic rupture in 14.8 %. Technical success was seen in 94.1 % of the operations, and the left subclavian artery was covered in 27.7%. 30-day mortality rate was 21.2% (22/104) and 1.75% (2/114) (p<0.001) for urgent and elective patients, respectively. Twelve patients (4.7%) died within 24 hours of treatment. Overall, long-term mortality recorded112 (43,8%) deaths, 29 patients had reinterventions (11.3 % (95% confidence interval: 7.7-15.9)), aneurysms accounted for 62.1% of all reinterventions. 24 (82.8%) reinterventions occurred within the first 5 years. CONCLUSION This long-term follow-up study shows excess mortality in patients treated for acute aortic syndrome compared to chronic aortic disease, within the first 30 days, this difference diminishes at the end of follow-up. Most endoleak occur within the first five years, though new endoleak continue to develop decades after in previous endoleak-free patients calling for lifelong surveillance.
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Affiliation(s)
- Mads Liisberg
- Department of Cardiothoracic and Vascular Surgery, Odense University Hospital, Denmark; Elite Research Centre of Individualised Treatment of Arterial Diseases (CIMA), Odense University Hospital, Denmark; Clinical Institute, University of Southern Denmark, Denmark.
| | - Francois Baudier
- Department of Cardiothoracic and Vascular Surgery, Odense University Hospital, Denmark; Elite Research Centre of Individualised Treatment of Arterial Diseases (CIMA), Odense University Hospital, Denmark
| | - Cengiz Akgül
- Department of Cardiothoracic and Vascular Surgery, Odense University Hospital, Denmark; Elite Research Centre of Individualised Treatment of Arterial Diseases (CIMA), Odense University Hospital, Denmark
| | - Jes S Lindholt
- Department of Cardiothoracic and Vascular Surgery, Odense University Hospital, Denmark; Elite Research Centre of Individualised Treatment of Arterial Diseases (CIMA), Odense University Hospital, Denmark; Clinical Institute, University of Southern Denmark, Denmark
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Yuan X, Mitsis A, Mozalbat D, Nienaber CA. Alternative management of proximal aortic dissection: concept and application. Indian J Thorac Cardiovasc Surg 2021; 38:183-192. [PMID: 35463707 PMCID: PMC8980987 DOI: 10.1007/s12055-021-01281-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 09/20/2021] [Accepted: 09/21/2021] [Indexed: 11/17/2022] Open
Abstract
Open surgery remains the mainstay of treatment for acute type A aortic dissection and should be offered to most patients. However, there are elderly patients in which surgical treatment may be deemed extremely high risk or futile. Endovascular treatment approaches have been applied to a small number of these patients and data are limited to case reports and small series. The application of endovascular therapies to ascending aorta is currently limited by anatomical and technical challenges posed by the dynamic motion of the ascending aorta and the proximity of vital structures to intended landing zones (aortic valve, coronary arteries, and supra-aortic branches) and lack of specially designed endografts to address these issues. While thoracic endovascular aortic repair (TEVAR) has replaced open aortic repair for a suitable lesion in distal aortic dissection, some selected patients with type A aortic dissection at high surgical may be candidates. Hence, there is potential because, in proximal (Stanford type A) dissections, 10–30% of patients are not accepted for surgery, and 30–50% are technically amenable for TEVAR. Recent experience has shown that carefully selected patients with favorable anatomical characteristics may be subject to endovascular stent-graft treatment as a last resort with mixed results. Technical improvement is necessary to offer. satisfactory endovascular options in non-surgical candidates.
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Lin W, Que L, Lin G, Chen R, Lu Q, Zhicheng Du MD, Hui Liu MD, Yu Z, Huang M. Using Machine Learning to Predict Five-Year Reintervention Risk in Type B Aortic Dissection Patients After Thoracic Endovascular Aortic Repair. JOURNAL OF MEDICAL IMAGING AND HEALTH INFORMATICS 2021. [DOI: 10.1166/jmihi.2021.3813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Purpose: Type B aortic dissection (TBAD) is a high-risk disease, commonly treated with thoracic endovascular aortic repair (TEVAR). However, for the long-term follow-up, it is associated with a high 5-year reintervention rate for patients after TEVAR. There is no accurate definition
of prognostic risk factors for TBAD in medical guidelines, and there is no scientific judgment standard for patients’ quality of life or survival outcome in the next five years in clinical practice. A large amount of medical data features makes prognostic analysis difficult. However,
machine learning (ML) permits lots of objective data features to be considered for clinical risk stratification and patient management. We aimed to predict the 5-year prognosis in TBAD after TEVAR by Ml, based on baseline, stent characteristics and computed tomography angiography (CTA) imaging
data, and provided a certain degree of scientific basis for prognostic risk score and stratification in medical guidelines. Materials and Methods: Dataset we recorded was obtained from 172 TBAD patients undergoing TEVAR. Totally 40 features were recorded, including 14 baseline, 5 stent
characteristics and 21 CTA imaging data. Information gain (IG) was used to select features highly associated with adverse outcome. Then, the Gradient Boost classifier was trained using grid search and stratified 5-fold cross-validation, and Its predictive performance was evaluated by the area
under the curve (AUC) in the receiver operating characteristic (ROC). Results: Totally 60 patients underwent reintervention during follow-up. Combing 24 features selected by IG, ML model predicted prognosis well in TBAD after TEVAR, with an AUC of 0.816 and a 95% confidence interval
of 0.797 to 0.837. Reintervention rate of prediction was slightly higher than the actual (48.2% vs. 34.8%). Conclusion: Machine learning, which combined with baseline, stent characteristics and CTA imaging data for personalized risk computations, effectively predicted reintervention
risk in TBAD patients after TEVAR in 5-year follow-up. The model could be used to efficiently assist the clinical management of TBAD patients and prompt high-risk factors.
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Affiliation(s)
- Weiyuan Lin
- College of Automation Science and Technology, South China University of Technology, Guangzhou, 510640, China
| | - Lifeng Que
- Medical Imaging Center, Shenzhen Hospital, Southern Medical University, Shenzhen, Guangdong, 518110, China
| | - Guisen Lin
- Department of Radiology, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, China
| | - Rui Chen
- Department of Radiology, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, China
| | - Qiyang Lu
- College of Automation Science and Technology, South China University of Technology, Guangzhou, 510640, China
| | - M. D. Zhicheng Du
- Department of Medical Statistics and Epidemiology, Health Information Research Center, Guangdong Key Laboratory of Medicine, School of Public Health, Sun Yat-sen University, Guangzhou, 510080, China
| | - M. D. Hui Liu
- Department of Radiology, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, China
| | - Zhuliang Yu
- College of Automation Science and Technology, South China University of Technology, Guangzhou, 510640, China
| | - Meiping Huang
- Department of Radiology, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, China
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Yau P, Lipsitz EC, Friedmann P, Indes J, Aldailami H. Aortic Neck Dilatation Following Thoracic Endovascular Aortic Repair. Ann Vasc Surg 2021; 76:104-113. [PMID: 34004324 DOI: 10.1016/j.avsg.2021.05.001] [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: 02/26/2021] [Revised: 04/14/2021] [Accepted: 05/04/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Thoracic endovascular aortic repair (TEVAR) has become a mainstay of treatment for a variety of thoracic aortic pathologies. Expansion of the proximal aortic neck after endovascular repair of abdominal aortic aneurysms has been demonstrated; however, dilatation of the proximal aortic neck after TEVAR has not been well described. We sought to describe remodeling of the proximal neck following TEVAR. METHODS This is a retrospective, single institution review of patients who underwent TEVAR for thoracic aortic aneurysm (TAA) and dissection with aneurysmal degeneration from 2010 to 2019. Postoperative computed tomography scans were reviewed and aortic diameter was measured in orthogonal planes using 3-dimensional centerline reconstruction software. The primary outcome was change in aortic diameter at the proximal aortic neck as compared to the initial postoperative computed tomography scan. Clinical and operative data were analyzed to identify factors associated with significant neck dilatation. RESULTS Of 87 patients who underwent TEVAR during the study period, 30 met inclusion criteria. Median follow up was 20.5 months. Median age was 67 years, and 15 patients (50%) were female. The proximal aortic neck experienced an overall increase over time in aortic diameter. Five mm distal to the graft showed the greatest rate of expansion, with a median increase of 1.3, 2.9, and 6.2 mm at one year, two years, and three years, respectively. When comparing patients who had mean expansion at this location of >2.0 mm/year to patients who did not, a higher percentage had dissection pathology (81.8% vs. 31.6%, P = 0.008), had graft placement at aortic landing zone 2 (36.4% vs. 5.3%, P = 0.028), and were smokers (100% vs. 52.6%, P = 0.006). Higher percent oversizing was shown to be associated with significant aortic neck dilatation for true aneurysms only. CONCLUSIONS Aortic neck dilatation occurs over time for the majority of patients following TEVAR with the distal neck experiencing the highest rate of expansion. Dissection pathology, aortic landing zone 2, and smoking were found to be associated with a higher rate of neck dilatation.
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Affiliation(s)
- Patricia Yau
- Division of Vascular and Endovascular Surgery, Montefiore Medical Center and The Albert Einstein College of Medicine, Bronx, NY.
| | - Evan C Lipsitz
- Division of Vascular and Endovascular Surgery, Montefiore Medical Center and The Albert Einstein College of Medicine, Bronx, NY
| | - Patricia Friedmann
- Department of Cardiovascular and Thoracic Surgery, Montefiore Medical Center, Bronx NY
| | - Jeffrey Indes
- Division of Vascular and Endovascular Surgery, Montefiore Medical Center and The Albert Einstein College of Medicine, Bronx, NY
| | - Hasan Aldailami
- Division of Vascular and Endovascular Surgery, Montefiore Medical Center and The Albert Einstein College of Medicine, Bronx, NY
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Aru RG, Richie CD, Badia DJ, Romesberg AM, Sheppard MB, Minion DJ, Tyagi S. Hybrid Repair of Type B Aortic Dissection With Thoracoabdominal Aortic Aneurysmal Degeneration in the Setting of Marfan Syndrome. Vasc Endovascular Surg 2021; 55:619-622. [PMID: 33627054 DOI: 10.1177/1538574420988279] [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] [Indexed: 11/16/2022]
Abstract
Aneurysmal degeneration of the thoracoabdominal aorta after aortic dissection is a well-documented sequela of Marfan syndrome (MFS). Hybrid technique (HT), an emerging treatment modality for complex aortic pathologies, decreases morbidity and mortality relative to open surgery. However, outcome data regarding HT in genetic aortopathies such as MFS is limited. We describe a case of a young male with hypertension and type B aortic dissection (AD) complicated by a symptomatic thoracoabdominal aortic aneurysm (TAAA). He underwent staged HT comprised of carotid-carotid transposition followed by zone 1 thoracic endovascular aortic repair and concurrent retrograde left subclavian stent graft placement. Genetic analysis was consistent with Marfan syndrome. Subsequent growth of his TAAA warranted open extent type IV TAAA repair with individual renovisceral and iliac bypasses. The patient recovered from the second surgery without further progression of disease or late complication.
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Affiliation(s)
- Roberto G Aru
- Department of Surgery, University of Kentucky Albert B. Chandler Hospital, Lexington, KY, USA
| | - Cheryl D Richie
- Department of Surgery, University of Kentucky Albert B. Chandler Hospital, Lexington, KY, USA
| | - Daniel J Badia
- Department of Surgery, University of Kentucky Albert B. Chandler Hospital, Lexington, KY, USA
| | - Amanda M Romesberg
- Department of Surgery, University of Kentucky Albert B. Chandler Hospital, Lexington, KY, USA
| | - Mary B Sheppard
- Department of Surgery, University of Kentucky Albert B. Chandler Hospital, Lexington, KY, USA
| | - David J Minion
- Department of Surgery, University of Kentucky Albert B. Chandler Hospital, Lexington, KY, USA
| | - Sam Tyagi
- Department of Surgery, University of Kentucky Albert B. Chandler Hospital, Lexington, KY, USA
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Meisenbacher K, Osswald A, Bischoff MS, Böckler D, Karck M, Ruhparwar A, Geisbüsch P. TEVAR Following FET: Current Outcomes of Rendezvous Procedures in Clinical Practice. Thorac Cardiovasc Surg 2021; 70:314-322. [PMID: 33580489 DOI: 10.1055/s-0040-1722732] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND The treatment of extensive thoracic/thoracoabdominal aortic pathologies with arch involvement remains a challenging task in aortic surgery. The introduction of the frozen elephant trunk (FET) technique offered a link between open surgery and thoracic endovascular aortic repair (TEVAR). Despite a decade of experience, data on the complementary use of these techniques are scant. The aim of this study was to evaluate TEVAR following FET in clinical reality. METHODS Between November 2006 and June 2018, 20 patients (9 females; median age of 69 years) underwent endovascular second-stage completion after FET. The clinical outcomes, technical feasibility, and morphological findings were analyzed retrospectively. RESULTS Eleven of the 20 interventions were intended "rendezvous procedures" in a multistage approach; 4 were elective reinterventions, and 5 were emergency complication repairs. The median interval between FET and TEVAR was 231 days (11 days-7.4 years). The technical success rate was 100%. During a median follow-up (FU) period of 58.3 months, the overall survival rate was 95%, with one in-hospital death. Neurological complications occurred in three cases (spinal cord injury: n = 1; stroke: n = 2). Computed tomography angiography showed overall regression in the median diameter of the proximal descending aorta (from 57 to 48.5 mm). CONCLUSION TEVAR as a second-stage intervention after FET is a feasible option, with satisfactory results at medium-term FU. In extensive thoracoabdominal aortic disease without proximal landing zones, the complementary use of both techniques in a multistage approach should be considered.
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Affiliation(s)
- Katrin Meisenbacher
- Department of Vascular and Endovascular Surgery, Heidelberg University Hospital, Heidelberg, Baden-Württemberg, Germany
| | - Anja Osswald
- Department of Cardiac Surgery, Heidelberg University Hospital, Heidelberg, Baden-Württemberg, Germany
| | - Moritz Sebastian Bischoff
- Department of Vascular and Endovascular Surgery, Heidelberg University Hospital, Heidelberg, Baden-Württemberg, Germany
| | - Dittmar Böckler
- Department of Vascular and Endovascular Surgery, Heidelberg University Hospital, Heidelberg, Baden-Württemberg, Germany
| | - Matthias Karck
- Department of Cardiac Surgery, Heidelberg University Hospital, Heidelberg, Baden-Württemberg, Germany
| | - Arjang Ruhparwar
- Department of Cardiac Surgery, Heidelberg University Hospital, Heidelberg, Baden-Württemberg, Germany
| | - Philipp Geisbüsch
- Department of Vascular and Endovascular Surgery, Heidelberg University Hospital, Heidelberg, Baden-Württemberg, Germany
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Meisenbacher K, Hagedorn M, Grond-Ginsbach C, Weber D, Böckler D, Bischoff MS. Outcomes of thoracic endovascular aortic repair in thoracic aortic aneurysm and penetrating aortic ulcer using the Conformable Gore TAG within and outside the instructions for use. Vascular 2020; 29:486-498. [PMID: 33131466 DOI: 10.1177/1708538120970033] [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: 11/16/2022]
Abstract
OBJECTIVE To describe the outcome of thoracic endovascular aortic repair (TEVAR) in thoracic aortic aneurysm and penetrating aortic ulcer with respect to instructions for use status. METHODS Between October 2009 and September 2017, a total of 532 patients underwent TEVAR; of which 195 have been treated using the Conformable GORE® TAG® thoracic endoprosthesis (CTAG). Fifty-six patients of this cohort underwent TEVAR for thoracic aortic aneurysm/penetrating aortic ulcer using the CTAG. Depending on the preoperative computed tomography angiography findings, patients were classified as inside or outside the device's instructions for use. All inside instruction for use patients underwent postoperative reclassification regarding the instructions for use status. Study endpoints included TEVAR-related reintervention, exclusion of the pathology (endoleak type I/III), TEVAR-related mortality, and graft-related serious adverse events. The median duration of follow-up was 29.7 months (range: 0-109.4 months). RESULTS Of the 56 patients, 17 were primarily classified as outside instruction for use, and in additional 13 patients, TEVAR was performed outside instruction for use, leading to 30 outside instruction for use patients (53.6%). Twenty-six patients (46.4%) were treated inside instruction for use. Reintervention-free survival was lower in outside instruction for use patients (P = 0.016) with a hazard ratio of 9.74 (confidence interval 1.2-80.2; P = 0.034) for TEVAR-related reintervention. With respect to endoleak type I/III, relevant difference was detected between inside/outside instruction for use status (P = 0.012). The serious adverse event rate was 30.4%, mainly in outside instruction for use patients (P = 0.004). Logistic regression analysis indicated an association between graft-related serious adverse event/instructions for use status (odds ratio 6.11; confidence interval 1.6-30.06; P = 0.012). In-hospital death was seen more frequently in outside instruction for use patients (P = 0.12) as was procedure-related death (log-rank test: P = 0.21). CONCLUSION TEVAR for thoracic aortic aneurysm/penetrating aortic ulcer is frequently performed outside instruction for use despite preoperative inside instruction for use eligibility, leading to important consequences for technical/clinical outcome. Instructions for use adherence in TEVAR should be of interest for further large-scale studies.
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Affiliation(s)
- Katrin Meisenbacher
- Department of Vascular and Endovascular Surgery, Heidelberg University Hospital, Germany
| | - Matthias Hagedorn
- Department of Vascular and Endovascular Surgery, Heidelberg University Hospital, Germany
| | - Caspar Grond-Ginsbach
- Department of Vascular and Endovascular Surgery, Heidelberg University Hospital, Germany
| | - Dorothea Weber
- Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - Dittmar Böckler
- Department of Vascular and Endovascular Surgery, Heidelberg University Hospital, Germany
| | - Moritz S Bischoff
- Department of Vascular and Endovascular Surgery, Heidelberg University Hospital, Germany
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King RW, Wooster MD, Ruddy JM, Genovese EA, Anderson JM, Brothers TE, Veeraswamy RK. Previous thoracic aortic repair is not associated with adverse outcomes after thoracic endovascular aortic repair. J Vasc Surg 2020; 71:1097-1108. [PMID: 31619351 PMCID: PMC7189752 DOI: 10.1016/j.jvs.2019.07.077] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 07/18/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND As many as 20% of patients who have undergone previous thoracic aortic repair will require reintervention, which could entail thoracic endovascular aortic repair (TEVAR). A paucity of data is available on mortality and the incidence of spinal cord ischemia (SCI) and other postoperative complications associated with TEVAR after previous aortic repairs exclusive to the thoracic aorta. The aim of the present study was to assess the effect of previous thoracic aortic repair on the 30-day mortality and SCI outcomes for patients after TEVAR. METHODS The Society for Vascular Surgery Vascular Quality Initiative database was queried for all cases of TEVAR from 2012 to 2018. Patients were excluded if they had undergone previous abdominal aortic repair, the TEVAR had extended beyond aortic zone 5, or SCI data were missing. The 3 cohorts compared were TEVAR with previous ascending aortic or aortic arch repair (group 1), TEVAR with previous descending thoracic aortic repair (group 2), and TEVAR without previous repair (group 3). The primary outcomes of interest were 30-day mortality and SCI. The secondary outcomes included stroke, myocardial infarction, cardiac complications, respiratory complications, postoperative length of stay, and reintervention. The patient variables were compared using χ2 tests, analysis of variance, or Kruskal-Wallis tests, as appropriate. Logistic regression analysis was performed to identify the predictors of 30-day mortality and SCI. RESULTS A total of 4010 patients met the inclusion criteria, with 470 in group 1, 132 in group 2, and 3408 in group 3. The 30-day mortality was 4% (19 of 470) in group 1, 6% (8 of 132) in group 2, and 6% (213 of 3408) in group 3 (P = .17). The incidence of SCI was 3% (14 of 470) in group 1, 3% (4 of 132) in group 2, and 3.8% (128 of 3408) in group 3 (P = .65). Stroke, reintervention, myocardial infarction, and cardiac complications were not significantly different among the 3 groups. The incidence of respiratory complications was greatest for group 3 (11%; 360 of 3408) compared with groups 1 (9%; 44 of 470) and 2 (4%; 5 of 132; P = .034). Similarly, the postoperative length of stay was longest for group 3 (9.6 ± 19.4 days vs 8.2 ± 18.3 days for group 1 and 5.9 ± 8.6 days for group 2; P = .038). The independent predictors of 30-day mortality for all TEVAR patients included units of packed red blood cells transfused intraoperatively, urgent or emergent repairs, older age, increasing serum creatinine level, inability to perform self-care, total procedure time, occlusion of the left subclavian artery intraoperatively, distal endograft landing zone 5, and diabetes. The predictors of SCI included the total procedure time, urgent and emergent repairs, and increasing serum creatinine level. CONCLUSIONS TEVAR after previous thoracic aortic repair was not associated with an increased risk of SCI or 30-day mortality compared with TEVAR without previous aortic repair.
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Affiliation(s)
- Ryan W King
- Division of Vascular Surgery, Medical University of South Carolina, Charleston, SC.
| | - Mathew D Wooster
- Division of Vascular Surgery, Medical University of South Carolina, Charleston, SC
| | - Jean M Ruddy
- Division of Vascular Surgery, Medical University of South Carolina, Charleston, SC; Ralph H. Johnson Department of Veteran Affairs Medical Center, Charleston, SC
| | - Elizabeth A Genovese
- Division of Vascular Surgery, Medical University of South Carolina, Charleston, SC; Ralph H. Johnson Department of Veteran Affairs Medical Center, Charleston, SC
| | - Joseph M Anderson
- Division of Vascular Surgery, Medical University of South Carolina, Charleston, SC
| | - Thomas E Brothers
- Division of Vascular Surgery, Medical University of South Carolina, Charleston, SC; Ralph H. Johnson Department of Veteran Affairs Medical Center, Charleston, SC
| | - Ravi K Veeraswamy
- Division of Vascular Surgery, Medical University of South Carolina, Charleston, SC
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Belvroy VM, de Beaufort HW, van Herwaarden JA, Trimarchi S, Moll FL, Bismuth J. Type 1b Endoleaks After Thoracic Endovascular Aortic Repair are Inadequately Reported: A Systematic Review. Ann Vasc Surg 2020; 62:474-483. [DOI: 10.1016/j.avsg.2019.06.030] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 06/19/2019] [Accepted: 06/20/2019] [Indexed: 11/24/2022]
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Fairman AS, Beck AW, Malas MB, Goodney PP, Osborne NH, Schermerhorn ML, Wang GJ. Reinterventions in the modern era of thoracic endovascular aortic repair. J Vasc Surg 2019; 71:408-422. [PMID: 31327616 DOI: 10.1016/j.jvs.2019.04.484] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 04/20/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Using a national data set, we sought to describe the population of patients and the nature and timing of reinterventions after thoracic endovascular aortic repair (TEVAR) by aortic disease as well as their impact on survival. METHODS We evaluated the national data set for TEVAR in the Vascular Quality Initiative from 2010 to 2017. Student t-test and χ2 analysis were used to compare continuous and categorical variables in the reintervention and no reintervention groups, respectively. Freedom from reintervention and survival analysis was performed using Kaplan-Meier methods. RESULTS A total of 7006 patients were evaluated: 51.2% thoracic aortic aneurysm, 33.5% type B dissection (TBD), 7.0% penetrating aortic ulcer, 6.7% trauma, and 1.6% intramural hematoma. Overall, 553 patients (7.9%) underwent at least one reintervention, with an in-hospital reintervention rate of 3.5%. Reinterventions were most commonly performed for TBD (11.5%), with reinterventions for other diseases occurring at lower rates: thoracic aortic aneurysm, 6.7%; intramural hematoma, 5.4%; penetrating aortic ulcer, 4.8%; and trauma, 1.8%. The most common cause of reintervention across all aortic diseases was type I endoleak. The most common long-term reinterventions were placement of endovascular stent graft (65%), other surgical treatments (15.9%), other endovascular treatment (13%), endovascular branch treatment (12.4%), surgical treatment with no device removal (11.0%), and surgical branch treatment (10.4%). Freedom from reintervention was decreased for TBD compared with other diseases (P < .001). There was no difference in survival comparing patients undergoing reinterventions and those without (P = .87). However, patients undergoing in-hospital reintervention trended toward increased mortality (P = .075). CONCLUSIONS Whereas reinterventions were not rare after TEVAR, there was no difference in mortality between patients undergoing reintervention and those without. Patients undergoing TEVAR for TBD demonstrated the highest reintervention rate. This study highlights the importance of long-term follow-up to address disease-specific patterns of reintervention.
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Affiliation(s)
- Alexander S Fairman
- Division of Vascular Surgery and Endovascular Therapy, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Adam W Beck
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama Birmingham Hospital, Birmingham, Ala
| | - Mahmoud B Malas
- Divison of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego Health System, San Diego, Calif
| | - Philip P Goodney
- Division of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Nicholas H Osborne
- Section of Vascular Surgery, University of Michigan Medical Center, Ann Arbor, Mich
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Grace J Wang
- Division of Vascular Surgery and Endovascular Therapy, Hospital of the University of Pennsylvania, Philadelphia, Pa.
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Endograft migration after thoracic endovascular aortic repair. J Vasc Surg 2019; 69:1387-1394. [DOI: 10.1016/j.jvs.2018.07.073] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Accepted: 07/27/2018] [Indexed: 11/20/2022]
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13
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Spinella G, Finotello A, Conti M, Faggiano E, Gazzola V, Auricchio F, Chakfé N, Palombo D, Pane B. Assessment of geometrical remodelling of the aortic arch after hybrid treatment. Eur J Cardiothorac Surg 2018; 55:1045-1053. [DOI: 10.1093/ejcts/ezy397] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 10/17/2018] [Accepted: 10/25/2018] [Indexed: 11/14/2022] Open
Affiliation(s)
- Giovanni Spinella
- Department of Vascular and Endovascular Surgery, Ospedale Policlinico San Martino, University of Genoa, Genoa, Italy
| | - Alice Finotello
- Department of Vascular and Endovascular Surgery, Ospedale Policlinico San Martino, University of Genoa, Genoa, Italy
- Department of Experimental Medicine, University of Genoa, Genoa, Italy
| | - Michele Conti
- Department of Civil Engineering and Architecture, University of Pavia, Pavia, Italy
| | - Elena Faggiano
- Department of Civil Engineering and Architecture, University of Pavia, Pavia, Italy
| | - Valerio Gazzola
- Department of Vascular and Endovascular Surgery, Ospedale Policlinico San Martino, University of Genoa, Genoa, Italy
| | - Ferdinando Auricchio
- Department of Civil Engineering and Architecture, University of Pavia, Pavia, Italy
| | - Nabil Chakfé
- Department of Vascular Surgery and Kidney Transplantation, University Hospital of Strasbourg, Strasbourg, France
- European Group for Research on Prostheses Applied for Vascular Surgery (GEPROVAS), Strasbourg, France
| | - Domenico Palombo
- Department of Vascular and Endovascular Surgery, Ospedale Policlinico San Martino, University of Genoa, Genoa, Italy
| | - Bianca Pane
- Department of Vascular and Endovascular Surgery, Ospedale Policlinico San Martino, University of Genoa, Genoa, Italy
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14
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Chou AH, Chen CC, Lin YS, Lin MS, Wu VCC, Ting PC, Chen SW. A population-based analysis of endovascular aortic stent graft therapy in patients with liver cirrhosis. J Vasc Surg 2018; 69:1395-1404.e4. [PMID: 30528408 DOI: 10.1016/j.jvs.2018.06.225] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Accepted: 06/25/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Endovascular aneurysm repair (EVAR) and thoracic endovascular aortic repair (TEVAR) are effective and minimally invasive treatments for high-risk surgical candidates. However, information about the management of EVAR and TEVAR in liver cirrhosis (LC) is lacking. The aim of our study was to evaluate outcomes after EVAR and TEVAR in patients with LC. METHODS Using Taiwan's National Health Insurance Research Database, we retrospectively evaluated patients who underwent EVAR and TEVAR therapy between January 1, 2006, and December 31, 2013. RESULTS A total of 146 patients with LC and 730 matched patients without LC were eligible for analysis after propensity score matching. In-hospital mortality and perioperative complications were not statistically significantly different between the two cohorts, although the LC group had an increased volume of blood transfusion and a trend toward a lower survival rate (P of stratified Cox = .092). However, patients with LC had a higher adjusted hazard ratio for death (1.66; 95% confidence interval, 1.31-2.12; P < .001) in the sensitivity analysis by traditional multivariable adjustment. The LC cohort had a higher risk of liver-related death (4.1% vs 0.7%; P = .001) and liver-related readmission (6.2% vs 0.3%; P < .001). As expected, the advanced LC group had a higher mortality rate than the early LC group (P = .022). The risk for reintervention, redo open aortic surgery (P = .859), and redo stent graft therapy (P = .179) was not statistically significantly different between the two cohorts. CONCLUSIONS Short-term results after EVAR and TEVAR are promising in patients with LC, despite poor long-term outcomes, because of the nature of LC. Innovations in endovascular therapy for aortic disease have improved surgical outcomes, even in high-risk patients with LC.
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Affiliation(s)
- An-Hsun Chou
- Department of Anesthesiology, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University, Taoyuan City, Taipei, Taiwan; Department of Medicine, Chang Gung University, Taoyuan City, Taipei, Taiwan
| | - Ching-Chang Chen
- Department of Neurosurgery, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University, Taoyuan City, Taipei, Taiwan
| | - Yu-Sheng Lin
- Department of Cardiology, Chang Gung Memorial Hospital, Chiayi Branch, Chiayi City, Taiwan
| | - Ming-Shyan Lin
- Department of Cardiology, Chang Gung Memorial Hospital, Chiayi Branch, Chiayi City, Taiwan
| | - Victor Chien-Chia Wu
- Department of Cardiology, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University, Taoyuan City, Taipei, Taiwan
| | - Pei-Chi Ting
- Department of Anesthesiology, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University, Taoyuan City, Taipei, Taiwan
| | - Shao-Wei Chen
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University, Taoyuan City, Taipei, Taiwan; Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan City, Taipei, Taiwan.
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15
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Editor's Choice – Open Thoracic and Thoraco-abdominal Aortic Repair After Prior Endovascular Therapy. Eur J Vasc Endovasc Surg 2018; 56:57-67. [DOI: 10.1016/j.ejvs.2018.03.015] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Accepted: 03/12/2018] [Indexed: 11/18/2022]
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16
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Lee SI, Choi CH, Park KY, Park CH. Explantation of a failed endovascular stent graft in a patient with a type B dissection. J Card Surg 2018; 33:282-285. [PMID: 29687497 DOI: 10.1111/jocs.13575] [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: 11/29/2022]
Abstract
We report a patient who underwent insertion of an endovascular stent graft in the descending aorta for an aneurysmal type B dissection. The patient developed a proximal type I endoleak which required explantation of the graft and replacement of the descending aorta. Carotid artery cannulation was utilized for antegrade perfusion during the period of circulatory arrest.
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Affiliation(s)
- Seok In Lee
- Department of Thoracic and Cardiovascular Surgery, Gil Medical Center, Gachon Cardiovascular Research Institute, Gachon University, Incheon, South Korea
| | - Chang Hyu Choi
- Department of Thoracic and Cardiovascular Surgery, Gil Medical Center, Gachon Cardiovascular Research Institute, Gachon University, Incheon, South Korea
| | - Kook Yang Park
- Department of Thoracic and Cardiovascular Surgery, Gil Medical Center, Gachon Cardiovascular Research Institute, Gachon University, Incheon, South Korea
| | - Chul-Hyun Park
- Department of Thoracic and Cardiovascular Surgery, Gil Medical Center, Gachon Cardiovascular Research Institute, Gachon University, Incheon, South Korea
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17
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Ranney DN, Cox ML, Yerokun BA, Benrashid E, McCann RL, Hughes GC. Long-term results of endovascular repair for descending thoracic aortic aneurysms. J Vasc Surg 2018; 67:363-368. [PMID: 28847657 PMCID: PMC9799071 DOI: 10.1016/j.jvs.2017.06.094] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Accepted: 06/15/2017] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Since thoracic endovascular aortic repair (TEVAR) received U.S. Food and Drug Administration approval for the treatment of descending thoracic aneurysms in March 2005, excellent 30-day and midterm outcomes have been described. However, data on long-term outcomes are lacking with Medicare data suggesting that TEVAR has worse late survival compared with open descending repair. As such, the purpose of this study was to examine the long-term outcomes for on-label use of TEVAR for repair of descending thoracic aneurysms. METHODS Of 579 patients undergoing TEVAR between March 2005 and April 2016 at a single referral center for aortic surgery, 192 (33.2%) were performed for a descending thoracic aneurysm indication in accordance with the device instructions for use, including 106 fusiform (55.2%), 80 saccular (41.7%), and 6 with both saccular and fusiform (3.1%) aneurysms. All aneurysms were located distal to the left subclavian artery and proximal to the celiac axis, and hybrid procedures including arch or visceral debranching were excluded with the exception of left carotid-subclavian artery bypass. Aortic dissection and intramural hematoma as indications for TEVAR were also excluded. Primary 30-day and in-hospital outcomes included mortality, stroke, need for new permanent dialysis, and permanent paraparesis or paraplegia. Primary long-term outcomes included survival and rate of reintervention secondary to endoleak. The Kaplan-Meier method was used to estimate long-term overall and aorta-specific survivals. RESULTS The mean age was 71.1 ± 10.4 years. All aneurysms in this series were degenerative in nature and no patients with a connective tissue disorder were included. The mean aortic diameter was 5.9 ± 1.5 cm at time of intervention. Rates of 30-day and in-hospital mortality, stroke, permanent dialysis, and permanent paraparesis and paraplegia were 4.7%, 2.1%, 0.5%, and 0.5%, respectively. At a mean follow-up of 69 ± 44 months (range, 3-141 months), there were 68 late deaths (35.4%), two of which were due to aortic rupture. Overall and aorta-specific survivals at 141 months (11.8 years) were 45.7% and 96.2%, respectively. Endovascular reintervention was required in 14 patients (7.3%) owing to type I (n = 10), type II (n = 2), and type III (n = 2) endoleak, all of which subsequently resolved. No patient required open reintervention for any cause. CONCLUSIONS Long-term (12-year) aorta-specific survival after on-label endovascular repair of degenerative descending thoracic aneurysms in nonsyndromic patients is excellent (96%) with sustained protection from rupture, and a low rate of reintervention owing to endoleak (7%). Endovascular repair should be considered the treatment of choice for this pathology.
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Affiliation(s)
- David N Ranney
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Morgan L Cox
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Babatunde A Yerokun
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Ehsan Benrashid
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Richard L McCann
- Division of Vascular Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - G Chad Hughes
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC.
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18
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A systematic review of primary endovascular repair of the ascending aorta. J Vasc Surg 2018; 67:332-342. [DOI: 10.1016/j.jvs.2017.06.099] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Accepted: 06/19/2017] [Indexed: 11/21/2022]
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19
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Open descending thoracic or thoracoabdominal aortic approaches for complications of endovascular aortic procedures: 19-year experience. J Thorac Cardiovasc Surg 2018; 155:10-18. [DOI: 10.1016/j.jtcvs.2017.08.023] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Revised: 07/20/2017] [Accepted: 08/11/2017] [Indexed: 11/19/2022]
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20
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Chisci E, Bellandi G, Michelagnoli S. Thoracic Endovascular Aneurysm Sealing of a Complex Thoracoabdominal Aneurysm. J Endovasc Ther 2017; 25:62-67. [PMID: 29264997 DOI: 10.1177/1526602817749309] [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: 11/17/2022]
Abstract
PURPOSE To report bailout treatment of a thoracoabdominal aortic aneurysm using a single Nellix stent and parallel stents. CASE REPORT A 74-year-old man with multiple comorbidities and a previous fenestrated Anaconda stent-graft for a 60-mm juxtarenal aneurysm was diagnosed with a type IV thoracoabdominal aneurysm on the 2-year computed tomography angiography (CTA) scans. The imaging showed >10-mm downward migration of the proximal Anaconda stent with a massive type Ia endoleak and aneurysmal evolution of the distal descending thoracic aorta; the superior mesenteric artery (SMA) and renal artery covered stents were patent and intact. Open conversion or a second custom-made endograft was not feasible. A plan was devised to use off-the-shelf materials, including the deployment of a single Nellix stent extending from the descending thoracic aorta into the stented area of the fenestrated endograft, with parallel chimney stent-grafts into the SMA and right renal artery; the left renal artery was treated with a bare stent in a periscope configuration. Transient paraparesis was resolved with cerebrospinal fluid drainage. At 6-month CTA, ongoing aneurysm exclusion with patent SMA and renal arteries was confirmed. CONCLUSION Thoracic endovascular aneurysm sealing with visceral and renal stenting seems to be a feasible bailout alternative treatment for urgent, complex cases without reconstruction options.
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Affiliation(s)
- Emiliano Chisci
- 1 Department of Surgery, Vascular and Endovascular Surgery Unit "San Giovanni di Dio" Hospital, Florence, Italy
| | - Guido Bellandi
- 1 Department of Surgery, Vascular and Endovascular Surgery Unit "San Giovanni di Dio" Hospital, Florence, Italy
| | - Stefano Michelagnoli
- 1 Department of Surgery, Vascular and Endovascular Surgery Unit "San Giovanni di Dio" Hospital, Florence, Italy
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21
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A current systematic evaluation and meta-analysis of chimney graft technology in aortic arch diseases. J Vasc Surg 2017; 66:1602-1610.e2. [DOI: 10.1016/j.jvs.2017.06.100] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Accepted: 06/19/2017] [Indexed: 12/20/2022]
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22
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Open reoperations for complications of endovascular aortic procedures: Tip of the iceberg? J Thorac Cardiovasc Surg 2017; 155:19-20. [PMID: 28986042 DOI: 10.1016/j.jtcvs.2017.09.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Accepted: 09/02/2017] [Indexed: 11/20/2022]
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23
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Gambardella I, Antoniou GA, Torella F, Spadaccio C, Oo AY, Gaudino M, Nappi F, Shaw MA, Girardi LN. Secondary Open Aortic Procedure Following Thoracic Endovascular Aortic Repair: Meta-Analytic State of the Art. J Am Heart Assoc 2017; 6:e006618. [PMID: 28903940 PMCID: PMC5634303 DOI: 10.1161/jaha.117.006618] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Accepted: 07/28/2017] [Indexed: 01/16/2023]
Abstract
BACKGROUND Thoracic endovascular aortic repair is characterized by a substantial need for reintervention. Secondary open aortic procedure becomes necessary when further endoluminal options are exhausted. This synopsis and quantitative analysis of available evidence aims to overcome the limitations of institutional cohort reports on secondary open aortic procedure. METHODS AND RESULTS Electronic databases were searched from 1994 to the present date with a prospectively registered protocol. Pooled quantification of pre/intraoperative variables, and proportional meta-analysis with random effect model of early and midterm outcomes were performed. Subgroup analysis was conducted for patients who had early mortality. Fifteen studies were elected for final analysis, encompassing 330 patients. The following values are expressed as "pooled mean, 95% confidence interval." Type B dissection was the most common pathology at index thoracic endovascular aortic repair (51.2%, 44.4-57.9). The most frequent indication for secondary open aortic procedure was endoleak (39.7%, 34.6-45.1). More than half of patients had surgery on the descending aorta (51.2%, 45.8-56.6), and one fourth on the arch (25.2%, 20.8-30.1). Operative mortality was 10.6% (7.4-14.9). Neurological morbidity was substantial between stroke (5.1%, 2.8-9.1) and paraplegia (8.3%, 5.2-13.1). At 2-year follow-up, mortality (20.4%, 11.5-33.5) and aortic adverse event (aortic death 7.7%, 4.3-13.3, tertiary aortic open procedure 7.4%, 4.0-13.2) were not negligible. CONCLUSIONS In the secondary open aortic procedure population, type B dissection was both the most common pathology and the one associated with the lowest early mortality, whereas aortic infection and extra-anatomical bypass were associated with the most ominous prognosis.
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Affiliation(s)
- Ivancarmine Gambardella
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - George A Antoniou
- Department of Vascular and Endovascular Surgery, The Royal Oldham Hospital, Manchester, United Kingdom
| | - Francesco Torella
- Vascular and Endovascular Service, Royal Liverpool University Hospital, Liverpool, United Kingdom
| | - Cristiano Spadaccio
- Department of Cardiothoracic Surgery, Golden Jubilee National Hospital, Glasgow, United Kingdom
| | - Aung Y Oo
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Francesco Nappi
- Cardiac Surgery Center, Cardiologique du Nord de Saint-Denis, Paris, France
| | - Matthew A Shaw
- Information Department, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Leonard N Girardi
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
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Farber MA, Lee WA, Szeto WY, Panneton JM, Kwolek CJ. Initial and midterm results of the Bolton Relay Thoracic Aortic Endovascular Pivotal Trial. J Vasc Surg 2017; 65:1556-1566.e1. [PMID: 28527926 DOI: 10.1016/j.jvs.2016.11.061] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2016] [Accepted: 11/25/2016] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To report the initial and midterm results of the Bolton Relay Thoracic Stent Graft for the endovascular treatment of thoracic aortic lesions [thoracic endovascular aortic repair (TEVAR)]. METHODS The Bolton Relay Thoracic Aortic Endovascular Pivotal Trial was a prospective, nonrandomized, multicenter, U.S. Investigational Device Exemption study conducted at 27 U.S. investigational sites. One hundred twenty TEVAR subjects were treated with the Relay device between January 2007 and May 2010, with 13 patients enrolled during the continued access phase through September 2012. TEVAR outcomes were compared with a prospectively and retrospectively enrolled surgical cohort consisting of 60 patients enrolled under similar inclusion/exclusion criteria. Follow-up examinations were prescribed at 1 month, 6 months, and yearly thereafter for 5 years. Major adverse events (MAEs) included stroke, paralysis/paraplegia, myocardial infarction, procedural bleeding, respiratory failure, renal failure, wound healing complications, and aneurysm-related mortality. RESULTS Stent grafts were successfully delivered and deployed in 129 of 133 patients (97.0%). At 30 days, a lower rate of mortality was observed in the TEVAR arm (5.3% vs 10.0%; P = .230), and TEVAR was associated with a significantly lower rate of MAEs (20.3% vs 48.3%; P < .001), primarily driven by a lower frequency of respiratory failure in the cohort (5.5% vs 21.6%; P = .007) and procedural bleeding. Freedom from aneurysm-related mortality through 5 years was similar at 91.3% for the TEVAR cohort and 89.4% for the surgical cohort (P = .406); with 5-year freedom from all-cause mortality at 57.1% and 50.2% (P = .289), respectively. Freedom from MAEs through 5 years was significantly higher in the TEVAR cohort (65.7% vs 44.7%; P = .001). Six TEVAR patients (4.5%) experienced core laboratory-reported type I or III endoleaks, and secondary procedures were performed in 10 patients (7.5%), with seven procedures to correct endoleak and one surgical conversion. Endograft migration occurred in three patients (2.3%) and wireform fractures were assessed in two patients (1.5%). Aneurysm sac size decreased or remained stable in 113 patients (85.0%) over 5-year follow-up. There were no instances of rupture or endograft occlusion. A 38-subject subset treated with the newer Relay Plus Delivery System had a significantly reduced MAE rate (15.8% vs 35.8%; P = .035), and fewer perioperative strokes (2.6% vs 12.6%; P = .108). CONCLUSIONS Data from the Relay TEVAR clinical trial demonstrate safety and effectiveness of the Relay device compared with surgical controls, indicating continued device durability with a low rate of device-related complications through 5 years.
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Affiliation(s)
- Mark A Farber
- Division of Vascular Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC.
| | | | - Wilson Y Szeto
- Department of Surgery, University of Pennsylvania, Philadelphia, Pa
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25
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Aortobronchial Fistula after Thoracic Endovascular Aortic Repair (TEVAR) for Descending Thoracic Aortic Aneurysm. Ann Vasc Surg 2017; 41:283.e1-283.e4. [DOI: 10.1016/j.avsg.2016.10.040] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Revised: 09/07/2016] [Accepted: 10/13/2016] [Indexed: 11/18/2022]
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Hu H, Zheng T, Zhu J, Liu Y, Qi R, Sun L. Thoracoabdominal aortic replacement for Crawford extent II aneurysm after thoracic endovascular aortic repair. J Thorac Dis 2017; 9:64-69. [PMID: 28203407 DOI: 10.21037/jtd.2017.01.54] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND The surgical treatment of Crawford extent II aneurysms after thoracic endovascular aortic repair (TEVAR) remains challenging, because of the need to remove the failed endograft and the complexity of the aortic reconstruction. We retrospectively reviewed our experience with surgical management of Crawford extent II aneurysms after TEVAR using thoracoabdominal aortic replacement (TAAR). METHODS Eleven patients (10 males, 1 female) with Crawford extent II aneurysm after TEVAR were treated with TAAR between August 2012 and May 2015. The indications included: diameter >5.0 cm; persistent pain; size increase >0.5 cm/year; and no suitable landing zone for re-TEVAR. Five patients underwent surgery under deep hypothermic cardiac arrest, two under mild hypothermic cardiopulmonary bypass, and four under direct aortic cross-clamping under normothermia. Two patients had Marfan syndrome. RESULTS There were no in-hospital deaths. Continuous renal replacement therapy was required in three patients. One patient needed re-intubation, and two patients had prolonged intubation (>72 h). One patient sustained paraplegia after surgery but recovered during follow-up. Cerebrospinal fluid drainage were used in four patients (3 immediately in the operation room, and 1 in the intensive care unit when the patient suffered paraplegia). One patient died during follow-up. CONCLUSIONS TAAR represents a feasible option for the treatment of Crawford extent II aneurysms after TEVAR, with acceptable surgical risks and favorable results.
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Affiliation(s)
- Haiou Hu
- Department of Cardiovascular Surgery, Beijing Aortic Disease Centre, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing Engineering Research Centre for Vascular Prostheses, Beijing 100029, China
| | - Tie Zheng
- Department of Cardiovascular Surgery, Beijing Aortic Disease Centre, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing Engineering Research Centre for Vascular Prostheses, Beijing 100029, China
| | - Junming Zhu
- Department of Cardiovascular Surgery, Beijing Aortic Disease Centre, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing Engineering Research Centre for Vascular Prostheses, Beijing 100029, China
| | - Yongmin Liu
- Department of Cardiovascular Surgery, Beijing Aortic Disease Centre, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing Engineering Research Centre for Vascular Prostheses, Beijing 100029, China
| | - Ruidong Qi
- Department of Cardiovascular Surgery, Beijing Aortic Disease Centre, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing Engineering Research Centre for Vascular Prostheses, Beijing 100029, China
| | - Lizhong Sun
- Department of Cardiovascular Surgery, Beijing Aortic Disease Centre, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing Engineering Research Centre for Vascular Prostheses, Beijing 100029, China
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27
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Open aortic surgery after thoracic endovascular aortic repair. Gen Thorac Cardiovasc Surg 2016; 64:441-9. [DOI: 10.1007/s11748-016-0658-8] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Accepted: 05/13/2016] [Indexed: 01/10/2023]
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28
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Bischoff MS, Ante M, Meisenbacher K, Böckler D. Outcome of thoracic endovascular aortic repair in patients with thoracic and thoracoabdominal aortic aneurysms. J Vasc Surg 2016; 63:1170-1181.e1. [DOI: 10.1016/j.jvs.2015.11.045] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Accepted: 11/12/2015] [Indexed: 01/16/2023]
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29
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Bosanquet DC, Twine CP, Tang TY, Boyle JR, Bell RE, Bicknell CD, Jenkins MP, Loftus IM, Modarai B, Vallabhaneni SR. Pragmatic Minimum Reporting Standards for Thoracic Endovascular Aortic Repair. J Endovasc Ther 2015; 22:356-67. [DOI: 10.1177/1526602815584925] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- David C. Bosanquet
- South East Wales Regional Vascular Network, Royal Gwent Hospital, Newport, Wales, UK
| | - Christopher P. Twine
- South East Wales Regional Vascular Network, Royal Gwent Hospital, Newport, Wales, UK
| | - Tjun Y. Tang
- Department of General Surgery, Changi General Hospital, Singapore
| | - Jonathan R. Boyle
- Regional Vascular Unit, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
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Gillen JR, Schaheen BW, Yount KW, Cherry KJ, Kern JA, Kron IL, Upchurch GR, Lau CL. Cost analysis of endovascular versus open repair in the treatment of thoracic aortic aneurysms. J Vasc Surg 2015; 61:596-603. [PMID: 25449008 PMCID: PMC4344903 DOI: 10.1016/j.jvs.2014.09.009] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2014] [Accepted: 09/14/2014] [Indexed: 11/16/2022]
Abstract
OBJECTIVE For descending thoracic aortic aneurysms (TAAs), it is generally considered that thoracic endovascular aortic repairs (TEVARs) reduce operative morbidity and mortality compared with open surgical repair. However, long-term differences in survival of patients have not been demonstrated, and an increased need for aortic reintervention has been observed. Many assume that TEVAR becomes less cost-effective through time because of higher rates of reintervention and surveillance imaging. This study investigated midterm outcomes and hospital costs of TEVAR compared with open TAA repair. METHODS This was a retrospective, single-institution review of elective TAA repairs between 2005 and 2012. Patient demographics, operative outcomes, reintervention rates, and hospital costs were assessed. The literature was also reviewed to determine commonly observed complication and reintervention rates for TEVAR and open repair. Monte Carlo simulation was used to model and to forecast hospital costs for TEVAR and open TAA repair up to 3 years after intervention. RESULTS Our cohort consisted of 131 TEVARs and 27 open repairs. TEVAR patients were significantly older (67.2 vs 58.7 years old; P = .02) and trended toward a more severe comorbidity profile. Operative mortality for TEVAR and open repair was 5.3% and 3.7%, respectively (P = 1.0). There was a trend toward more complications in the TEVAR group, although not statistically significant (all P > .05). In-hospital costs were significantly greater in the TEVAR group ($52,008 vs $37,172; P = .001). However, cost modeling by use of reported complication and reintervention rates from the literature overlaid with our cost data produced a higher cost for the open group in-hospital ($55,109 vs $48,006) and at 3 years ($58,426 vs $52,825). Interestingly, TEVAR hospital costs, not reintervention rates, were the most significant driver of cost in the TEVAR group. CONCLUSIONS Our institutional data showed a trend toward lower mortality and complication rates with open TAA repair, with significantly lower costs within this cohort compared with TEVAR. These findings were likely, at least in part, to be due to the milder comorbidity profile of these patients. In contrast, cost modeling by Monte Carlo simulation demonstrated lower costs with TEVAR compared with open repair at all time points up to 3 years after intervention. Our institutional data show that with appropriate selection of patients, open repair can be performed safely with low complication rates comparable to those of TEVAR. The cost model argues that despite the costs associated with more frequent surveillance imaging and reinterventions, TEVAR remains the more cost-effective option even years after TAA repair.
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Affiliation(s)
- Jacob R Gillen
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia Health System, Charlottesville, Va
| | - Basil W Schaheen
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia Health System, Charlottesville, Va
| | - Kenan W Yount
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia Health System, Charlottesville, Va
| | - Kenneth J Cherry
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia Health System, Charlottesville, Va
| | - John A Kern
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia Health System, Charlottesville, Va
| | - Irving L Kron
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia Health System, Charlottesville, Va
| | - Gilbert R Upchurch
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia Health System, Charlottesville, Va
| | - Christine L Lau
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia Health System, Charlottesville, Va.
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Kotelis D, Brenke C, Wörz S, Rengier F, Rohr K, Kauczor HU, Böckler D, von Tengg-Kobligk H. Aortic morphometry at endograft position as assessed by 3D image analysis affects risk of type I endoleak formation after TEVAR. Langenbecks Arch Surg 2015; 400:523-9. [PMID: 25702140 DOI: 10.1007/s00423-015-1291-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2014] [Accepted: 02/12/2015] [Indexed: 10/24/2022]
Abstract
PURPOSE The purpose of this study was to identify morphologic factors affecting type I endoleak formation and bird-beak configuration after thoracic endovascular aortic repair (TEVAR). METHODS Computed tomography (CT) data of 57 patients (40 males; median age, 66 years) undergoing TEVAR for thoracic aortic aneurysm (34 TAA, 19 TAAA) or penetrating aortic ulcer (n = 4) between 2001 and 2010 were retrospectively reviewed. In 28 patients, the Gore TAG® stent-graft was used, followed by the Medtronic Valiant® in 16 cases, the Medtronic Talent® in 8, and the Cook Zenith® in 5 cases. Proximal landing zone (PLZ) was in zone 1 in 13, zone 2 in 13, zone 3 in 23, and zone 4 in 8 patients. In 14 patients (25%), the procedure was urgent or emergent. In each case, pre- and postoperative CT angiography was analyzed using a dedicated image processing workstation and complimentary in-house developed software based on a 3D cylindrical intensity model to calculate aortic arch angulation and conicity of the landing zones (LZ). RESULTS Primary type Ia endoleak rate was 12% (7/57) and subsequent re-intervention rate was 86% (6/7). Left subclavian artery (LSA) coverage (p = 0.036) and conicity of the PLZ (5.9 vs. 2.6 mm; p = 0.016) were significantly associated with an increased type Ia endoleak rate. Bird-beak configuration was observed in 16 patients (28%) and was associated with a smaller radius of the aortic arch curvature (42 vs. 65 mm; p = 0.049). Type Ia endoleak was not associated with a bird-beak configuration (p = 0.388). Primary type Ib endoleak rate was 7% (4/57) and subsequent re-intervention rate was 100%. Conicity of the distal LZ was associated with an increased type Ib endoleak rate (8.3 vs. 2.6 mm; p = 0.038). CONCLUSIONS CT-based 3D aortic morphometry helps to identify risk factors of type I endoleak formation and bird-beak configuration during TEVAR. These factors were LSA coverage and conicity within the landing zones for type I endoleak formation and steep aortic angulation for bird-beak configuration.
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Affiliation(s)
- Drosos Kotelis
- Department of Vascular and Endovascular Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany,
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Sadek M, Abjigitova D, Pellet Y, Rachakonda A, Panagopoulos G, Plestis K. Operative Outcomes After Open Repair of Descending Thoracic Aortic Aneurysms in the Era of Endovascular Surgery. Ann Thorac Surg 2014; 97:1562-7. [DOI: 10.1016/j.athoracsur.2014.01.046] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Revised: 01/07/2014] [Accepted: 01/17/2014] [Indexed: 11/27/2022]
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Comparison of attachment site endoleak rates in Dacron versus native aorta landing zones after thoracic endovascular aortic repair. J Vasc Surg 2014; 59:921-9. [DOI: 10.1016/j.jvs.2013.10.086] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2013] [Revised: 10/17/2013] [Accepted: 10/17/2013] [Indexed: 11/20/2022]
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Matsumoto AH, Angle JF, Secic M, Carlson GA, Fisher L, Fairman RM. Secondary procedures following thoracic aortic stent grafting in the first 3 years of the VALOR test and VALOR II trials. J Vasc Interv Radiol 2014; 25:685-692.e5. [PMID: 24529546 DOI: 10.1016/j.jvir.2013.12.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2013] [Revised: 12/05/2013] [Accepted: 12/13/2013] [Indexed: 10/25/2022] Open
Abstract
PURPOSE To compare the durability of thoracic endovascular aortic repair (TEVAR) in two similar clinical trials that used early- and later-generation stent grafts. MATERIALS AND METHODS Secondary procedures from the prospective, nonrandomized, multicenter, clinical trial databases of the test arm of the VALOR and VALOR II trials were analyzed at 3 years. Descriptive and statistical analyses were employed to compare the rate of and potential predictors for secondary procedures. RESULTS A total of 127 and 96 patients were available for a minimum of 3 years of follow-up in the test arm of VALOR and VALOR II, respectively. By the first year after the index procedure, VALOR II patients were significantly less likely to have undergone a secondary procedure versus patients in the test arm of VALOR (odds ratio [OR], 0.08; 95% confidence interval [CI], 0.01-0.63; P = .02), with most procedures performed for type I endoleak. Multivariate predictors at 3 years for the need for a secondary procedure in the VALOR test arm were maximum aneurysm diameter (P = .002) and aneurysm length (P = .01), both of which remained significant at the end of the study period. The estimated freedoms from secondary procedures in the VALOR test arm and VALOR II at 3 years were 85.1% (95% CI, 78.5%-89.8%) and 94.9% (95% CI, 88.8%-97.7%), respectively (P < .001). CONCLUSIONS The rate of secondary procedures after TEVAR differed between the two cohorts, being substantially lower in the VALOR II trial at 1 year of follow-up. This finding suggests significant benefit from advances in some combination of operator experience, imaging systems, treatment planning, and device design.
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Affiliation(s)
- Alan H Matsumoto
- Department of Radiology and Medical Imaging, University of Virginia Health System, 1215 Lee St., Box 800170, Room 1839, Charlottesville, VA 22908.
| | - John F Angle
- Department of Radiology and Medical Imaging, University of Virginia Health System, 1215 Lee St., Box 800170, Room 1839, Charlottesville, VA 22908
| | | | - Grace A Carlson
- Office of Medical Affairs, Medtronic Vascular, Santa Rosa, California
| | - Lois Fisher
- Office of Medical Affairs, Medtronic Vascular, Santa Rosa, California
| | - Ronald M Fairman
- Division of Vascular Surgery and Endovascular Therapy, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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Tanaka K, Yoshitaka H, Chikazawa G, Sakaguchi T, Totsugawa T, Tamura K. Investigation of the surgical complications during thoracic endovascular aortic repair: experiences with 148 consecutive cases treated at a single institution in Japan. Surg Today 2014; 45:22-8. [DOI: 10.1007/s00595-014-0840-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2013] [Accepted: 12/10/2013] [Indexed: 10/25/2022]
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Hofmockel T, Plodeck V, Grützmann R, Weiss N, Laniado M, Hoffmann RT. [Endovascular treatment of thoracic aneurisms: indications, techniques and results]. Radiologe 2014; 53:513-8. [PMID: 23681511 DOI: 10.1007/s00117-012-2452-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
UNLABELLED CLINICAL ISSUE OF THORACIC ANEURYSMS: Aneurysms are among the most common diseases affecting the thoracic aorta, with a continuous increase in incidence over the recent decades. The main cause of thoracic aneurysms is atherosclerosis, which, due to the frequent lack of major symptoms and the potentially lethal complications such as ruptured aortic aneurysm, remains a challenge in clinical practice. STANDARD RADIOLOGICAL METHODS CT angiography remains the imaging method of choice for acute aortic aneurysms, with MR angiography being increasingly used for follow-up imaging. THRESHOLD FOR TREATMENT: In the ascending aorta a diameter larger than 5-5.5 cm (descending aorta 6.5 cm) is regarded as the threshold for treatment. THORACIC ENDOVASCULAR AORTIC REPAIR: The continuous evolution of aortic stent grafting (i.e., thoracic endovascular aortic repair [TEVAR]) since Parodi, Palmaz and Dake has led to a steep rise in stent grafting procedures in recent years. PRACTICAL RECOMMENDATIONS Particularly in elderly patients with multiple comorbidities, TEVAR is a valuable, less invasive option compared to open surgical repair.
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Affiliation(s)
- T Hofmockel
- Institut und Poliklinik für Radiologische Diagnostik, Universitätsklinikum Carl-Gustav Carus Dresden, Fetscherstr. 74, 01307 Dresden, Deutschland
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Wilson A, Zhou S, Bachoo P, Tambyraja AL. Systematic review of chimney and periscope grafts for endovascular aneurysm repair. Br J Surg 2014; 100:1557-64. [PMID: 24264776 DOI: 10.1002/bjs.9274] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/22/2013] [Indexed: 12/19/2022]
Abstract
BACKGROUND Conventional endovascular aneurysm repair (EVAR) needs a proximal aortic seal zone that is free from aortic branch vessels. The modified application of conventional EVAR devices using adjuvant chimney or periscope grafts is described as a pragmatic alternative to custom-made fenestrated and branched endografts. This systematic review examined the application and outcomes of chimney or periscope grafts for aortic aneurysm. METHODS A search was performed for all studies of chimney or periscope grafts for EVAR. Clinical details and outcome in terms of technical success, survival, freedom from endoleak and branch vessel patency were examined. RESULTS Twenty-four studies describing 234 patients who underwent EVAR with one or more chimney or periscope grafts for aortic branch vessels were identified. Most procedures were elective; only 62 (26.5 per cent) were performed urgently. There were 176 patients with an abdominal aortic aneurysm and 58 with a thoracic or thoracoabdominal aortic aneurysm. Three hundred and seventy-six branch vessels were perfused. Twelve patients (5.1 per cent) died within 30 days of aneurysm repair. Twenty-seven patients (11.5 per cent) developed a type I endoleak. After a mean(s.d.) follow-up of 12(5) months, seven branch vessels stents had occluded. CONCLUSION These highly selected data support the potential value of chimney and periscope graft techniques for patients with challenging aortic aneurysm morphology. There is a lack of medium- and long-term follow-up data.
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Affiliation(s)
- A Wilson
- Aberdeen Vascular Surgical Service, Aberdeen Royal Infirmary, Foresterhill, Aberdeen AB25 2ZN, UK
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Botsios S, Frömke J, Walterbusch G, Schuermann K, Subramanian S, Reinstadler J, Dohmen G. Secondary Interventions After Endovascular Thoracic Aortic Repair. J Card Surg 2013; 29:66-73. [DOI: 10.1111/jocs.12252] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Spiridon Botsios
- Department of Thoracic- and Cardiovascular Surgery; St. Johannes Hospital Dortmund; Dortmund Germany
- Faculty of Health; University Witten/Herdecke; Witten Germany
| | - Johannes Frömke
- Department of Thoracic- and Cardiovascular Surgery; St. Johannes Hospital Dortmund; Dortmund Germany
| | - Gerhard Walterbusch
- Department of Thoracic- and Cardiovascular Surgery; St. Johannes Hospital Dortmund; Dortmund Germany
| | - Karl Schuermann
- Department of Radiology; St. Johannes Hospital Dortmund; Dortmund Germany
| | | | - Jan Reinstadler
- Department of Thoracic- and Cardiovascular Surgery; St. Johannes Hospital Dortmund; Dortmund Germany
| | - Guido Dohmen
- Department of Thoracic- and Cardiovascular Surgery; St. Johannes Hospital Dortmund; Dortmund Germany
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Nozdrzykowski M, Etz CD, Luehr M, Garbade J, Misfeld M, Borger MA, Mohr FW. Optimal treatment for patients with chronic Stanford type B aortic dissection: endovascularly, surgically or both? Eur J Cardiothorac Surg 2013; 44:e165-74; discussion e174. [PMID: 23761415 DOI: 10.1093/ejcts/ezt291] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Patients with chronic Stanford type B aortic dissections (TBAD) are traditionally treated medically, but some of the affected thoracic and thoracoabdominal aortic segments progress to large aneurysms with a significant risk of rupture. The purpose of this study is to retrospectively evaluate, with an 'all-comers' approach, the survival and the outcome of patients following thoracic endovascular aortic repair (TEVAR) or conventional open surgery for chronic TBAD as a first-line therapy or a secondary option after failed medical treatment. METHODS Between January 2000 and May 2010, 80 consecutive patients (59 males, median age 63, inter-quartile range (IQR) 55-69) suffering from chronic TBAD were treated at our institution. Thirty-three were treated medically (Group A, median age: 65, IQR: 58.5-71.5), 32 received TEVAR (Group B, median age: 62, IQR: 54-67.5) and 15 patients underwent conventional open surgery (Group C, median age: 61, IQR: 54-66). The median follow-up was 42 months (range: 0.1-124.7) and 100% complete. RESULTS There were no significant differences with regard to age, gender and associated comorbidities between the treatment groups. The overall hospital mortality for chronic TBAD was 6.3% (n = 5); in-hospital mortalities for Groups A, B and C were 3.0, 6.2 and 13.4%, respectively. The incidence of major complications, such as paraplegia, malperfusion, renal failure and cardiac arrhythmia, did not significantly differ between the three groups. Postoperative stroke occurred more often after conventional open surgery (Group C: 13.3%; P = 0.07). Reintervention for TBAD pathology was required in Groups A, B and C in 12.1, 28.1 and 0%, respectively (P = 0.03). Secondary open surgery post-TEVAR was required in 7 cases (21.8%) with no postoperative paraplegia. CONCLUSIONS Open surgery for extensive thoracic and thoracoabdominal repair in chronic TBAD may be performed with acceptable early and mid-term outcomes. TEVAR for aortic complications in patients with chronic dissection may be successfully performed as a first-stage procedure in order to stabilize the patient and serve as a 'bridge' to secondary open surgery. However, close surveillance is mandatory for the timely detection of aneurysm enlargement, malperfusion or impending rupture after TEVAR.
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Affiliation(s)
- Michal Nozdrzykowski
- Department of Cardiac Surgery, Heart Center Leipzig, University of Leipzig, Leipzig, Germany
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Bischoff MS, Geisbüsch P, Kotelis D, Müller-Eschner M, Hyhlik-Dürr A, Böckler D. Clinical significance of type II endoleaks after thoracic endovascular aortic repair. J Vasc Surg 2013; 58:643-50. [PMID: 23683377 DOI: 10.1016/j.jvs.2013.03.026] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2013] [Revised: 03/13/2013] [Accepted: 03/18/2013] [Indexed: 11/30/2022]
Abstract
BACKGROUND To evaluate the clinical significance of type II endoleaks (ELII) after thoracic endovascular aortic repair (TEVAR). METHODS From January 1997 to June 2012, a total of 344 patients received TEVAR in our institution. ELII was diagnosed in 30 patients (8.7%; 13 males; median age: 65 years, range: 24 to 84 years), representing the study population of this retrospective, single-center analysis. Mean follow-up was 29.5 months (range, 8 months to 9.5 years). RESULTS Primary ELII was observed in all but two cases (28/30; 93.3%). The most common sources of ELII were the left subclavian artery (LSA; 13/30; 43.3%) and intercostal/bronchial vessels (13/30; 43.3%), followed by visceral arteries (4/30; 13.4%). Overall mortality was 33.3% (10/30). ELII-related death (secondary rupture) was observed in 20% (2/10). Reintervention (RI) procedures for ELII were performed in 9 of 30 patients (30.0%); 5 of 9 (55.6%) in cases with ELII via the LSA. Indications for RI were diameter expansion in five and extensive leakage in four cases. Treatment was successful in five patients (55.6%) but failed in four cases (44.4%). In 12 of 21 (57.1%) untreated patients, ELII sealed during follow-up. In conservatively treated patients, an increase in aortic diameter has been only observed in a patient with secondary ELII. CONCLUSIONS The results presented herein suggest that the clinical impact of ELII after TEVAR must not be underestimated. Albeit a transient finding in most cases, ELII is associated with a relevant RI rate, particularly in cases involving the LSA. RI seems indicated in patients with increasing aortic diameter and/or extensive leakage. Careful surveillance of all patients with ELII is recommended.
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Affiliation(s)
- Moritz S Bischoff
- Department of Vascular and Endovascular Surgery, Ruprecht-Karls University Heidelberg, Heidelberg, Germany.
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Szeto WY, Desai ND, Moeller P, Moser GW, Woo EY, Fairman RM, Pochettino A, Bavaria JE. Reintervention for endograft failures after thoracic endovascular aortic repair. J Thorac Cardiovasc Surg 2013; 145:S165-70. [PMID: 23410774 DOI: 10.1016/j.jtcvs.2012.11.046] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2012] [Revised: 10/11/2012] [Accepted: 11/20/2012] [Indexed: 10/27/2022]
Abstract
OBJECTIVE Thoracic endovascular aortic repair has emerged as an effective therapy for a variety of thoracic aortic pathologic entities. However, endograft failure remains a concern, and its treatment is often challenging. We examined our experience with endograft failure and its treatment by endovascular and open repair. METHODS From January 2000 to January 2012, 680 patients underwent thoracic endovascular aortic repair at the University of Pennsylvania, and their charts were reviewed for the late outcomes and follow-up data. RESULTS Of the 680 patients, 73 underwent 80 reinterventions (11.7%) during follow-up. The indications for index thoracic endovascular aortic repair were thoracic aortic aneurysms in 381, type A dissection with frozen elephant trunk in 52, type B dissection in 111, hybrid arch repair in 46, traumatic transection in 37, infection in 10, penetrating atherosclerotic ulcer in 25, and others in 18. The median interval from index thoracic endovascular aortic repair to reintervention was 210 days. Endograft failures included endoleak in 45, proximal aortic events in 11, distal aortic events in 15, endograft infection in 3, and others in 6. Endovascular reintervention (n = 80) was performed in 60 patients. In 20 patients, open aortic reconstructive procedures were performed. The overall 30-day mortality was 8.7% (7/80). During follow-up, 10 late deaths occurred. The overall survival in all patients was 81%, 60%, and 52% at 1, 5, and 7 years, respectively. The late survival for patients after reintervention for endograft failure was similar that for the patients who did not require reintervention (P = .31). CONCLUSIONS Reintervention for endograft failure can be performed with acceptable early outcomes. The mid-term survival for patients requiring reintervention for endograft failure was similar to that of the patients without endograft failure. Thus, reintervention for endograft failure should be aggressively considered when indicated.
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Affiliation(s)
- Wilson Y Szeto
- Division of Cardiovascular Surgery, University of Pennsylvania Medical Center, Philadelphia, Pa 19104, USA.
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Scheumann J, Heilmann C, Beyersdorf F, Siepe M, Brenner RM, Böckler D, Griepp RB, Bischoff MS. Early histological changes in the porcine aortic media after thoracic stent-graft implantation. J Endovasc Ther 2012; 19:363-9. [PMID: 22788888 DOI: 10.1583/12-3845r.1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
PURPOSE To describe the histological findings in the aortic wall 5 days after thoracic endovascular aortic repair (TEVAR) in a porcine model. METHODS Two overlapping stent-grafts were implanted in each of 6 juvenile pigs, covering the entire descending thoracic aorta (DTA). On the 5(th) postoperative day, tissue samples were taken from the DTA in each animal. Medial thickness and medial necrosis were quantified and compared to measurements from the aortas of 6 control animals. RESULTS Significant medial thinning was observed in stent-covered regions in the test animals. At the proximal landing zone, aortic wall thickness changed from 1387±68 to 782±74 µm within the covered aortic segment (p = 0.028); at the distal landing site, the wall thickness was 365±67 µm within the stent and 501±57 µm distally (p = 0.028). In the overlap zone, the aortic wall measured 524±122 vs. 1053±77 µm in native controls (p = 0.004). Aortic thickness proximal to the graft did not differ from the proximal region of native aortas (1468±96 vs. 1513±80 µm, p = 0.423), but the aorta was significantly thinner distal to the stent (707±38 vs. 815±52 µm, p = 0.004). Laminar necrosis constituted 38%±7% of the media in the proximal landing zone, 54%±4% in the overlap zone, and 46%±13% in the distal landing zone. CONCLUSION In this porcine model, significant medial thinning and necrosis of the stented aorta was observed. The findings suggest an early phase of vulnerability of the aortic wall, before scarring and adaptive changes have strengthened the residual aorta.
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Affiliation(s)
- Johannes Scheumann
- Department of Cardiothoracic Surgery, Mount Sinai School of Medicine, New York, NY, USA.
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Shah AA, Barfield ME, Andersen ND, Williams JB, Shah JA, Hanna JM, McCann RL, Hughes GC. Results of thoracic endovascular aortic repair 6 years after United States Food and Drug Administration approval. Ann Thorac Surg 2012; 94:1394-9. [PMID: 22785216 PMCID: PMC4089907 DOI: 10.1016/j.athoracsur.2012.05.072] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2012] [Revised: 05/13/2012] [Accepted: 05/16/2012] [Indexed: 11/28/2022]
Abstract
BACKGROUND Since United States Food and Drug Administration approval in 2005, the short-term safety and efficacy of thoracic endovascular aortic repair (TEVAR) have been established. However, longer-term follow-up data remain lacking. The objective of this study is to report 6-year outcomes of TEVAR in clinical practice. METHODS A prospective cohort review was performed of all patients undergoing TEVAR at a single referral institution between March 2005 and May 2011. Rates of reintervention were noted. Overall and aortic-specific survival were determined using Kaplan-Meier methods. Log-rank tests were used to compare survival between groups. RESULTS During the study interval, 332 TEVAR procedures were performed in 297 patients. Reintervention was required after 12% of procedures at a mean of 8 ± 14 months after initial TEVAR and was higher in the initial tercile of patients (15.0% vs 9.9%). The 6-year freedom from reintervention was 84%. Type I endoleak was the most common cause of reintervention (5%). Six-year overall survival was 54%, and aorta-specific survival was 92%. Long-term survival was significantly lower than that of an age- and sex-matched United States population (p < 0.001). Survival was similar between patients requiring a reintervention vs those not (p = 0.26). Survival was different based on indication for TEVAR (p = 0.007), and patients with degenerative aneurysms had the lowest survival (47% at 6 years). Cardiopulmonary pathologies were the most common cause of death (27 of 93 total deaths). CONCLUSIONS Long-term aortic-related survival after TEVAR is high, and the need for reintervention is infrequent. However, overall long-term survival is low, particularly for patients with degenerative aneurysms, and additional work is needed to identify patients unlikely to derive a survival benefit from TEVAR.
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Affiliation(s)
- Asad A Shah
- Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
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Descending thoracic aortic surgery: update on mortality, morbidity, risk assessment and management. Curr Opin Crit Care 2012; 18:393-8. [PMID: 22710279 DOI: 10.1097/mcc.0b013e32835559a6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review is to summarize the literature on thoracic aortic surgery, as well as key management guidelines in the perioperative period. This is particularly timely, as endovascular techniques continue to evolve and become more available. RECENT FINDINGS Endovascular treatment of thoracic aortic disease is expanding in applications and case complexity. SUMMARY With the expanded use of endovascular techniques to treat aortic disease, midterm and long-term outcome studies and comparisons to open surgical approach are now being published with increasing frequency. This review analyzes the available literature on preventing adverse outcomes after descending thoracic aortic surgery, with specific attention to mortality, morbidity, risk assessment and management in the perioperative setting.
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Johnson PT, Black JH, Zimmerman SL, Fishman EK. Thoracic Endovascular Aortic Repair: Literature Review With Emphasis on the Role of Multidetector Computed Tomography. Semin Ultrasound CT MR 2012; 33:247-64. [DOI: 10.1053/j.sult.2012.01.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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LeMaire SA, Green SY, Kim JH, Sameri A, Parenti JL, Lin PH, Huh J, Coselli JS. Thoracic or thoracoabdominal approaches to endovascular device removal and open aortic repair. Ann Thorac Surg 2012; 93:726-32; discussion 733. [PMID: 22364967 DOI: 10.1016/j.athoracsur.2011.10.080] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2010] [Revised: 10/01/2011] [Accepted: 10/06/2011] [Indexed: 12/01/2022]
Abstract
BACKGROUND Endovascular aortic repair is becoming increasingly common and diverse in its application despite ongoing uncertainty about long-term durability. Recent reports detail late conversion to open surgical repair to treat disease progression and repair failure. We describe our experience with using thoracic or thoracoabdominal approaches to endovascular device removal and open aortic repair after previous endovascular procedures. METHODS Thirty-five patients underwent open aortic repair through thoracotomy (n=7) or thoracoabdominal incision (n=28) 0.5 to 48 months after undergoing endovascular thoracic (n=27) or abdominal (n=8) aortic procedures. Indications for open repair included expanding aneurysm (n=23), device infection (n=8), fistula (n=5), pseudoaneurysm (n=2), aneurysm rupture (n=2), and restenosis (n=1). Endovascular devices were completely removed in 26 patients and partially removed in 9. Descending thoracic aortic repair was performed in 10 patients, thoracoabdominal aortic repair in 24, and juxtarenal abdominal aortic repair in 1. RESULTS There were 2 in-hospital deaths (6%), both in patients who presented with endovascular device infection. There were 8 late deaths. Overall 1-year survival was 83%±7%. Among the patients who presented with infected devices, 3 experienced major late complications, including persistent infection, pseudoaneurysm, and recurrent fistula; 2 of these patients succumbed to late deaths. CONCLUSIONS Open surgical repair after previous endovascular aortic procedures is successful in the majority of patients, particularly in those without device infections. Achieving definitive aortic repair in patients with infected endovascular devices is particularly challenging.
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Affiliation(s)
- Scott A LeMaire
- The Texas Heart Institute at St. Luke's Episcopal Hospital, and Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas 77030, USA.
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Lotfi S, Clough RE, Ali T, Salter R, Young CP, Bell R, Modarai B, Taylor P. Hybrid Repair of Complex Thoracic Aortic Arch Pathology: Long-Term Outcomes of Extra-anatomic Bypass Grafting of the Supra-aortic Trunk. Cardiovasc Intervent Radiol 2012; 36:46-55. [DOI: 10.1007/s00270-012-0383-3] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2012] [Accepted: 03/25/2012] [Indexed: 10/28/2022]
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