1
|
Natural history of the proximal aorta in patients with descending thoracic aortic disease. J Vasc Surg 2017; 67:1659-1663. [PMID: 29276106 DOI: 10.1016/j.jvs.2017.10.062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2017] [Accepted: 10/07/2017] [Indexed: 11/21/2022]
Abstract
OBJECTIVE This study investigated the growth and behavior of the ascending aorta in patients with descending thoracic aortic disease. METHODS We examined 200 patients with descending thoracic aortic disease including acute type B dissection (n = 95), chronic type B dissection (n = 38), intramural hematoma (n = 23), and thoracoabdominal aortic aneurysms (n = 44). Images from computed tomography and magnetic resonance imaging were evaluated after three-dimensional reconstruction to examine the growth rate in those with >1 year of imaging follow-up (n = 108). Survival data were derived from all 200 patients in this study. RESULTS Average proximal aortic dimensions at the index image were relatively small, measuring 3.65 ± 0.51 cm in the root, 3.67 ± 0.48 cm in the ascending aorta, and 3.50 ± 0.44 cm in the proximal arch. Average growth rate was low for the aortic root, ascending aorta, and proximal arch at 0.36 ± 0.64 mm/y, 0.26 ± 0.44 mm/y, and 0.25 ± 0.44 mm/y, respectively. There was no difference in baseline proximal aortic dimensions and growth rate between the four subgroups. An index aortic diameter ≥4.1 cm grew faster than those <4.1 cm at the ascending aorta (P = .028) and proximal arch (P = .019). There was no difference in aortic growth rates at the aortic root (P = .887). After the index scan, five patients underwent six ascending aortic replacement procedures, leading to a 3% ascending aortic intervention rate. Overall median life expectancy was 86.15 years. CONCLUSIONS Native ascending aortic growth in patients with descending thoracic aortic disease is slow. We suggest regular follow-up for index ascending aorta ≥4.1 cm because of its larger initial size and more rapid growth.
Collapse
|
2
|
Zhou JC, Zhang N, Zhang ZH, Wang TT, Zhu YF, Kang H, Zhang WM, Li DL, Li WD, Liu ZJ, Qian XM, Zhang MY, Wang J, Zhou M, Yang ZT, Yu YX, Li HY, Zhang J, Wang YG, Gao JP, Ling L, Pan KH. Intensive blood pressure control in patients with acute type B aortic dissection (RAID): study protocol for randomized controlled trial. J Thorac Dis 2017; 9:1369-1374. [PMID: 28616291 PMCID: PMC5465133 DOI: 10.21037/jtd.2017.03.180] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Blood pressure control is an essential therapy for patients with acute type B aortic dissection (ABAD) and should be maintained throughout the entire treatment. Thus, vast majority current guidelines recommend control the blood pressure to lower than 140/90 mmHg. Theoretically, a much lower target may further decrease the risk of propagation of dissection. However, some argued that too lower blood pressure would compromise the organ perfusion. Thus, there is no unanimous optimal target for blood pressure in patients with ABAD so far. The present study aimed to investigate the optimal blood pressure target for patients with ABAD, in the hope that the result would optimize the treatment of aortic dissection (AD). METHODS The study is a multi-center randomized controlled clinical trial. Study population will include patients with new diagnosed ABAD and hypertension. Blocked randomization was performed where intensive blood pressure control (<120 mmHg) with conventional blood pressure control (<140 mmHg) were allocated at random in a ratio of 1:1 in blocks of sizes 4, 6, 8, and 10 to 360 subjects. Interim analysis will be performed. The primary outcome is a composite in-hospital adverse outcome, including death, permanent paraplegia or semi- paralysis during the hospitalization, and renal failure requiring hemodialysis at discharge. While the secondary outcomes include the aortic size, lower extremity or visceral ischemia, retrograde propagation into aortic arch or ascending aorta, mortality in 6 months and 1 year, intensive care unit (ICU) length of stay, total length of hospital stay, creatinine level, and surgical or endovascular intervention. ETHICS AND DISSEMINATION The study was approved by the institutional review board of Sir Run Run Shaw Hospital (approval number: 20160920-9). Informed consent will be obtained from participants or their next-of-kin. The results will be published in a peer-reviewed journal and shared with the worldwide medical community. TRIAL REGISTRATION NCT03001739 (https://register.clinicaltrials.gov/).
Collapse
Affiliation(s)
- Jian-Cang Zhou
- Department of Critical Care Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China
| | - Nan Zhang
- Department of Emergency, The First Hospital of Jilin University, Changchun 130021, China
| | - Zhong-Heng Zhang
- Department of Critical Care Medicine, Jinhua Municipal Central Hospital, Jinhua Hospital of Zhejiang University, Jinhua 321000, China
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China
| | - Ting-Ting Wang
- Department of Critical Care Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China
| | - Yue-Feng Zhu
- Department of Vascular Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China
| | - Hui Kang
- Department of Critical Care Medicine, West China Hospital, Sichuan University School of Medicine, Chengdu 610041, China
| | - Wei-Min Zhang
- Department of Cardiac Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China
| | - Dong-Lin Li
- Department of Vascular Surgery, 1 affiliated Hospital Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Wei-Dong Li
- Department of Cardiac Surgery, 1 affiliated Hospital Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Zhen-Jie Liu
- Department of Vascular Surgery, 2 affiliated Hospital Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Xi-Min Qian
- Department of Cardiac Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China
| | - Ming-You Zhang
- Department of Emergency, The First Hospital of Jilin University, Changchun 130021, China
| | - Jue Wang
- Department of Cardiac Surgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
| | - Mi Zhou
- Department of Cardiac Surgery, Rui Jin Hospital Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Zhi-Tao Yang
- Department of Emergency Medicine, Rui Jin Hospital Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Yun-Xian Yu
- Department of Biomedical Informatics, Zhejiang University School of Medicine, Hangzhou 310016, China
| | - Hang-Yang Li
- Department of Critical Care Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China
| | - Jian Zhang
- Department of Critical Care Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China
| | - Yong-Gang Wang
- Department of Critical Care Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China
| | - Jian-Ping Gao
- Department of Critical Care Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China
| | - Lin Ling
- Department of Critical Care Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China
| | - Kong-Han Pan
- Department of Critical Care Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China
| | | |
Collapse
|
3
|
Hu H, Zheng T, Zhu J, Liu Y, Qi R, Sun L. Thoracoabdominal aortic replacement for Crawford extent II aneurysm after thoracic endovascular aortic repair. J Thorac Dis 2017; 9:64-69. [PMID: 28203407 DOI: 10.21037/jtd.2017.01.54] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND The surgical treatment of Crawford extent II aneurysms after thoracic endovascular aortic repair (TEVAR) remains challenging, because of the need to remove the failed endograft and the complexity of the aortic reconstruction. We retrospectively reviewed our experience with surgical management of Crawford extent II aneurysms after TEVAR using thoracoabdominal aortic replacement (TAAR). METHODS Eleven patients (10 males, 1 female) with Crawford extent II aneurysm after TEVAR were treated with TAAR between August 2012 and May 2015. The indications included: diameter >5.0 cm; persistent pain; size increase >0.5 cm/year; and no suitable landing zone for re-TEVAR. Five patients underwent surgery under deep hypothermic cardiac arrest, two under mild hypothermic cardiopulmonary bypass, and four under direct aortic cross-clamping under normothermia. Two patients had Marfan syndrome. RESULTS There were no in-hospital deaths. Continuous renal replacement therapy was required in three patients. One patient needed re-intubation, and two patients had prolonged intubation (>72 h). One patient sustained paraplegia after surgery but recovered during follow-up. Cerebrospinal fluid drainage were used in four patients (3 immediately in the operation room, and 1 in the intensive care unit when the patient suffered paraplegia). One patient died during follow-up. CONCLUSIONS TAAR represents a feasible option for the treatment of Crawford extent II aneurysms after TEVAR, with acceptable surgical risks and favorable results.
Collapse
Affiliation(s)
- Haiou Hu
- Department of Cardiovascular Surgery, Beijing Aortic Disease Centre, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing Engineering Research Centre for Vascular Prostheses, Beijing 100029, China
| | - Tie Zheng
- Department of Cardiovascular Surgery, Beijing Aortic Disease Centre, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing Engineering Research Centre for Vascular Prostheses, Beijing 100029, China
| | - Junming Zhu
- Department of Cardiovascular Surgery, Beijing Aortic Disease Centre, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing Engineering Research Centre for Vascular Prostheses, Beijing 100029, China
| | - Yongmin Liu
- Department of Cardiovascular Surgery, Beijing Aortic Disease Centre, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing Engineering Research Centre for Vascular Prostheses, Beijing 100029, China
| | - Ruidong Qi
- Department of Cardiovascular Surgery, Beijing Aortic Disease Centre, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing Engineering Research Centre for Vascular Prostheses, Beijing 100029, China
| | - Lizhong Sun
- Department of Cardiovascular Surgery, Beijing Aortic Disease Centre, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing Engineering Research Centre for Vascular Prostheses, Beijing 100029, China
| |
Collapse
|
4
|
Kamman AV, de Beaufort HWL, van Bogerijen GHW, Nauta FJH, Heijmen RH, Moll FL, van Herwaarden JA, Trimarchi S. Contemporary Management Strategies for Chronic Type B Aortic Dissections: A Systematic Review. PLoS One 2016; 11:e0154930. [PMID: 27144723 PMCID: PMC4856408 DOI: 10.1371/journal.pone.0154930] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2015] [Accepted: 04/21/2016] [Indexed: 01/16/2023] Open
Abstract
Background Currently, the optimal management strategy for chronic type B aortic dissections (CBAD) is unknown. Therefore, we systematically reviewed the literature to compare results of open surgical repair (OSR), standard thoracic endovascular aortic repair (TEVAR) or branched and fenestrated TEVAR (BEVAR/FEVAR) for CBAD. Methods EMBASE and MEDLINE databases were searched for eligible studies between January 2000 and October 2015. Studies describing outcomes of OSR, TEVAR, B/FEVAR, or all, for CBAD patients initially treated with medical therapy, were included. Primary endpoints were early mortality, and one-year and five-year survival. Secondary endpoints included occurrence of complications. Furthermore, a Time until Treatment Equipoise (TUTE) graph was constructed. Results Thirty-five articles were selected for systematic review. A total of 1081 OSR patients, 1397 TEVAR patients and 61 B/FEVAR patients were identified. Early mortality ranged from 5.6% to 21.0% for OSR, 0.0% to 13.7% for TEVAR, and 0.0% to 9.7% for B/FEVAR. For OSR, one-year and five-year survival ranged 72.0%-92.0% and 53.0%-86.7%, respectively. For TEVAR, one-year survival was 82.9%-100.0% and five-year survival 70.0%-88.9%. For B/FEVAR only one-year survival was available, ranging between 76.4% and 100.0%. Most common postoperative complications included stroke (OSR 0.0%-13.3%, TEVAR 0.0%-11.8%), spinal cord ischemia (OSR 0.0%-16.4%, TEVAR 0.0%-12.5%, B/FEVAR 0.0%-12.9%) and acute renal failure (OSR 0.0%-33.3%, TEVAR 0.0%-34.4%, B/FEVAR 0.0%-3.2%). Most common long-term complications after OSR included aneurysm formation (5.8%-20.0%) and new type A dissection (1.7–2.2%). Early complications after TEVAR included retrograde dissection (0.0%-7.1%), malperfusion (1.3%–9.4%), cardiac complications (0.0%–5.9%) and rupture (0.5%–5.0%). Most common long-term complications after TEVAR were rupture (0.5%–7.1%), endoleaks (0.0%–15.8%) and cardiac complications (5.9%-7.1%). No short-term aortic rupture or malperfusion was observed after B/FEVAR. Long-term complications included malperfusion (6.5%) and endoleaks (0.0%-66.7%). Reintervention rates after OSR, TEVAR and B/FEVAR were 5.8%-29.0%, 4.3%-47.4% and 0.0%-53.3%, respectively. TUTE for OSR was 2.7 years, for TEVAR 9.9 months and for B/FEVAR 10.3 months. Conclusion We found a limited early survival benefit of standard TEVAR over OSR for CBAD. Complication rates after TEVAR are higher, but complications after OSR are usually more serious. Initial experiences with B/FEVAR show its feasibility, but long-term results are needed to compare it to OSR and standard TEVAR. We conclude that optimal treatment of CBAD remains debatable and merits a patient specific decision. TUTE seems a feasible and useful tool to better understand management outcomes of CBAD.
Collapse
Affiliation(s)
- Arnoud V. Kamman
- Thoracic Aortic Research Center, Policlinico San Donato IRCCS, University of Milan, San Donato Milanese, Italy
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
- * E-mail:
| | - Hector W. L. de Beaufort
- Thoracic Aortic Research Center, Policlinico San Donato IRCCS, University of Milan, San Donato Milanese, Italy
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Guido H. W. van Bogerijen
- Thoracic Aortic Research Center, Policlinico San Donato IRCCS, University of Milan, San Donato Milanese, Italy
| | - Foeke J. H. Nauta
- Thoracic Aortic Research Center, Policlinico San Donato IRCCS, University of Milan, San Donato Milanese, Italy
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
- Departments of Surgery and Biomedical Engineering, University of Michigan, Ann Arbor, Michigan, United States of America
| | - Robin H. Heijmen
- Department of Cardiothoracic Surgery, St. Antonius Hospital Nieuwegein, Nieuwegein, The Netherlands
| | - Frans L. Moll
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Santi Trimarchi
- Thoracic Aortic Research Center, Policlinico San Donato IRCCS, University of Milan, San Donato Milanese, Italy
| |
Collapse
|
5
|
Abstract
OBJECTIVES To conduct the first population-level incidence study of aortic dissection in pregnancy using linked hospital-based data in England. SETTING Hospital-based data (Hospital Episode Statistics (HES) linked with mortality data from the Office of National Statistics), national enquiries (Confidential Enquiries into Maternal Mortality) and surveys (UK Obstetric Surveillance System; UKOSS) of aortic dissection in pregnancy from 2003 to 2011 in England. PARTICIPANTS Between 2003 and 2011, all female patients admitted with diagnoses of aortic dissection (not necessarily as the primary cause of admission) and of pregnancy, childbirth and puerperium, were included. OUTCOME MEASURES Diagnosis of aortic dissection during pregnancy, operated or not operated, with outcome of death or live patient from 2003 to 2011 in England. RESULTS There were significant differences in characteristics of databases with respect to study population, time of study, recorded event and follow-up of outcomes. On the basis of HES, annual incidence of aortic dissection was 1.23 (95% CI 1.22 to 1.24) per 100 000 maternities. Incidence of aortic dissection with death within 1 year was 0.30 (0.29 to 0.31) per 100 000 maternities. Incidence of aortic dissection increased from 0.74 (0.73 to 0.75) per 100 000 maternities in 2003-2005 to 1.52 (1.51 to 1.53) per 100 000 maternities in 2009-2011. In the Confidential Enquiries into Maternal Deaths, incidence of deaths was highest for 2003-2005 (0.43/100 000 maternities) and lowest for 1997-1999 (0.21/100 000 maternities). In the UK Obstetric Surveillance System, national incidence of aortic dissection was 0.80 (0.50 to 1.50) per 100 000 maternities between 2009 and 2011. CONCLUSIONS The case of aortic dissection in pregnancy illustrates data limitations regarding complications in pregnancy from different sources in the UK, even for a diagnosis with seemingly few alternative coding and diagnostic possibilities. These limitations should be acknowledged when estimating incidence and outcome.
Collapse
Affiliation(s)
- Amitava Banerjee
- University of Birmingham Centre for Cardiovascular Sciences, Birmingham, UK
| | - Irena Begaj
- Quality Outcomes Research Unit, Queen Elizabeth Hospital, Birmingham, UK
| | - Sara Thorne
- Department of Cardiology, Queen Elizabeth Hospital, Birmingham, UK
| |
Collapse
|