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Mills AC, Sandhu HK, Ikeno Y, Tanaka A. Heritable thoracic aortic disease: a literature review on genetic aortopathies and current surgical management. Gen Thorac Cardiovasc Surg 2024; 72:293-304. [PMID: 38480670 DOI: 10.1007/s11748-024-02017-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Accepted: 02/09/2024] [Indexed: 04/16/2024]
Abstract
Heritable thoracic aortic disease puts patients at risk for aortic aneurysms, rupture, and dissections. The diagnosis and management of this heterogenous patient population continues to evolve. Last year, the American Heart Association/American College of Cardiology Joint Committee published diagnosis and management guidelines for aortic disease, which included those with genetic aortopathies. Additionally, evolving research studying the implications of underlying genetic aberrations with new genetic testing continues to become available. In this review, we evaluate the current literature surrounding the diagnosis and management of heritable thoracic aortic disease, as well as novel therapeutic approaches and future directions of research.
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Affiliation(s)
- Alexander C Mills
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at UTHealth Houston, 6400 Fannin St., Ste. #2850, Houston, TX, 77030, USA
| | - Harleen K Sandhu
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at UTHealth Houston, 6400 Fannin St., Ste. #2850, Houston, TX, 77030, USA
| | - Yuki Ikeno
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at UTHealth Houston, 6400 Fannin St., Ste. #2850, Houston, TX, 77030, USA
| | - Akiko Tanaka
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at UTHealth Houston, 6400 Fannin St., Ste. #2850, Houston, TX, 77030, USA.
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Krebs JR, Fazzone B, Anderson EM, Ueland W, Spratt JR, Back MR, Shahid Z, Huber TS, Upchurch GR, Cooper MA. Presentation and Outcomes of Elective and Nonelective Complex Endovascular Repair for Thoracoabdominal and Juxtarenal Aortic Aneurysms. Ann Vasc Surg 2023; 97:248-256. [PMID: 37714262 DOI: 10.1016/j.avsg.2023.09.001] [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: 07/04/2023] [Revised: 08/17/2023] [Accepted: 09/08/2023] [Indexed: 09/17/2023]
Abstract
BACKGROUND Endovascular repair of thoracoabdominal aortic aneurysms (TAAA) and juxtarenal aortic aneurysms (JAA) with fenestrated and/or branched endografts (B/FEVAR) has become common. Physician modified endografts for patients presenting with symptomatic or contained ruptures has made B/FEVAR a feasible option in nonelective settings. The purpose of this study was to describe our 10-year institutional experience with endovascular interventions for TAAA in elective and nonelective cases to evaluate differences in outcomes and the clinical risk factors associated with nonelective presentation. METHODS A prospectively maintained database was retrospectively queried for patients undergoing B/FEVAR for TAAA and JAA at a single tertiary care academic institution between 1/2011 and 12/2020. Data collected included demographics, comorbidities, presenting symptoms, aneurysm characteristics, and clinical outcomes. Nonelective repair was defined as any patient that presented through the Emergency Department, as a hospital transfer, or as a direct admission from clinic and had aortic repair performed during the same admission. Univariate analyses were used to compare patients. The primary outcomes were 30-day and 1-year mortality. Secondary outcomes included perioperative complications and nonhome discharge. RESULTS Between 1/201 and 12/2020, a total of 208 patients underwent B/FEVAR for TAAA (173) and JAA (35). Nonelective repair was performed in 44 (21%) patients with 39 for TAAA (23%) and 5 for JAA (14%). Nonelective patients were younger (71 ± 11 vs. 74 ± 7 years, P = 0.03), more likely to be self-pay or have Medicaid (11% vs. 2%, P = 0.02) and had a different race distribution compared to the elective cohort (P < 0.01). Thirty-day mortality was 4% (n = 6) in elective repairs and 7% (n = 3) in nonelective repairs. One-year mortality was 13% (n = 22) in elective repairs and 18% (n = 8) in nonelective repairs. There were no differences between patients receiving elective versus nonelective repair in 30-day (P = 0.40) or 1-year mortality (P = 0.47). Nonelective patients had longer median duration of stay (11 interquartile range (IQR) 6-15 vs. 5 IQR 4-8, P < 0.01), postoperative length of stay (7 IQR 5-12 vs. 4 IQR 3-7, P < 0.01), and more intensive care unit days (6 IQR 3-8 vs. 3 IQR 2-5, P < 0.01). There were no differences in other secondary outcomes between elective and nonelective patients including inpatient and access-related complications, re-interventions, and nonhome discharge (P > 0.05 for all comparisons). A composite "any complication" occurred more frequently in patients with nonelective repair (50% vs. 35%, P = 0.03). CONCLUSIONS Endovascular repair for TAAA or JAA is a good option in patients undergoing nonelective surgical intervention, with comparable 30-day mortality, 1-year mortality, and perioperative morbidity to that of patients undergoing elective B/FEVAR.
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Affiliation(s)
- Jonathan R Krebs
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Florida, Gainesville, FL
| | - Brian Fazzone
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Florida, Gainesville, FL
| | - Erik M Anderson
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Florida, Gainesville, FL
| | - Walker Ueland
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Florida, Gainesville, FL
| | - John R Spratt
- Division of Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, FL
| | - Martin R Back
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Florida, Gainesville, FL
| | - Zain Shahid
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Florida, Gainesville, FL
| | - Thomas S Huber
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Florida, Gainesville, FL
| | - Gilbert R Upchurch
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Florida, Gainesville, FL
| | - Michol A Cooper
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Florida, Gainesville, FL.
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Milam AJ, Hung P, Bradley AS, Herrera-Quiroz D, Soh I, Ramakrishna H. Open Versus Endovascular Repair of Descending Thoracic Aneurysms: Analysis of Outcomes. J Cardiothorac Vasc Anesth 2023; 37:483-492. [PMID: 36522256 DOI: 10.1053/j.jvca.2022.11.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 11/16/2022] [Indexed: 11/25/2022]
Affiliation(s)
- Adam J Milam
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Phoenix, AZ
| | - Penny Hung
- Medical Student, Mayo Clinic Alix School of Medicine, Scottsdale, AZ
| | - A Steven Bradley
- Department of Anesthesiology, Uniformed Services University of Health Sciences, Bethesda, MD
| | | | - Ina Soh
- Division of Vascular Surgery, Department of Surgery, Mayo Clinic, Phoenix, AZ
| | - Harish Ramakrishna
- Division of Cardiovascular Anesthesia, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.
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Kahlberg A, Tshomba Y, Baccellieri D, Bertoglio L, Rinaldi E, Ardita V, Colombo E, Moscato U, Melissano G, Chiesa R. Renal perfusion with histidine-tryptophan-ketoglutarate compared with Ringer's solution in patients undergoing thoracoabdominal aortic open repair. J Thorac Cardiovasc Surg 2023; 165:569-579.e5. [PMID: 33820636 DOI: 10.1016/j.jtcvs.2021.02.090] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 02/22/2021] [Accepted: 02/22/2021] [Indexed: 01/18/2023]
Abstract
OBJECTIVE The objective of this study was to compare the efficacy of renal perfusion with Custodiol (Dr Franz-Kohler Chemie GmbH, Bensheim, Germany) versus enriched Ringer's solution for renal protection in patients undergoing open thoracoabdominal aortic aneurysm (TAAA) repair. METHODS Ninety consecutive patients scheduled for elective open TAAA repair were enrolled between 2015 and 2017 in a single-center, phase IV, prospective, parallel, randomized, double-blind trial (the CUstodiol versus RInger: whaT Is the Best Agent [CURITIBA] trial), and randomized to renal arteries perfusion with 4°C Custodiol (Dr Franz-Kohler Chemie GmbH, Bensheim, Germany; n = 45) or 4°C lactated Ringer's solution (n = 45). The incidence of acute kidney injury (AKI) in patients undergoing TAAA open surgery using Custodiol renal perfusion versus an enriched Ringer's solution was the primary end point. RESULTS Ninety patients completed the study (45 patients in each group). The incidence of postoperative AKI was significantly lower in the Custodiol group (48.9% vs 75.6%; P = .02). In the multivariable model, only the use of Custodiol solution resulted as protective from the occurrence of any AKI (odds ratio, 0.230; 95% confidence interval, 0.086-0.614; P = .003), whereas TAAA type II extent was associated with the development of severe AKI (odds ratio, 4.277; 95% confidence interval, 1.239-14.762; P = .02). At 1-year follow-up, serum creatinine was not significantly different from the preoperative values in both groups. CONCLUSIONS The use of Custodiol during open TAAA repair was safe and resulted in significantly lower rates of postoperative AKI compared with Ringer's solution. These findings support safety and efficacy of Custodiol in this specific setting, which is currently off-label.
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Affiliation(s)
- Andrea Kahlberg
- Department of Vascular Surgery, Vita-Salute University School of Medicine, San Raffaele Scientific Institute, Milano, Italy.
| | - Yamume Tshomba
- Vascular Surgery Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Domenico Baccellieri
- Department of Vascular Surgery, Vita-Salute University School of Medicine, San Raffaele Scientific Institute, Milano, Italy
| | - Luca Bertoglio
- Department of Vascular Surgery, Vita-Salute University School of Medicine, San Raffaele Scientific Institute, Milano, Italy
| | - Enrico Rinaldi
- Department of Vascular Surgery, Vita-Salute University School of Medicine, San Raffaele Scientific Institute, Milano, Italy
| | - Vincenzo Ardita
- Department of Vascular Surgery, Vita-Salute University School of Medicine, San Raffaele Scientific Institute, Milano, Italy
| | - Elisa Colombo
- Department of Vascular Surgery, Vita-Salute University School of Medicine, San Raffaele Scientific Institute, Milano, Italy
| | - Umberto Moscato
- Department of Women's Health, Child and Public Health Sciences, Hospital Hygiene - and Occupational Health - Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Germano Melissano
- Department of Vascular Surgery, Vita-Salute University School of Medicine, San Raffaele Scientific Institute, Milano, Italy
| | - Roberto Chiesa
- Department of Vascular Surgery, Vita-Salute University School of Medicine, San Raffaele Scientific Institute, Milano, Italy
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Rashid HN, Chehab O, Hurrell H, Androshchuk V, Sularz A, Patterson T, Lucchese G, Redwood S. Conventional aortic root vs valve-sparing root replacement surgery in aortic dilatation syndromes: a comparison of mortality and postoperative complications. Expert Rev Cardiovasc Ther 2023; 21:57-65. [PMID: 36543329 DOI: 10.1080/14779072.2023.2162039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 12/20/2022] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Conventional aortic root and valve-sparing root replacement surgery are two current surgical treatments for aortic dilatation syndromes. This review article aims to review the current literature surrounding these two established techniques. AREAS COVERED This review article will address the current indications for valve-sparing root replacement surgery, technical considerations in surgical planning and a comparison of clinical outcomes between these two surgical techniques. EXPERT OPINION Valve-sparing root replacement surgery is a safe and established treatment for aortic syndromes. Valve-sparing surgery procedure avoids the inherent risk of prosthetic valve dysfunction and prosthesis infection by preserving the native aortic valve compared to conventional aortic root surgery. This has been demonstrated in various observational studies and should be considered in clinically and anatomically appropriate patients. Other technical considerations, such as reimplantation versus remodeling technique and aortic cusp repair in select patients, may impact in short-term procedural and long-term clinical success with valve-sparing surgery.
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Affiliation(s)
- Hashrul N Rashid
- Department of Cardiology and Cardiac Surgery, Guy's & St. Thomas' Hospital, London, UK
- School of Cardiovascular Medicine & Sciences, King's College London, London, UK
| | - Omar Chehab
- Department of Cardiology and Cardiac Surgery, Guy's & St. Thomas' Hospital, London, UK
- School of Cardiovascular Medicine & Sciences, King's College London, London, UK
| | - Harriet Hurrell
- Department of Cardiology and Cardiac Surgery, Guy's & St. Thomas' Hospital, London, UK
- School of Cardiovascular Medicine & Sciences, King's College London, London, UK
| | - Vitaliy Androshchuk
- Department of Cardiology and Cardiac Surgery, Guy's & St. Thomas' Hospital, London, UK
- School of Cardiovascular Medicine & Sciences, King's College London, London, UK
| | - Agata Sularz
- Department of Cardiology and Cardiac Surgery, Guy's & St. Thomas' Hospital, London, UK
| | - Tiffany Patterson
- Department of Cardiology and Cardiac Surgery, Guy's & St. Thomas' Hospital, London, UK
- School of Cardiovascular Medicine & Sciences, King's College London, London, UK
| | - Gianluca Lucchese
- Department of Cardiology and Cardiac Surgery, Guy's & St. Thomas' Hospital, London, UK
| | - Simon Redwood
- Department of Cardiology and Cardiac Surgery, Guy's & St. Thomas' Hospital, London, UK
- School of Cardiovascular Medicine & Sciences, King's College London, London, UK
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Cooper MA, Shahid Z, Upchurch GR. Endovascular Repair of Descending Thoracic Aortic Aneurysms. Adv Surg 2022; 56:129-150. [PMID: 36096564 DOI: 10.1016/j.yasu.2022.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Descending thoracic aortic aneurysms (DTAAs) are an important cause of morbidity and mortality in the elderly. Once diagnosed, they should be surveilled and then repaired at a diameter of 5.5 to 6 cm, depending on the individual patient's physiologic and anatomic risk of repair. Thoracic endovascular aortic repair (TEVAR) is the preferred approach for repair and there are multiple procedural adjuncts that can expand indications for and use of TEVAR. Spinal cord injuries are an important and highly morbid complication after TEVAR and it is imperative to mitigate this risk.
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Affiliation(s)
- Michol A Cooper
- University of Florida College of Medicine, Division of Vascular Surgery and Endovascular Therapy, 1600 SW Archer Road, Room NG-45, Gainesville, FL 32610-0128 USA.
| | - Zain Shahid
- University of Florida College of Medicine, Division of Vascular Surgery and Endovascular Therapy, 1600 SW Archer Road, Room NG-45, Gainesville, FL 32610-0128 USA
| | - Gilbert R Upchurch
- University of Florida College of Medicine, Department of Surgery, 1600 SW Archer Road, Room 6174, Gainesville, FL 32610-0286 USA
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Fleischmann D, Afifi RO, Casanegra AI, Elefteriades JA, Gleason TG, Hanneman K, Roselli EE, Willemink MJ, Fischbein MP. Imaging and Surveillance of Chronic Aortic Dissection: A Scientific Statement From the American Heart Association. Circ Cardiovasc Imaging 2022; 15:e000075. [PMID: 35172599 DOI: 10.1161/hci.0000000000000075] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
All patients surviving an acute aortic dissection require continued lifelong surveillance of their diseased aorta. Late complications, driven predominantly by chronic false lumen degeneration and aneurysm formation, often require surgical, endovascular, or hybrid interventions to treat or prevent aortic rupture. Imaging plays a central role in the medical decision-making of patients with chronic aortic dissection. Accurate aortic diameter measurements and rigorous, systematic documentation of diameter changes over time with different imaging equipment and modalities pose a range of practical challenges in these complex patients. Currently, no guidelines or recommendations for imaging surveillance in patients with chronic aortic dissection exist. In this document, we present state-of-the-art imaging and measurement techniques for patients with chronic aortic dissection and clarify the need for standardized measurements and reporting for lifelong surveillance. We also examine the emerging role of imaging and computer simulations to predict aortic false lumen degeneration, remodeling, and biomechanical failure from morphological and hemodynamic features. These insights may improve risk stratification, individualize contemporary treatment options, and potentially aid in the conception of novel treatment strategies in the future.
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Hagiya K, Ozaki K, Nanasato M, Iguchi N, Takayama M, Shimokawa T, Tanabe N, Minamino T, Isobe M. Relationship Between Heart Rate at Discharge and Long-Term Outcomes of Surgically Treated Patients With Type A Acute Aortic Dissections. Circ J 2021; 85:2191-2200. [PMID: 33790141 DOI: 10.1253/circj.cj-20-0914] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Resting heart rate (HR) at discharge is an important predictor of mortality after acute myocardial infarction. However, in patients with Stanford type A acute aortic dissections (TA-AADs), the relationship between HR and long-term outcomes is unclear. Therefore, this relationship was investigated in the present study.Methods and Results:Surgically treated consecutive patients with TA-AAD (n=721) were retrospectively categorized according to HR quartiles, recorded within 24 h before discharge (<70, 70-77, 78-83, and ≥84 beats/min). The study endpoints included aortic aneurysm-related deaths, sudden deaths, aortic surgeries, and hospitalizations for recurrence of acute aortic dissections. The mean (±SD) patient age was 65.8±13.0 years. During a median observation period of 5.8 years (interquartile range 3.9-8.5 years), 17.2% of patients (n=124) experienced late aortic events. Late aortic surgery was performed in 14.0% of patients. After adjusting for potential confounders, including β-blocker use, HR at discharge remained an independent predictor of long-term aortic outcomes. Patients with discharge HR ≥84 beats/min had a higher risk (hazard ratio 1.86; 95% confidence interval 1.06-3.25; P=0.029) of long-term aortic events than those with HR <70 beats/min; the cumulative survival rates were similar among the groups (log-rank, P=0.905). CONCLUSIONS In surgically treated patients with TA-AAD, HR at discharge independently predicted long-term aortic outcomes. Consequently, HR in patients with TA-AAD should be optimized before discharge, particularly if the HR is ≥84 beats/min.
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Affiliation(s)
- Kenichi Hagiya
- Department of Cardiology, Sakakibara Heart Institute.,Department of Cardiovascular Biology and Medicine, Niigata University Graduate School of Medical and Dental Sciences
| | - Kazuyuki Ozaki
- Department of Cardiovascular Biology and Medicine, Niigata University Graduate School of Medical and Dental Sciences
| | | | - Nobuo Iguchi
- Department of Cardiology, Sakakibara Heart Institute
| | | | - Tomoki Shimokawa
- Department of Cardiovascular Surgery, Sakakibara Heart Institute
| | - Naohito Tanabe
- Department of Health and Nutrition, Faculty of Human Life Studies, University of Niigata Prefecture
| | - Tohru Minamino
- Department of Cardiovascular Biology and Medicine, Niigata University Graduate School of Medical and Dental Sciences
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Miyashita F, Kinoshita T, Suzuki T, Asai T. Respiratory Failure after Open Descending Aortic Aneurysm Repair: Risk Factors and Outcomes. Ann Thorac Cardiovasc Surg 2021; 27:41-48. [PMID: 32611930 PMCID: PMC8043027 DOI: 10.5761/atcs.oa.20-00020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose: This study was conducted to identify predictors of respiratory failure after open repair of descending thoracic aortic aneurysm (DTAA), and to identify any relationship between respiratory failure and long-term survival. Methods: A total of 75 patients undergoing elective open DTAA repair at the Shiga University of Medical Science Hospital were included in the study. Univariate and multivariate logistic regression analyses were performed to assess the odds ratios for incident postoperative respiratory failure after open DTAA repair. Survival over time was estimated by the Kaplan–Meier method. Results: Respiratory failure, defined as ventilation dependence for longer than 48 hours, occurred in 11 patients (14.7%). Independent predictors of respiratory failure after DTAA included prolonged operation time and reduced preoperative forced expiratory volume in 1 second/forced vital capacity × 100 (FEV1%). In-hospital mortality was higher (p = 0.020) among patients with respiratory failure (18.2% of those who suffered respiratory failure) than among those without (0%). The survival rates at 8 years were significantly lower (p = 0.010) in the respiratory failure group (at 44.2%) than in the group without respiratory failure (at 89.0%). Conclusion: Lower FEV1% and longer operation time were risk factors of postoperative respiratory failure after open repair of DTAA, which in turn is associated with significantly reduced long-term survival.
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Affiliation(s)
- Fumihiro Miyashita
- Department of Cardiovascular Surgery, Shiga University of Medical Science, Otsu, Shiga, Japan
| | - Takeshi Kinoshita
- Department of Cardiovascular Surgery, Shiga University of Medical Science, Otsu, Shiga, Japan
| | - Tomoaki Suzuki
- Department of Cardiovascular Surgery, Shiga University of Medical Science, Otsu, Shiga, Japan
| | - Tohru Asai
- Department of Cardiovascular Surgery, Shiga University of Medical Science, Otsu, Shiga, Japan
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Abstract
Thoracoabdominal aortic aneurysms, although rare, continue to be associated with high morbidity and mortality in the modern era of vascular surgery, and knowledge of this disease is essential for those in clinical practice. Given the clinically silent nature of the disease, it is difficult to determine disease incidence, with most epidemiologic recommendations not made based on evidence regarding those diagnosed with the disease, but extrapolated from data on surgical outcomes. It appears that although men are more likely to develop thoracoabdominal aortic aneurysms, the distribution is not as skewed as in abdominal aortic aneurysms. Current evidence suggests that Black and Hispanic patients continue to have disproportionately poor disease outcomes, mostly attributed to later presentation and undergoing interventions at lower-volume centers. Although select patients meet criteria for disease screening based on personal or family history of aneurysmal disease, general population screening has not been recommended by any professional organization to date. Vascular surgeons need to continue to be at the forefront of thoracoabdominal aortic aneurysm management, especially as care becomes centered around comprehensive "aortic care centers" and as more endovascular therapies become available.
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Affiliation(s)
- Jordan B Stoecker
- Department of Surgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, Maloney 4th Floor, Philadelphia, PA 19104.
| | - Grace J Wang
- Division of Vascular Surgery and Endovascular Therapy, Hospital of the University of Pennsylvania, 3400 Spruce Street, Maloney 4th Floor, Philadelphia, PA 19104.
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Upchurch GR, Escobar GA, Azizzadeh A, Beck AW, Conrad MF, Matsumura JS, Murad MH, Perry RJ, Singh MJ, Veeraswamy RK, Wang GJ. Society for Vascular Surgery clinical practice guidelines of thoracic endovascular aortic repair for descending thoracic aortic aneurysms. J Vasc Surg 2021; 73:55S-83S. [DOI: 10.1016/j.jvs.2020.05.076] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 05/29/2020] [Indexed: 12/17/2022]
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Heslin RT, Sutzko DC, Axley J, Novak Z, Aucoin VJ, Patterson MA, Pearce BJ, Passman MA, Scali ST, McFarland GE, Beck AW. Association between thoracoabdominal aneurysm extent and mortality after complex endovascular repair. J Vasc Surg 2020; 73:1925-1933.e3. [PMID: 33098946 DOI: 10.1016/j.jvs.2020.10.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 10/08/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Traditional open surgical repair of thoracoabdominal aortic aneurysms (TAAAs) has historically resulted in 30-day mortality rates ranging from 6% to 20%, depending on the Crawford anatomic extent. Although short-term survival is important, long-term survival is essential for patients to benefit from these often elective and potentially morbid procedures. The aneurysm extent affects the long-term survival after open repair; however, effect on endovascular repair is unknown and could influence the decision process for repair. We evaluated the association between aneurysm extent and survival and identified patient and perioperative factors associated with mortality after endovascular repair. METHODS A retrospective cohort of patients treated for TAAAs recorded in the Society for Vascular Surgery Vascular Quality Initiative thoracic and complex endovascular aneurysm repair registry were evaluated. All patients treated for asymptomatic degenerative aneurysms from 2010 to 2019 were included. Crawford extent I to V was defined according to the proximal and distal landing zones documented in the registry. Patients without extension into the visceral aorta were used for comparison and categorized as having extent 0a or 0b, depending on the distal landing zone in the thoracic aorta. Kaplan-Meier plots were used to estimate survival, and Cox proportional hazard regression models were created to identify the predictors of mortality. RESULTS From 2010 to 2019, 15,333 patients were entered into the registry, of whom 2062 met the inclusion criteria. The Crawford extent was 0a for 379, 0b for 848, I for 81, II for 98, III for 130, IV for 454, and V for 72. Three groups were created in accordance with the similar outcomes noted on a preliminary analysis: (1) extent 0a and 0b; (2) extent I, II, and III; and (3) extent IV and V. The mean survival time for the extent 0a and 0b group was 70.7 ± 1.43 months and was 48.6 ± 1.65 months for the extent I, II, and III group and 57.6 ± 1.24 months for the extent IV and V group. The corresponding 1-year mortality was 8.4%, 18.4%, and 7.8%. Cox regression analysis identified the following preoperative factors were associated with mortality: chronic obstructive pulmonary disease (odds ratio [OR], 1.70; P < .001), Crawford extent I to III (OR, 1.64; P = .015), preexisting chronic kidney disease (OR, 1.37; P = .024), and age per year (OR, 1.03; P < .001). A number of postoperative factors were also associated with mortality. CONCLUSIONS Similar to open TAAA repair, patients with more extensive aortic disease treated with endovascular repair had worse 1-year and long-term survival. The extent of aortic disease and anticipated postoperative survival should factor prominently into the surgical decision-making process for elective endovascular TAAA repair.
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Affiliation(s)
- Ryan T Heslin
- University of South Alabama College of Medicine, Mobile, Ala
| | - Danielle C Sutzko
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala
| | - John Axley
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala
| | - Zdenek Novak
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala
| | - Victoria J Aucoin
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala
| | - Mark A Patterson
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala
| | - Benjamin J Pearce
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala
| | - Marc A Passman
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala
| | - Salvatore T Scali
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Fla
| | - Graeme E McFarland
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala
| | - Adam W Beck
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala.
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Abstract
Aortic aneurysms were the primary cause of nearly 10,000 deaths in 2014 according to data from the Centers for Disease Control and may involve segments of the thoracic or abdominal aorta. Thoracic aortic aneurysms and dissections are more commonly associated with an underlying genetic etiology. In the past several decades, in parallel with the burst of new genome sequencing technologies, a number of genetic aortopathies have been identified. These have provided important insights into the molecular mechanisms of aneurysmal disease, but pose challenges in clinical practice as there are limited consensus recommendations at this time. In this review, we aim to address the pathophysiology, clinical presentation, and treatment considerations in the key heritable thoracic aortopathies.
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Affiliation(s)
- Rohan Bhandari
- Department of Cardiovascular Medicine, Section of Vascular Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Rajani D Aatre
- Division of Cardiovascular Medicine, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, MI, USA
| | - Yogendra Kanthi
- Division of Cardiovascular Medicine, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, MI, USA.,Cardiovascular Medicine, Ann Arbor Veterans Affairs Health System, Ann Arbor, MI, USA
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Kauhanen SP, Liimatainen T, Kariniemi E, Korhonen M, Parkkonen J, Vienonen J, Vanninen R, Hedman M. A smaller heart-aorta-angle associates with ascending aortic dilatation and increases wall shear stress. Eur Radiol 2020; 30:5149-5157. [PMID: 32323010 PMCID: PMC7431431 DOI: 10.1007/s00330-020-06852-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Revised: 03/10/2020] [Accepted: 03/31/2020] [Indexed: 12/18/2022]
Abstract
OBJECTIVES The aim of this study was to evaluate whether the orientation of the heart, measured as an angle between the long axis of the heart and ascending aorta midline (heart-aorta-angle, HAA), associates with ascending aortic (AA) dilatation. Furthermore, the association between HAA and wall shear stress (WSS) was studied. METHODS HAA was retrospectively measured in 1000 consecutive coronary artery computed tomographic angiography (CCTA) images in patients with low-to-moderate pretest probability for coronary artery disease (CAD). To evaluate the effects of HAA on AA flow, 4D flow MRI was performed for 28 patients with AA dilatation (> 40 mm) and WSS was analyzed. RESULTS The mean age of patients undergoing CCTA was 52.9 ± 9.8 years; 66.5% were women. Their median HAA was 128.7° and interquartile range 123.3-134.1°. HAA was significantly smaller in patients with dilated AA (median 126.7° [121.3-130.8°]) compared with the patients with normal AA (median 129.5° [124.3-135.3°], p < 0.001). HAA was smaller in males (p < 0.001) and in patients with diabetes (p = 0.016), hypertension (p = 0.001), CAD (p = 0.003), hypercholesterolemia (p < 0.001), and bicuspid aortic valve (p = 0.025) than without these factors. In a subpopulation without any of these underlying diseases (n = 233), HAA was still significantly smaller in the patients with dilated AA (median 127.9° [124.3-134.3°]) compared with patients with normal AA (median 131.9° [127.6-136.9°], p = 0.013). In 4D flow MRI, a smaller HAA correlated with increased total WSS in the outer curvature of the proximal AA (r = - 0.510, p = 0.006). CONCLUSION A smaller HAA associates with AA dilatation and affects the blood flow in the proximal AA. KEY POINTS • A smaller angle between the long axis of the heart and ascending aorta midline associated with ascending aortic dilatation. • A smaller heart-aorta-angle correlated with increased total wall shear stress in the outer curvature of the proximal ascending aorta.
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Affiliation(s)
- S Petteri Kauhanen
- Doctoral Programme of Clinical Research, University of Eastern Finland, Kuopio, Finland.
- Department of Clinical Radiology, Clinical Imaging Center, Kuopio University Hospital, Kuopio, Finland.
| | - Timo Liimatainen
- Research Unit of Medical Imaging, Physics and Technology, University of Oulu, Oulu, Finland
- Department of Diagnostic Radiology, Oulu University Hospital, Oulu, Finland
| | - Elina Kariniemi
- Department of Clinical Radiology, Clinical Imaging Center, Kuopio University Hospital, Kuopio, Finland
- Department of Clinical Physiology and Nuclear Medicine, Clinical Imaging Center, Kuopio University Hospital, Kuopio, Finland
| | - Miika Korhonen
- Department of Clinical Radiology, Clinical Imaging Center, Kuopio University Hospital, Kuopio, Finland
| | - Johannes Parkkonen
- School of Medicine, Clinical Radiology, University of Eastern Finland, Kuopio, Finland
| | - Juska Vienonen
- School of Medicine, Clinical Radiology, University of Eastern Finland, Kuopio, Finland
| | - Ritva Vanninen
- Department of Clinical Radiology, Clinical Imaging Center, Kuopio University Hospital, Kuopio, Finland
- School of Medicine, Clinical Radiology, University of Eastern Finland, Kuopio, Finland
| | - Marja Hedman
- Department of Clinical Radiology, Clinical Imaging Center, Kuopio University Hospital, Kuopio, Finland
- Department of Cardiothoracic Surgery, Heart Center, Kuopio University Hospital, Kuopio, Finland
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15
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Commentary: The hinge point doubles down-What's next for descending thoracic and thoracoabdominal aortic repair. J Thorac Cardiovasc Surg 2020; 161:512-513. [PMID: 31987619 DOI: 10.1016/j.jtcvs.2019.11.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 11/01/2019] [Accepted: 11/03/2019] [Indexed: 11/22/2022]
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Kazimierczak A, Rynio P, Jędrzejczak T, Mokrzycki K, Samad R, Brykczyński M, Rybicka A, Zair L, Gutowski P. Expanded Petticoat technique to promote the reduction of contrasted false lumen volume in patients with chronic type B aortic dissection. J Vasc Surg 2019; 70:1782-1791. [PMID: 31521400 DOI: 10.1016/j.jvs.2019.01.073] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Accepted: 01/31/2019] [Indexed: 12/01/2022]
Abstract
OBJECTIVE This study examined the outcomes of our novel concept of expanded provisional extension to induce complete attachment strategy (Petticoat) for safety, durability, and remodeling of chronic type B dissections. METHODS Twenty patients with chronic type B aortic dissection with aneurysmal degeneration qualified for an expanded Petticoat strategy (stent graft in the thoracic, plus additional distal bare stent into the abdominal and infrarenal aorta, followed by parallel stent grafts into common iliac arteries). Computed tomography was performed preoperatively and at 1, 6, and 12 months after surgery. RESULTS The primary technical success was 100%. The 30-day mortality rate was 0%. At 12 months, favorable aortic remodeling and complete false lumen (FL) thrombosis were noted as 100% in the thoracic and infrarenal aorta. The volume of contrast-enhanced FL decreased from 186 ± 75.4 mL all along the dissection preoperatively (range, 70-360 mL), to 6.32 ± 5.4 mL postoperatively (range, 0.0-19.6 mL) and was only observed in the visceral aorta (P = .000089). Despite persistent flow in a small area of the FL, the maximal aortic size was stable in follow-up. Neither paraplegia nor visceral branch occlusion were noted in the follow-up. CONCLUSIONS The treatment of aortic dissections with an expanded Petticoat strategy seems to be safe and offers good early results. It significantly reduced the volume of contrast enhanced FL. Further investigation of any subsequent results will be necessary.
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Affiliation(s)
- Arkadiusz Kazimierczak
- Department of Vascular Surgery, Pomeranian Medical University of Szczecin, Szczecin, Poland.
| | - Paweł Rynio
- Department of Vascular Surgery, Pomeranian Medical University of Szczecin, Szczecin, Poland
| | - Tomasz Jędrzejczak
- Cardiac Surgery Department, Pomeranian Medical University of Szczecin, Szczecin, Poland
| | - Krzysztof Mokrzycki
- Cardiac Surgery Department, Pomeranian Medical University of Szczecin, Szczecin, Poland
| | - Rabih Samad
- Department of Vascular Surgery, Pomeranian Medical University of Szczecin, Szczecin, Poland
| | - Mirosław Brykczyński
- Cardiac Surgery Department, Pomeranian Medical University of Szczecin, Szczecin, Poland
| | - Anita Rybicka
- Department of Nursing, Pomeranian Medical University of Szczecin, Szczecin, Poland
| | - Labib Zair
- Department of General Surgery and Transplantation, Pomeranian Medical University of Szczecin, Szczecin, Poland
| | - Piotr Gutowski
- Department of Vascular Surgery, Pomeranian Medical University of Szczecin, Szczecin, Poland
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Nguyen TT, Simons JP, Schanzer A. Use of fenestrated-branched endovascular aneurysm repair to treat Carrel patch aneurysmal degeneration after open thoracoabdominal aortic aneurysm repair. JOURNAL OF VASCULAR SURGERY CASES INNOVATIONS AND TECHNIQUES 2019; 5:117-121. [PMID: 31193425 PMCID: PMC6529688 DOI: 10.1016/j.jvscit.2018.12.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Accepted: 12/11/2018] [Indexed: 10/28/2022]
Abstract
Two patients with a history of open type II thoracoabdominal aortic aneurysm repair presented with saccular aneurysmal degeneration of the Carrel patch. The degenerated segments measured 6.2 cm and 7.4 cm, respectively, and involved the celiac artery, superior mesenteric artery, and right renal artery. Both patients successfully underwent a custom fenestrated-branched endovascular aneurysm repair with downgoing branches to the celiac artery, superior mesenteric artery, and right renal artery and a stented fenestration to the left renal artery. Completion angiography demonstrated no endoleak and patent visceral-renal segments. Both patients were discharged home on postoperative day 2.
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Affiliation(s)
- Tammy T Nguyen
- UMassMemorial Center for Complex Aortic Disease, Division of Vascular and Endovascular Surgery, University of Massachusetts Medical School, Worcester, Mass
| | - Jessica P Simons
- UMassMemorial Center for Complex Aortic Disease, Division of Vascular and Endovascular Surgery, University of Massachusetts Medical School, Worcester, Mass
| | - Andres Schanzer
- UMassMemorial Center for Complex Aortic Disease, Division of Vascular and Endovascular Surgery, University of Massachusetts Medical School, Worcester, Mass
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Rocha RV, Friedrich JO, Elbatarny M, Yanagawa B, Al-Omran M, Forbes TL, Lindsay TF, Ouzounian M. A systematic review and meta-analysis of early outcomes after endovascular versus open repair of thoracoabdominal aortic aneurysms. J Vasc Surg 2019; 68:1936-1945.e5. [PMID: 30470373 DOI: 10.1016/j.jvs.2018.08.147] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 08/05/2018] [Indexed: 12/23/2022]
Abstract
OBJECTIVE The objective of this study was to compare the early results of endovascular vs open thoracoabdominal aortic aneurysm (TAAA) repair. METHODS MEDLINE and Embase were searched for studies from January 2006 to March 2018 that compared endovascular vs open repair of TAAA using branched or fenestrated endografts. Data were subjected to a meta-analysis using a random-effects model. The outcomes of interest included early mortality, spinal cord injury, renal failure requiring dialysis, stroke, and hospital length of stay. RESULTS Eight comparative studies met inclusion criteria. There were two retrospective propensity-matched studies, two unadjusted single-center retrospective studies, and four unadjusted national population-based studies. Mortality in the matched studies was equivalent in both groups. Pooled analysis of all unmatched observational studies revealed a survival benefit for endovascular over open repair (relative risk [RR], 0.63; 95% confidence interval [CI],0.45-0.87); P < .01, I2 = 47%). Endovascular repair was also associated with lower incidence of spinal cord injury (RR, 0.65; 95% CI, 0.42-1.01; P = .05; I2 = 28%). For unmatched studies, pooled RR of renal failure requiring dialysis significantly favored endovascular repair (RR, 0.44; 95% CI, 0.23-0.85; P = .01; I2 = 0%), although in the adjusted cohort, risk of dialysis was not different (RR, 1.00; 95% CI, 0.06-15.65; P = 1.00). Postoperative stroke rate was reported in three unadjusted studies and was not different between groups (RR, 0.81; 95% CI, 0.28-2.40; P = .71; I2 = 77%). Hospital length of stay was reported in four studies and was shorter in the endovascular group (mean difference, -4.4 days; 95% CI, -6.6 to -1.7; P < .01; I2 = 73%). CONCLUSIONS There are few reports comparing endovascular vs open repair of TAAAs. Short-term outcomes may be improved in patients undergoing endovascular treatment of TAAA on the basis of a limited number of studies with high risk of bias. These findings highlight the need for larger comparative studies with standardization of reporting.
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Affiliation(s)
- Rodolfo V Rocha
- Division of Cardiac Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, Ontario, Canada
| | - Jan O Friedrich
- Department of Critical Care Medicine, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Malak Elbatarny
- Division of Cardiac Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, Ontario, Canada
| | - Bobby Yanagawa
- Division of Cardiac Surgery, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Mohammed Al-Omran
- Division of Vascular Surgery, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Thomas L Forbes
- Division of Vascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, Ontario, Canada
| | - Thomas F Lindsay
- Division of Vascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, Ontario, Canada
| | - Maral Ouzounian
- Division of Cardiac Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, Ontario, Canada.
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Goel N, Jain D, Savlania A, Bansal A. Thoracoabdominal Aortic Aneurysm Repair: What Should the Anaesthetist Know? Turk J Anaesthesiol Reanim 2019; 47:1-11. [PMID: 31276105 DOI: 10.5152/tjar.2018.39129] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Accepted: 08/06/2018] [Indexed: 11/22/2022] Open
Abstract
The surgical repair of descending thoracic aortic (DTA) and thoracoabdominal aortic aneurysms (TAAAs) presents one of the greatest challenges for anaesthesiologists. The challenge comes from the fine balance of complex medical issues in the setting of altered physiology that occurs during the perioperative period. Patients presenting for TAAA repair usually have multiple pre-existing comorbid conditions involving their cardiac, pulmonary and renal systems; and aneurysm repair poses a direct and immediate threat to these systems in addition to that to the gastrointestinal and neurologic systems. Operative mortality in thoracoabdominal aortic surgery is quite high to the extent of 5%-12% with a 5-year survival rate of 70%-79% for DTA aneurysm and 59% for thoracoabdominal aortic aneurysm surgeries. Complex haemodynamic changes associated with the clamping and declamping of aorta requires thorough knowledge and expertise for the management of TAAA. We present a brief review on the anaesthetic management and possible complications that anaesthetists should be aware of during TAAA repair.
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Affiliation(s)
- Nitika Goel
- Department of Anaesthesia, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Divya Jain
- Department of Anaesthesia, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ajay Savlania
- Department of Vascular Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ashwani Bansal
- Department of Cardiothoracic and Vascular Surgery, Max Hospital, Chandigarh, India
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Parotto M, Ouzounian M, Djaiani G. Spinal Cord Protection in Elective Thoracoabdominal Aortic Procedures. J Cardiothorac Vasc Anesth 2019; 33:200-208. [DOI: 10.1053/j.jvca.2018.05.044] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Indexed: 11/11/2022]
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Kazimierczak A, Jedrzejczak T, Rynio P, Waligórski S. Favorable remodeling after hybrid arch debranching and modified provisional extension to induce complete attachment technique in type a aortic dissection: A case report. Medicine (Baltimore) 2018; 97:e12409. [PMID: 30213017 PMCID: PMC6155974 DOI: 10.1097/md.0000000000012409] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
RATIONALE Type A aortic dissection (TAAD) usually requires emergency open repair of the ascending aorta. In cases of diffuse dissection that spreads along the descending and abdominal aorta (type I, DeBakey classification), the risk of aneurysmal degeneration varies between 30% and 50% during 5 years and increases even higher during a longer follow-up. Those patients might require complex intervention to prevent aortic rupture. A combination of hybrid arch debranching and the extended provisional extension to induce complete attachment (e-PETTICOAT) technique might be an available alternative in such cases. This is the first report of the successful use of the e-PETTICOAT technique for treating degenerative, diffuse TAAD. PATIENT CONCERNS Acute chest pain and syncope were the initial symptoms of diffuse TAAD in our 66-year-old female patient. Open replacement of the ascending aorta followed by surgical arch debranching was performed as a staged procedure. Unfortunately, progressive aneurysmal degeneration was revealed 6 months later in the thoracic, abdominal, and infrarenal aorta with the recurrence of chest and lumbar pain. DIAGNOSES Computed angiotomography revealed severe aneurysmal degeneration of aortic dissection in the thoracic and abdominal aorta. INTERVENTION The e-PETTICOAT enabled good remodeling and stopped degeneration. OUTCOME At the 2-year follow-up, good remodeling with complete false lumen thrombosis and a stable aortic size were confirmed. LESSON Lifelong follow-up in extensive TAAD should be considered. The e-PETTICOAT technique is an available alternative to fenestrated endovascular aortic repair for degenerative TAAD, as it promotes favorable remodeling after successful surgery of the ascending aorta.
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Affiliation(s)
| | - Tomasz Jedrzejczak
- Department of Cardiosurgery, Pomeranian Medical University in Szczecin, Szczecin, Poland
| | | | - Szymon Waligórski
- Department of Cardiosurgery, Pomeranian Medical University in Szczecin, Szczecin, Poland
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22
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Outcomes Following Non-operative Management of Thoracic and Thoracoabdominal Aneurysms. World J Surg 2018; 43:273-281. [PMID: 30128772 DOI: 10.1007/s00268-018-4768-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND Surgical decision making remains difficult in several patients with aneurysmal disease of the descending thoracic (DT) or thoracoabdominal (TA) aorta. Despite previous studies that have investigated aneurysms treated non-operatively using a prospective growth analysis, completeness and accuracy of follow-up were inconsistent. We aim to describe the survival and freedom from adverse aortic events in patients with DT and TA who did not undergo operative repair. METHODS This is a single-center retrospective analysis of all patients with either a descending degenerative atherosclerotic or dissection-related DT or TA aortic lesion who were treated non-operatively from April 2002 to December 2016. We studied patients who did not undergo operative repair of descending degenerative atherosclerotic or dissection-related DT or TA aortic lesion. Primary end points were overall survival and freedom from aortic-related mortality (ARM). RESULTS Of the 315 patients diagnosed with DT or TA disease, 56 (18%) did not undergo surgical repair. Mean aneurysm diameter was 65 mm ± 15 (range 50-120; IQR 5.4-7.15). Extent of the aortic aneurysms was DT in 36 (11%) patients and TA in 20 (6%). Median duration of follow-up was 12 months (range 1-108; IQR 3-36). Over the course of the study, 41 (73%) patients died for an overall survival rate of 53% ± 7 at 1 year (95% CI 40-65) and 23% ± 7 at 3 year (95% CI 17-42.5). Aortic-related mortality was 27% (n = 15), significantly higher in patients with aneurysms ≥ 60 mm [n = 13, (39%) vs. n = 2, (9%); P = 0.025; OR = 5.04]. Overall, estimated freedom from ARM was 81% ± 5.5 at 1 year (95% CI 68-89) and 66.5% ± 9 at 3 year (95% CI 48-81). Only TA extent was independently associated with freedom from ARM during the follow-up (P = 0.005; HR: 5.74; 95% CI 1.711-19.729). CONCLUSIONS Thoracoabdominal extent of the aneurysmal aortic disease is the most important predictor of ARM in unrepaired DT or TA aortic diseases. Mortality from aortic-related events was significantly more premature than mortality from non-aortic-related mortality.
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Beach JM, Rajeswaran J, Parodi FE, Kuramochi Y, Brier C, Blackstone E, Eagleton MJ. Survival affects decision making for fenestrated and branched endovascular aortic repair. J Vasc Surg 2018; 67:722-734.e8. [DOI: 10.1016/j.jvs.2017.07.118] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Accepted: 07/15/2017] [Indexed: 11/25/2022]
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Riambau V, Böckler D, Brunkwall J, Cao P, Chiesa R, Coppi G, Czerny M, Fraedrich G, Haulon S, Jacobs M, Lachat M, Moll F, Setacci C, Taylor P, Thompson M, Trimarchi S, Verhagen H, Verhoeven E, ESVS Guidelines Committee, Kolh P, de Borst G, Chakfé N, Debus E, Hinchliffe R, Kakkos S, Koncar I, Lindholt J, Vega de Ceniga M, Vermassen F, Verzini F, Document Reviewers, Kolh P, Black J, Busund R, Björck M, Dake M, Dick F, Eggebrecht H, Evangelista A, Grabenwöger M, Milner R, Naylor A, Ricco JB, Rousseau H, Schmidli J. Editor's Choice – Management of Descending Thoracic Aorta Diseases. Eur J Vasc Endovasc Surg 2017; 53:4-52. [DOI: 10.1016/j.ejvs.2016.06.005] [Citation(s) in RCA: 598] [Impact Index Per Article: 85.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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Bakoyiannis C, Moris D, Karaolanis G, Patelis N, Schizas D, Georgopoulos S, Liakakos T. Thoracic Aorta Aneurysm Repair in a Patient with a Solitary Kidney: Hybrid Surgery as a Bailout Procedure. Front Surg 2016; 3:62. [PMID: 27891504 PMCID: PMC5102893 DOI: 10.3389/fsurg.2016.00062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Accepted: 10/27/2016] [Indexed: 11/15/2022] Open
Abstract
Thoracic endovascular aortic repair (TEVAR) is an emerging treatment option for thoracic aorta aneurysms (TAA). Endovascular access is a challenge. We present a novel TEVAR technique in a patient with single kidney and a 6.4 cm TAA. Attempting to place a sheath through iliac arteries was unsuccessful. The decision to proceed to hybrid TEVAR was made. The protection of the solitary kidney was achieved through axillo-femoral bypass, followed by an end-to-side anastomosis between the aorta and a bifurcated graft. Through the graft, a stent was introduced in the thoracic aorta. With the use of contrast material, the right position of the graft was confirmed.
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Affiliation(s)
| | - Demetrios Moris
- Lerner Research Institute, Cleveland Clinic , Cleveland, OH , USA
| | | | - Nikolaos Patelis
- Department of Surgery, Laikon General Hospital , Athens , Greece
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Fleck T, Hamilton C, Ehrlich MP, Hutschala D, Koinig H, Wolner E, Grabenwoger M. Thoracoabdominal Aortic Aneurysm Repair: Reducing Adverse Outcome with Left Heart Bypass, Selective Visceral Perfusion and Renal Protection. Semin Cardiothorac Vasc Anesth 2016. [DOI: 10.1177/108925320200600402] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective: To report our experience with left heart bypass and selective visceral perfusion for prevention of permanent spinal cord injury and distal organ failure in patients undergoing thoracoabdominal aortic aneurysm repair. Methods: From April 2001 to March 2002 seven patients were electively operated on with left heart bypass and selective perfusion of the visceral and renal organs at the University Clinic of Vienna, Austria. There were four males (57%) and two females (43%) with a mean age of 70 ± 6 years. Etiology of the aneurysm was a chronic dissection in one patient and athereosclerotic in the remaining five. Crawford classification was I in one patient (14%), II in five patients (86%) and III in one patient (14%). Existing comorbidities were hypertension in all seven patients, coronary artery disease in two patients (29%), chronic pulmonary obstructive disease in two patients (29%), and lung cancer resection and peripheral artery occlusive disease in one patient (14%) each. Two patients had a history of prior aortic aneurysm repair, namely elective repair of the ascending thoracic aorta 2 months before the thoracoabdominal aortic aneurysm repair, and replacement of the infrarenal aorta 12 years previously in another patient. Results: All patients survived the operation and were discharged after a mean hospital stay of 25 ± 13 days. Adverse outcome occurred in three out of seven patients. One patient with Crawford classification 11 developed acute renal insufficiency, and two patients with class 11 and III showed signs of transient paraparesis, respectively. Mean intraoperative blood loss was 3315 ± 701 ml. On average, 6.7 ± 2.8 units of packed red cells, 10 units of fresh frozen plasma, and 1 unit of platelets were given during the operation. Intensive care unit stay ranged from 2 to 16 days. Conclusions: The combined usage of left heart bypass, selective visceral perfusion, and renal protection can be recommended as a useful and effective technique in order to minimize adverse outcome in patients undergoing repair of the thoracoabdominal aorta.
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Affiliation(s)
| | | | | | - Doris Hutschala
- Department of Cardiothoracic Surgery, University of Vienna, Vienna, Austria
| | - Herbert Koinig
- Department of Anesthesia, University of Vienna, Vienna, Austria
| | - Ernst Wolner
- Department of Cardiothoracic Surgery, University of Vienna, Vienna, Austria
| | - Martin Grabenwoger
- Department of Cardiothoracic Surgery, AKH Vienna, Leitstelle 20A, Waehringer Guertel 18-20, 1090 Vienna, Austria
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Abstract
The conduct of partial left heart bypass or partial car diopulmonary bypass (CPB) during surgery involving the descending thoracic aorta or thoracoabdominal aorta is one of the most unappreciated and misunder stood extracorporeal circulation procedures in cardio vascular surgery. It is different from conventional CPB, and although some uninitiated practitioners consider it simpler, it is in fact more complicated than conven tional CPB and involves different concepts. It requires expertise and skill in regulating the flow, pressure, and oxygenation of blood going to both the proximal and distal parts of the body and management of the special bypass or shunt procedures used, specialized monitor ing, and knowledge about the protection and preserva tion of organs both proximal and distal to the aortic clamping. It demands exquisite communication and un derstanding of the unique problems faced by the sur geon, anesthesiologist, and perfusionist.
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Affiliation(s)
- Eugene A. Hessel
- Department of Anesthesiology, College of Medicine, Chandler Medical Center, University of Kentucky, Louisville, KY
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Li XX, Wang SM, Chen W, Zhuang WQ, Wu ZH, Chang GQ, Li SQ, Yang JY, Lin YJ. Endovascular Stent-Graft Repair of Aortic Dissection. Asian Cardiovasc Thorac Ann 2016; 12:99-102. [PMID: 15213072 DOI: 10.1177/021849230401200203] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Between October 2000 and January 2002, 9 consecutive male patients with subacute or chronic aortic dissection underwent stent-graft placement. The indication for surgery was continuous pain or aneurysm development. One patient had a type A dissecting aortic aneurysm with a primary tear in the ascending thoracic aorta; the other 8 had type B dissection. Placement of an endovascular stent-graft was technically successful in 8 patients, and one underwent an open procedure for abdominal aortic fenestration. The entry site was sealed and the false lumen disappeared in 8 cases, and thrombosis of the false lumen was obtained. Rupture of an iliac artery dissecting aneurysm occurred in one patient 2 days after stent-graft placement; abdominal aortic fenestration with prosthetic replacement of the distal abdominal aorta was performed. One patient died of myocardial infarction 3 days after the stent-graft procedure. During a mean follow-up period of 7 months (1–16 months), one patient died of acute myocardial infarction at 11 months. It was concluded on the basis of these short-term results that endovascular repair of aortic dissection is a promising treatment, and abdominal aortic fenestration is a useful adjuvant procedure.
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Affiliation(s)
- Xiao-Xi Li
- Department of Surgery, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, People's Republic of China.
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Carroccio A, Spielvogel D, Ellozy SH, Lookstein RA, Chin IY, Minor ME, Sheahan CM, Teodorescu VJ, Griepp RB, Marin ML. Aortic Arch and Descending Thoracic Aortic Aneurysms: Experience with Stent Grafting for Second-Stage “Elephant Trunk” Repair. Vascular 2016; 13:5-10. [PMID: 15895668 DOI: 10.1258/rsmvasc.13.1.5] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Reconstruction of aortic arch and descending thoracic aortic aneurysms (TAAs) is technically challenging and associated with significant morbidity and mortality. We report our experience with extensive TAAs using a two-stage “elephant trunk” repair, with the second stage completed using an endovascular stent graft (ESG). Over 6 years, 111 patients underwent ESG treatment of TAAs at Mount Sinai Medical Center. Twelve of these patients were referred for ESG placement for the second stage of elephant trunk reconstruction because comorbidities placed them at high risk of open surgical repair. Our database was analyzed for technical and clinical success and perioperative complications. The mean follow-up was 11.8 months (range 1–64 months). Twelve patients (five women and seven men) with a mean age of 69 ± 10 years underwent repair of their distal aortic arch and descending TAAs. These aneurysms included nine atherosclerotic aneurysms, one pseudoaneurysm, and two penetrating atherosclerotic ulcers. Three patients were symptomatic. Stent graft repair was technically successful in 91.7% or 11 of 12 patients. Excessive aortic arch tortuosity resulted in failure to deploy a stent graft in one patient. An antegrade approach through the open elephant trunk was used in two patients with severe iliac occlusive disease. Endoleaks (type 2) were identified in two patients with no aneurysm expansion; however, a 14 mm expansion over 1 year occurred in a patient with no identifiable endoleak. One early mortality occurred in a patient with a ruptured 6 cm infrarenal AAA after successful exclusion of the 8 cm TAA. Second-stage elephant trunk reconstruction of an extensive TAA using an ESG is effective in the short term. Its long-term durability remains to be determined.
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Affiliation(s)
- Alfio Carroccio
- Division of Vascular Surgery, Mount Sinai School of Medicine, New York, NY, USA.
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Abraha I, Romagnoli C, Montedori A, Cirocchi R. Thoracic stent graft versus surgery for thoracic aneurysm. Cochrane Database Syst Rev 2016; 2016:CD006796. [PMID: 27265222 PMCID: PMC7388299 DOI: 10.1002/14651858.cd006796.pub4] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Thoracic aortic aneurysm (TAA) is an uncommon disease with an incidence of 10.4 per 100,000 inhabitants. It occurs mainly in older individuals and is evenly distributed among both sexes. There are no signs or symptoms indicative of the presence of the disease. Progressive but unpredictable enlargement of the dilated aorta is the natural course of the disease and can lead to rupture. Open chest surgical repair using prosthetic graft interposition has been a conventional treatment for TAAs. Despite improvements in surgical procedures perioperative complications remain significant. The alternative option of thoracic endovascular aneurysm repair (TEVAR) is considered a less invasive and potentially safer technique, with lower morbidity and mortality compared with conventional treatment. Evidence is needed to support the use of TEVAR for these patients, rather than open surgery. This is an update of the review first published in 2009. OBJECTIVES This review aimed to assess the efficacy of TEVAR versus conventional open surgery in patients with thoracic aortic aneurysms. SEARCH METHODS For this update the Cochrane Vascular Information Specialist searched the Specialised Register (last searched January 2016) and CENTRAL (2015, Issue 12). SELECTION CRITERIA Randomised controlled trials in which patients with TAAs were randomly assigned to TEVAR or open surgical repair. DATA COLLECTION AND ANALYSIS Two review authors independently identified and evaluated potential trials for eligibility. Excluded studies were further checked by another author. We did not perform any statistical analyses as no randomised controlled trials were identified. MAIN RESULTS We did not find any published or unpublished randomised controlled trials comparing TEVAR with conventional open surgical repair for the treatment of thoracic aortic aneurysms. AUTHORS' CONCLUSIONS Stent grafting of the thoracic aorta is technically feasible and non-randomised studies suggest reduction of early outcomes such as paraplegia, mortality and hospital stay. High quality randomised controlled trials assessing all clinically relevant outcomes including open-conversion, aneurysm exclusion, endoleaks, and late mortality are needed.
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Affiliation(s)
- Iosief Abraha
- Health Planning Service, Regional Health Authority of UmbriaPerugiaItaly
| | | | - Alessandro Montedori
- Regional Health Authority of UmbriaHealth Planning ServiceVia Mario Angeloni 61PerugiaUmbriaItaly06124
| | - Roberto Cirocchi
- University of PerugiaDepartment of General SurgeryTerniItaly05100
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33
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34
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García-Fuster R. Aneurismas de aorta ascendente: tratamiento quirúrgico. CIRUGIA CARDIOVASCULAR 2015. [DOI: 10.1016/j.circv.2015.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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36
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Etz CD, Weigang E, Hartert M, Lonn L, Mestres CA, Di Bartolomeo R, Bachet JE, Carrel TP, Grabenwöger M, Schepens MA, Czerny M. Contemporary spinal cord protection during thoracic and thoracoabdominal aortic surgery and endovascular aortic repair: a position paper of the vascular domain of the European Association for Cardio-Thoracic Surgery†. Eur J Cardiothorac Surg 2015; 47:943-57. [DOI: 10.1093/ejcts/ezv142] [Citation(s) in RCA: 173] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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37
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Contemporary outcomes of open thoracoabdominal aortic aneurysm repair in octogenarians. J Thorac Cardiovasc Surg 2015; 149:S134-41. [DOI: 10.1016/j.jtcvs.2014.09.038] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2014] [Revised: 09/02/2014] [Accepted: 09/10/2014] [Indexed: 11/24/2022]
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38
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Martufi G, Gasser TC, Appoo JJ, Di Martino ES. Mechano-biology in the thoracic aortic aneurysm: a review and case study. Biomech Model Mechanobiol 2014; 13:917-28. [DOI: 10.1007/s10237-014-0557-9] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2013] [Accepted: 01/27/2014] [Indexed: 01/22/2023]
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39
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Apostolakis E, Shuhaiber JH. Antegrade or retrograde cerebral perfusion as an adjunct during hypothermic circulatory arrest for aortic arch surgery. Expert Rev Cardiovasc Ther 2014; 5:1147-61. [DOI: 10.1586/14779072.5.6.1147] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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40
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Yusuf Beebeejaun M, Malec A, Gupta R, Alkhawam H. Conservative management of chronic aortic dissection with underlying aortic aneurysm. Heart Int 2013; 8:e4. [PMID: 24179638 PMCID: PMC3805168 DOI: 10.4081/hi.2013.e4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2012] [Accepted: 10/08/2012] [Indexed: 11/22/2022] Open
Abstract
Aortic dissection is one of the most common aortic emergencies affecting around 2000 Americans each year. It usually presents in the acute state but in a small percentage of patients aortic dissections go unnoticed and these patients survive without any adequate therapy. With recent advances in medical care and diagnostic technologies, aortic dissection can be successfully managed through surgical or medical options, consequently increasing the related survival rate. However, little is known about the optimal long-term management of patients suffering from chronic aortic dissection. The purpose of the present report is to review aortic dissection, namely its pathology and the current diagnostic tools available, and to discuss the management options for chronic aortic dissection. We report a patient in which chronic aortic dissection presented with recurring episodes of vomiting and also discuss the management plan of our patient who had a chronic aortic dissection as well as an underlying aortic aneurysm.
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Lee M, Lee DY, Kim MD, Lee MS, Won JY, Park SI, Yoon YN, Lee S, Choi D, Ko YG. Outcomes of Endovascular Management for Complicated Chronic Type B Aortic Dissection: Effect of the Extent of Stent Graft Coverage and Anatomic Properties of Aortic Dissection. J Vasc Interv Radiol 2013; 24:1451-60. [DOI: 10.1016/j.jvir.2013.06.007] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2012] [Revised: 06/04/2013] [Accepted: 06/05/2013] [Indexed: 11/25/2022] Open
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Abstract
BACKGROUND Thoracic aortic aneurysm (TAA) is an uncommon disease with an incidence of 10.4 per 100,000 inhabitants. It occurs mainly in older individuals and is evenly distributed among both sexes. There are no signs or symptoms indicative of the presence of the disease. Progressive but unpredictable enlargement of the dilated aorta is the natural course of the disease and can lead to rupture. Open chest surgical repair using prosthetic graft interposition has been a conventional treatment for TAAs. Despite improvements in surgical procedures perioperative complications remain significant. The alternative option of thoracic endovascular aneurysm repair (TEVAR) is considered a less invasive and potentially safer technique, with lower morbidity and mortality compared with conventional treatment. Evidence is needed to support the use of TEVAR for these patients, rather than open surgery. OBJECTIVES The aim of this review is to assess the efficacy of TEVAR versus conventional open surgery in patients with TAAs. SEARCH METHODS For this update the Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched the Specialised Register (last searched March 2013) and CENTRAL (2013, Issue 2). SELECTION CRITERIA Randomised controlled trials in which patients with TAAs were randomly assigned to TEVAR or open surgical repair. DATA COLLECTION AND ANALYSIS Two review authors independently identified and evaluated potential trials for eligibility. Excluded studies were further checked by another author. We did not perform any statistical analyses as no randomised controlled trials were identified. MAIN RESULTS We did not find any published or unpublished randomised controlled trials comparing TEVAR with conventional open surgical repair for the treatment of thoracic aortic aneurysms. AUTHORS' CONCLUSIONS Though stent grafting of the thoracic aorta is technically feasible and non-randomised studies suggest reduction of early outcomes such as paraplegia, mortality and hospital stay, high quality randomised controlled trials assessing all clinically relevant outcomes including open-conversion, aneurysm exclusion, endoleaks, and late mortality are needed.
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Affiliation(s)
- Iosief Abraha
- Epidemiology Department, Regional Health Authority of Umbria, Via Mario Angeloni, 61, Perugia, Italy, 06124
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43
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Field ML, Harrington D, Bashir M, Kuduvalli M, Oo A. Intervention on thoracic and thoracoabdominal aortic aneurysms: can the UK offer a service? J R Soc Med 2012; 105:457-63. [PMID: 23257968 PMCID: PMC3526849 DOI: 10.1258/jrsm.2012.110354] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Affiliation(s)
- Mark L Field
- Institute of Cardiovascular Medicine and Science, Thoracic Aortic Aneurysm Service, Liverpool Heart and Chest Hospital, Liverpool LS14 3PE, UK.
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Abstract
Degenerative aneurysms of the thoracic aorta are increasing in prevalence; open repair of descending thoracic aortic aneurysms is associated with high rates of morbidity and mortality. Repair of isolated descending thoracic aortic aneurysms using stent grafts was introduced in 1995, and in an anatomically suitable subgroup of patients with thoracic aortic aneurysm, repair with endovascular stent graft provides favorable outcomes, with decreased perioperative morbidity and mortality relative to open repair. The cornerstones of successful thoracic endovascular aneurysm repair are appropriate patient selection, thorough preprocedural planning, and cautious procedural execution, the elements of which are discussed here.
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Affiliation(s)
- Laura K Findeiss
- Department of Radiological Sciences, UCI Medical Center, University of California, Irvine School of Medicine, Orange, California
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45
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Kang WC, Greenberg RK, Mastracci TM, Eagleton MJ, Hernandez AV, Pujara AC, Roselli EE. Endovascular repair of complicated chronic distal aortic dissections: Intermediate outcomes and complications. J Thorac Cardiovasc Surg 2011; 142:1074-83. [DOI: 10.1016/j.jtcvs.2011.03.008] [Citation(s) in RCA: 122] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2010] [Revised: 09/17/2010] [Accepted: 03/14/2011] [Indexed: 10/18/2022]
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46
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47
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Knepper J, Upchurch GR. A review of clinical trials and registries in descending thoracic aortic aneurysms. Semin Vasc Surg 2010; 23:170-5. [PMID: 20826294 DOI: 10.1053/j.semvascsurg.2010.05.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Aortic disease is a significant pathology, as it represents the 12(th) leading cause of overall death. Aneurysms of the descending thoracic aorta pose a small but significant part of this pathology. Traditional open descending thoracic aortic aneurysm (TAA) repair continues to be performed despite relatively high morbidity and mortality rates. As endovascular therapy to treat vascular disease has evolved, a paradigm shift has occurred such that likely most isolated TAAs are now repaired with an endovascular approach. Multiple, prospective trials have been performed comparing open and endovascular TAA repair with three company sponsored trials documenting clinical equipoise. In these studies, endovascular thoracic aortic aneurysm repair (ETAR) was mostly compared with historic controls or open repair from centers of excellence. While the trials all indicate that 30-day peri-operative morbidity and mortality is lower in the ETAR group, these trials were not designed to determine which patient is best served by an open versus an endovascular approach. In addition, long-term follow-up data is limited. Registry data of patients undergoing ETAR seems to mirror that of the aforementioned clinical trials and indicates acceptable morbidity and mortality profiles when compared to published open TAA repair results. Future prospective studies focused on patient selection likely will never be performed, as most believe the benefits of ETAR outweigh the lack of long term follow up data. This review will focus on repair of TAA, specifically clinical trial and registry data comparing open and endovascular repair.
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Affiliation(s)
- Jordan Knepper
- Department of Surgery, Section of Vascular Surgery, University of Michigan Hospitals and Health System, Ann Arbor, MI 48109-0329, USA
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48
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Fehrenbacher JW, Siderys H, Terry C, Kuhn J, Corvera JS. Early and late results of descending thoracic and thoracoabdominal aortic aneurysm open repair with deep hypothermia and circulatory arrest. J Thorac Cardiovasc Surg 2010; 140:S154-60; discussion S185-S190. [DOI: 10.1016/j.jtcvs.2010.08.054] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2010] [Revised: 08/10/2010] [Accepted: 08/23/2010] [Indexed: 10/18/2022]
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49
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Campbell-Lloyd AJ, Mundy J, Pinto N, Wood A, Beller E, Strahan S, Shah P. Contemporary Results Following Surgical Repair of Acute Type A Aortic Dissection (AAAD): A Single Centre Experience. Heart Lung Circ 2010; 19:665-72. [DOI: 10.1016/j.hlc.2010.05.009] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2009] [Revised: 04/04/2010] [Accepted: 05/03/2010] [Indexed: 11/28/2022]
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50
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Coady MA, Ikonomidis JS, Cheung AT, Matsumoto AH, Dake MD, Chaikof EL, Cambria RP, Mora-Mangano CT, Sundt TM, Sellke FW. Surgical Management of Descending Thoracic Aortic Disease: Open and Endovascular Approaches. Circulation 2010; 121:2780-804. [PMID: 20530003 DOI: 10.1161/cir.0b013e3181e4d033] [Citation(s) in RCA: 138] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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