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Ulsaker H, Halvorsen H, Braaten AO, Dorenberg E, Rikken Lindberg B, Nordhus KC, Jakobsen Ø, Brekken R, Seternes A, Manstad-Hulaas F. Early and mid-term results after endovascular repair of thoracoabdominal aortic aneurysms using the off-the-shelf multibranched t-Branch device: a national multi-center study. SCAND CARDIOVASC J 2024; 58:2335906. [PMID: 38613333 DOI: 10.1080/14017431.2024.2335906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 03/24/2024] [Indexed: 04/14/2024]
Abstract
Objective: The multibranched off-the-shelf Zenith® t-Branch (Cook Medical, Bloomington, IN) device is commonly chosen for endovascular repair of thoracoabdominal aortic aneurysms. The aim of this study was to report early and mid-term outcomes in all patients treated with the t-Branch in Norway; Design and Methods: A retrospective multicenter study with Norwegian centers performing complex endovascular aortic repair was undertaken. T-Branch patients from 2014 to 2020 were included. All postoperative computed tomography angiography images were reviewed, and demographic, anatomical, perioperative and follow-up data were analyzed; Results: Seventy patients were treated in a single-step (n = 55) or staged (n = 15) procedure. Symptomatic presentation was seen in 20 patients, six of which had a contained rupture. Technical success was 87% (n = 59), with failures caused by unsuccessful bridging of target vessels (n = 4), target vessel bleeding (n = 3), persisting type 1c endoleak (n = 1) and t-Branch malrotation (n = 1). 30-day mortality was 9% (n = 6) and was associated with high BMI (p = .038). The spinal cord ischemia rate was 21% (n = 15) and was associated with type II aneurysms (OR 5.4, 95% CI 1.1-26.7, p = .04), smoking (OR 6.0, 95% CI 1.3-27.6, p = .02) and intraoperative blood loss (OR 1.1, 95% CI 1.0-1.3, p = .01). Survival at one, two and three years was 84 ± 4%, 70 ± 6% and 67 ± 6%, respectively. Freedom from aortic-related reinterventions at one, two and three years was 80 ± 5%, 65 ± 7% and 50 ± 8%, respectively; Conclusion: The study showed low early mortality (9%) and satisfactory mid-term survival. Technical success was achieved in acceptable 87% of procedures. The rate of spinal cord ischemia was high, occurring in 21% of patients.
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Affiliation(s)
- Håvard Ulsaker
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Norwegian National Research Centre for Minimally Invasive and Image-guided Diagnostics and Therapy, St. Olavs Hospital, Trondheim, Norway
| | | | | | - Eric Dorenberg
- Department of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway
| | | | | | - Øyvind Jakobsen
- Department of Cardiothoracic and Vascular Surgery, University Hospital of North, Norway
| | - Reidar Brekken
- Norwegian National Research Centre for Minimally Invasive and Image-guided Diagnostics and Therapy, St. Olavs Hospital, Trondheim, Norway
- Department of Health Research, SINTEF, Trondheim, Norway
| | - Arne Seternes
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Department of Surgery, St. Olavs University Hospital, Trondheim, Norway
| | - Frode Manstad-Hulaas
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Norwegian National Research Centre for Minimally Invasive and Image-guided Diagnostics and Therapy, St. Olavs Hospital, Trondheim, Norway
- Department of Radiology, St. Olavs University Hospital, Trondheim, Norway
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Wanhainen A, Van Herzeele I, Bastos Goncalves F, Bellmunt Montoya S, Berard X, Boyle JR, D'Oria M, Prendes CF, Karkos CD, Kazimierczak A, Koelemay MJW, Kölbel T, Mani K, Melissano G, Powell JT, Trimarchi S, Tsilimparis N, Antoniou GA, Björck M, Coscas R, Dias NV, Kolh P, Lepidi S, Mees BME, Resch TA, Ricco JB, Tulamo R, Twine CP, Branzan D, Cheng SWK, Dalman RL, Dick F, Golledge J, Haulon S, van Herwaarden JA, Ilic NS, Jawien A, Mastracci TM, Oderich GS, Verzini F, Yeung KK. Editor's Choice -- European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Abdominal Aorto-Iliac Artery Aneurysms. Eur J Vasc Endovasc Surg 2024; 67:192-331. [PMID: 38307694 DOI: 10.1016/j.ejvs.2023.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 09/20/2023] [Indexed: 02/04/2024]
Abstract
OBJECTIVE The European Society for Vascular Surgery (ESVS) has developed clinical practice guidelines for the care of patients with aneurysms of the abdominal aorta and iliac arteries in succession to the 2011 and 2019 versions, with the aim of assisting physicians and patients in selecting the best management strategy. METHODS The guideline is based on scientific evidence completed with expert opinion on the matter. By summarising and evaluating the best available evidence, recommendations for the evaluation and treatment of patients have been formulated. The recommendations are graded according to a modified European Society of Cardiology grading system, where the strength (class) of each recommendation is graded from I to III and the letters A to C mark the level of evidence. RESULTS A total of 160 recommendations have been issued on the following topics: Service standards, including surgical volume and training; Epidemiology, diagnosis, and screening; Management of patients with small abdominal aortic aneurysm (AAA), including surveillance, cardiovascular risk reduction, and indication for repair; Elective AAA repair, including operative risk assessment, open and endovascular repair, and early complications; Ruptured and symptomatic AAA, including peri-operative management, such as permissive hypotension and use of aortic occlusion balloon, open and endovascular repair, and early complications, such as abdominal compartment syndrome and colonic ischaemia; Long term outcome and follow up after AAA repair, including graft infection, endoleaks and follow up routines; Management of complex AAA, including open and endovascular repair; Management of iliac artery aneurysm, including indication for repair and open and endovascular repair; and Miscellaneous aortic problems, including mycotic, inflammatory, and saccular aortic aneurysm. In addition, Shared decision making is being addressed, with supporting information for patients, and Unresolved issues are discussed. CONCLUSION The ESVS Clinical Practice Guidelines provide the most comprehensive, up to date, and unbiased advice to clinicians and patients on the management of abdominal aorto-iliac artery aneurysms.
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Brisard L, El Batti S, Borghese O, Maurel B. Risk Factors for Spinal Cord Injury during Endovascular Repair of Thoracoabdominal Aneurysm: Review of the Literature and Proposal of a Prognostic Score. J Clin Med 2023; 12:7520. [PMID: 38137589 PMCID: PMC10743399 DOI: 10.3390/jcm12247520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 11/29/2023] [Accepted: 11/30/2023] [Indexed: 12/24/2023] Open
Abstract
Despite recent improvements, spinal cord ischemia remains the most feared and dramatic complication following extensive aortic repair. Although endovascular procedures are associated with a lower risk compared with open procedures, this risk is still significant and must be considered. A combined medical and surgical approach may help to optimize the tolerance of the spinal cord to ischemia. The aim of this review is to describe the underlying mechanism involved in spinal cord injury during extensive endovascular aortic repair, to describe the different techniques used to improve spinal cord tolerance to ischemia-including the prophylactic or curative use of spinal drainage-and to propose our algorithm for spinal cord protection and the rational use of spinal drainage.
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Affiliation(s)
- Laurent Brisard
- Department of Anesthesiology and Critical Care, Laënnec Hospital, University Hospital of Nantes, F-44000 Nantes, France;
| | - Salma El Batti
- Department of Vascular and Endovascular Surgery, Hôpital Européen Georges Pompidou—Hôpitaux de Paris, Université de Paris Cité, F-75015 Paris, France;
| | - Ottavia Borghese
- Department of Cardiac and Vascular Surgery, L’Institut du Thorax, Nantes University Hospital, F-44093 Nantes, France;
| | - Blandine Maurel
- Department of Cardiac and Vascular Surgery, L’Institut du Thorax, Nantes University Hospital, F-44093 Nantes, France;
- Inserm UMR 1087/CNRS UMR 6291, L’Institut du Thorax, Université de Nantes, F-44000 Nantes, France
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Grandi A, Melloni A, D'Oria M, Lepidi S, Bonardelli S, Kölbel T, Bertoglio L. Emergent endovascular treatment options for thoracoabdominal aortic aneurysm. Semin Vasc Surg 2023; 36:174-188. [PMID: 37330232 DOI: 10.1053/j.semvascsurg.2023.04.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 04/04/2023] [Accepted: 04/04/2023] [Indexed: 06/19/2023]
Abstract
For a long time, parallel grafting, physician-modified endografts, and, more recently, in situ fenestration were the only go-to endovascular options for ruptured thoracoabdominal aortic aneurysm, offered mixed results, and depended mainly on the operator's and center's experience. As custom-made devices have become an established endovascular treatment option for elective thoracoabdominal aortic aneurysm, they are not a viable option in the emergency setting, as endograft production can take up to 4 months. The development of off-the-shelf (OTS) multibranched devices with a standardized configuration has allowed the treatment of ruptured thoracoabdominal aortic aneurysm with emergent branched endovascular procedures. The Zenith t-Branch device (Cook Medical) was the first readily available graft outside the United States to receive the CE mark (in 2012) and is currently the most studied device for those indications. A new device, the E-nside thoracoabdominal branch endoprosthesis OTS multibranched endograft (Artivion), has been made commercially available, and the GORE EXCLUDER thoracoabdominal branch endoprosthesis OTS multibranched endograft (W. L. Gore and Associates) is expected to be released in 2023. Due to the lack of guidelines on ruptured thoracoabdominal aortic aneurysm, this review summarizes the available treatment options (ie, parallel grafts, physician-modified endografts, in situ fenestrations, and OTS multibranched devices), compares the indications and contraindications, and points out the evidence gaps that should be filled in the next decade.
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Affiliation(s)
- Alessandro Grandi
- Department of Vascular Medicine, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Andrea Melloni
- Division of Vascular Surgery, Department of Clinical and Experimental Sciences, University of Brescia School of Medicine, ASST Spedali Civili of Brescia, Brescia, Italy
| | - Mario D'Oria
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Trieste Azienda sanitaria universitaria Giuliano Isontina, Trieste, Italy
| | - Sandro Lepidi
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Trieste Azienda sanitaria universitaria Giuliano Isontina, Trieste, Italy
| | - Stefano Bonardelli
- Division of Vascular Surgery, Department of Clinical and Experimental Sciences, University of Brescia School of Medicine, ASST Spedali Civili of Brescia, Brescia, Italy
| | - Tilo Kölbel
- Department of Vascular Medicine, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Luca Bertoglio
- Division of Vascular Surgery, Department of Clinical and Experimental Sciences, University of Brescia School of Medicine, ASST Spedali Civili of Brescia, Brescia, Italy.
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Chiesa R, Rinaldi E, Kahlberg A, Tinaglia S, Santoro A, Colacchio G, Melissano G. Outcomes following Management of Complex Thoracoabdominal Aneurysm by an Open Approach. J Clin Med 2023; 12:jcm12093193. [PMID: 37176634 PMCID: PMC10179404 DOI: 10.3390/jcm12093193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 04/11/2023] [Accepted: 04/27/2023] [Indexed: 05/15/2023] Open
Abstract
BACKGROUND In the last decade, advances in surgical techniques, and the introduction of adjuncts for organ protection, have modified the approach for thoracoabdominal aortic aneurysm (TAAA) surgical repair. The aim of this study is to determine whether the contemporary approach influenced the outcomes. METHODS From 1989 to 2022, patients who had received elective open surgical repair (OSR) for TAAA at our institution were retrospectively analyzed. This series has been divided in two groups: Group 1 (1989-2009), and Group 2 (2010-2022). Patients included in Group 1 were those treated with a selective use of adjuncts, and Group 2 included patients treated with the systematic use of adjuncts. RESULTS A total of 1107 patients were treated (Group 1: 455; Group 2: 652). The surgical management was significantly different between the two groups. The in-hospital mortality was significantly different between the two groups (Group 1: 13.4%, Group 2: 8.1%; p 0.004), as was the rate of permanent spinal cord ischemia (Group 1: 11.9%, Group 2: 7.8%; p 0.023). Renal and respiratory failure were reduced in Group 2, but not significantly. CONCLUSIONS The use of the adjuncts enabled the achievement of improvement in mortality and SCI prevention in TAAA OSR. Although a refined surgical technique, mortality and morbidity are still noteworthy in this complex aortic field.
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Affiliation(s)
- Roberto Chiesa
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Via Olgettina, 60, 20132 Milan, Italy
| | - Enrico Rinaldi
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Via Olgettina, 60, 20132 Milan, Italy
| | - Andrea Kahlberg
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Via Olgettina, 60, 20132 Milan, Italy
| | - Sarah Tinaglia
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Via Olgettina, 60, 20132 Milan, Italy
| | - Annarita Santoro
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Via Olgettina, 60, 20132 Milan, Italy
| | - Giovanni Colacchio
- Department of Vascular and Endovascular Surgery, General Regional Hospital Ente Ecclesiastico "F. Miulli", 70021 Acquaviva delle Fonti, Italy
| | - Germano Melissano
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Via Olgettina, 60, 20132 Milan, Italy
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