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Georgiadis GS, Trellopoulos G, Antoniou GA, Georgakarakos EI, Nikolopoulos ES, Pelekas D, Pitta X, Lazarides MK. Endovascular therapy for penetrating ulcers of the infrarenal aorta. ANZ J Surg 2013; 83:758-63. [PMID: 23336937 DOI: 10.1111/ans.12074] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/11/2012] [Indexed: 11/28/2022]
Abstract
BACKGROUND We sought to investigate the short- and mid-term results of the endovascular repair of infrarenal abdominal penetrating aortic ulcers (aPAUs). METHODS Patients with infrarenal aPAUs treated by endovascular means between March 2004 and June 2012 were recruited. Pre-interventional imaging included computed tomography (CT) or CT angiography. Endoprostheses were chosen and deployed according to standard elective endovascular aneurysm repair anatomical requirements. Endpoints included 30-day survival, in-hospital mortality, 1-year PAU-related mortality, 1-year all-cause mortality, freedom from death and freedom from cumulative complication and interventions. Statistically, the Kaplan-Meier method was applied. RESULTS Nineteen patients (18 men, median age 70 years (interquartile range, IQR = 59-75)) suffering aPAUs (n = 29, infrarenal = 25) were detected. The median co-morbid severity scoring was 1.0 (IQR = 0.4-1.4). The median follow-up period was 33 months (IQR = 8-51.5). Furthermore, 94.7% of patients had hypertension. Fourteen patients (73.7%) had symptoms, including four of them admitted with shock from large-contained PAU rupture. Endoluminal stent grafting was successfully delivered in all patients. In-hospital mortality was 10.5%. Two patients required secondary interventions (10.5%). The 30-day survival, 1-year PAU-related mortality and 1-year all-cause mortality were 94.7%, 89.5% and 89.5%, respectively. Freedom from death and freedom from cumulative complications and interventions was 86.4% and 86.4%, 78.9% and 78.9%, and 67.9% and 71.2% at 12, 24 and 36 months, respectively. CONCLUSIONS Urgent and elective endovascular repair of aPAUs can be achieved with high technical success. The significant co-morbid status of the treated patients is illustrated in the considerable in-hospital mortality and underlines the advantage of such treatment over open surgical repair.
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Affiliation(s)
- George S Georgiadis
- Department of Vascular Surgery, 'Demokritus' University of Thrace, University General Hospital of Alexandroupolis, Alexandroupolis, Greece
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Parker JD, Golledge J. Outcome of Endovascular Treatment of Acute Type B Aortic Dissection. Ann Thorac Surg 2008; 86:1707-12. [PMID: 19049790 DOI: 10.1016/j.athoracsur.2008.06.074] [Citation(s) in RCA: 91] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2008] [Revised: 06/11/2008] [Accepted: 06/13/2008] [Indexed: 11/28/2022]
Affiliation(s)
- Jun D Parker
- Vascular Biology Unit, School of Medicine, James Cook University, Townsville, Australia
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Pauls S, Orend KH, Sunder-Plassmann L, Kick J, Schelzig H. Endovascular Repair of Symptomatic Penetrating Atherosclerotic Ulcer of the Thoracic Aorta. Eur J Vasc Endovasc Surg 2007; 34:66-73. [PMID: 17324593 DOI: 10.1016/j.ejvs.2006.12.029] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2006] [Accepted: 12/20/2006] [Indexed: 10/23/2022]
Abstract
BACKGROUND In this study we evaluate published and personal experience of Endovascular Repair (EVAR) of penetrating atherosclerotic ulcers (PAU). PATIENTS AND METHOD In 12 patients (mean 74 years, 58-87 years) PAU was diagnosed with computer tomography (CT). Symptomatic ulcers were treated by vascular surgeons using stentgrafts via a femoral access route. Patients were followed up clinically and with CT for an average of 849 days (186-1968 days). RESULTS 11 patients had severe acute thoracic pain, one patient presented with hemoptysis. CT showed well outlined ulcer, intramural hematoma, and contrast enhancement of the aortic wall (n=12), pseudoaneurysm (n=11), intimal calcification adjoining the ulcer (n=10), pleural (n=9) and mediastinal fluid (n=4). Mean duration of surgery was 68min (32-120min). Primary technical success was achieved in all patients. There was no perioperative complications except one acute hemorrhage from an intercostal artery and one iliac dissection. 3 months after stentgraft application owing to a severe stenosis of the right common femoral artery, an iliofemoral bypass was performed in one patient. All patients were free of symptoms after the procedure. There was incomplete sealing of PAU in 2 of 12 patients, but no re-intervention was needed. All patients were alive during follow-up. CONCLUSION Symptomatic PAU is a potentially fatal lesion. Considering the low morbidity and mortality of EVAR, this option might be first choice.
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Affiliation(s)
- S Pauls
- Department of Diagnostic and Interventional Radiology, University of Ulm, Germany
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Piffaretti G, Tozzi M, Lomazzi C, Rivolta N, Riva F, Maida S, Caronno R, Laganà D, Carrafiello G, Cuffari S, Castelli P. Penetrating ulcers of the thoracic aorta: results from a single-centre experience. Am J Surg 2007; 193:443-7. [PMID: 17368285 DOI: 10.1016/j.amjsurg.2006.08.073] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2006] [Revised: 08/02/2006] [Accepted: 08/02/2006] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To report our mid-term results of stent-graft (SG) placement for the treatment of penetrating thoracic aortic ulcers. METHODS In the last 30 months, 11 patients (9 men; mean age 73 years; range 55 to 81) were treated for 12 penetrating thoracic aortic ulcers using SGs. Five patients were symptomatic: 2 had ruptured ulcers and 2 cases were complicated with dissection. Mean European System for Cardiac Operative Risk Evaluation (EuroSCORE) was 10. Three patients had concomitant endovascular repair for an infrarenal abdominal aortic aneurysm (AAA). Follow-up included periodic computed tomography angiography (CT-A) scans at 1, 4, and 12 months after the intervention, and yearly thereafter. RESULTS Primary technical success was achieved in 100% of patients; no conversion was required. In-hospital mortality did not occur. Paraplegia was not observed. Mean follow-up was 15 months (range 2 to 36). One patient died of respiratory failure 2 months after the intervention. Radiologic follow-up did not detect endoleaks. Survival was 90% at 1 and 3 years. CONCLUSIONS Our experience confirms the feasibility of SG treatment for elective and urgent repair of penetrating aortic ulcers. Our current attitude is to treat all the ulcers of the descending aorta using an endovascular technique, since SG treatment represents a good treatment option, as the morbidity and mortality are low.
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Affiliation(s)
- Gabriele Piffaretti
- Vascular Surgery-Department of Surgery, University of Insubria, Varese, Italy.
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Gawenda M, Aleksic M, Heckenkamp J, Reichert V, Gossmann A, Brunkwall J. Hybrid-procedures for the Treatment of Thoracoabdominal Aortic Aneurysms and Dissections. Eur J Vasc Endovasc Surg 2007; 33:71-7. [PMID: 17056286 DOI: 10.1016/j.ejvs.2006.09.002] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2006] [Accepted: 09/04/2006] [Indexed: 11/23/2022]
Abstract
AIM The conventional open repair of thoracoabdominal aneurysms and dissections remains complex and demanding and is associated with significant morbidity and mortality. We present our experience of hybrid open and endovascular treatment of thoracoabdominal aneurysms and dissections. METHODS Within an experience of 226 aortic stent-grafts between 1998 and April 2006, 6 of the patients (median age 60 years, range 35 to 68 years) with thoracoabdominal aneurysms (Crawford type I, II, III, and V) were treated with a combined endovascular and open surgical approach. Five men and one woman, with median aneurysm diameter of 75 mm (range 70-100 mm), received revascularization of the renal arteries, the superior mesenteric artery, and the coeliac trunk accomplished via transperitoneal bypass grafting. Aneurysmal exclusion was then performed by stent-graft deployment. RESULTS The entire procedure was technically successful in all patients. The patients were discharged a median of 9 days after the operation, while the postoperative studies revealed the patency of the vessels and no evidence of type I endoleak or secondary rupture of the aneurysm. During follow up (1 to 22 months) spiral-CT scanning revealed distinct shrinkage of the aneurysm, no graft migration or endoleak and patency of all revascularised vessels, except one renal artery in two patients. No patient experienced any temporary or permanent neurological deficit, and no dialysis was necessary. CONCLUSION The combined endovascular and open surgical approach is feasible, without cross clamping of the aorta and with minimized ischemia time for renal and visceral arteries, and seems to be an appropriate strategy for patients with a thoraco-abdominal aortic aneurysm or dissection.
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Affiliation(s)
- M Gawenda
- Division of Vascular Surgery, Medical Centre, University of Cologne, Cologne, Germany.
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Fattori R, Lovato L, Buttazzi K, Russo V. Evolving Experience of Percutaneous Management of Type B Aortic Dissection. Eur J Vasc Endovasc Surg 2006; 31:115-22. [PMID: 16368253 DOI: 10.1016/j.ejvs.2005.10.016] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2005] [Accepted: 10/10/2005] [Indexed: 11/16/2022]
Affiliation(s)
- R Fattori
- Cardiovascular Unit, Department of Radiology, University Hospital S. Orsola, Bologna, Italy.
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Eggebrecht H, Nienaber CA, Neuhäuser M, Baumgart D, Kische S, Schmermund A, Herold U, Rehders TC, Jakob HG, Erbel R. Endovascular stent-graft placement in aortic dissection: a meta-analysis. Eur Heart J 2005; 27:489-98. [PMID: 16227309 DOI: 10.1093/eurheartj/ehi493] [Citation(s) in RCA: 355] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
AIMS This article summarizes all available published data with respect to clinical success, complications, and outcomes of endovascular stent-graft placement among patients with descending aortic dissection (AD). METHODS AND RESULTS We performed a meta-analysis of all published series on retrograde endovascular stent-graft placement encompassing >or=3 patients with AD. Thirty-nine studies, involving a total of 609 patients, were included. Procedural success was reported in 98.2+/-0.5% of patients. Major complications were reported in 11.1+/-1.4%, with the most dreaded neurologic complications in 2.9+/-0.7% patients. Periprocedural stroke was encountered more frequently than paraplegia (1.9+/-0.6% vs. 0.8+/-0.4%). Overall complications were significantly higher in patients undergoing stent-graft placement for acute AD than in patients with chronic AD (21.7+/-2.8% vs. 9.1+/-2.3%, P=0.005). The overall 30-day mortality was 5.3+/-0.9%, and was three-fold higher in patients with acute AD when compared with chronic AD (9.8+/-2.2% vs. 3.2+/-1.4%, P=0.015). In addition, 2.8+/-0.7% of patients died over a mean follow-up period of 19.5+/-7.1 months. Kaplan-Meier analysis yielded overall survival rates of 90.6+/-1.6% at 6 months, 89.9+/-1.7% at 1 year, and 88.8+/-1.9% at 2 years, respectively. CONCLUSION Endovascular stent-graft placement in type B-AD is technically feasible with success rates of >95% in selected cohort. Although minimally invasive, major complications occurred in 14-18% of patients depending upon the acuity of presentation, with very low incidence of paraplegia. Both, acute and mid-term mortality of this novel treatment strategy appear to favourably compare with surgical treatment but further studies are necessary to compare stent-graft placement with medical treatment in uncomplicated AD.
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Affiliation(s)
- Holger Eggebrecht
- Department of Cardiology, West-German Heart Center Essen, University of Duisburg-Essen, Hufelandstrasse 55, 45122 Essen, Germany.
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Nienaber CA, Skriabina V, Schareck W, Ince H. To stent or not to stent aortic dissection: good news for a chosen few, but who? Eur Heart J 2005; 26:431-2. [PMID: 15695533 DOI: 10.1093/eurheartj/ehi119] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Roseborough G, Burke J, Sperry J, Perler B, Parra J, Williams GM. Twenty-year experience with acute distal thoracic aortic dissections. J Vasc Surg 2004; 40:235-46. [PMID: 15297816 DOI: 10.1016/j.jvs.2004.05.019] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND There are few large studies in the literature that document the clinical outcome of an acute dissection of the distal thoracic aorta (ADDA), particularly since the advent of percutaneous techniques for therapeutic and prophylactic treatment of complications of ADDA. The goal of this study was to evaluate the outcome of ADDA with respect to medical, surgical, and percutaneous treatment over a 20-year period, and to use this information to estimate the benefit that future prophylactic therapy may yield. METHODS The hospital records of all patients admitted with ADDA during the period of the study were reviewed retrospectively. RESULTS There were 119 patients who fit the criteria of ADDA. Medical management was performed in 92 patients, with an overall mortality in this group of 13% (12/92 patients). Major morbidity occurred in 34 of the 83 surviving patients managed nonoperatively. Percutaneous interventions consisting of aortic fenestration and branch vessel stenting in 5 patients had a mortality rate of 40% and was only effective in the treatment of isolated renal artery malperfusion. Twenty-two patients underwent aortic surgery for complications or risk of impending rupture. Postoperative mortality was 18% (4/22 patients). Significant risk factors for death were rupture, acute renal failure, mesenteric ischemia, and age >70. No patient who had surgical fenestration required reoperation on the tailored segment. On the basis of clinical outcomes, we estimate that a maximum of 37% of patients could benefit acutely from prophylactic treatment of ADDA with aortic stent grafts, and an additional 13% could benefit chronically from such prophylactic treatment. CONCLUSIONS ADDA remains a challenging clinical problem with many failures of medical, surgical, and percutaneous therapy. Surgery remains an effective therapeutic option in the treatment of complications of acute dissection of the distal thoracic aorta, and surgical aortic fenestration is a durable treatment for malperfusion. A minority of patients may benefit from prophylactic treatment of ADDA with thoracic stent grafts.
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Affiliation(s)
- Glen Roseborough
- Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD 21287-8611, USA.
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Melissano G, Tshomba Y, Civilini E, Chiesa R. Disappointing results with a new commercially available thoracic endograft. J Vasc Surg 2004; 39:124-30. [PMID: 14718829 DOI: 10.1016/s0741-5214(03)01034-6] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
INTRODUCTION New devices for endovascular treatment of thoracic aortic diseases were recently approved for clinical use by European authorities, obtaining the Conformité Européenne (CE) mark. In all patients who underwent endovascular treatment of a thoracic aortic disease in 2002, we used a new CE-marked device, the Endofit stent graft. The device is constituted of nitinol stents and polytetrafluoroethylene fabric, and has a simple design and delivery system. METHODS During 2002, 11 patients (mean age, 75 years; range, 66-85 years) underwent treatment of atherosclerotic aneurysm (n = 9), chronic type B dissection (n = 1), and intramural hematoma (n = 1). Disease involved the descending thoracic aorta in 7 patients and the distal aortic arch in 4 patients. RESULTS In all cases the Endofit stent grafts were successfully deployed in the intended position. No postoperative paraplegia or paraparesis was recorded. There were two in-hospital deaths: 1 patient died in the operating room (postmortem examination showed a kinked graft); and the other patient died in the intensive care unit on postoperative day 30, after an intraoperative stroke. One surgical conversion was performed 2 weeks after the procedure, because of total collapse of the graft due to rupture of three stents. Other graft-related complications included type I endoleak (n = 2), type II endoleak (n = 1), and incomplete opening of the device (n = 1). CONCLUSION Endovascular treatment of thoracic disease with the Endofit graft in this small heterogeneous group of patients resulted in several complications, which may arise from both the delivery system and the graft itself. At present, other commercially available endografts may be safer for endovascular treatment of thoracic aortic diseases.
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Affiliation(s)
- Germano Melissano
- Department of Vascular Surgery, Vita-Salute University, Scientific Institute San Raffaele, Via Olgettina 60, 20132 Milan, Italy.
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Lambrechts D, Casselman F, Schroeyers P, De Geest R, D'Haenens P, Degrieck I. Endovascular Treatment of the Descending Thoracic Aorta. Eur J Vasc Endovasc Surg 2003; 26:437-44. [PMID: 14512009 DOI: 10.1016/s1078-5884(03)00150-3] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
OBJECTIVES to report our initial experience with endovascular stent graft repair of a variety of thoracic aortic pathology. DESIGN retrospective single center study. MATERIAL AND METHODS between February 2000 and January 2002, endovascular stent graft repair was performed in 26 patients: traumatic aortic isthmus rupture (n=3), Type B dissection (n=11) and descending thoracic aortic aneurysm (n=12). The deployed stent graft systems were AneuRx-Medtronic (n=1), Talent-Medtronic (n=13) and Excluder-Gore (n=12). RESULTS successful deployment of the stent grafts in the intended position was achieved in all patients. No hospital mortality neither paraplegia were observed. Late, non procedure related, death occurred in four patients (15%). Access artery complications with rupture of the iliac artery occurred in two patients and were managed by iliac-femoral bypass. The left subclavian artery was overstented in seven patients (27%). Only the first patient received a carotido-subclavian bypass. The mean maximal aortic diameter decreased significantly in patients treated for descending thoracic aneurysm. Only one patient had an endoleak type II after 6 months without enlargement of the aneurysm. Complete thrombosis of the thoracic false lumen occurred in all but one patient treated for Type B dissection 6 months postoperatively. Two patients underwent a consecutive stent graft placement, due to a large re-entry tear distal to the first stent graft. CONCLUSIONS endovascular stent graft repair for Type B dissection, descending thoracic aneurysm and aortic isthmus rupture is a promising less-invasive alternative to surgical repair. Further studies are mandatory to determine its long-term efficacy.
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Affiliation(s)
- D Lambrechts
- Department of Cardiovascular and Thoracic Surgery, Aalst, Belgium
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Nienaber CA, Eagle KA. Aortic dissection: new frontiers in diagnosis and management: Part II: therapeutic management and follow-up. Circulation 2003; 108:772-8. [PMID: 12912795 DOI: 10.1161/01.cir.0000087400.48663.19] [Citation(s) in RCA: 173] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Christoph A Nienaber
- Division of Cardiology at the University Hospital Rostock, Rostock School of Medicine, Ernst-Heydemann-Str. 6, 18057 Rostock, Germany.
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