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Yerokun BA, Anand J, McCann RL, Hughes GC. Back stabber: ladder fall causing traumatic aortic transection. Asian Cardiovasc Thorac Ann 2019; 27:302-303. [PMID: 30808190 DOI: 10.1177/0218492319834449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
A 68-year-old man presented with back pain after falling from a ladder and was found to have anterolisthesis of thoracic vertebrae T11-12 with secondary focal aortic injury and disruption of the aortic wall. This was successfully repaired using thoracic endovascular aortic repair (TEVAR) followed by spinal fusion with excellent result.
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Affiliation(s)
- Babatunde A Yerokun
- 1 Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Jatin Anand
- 1 Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Richard L McCann
- 2 Department of Surgery, Division of Vascular and Endovascular Surgery, Duke University Medical Center, Durham, NC, USA
| | - G Chad Hughes
- 1 Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, NC, USA
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Voigt SL, Bishawi M, Ranney D, Yerokun B, McCann RL, Hughes GC. Outcomes of carotid-subclavian bypass performed in the setting of thoracic endovascular aortic repair. J Vasc Surg 2018; 69:701-709. [PMID: 30528402 DOI: 10.1016/j.jvs.2018.07.022] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 07/09/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Subclavian artery revascularization is frequently performed in the setting of thoracic endovascular aortic repair (TEVAR). However, there is little information on the short- and long-term outcomes of patients undergoing carotid to subclavian artery bypass in this clinical setting. As such, this study sought to define the early and late outcomes associated with this procedure. METHODS Patients undergoing carotid-subclavian bypass in conjunction with TEVAR between June 2005 and September 2016 were retrospectively identified from a prospectively maintained, single-center aortic surgery database. The 30-day outcomes specific to the carotid-subclavian bypass procedure were analyzed, including cervical plexus nerve injury, bleeding complications, and local vascular complications. All preoperative and postoperative chest radiographs were carefully analyzed to assess for hemidiaphragm elevation indicative of phrenic nerve palsy. Long-term outcomes included primary graft patency and anastomotic complications. RESULTS Of 579 consecutive patients undergoing TEVAR during this time interval, 112 patients (19%) underwent concomitant carotid-subclavian bypass. The cohort was 38% female (n = 43), with a mean age of 65 ± 14 years. The majority of conduits were 8-mm polytetrafluoroethylene grafts (n = 107 [95.5%]), with a minority being reversed saphenous vein (n = 4 [3.6%]) or Dacron (n = 1 [0.9%]) grafts. The bypass procedure was done concurrently at the time of TEVAR in 91% (n = 102) of cases. The short-term complication rate attributed specifically to the carotid-subclavian bypass was 29% (n = 33). These complications included phrenic nerve palsy in 25% (n = 27), recurrent laryngeal nerve palsy in 5% (n = 6), axillary nerve palsy in 2% (n = 2), and neck hematoma requiring re-exploration in 1% (n = 1) of patients. The 30-day in-hospital all-cause mortality rate was 5% (n = 6), and the rate of permanent paraparesis or paraplegia was 0.9% (n = 1). Of the operative survivors (n = 106), follow-up imaging of the bypass graft was available in 87% (n = 92) of patients. Actuarial primary graft patency was 97% at 5 years. There were three patients (3%) with bypass graft occlusions, two of which were clinically silent and detected on follow-up imaging. The third was detected because of symptoms of subclavian steal and required repeated revascularization. Two patients (2%) developed a late anastomotic pseudoaneurysm requiring either endovascular (n = 1) or surgical (n = 1) intervention. CONCLUSIONS Carotid-subclavian bypass for revascularization of the subclavian artery performed in the setting of TEVAR is durable, although the true complication rate is likely higher than is generally reported in the literature because of a not insignificant rate of phrenic nerve palsy. These data should serve well as "gold standard" comparison data for emerging branch graft devices.
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Affiliation(s)
- Soraya L Voigt
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Muath Bishawi
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - David Ranney
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Babatunde Yerokun
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Richard L McCann
- Division of Vascular Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - G Chad Hughes
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC.
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Ranney DN, Yerokun BA, Benrashid E, Bishawi M, Williams A, McCann RL, Hughes GC. Outcomes of Planned Two-Stage Hybrid Aortic Repair With Dacron-Replaced Proximal Landing Zone. Ann Thorac Surg 2018; 106:1136-1142. [DOI: 10.1016/j.athoracsur.2018.04.044] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Revised: 03/12/2018] [Accepted: 04/16/2018] [Indexed: 10/28/2022]
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Ortel TL, Gockerman JP, Califf RM, McCann RL, O’Connor CM, Metzler DM, Greenberg CS. Parenteral Anticoagulation with the Heparinoid Lomoparan (Org 10172) in Patients with Heparin Induced Thrombocytopenia and Thrombosis. Thromb Haemost 2018. [DOI: 10.1055/s-0038-1648434] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
SummaryProgressive thrombocytopenia may develop in as many as 5% of patients receiving heparin anticoagulation. In these patients, the risk of thromboembolic complications as well as continued thrombocytopenia necessitates discontinuation of heparin and initiation of an alternative anticoagulant when indicated. The heparinoid Lomoparan (Org 10172) is a mixture of several nonheparin low molecular weight glycosaminoglycans with proven anticoagulant efficacy that is generally non-reactive with platelets in the presence of plasma from patients with heparin induced thrombocytopenia, whereas standard heparin will induce platelet aggregation. We evaluated the role of heparinoid as a potential alternative anticoagulant in patients with heparin induced thrombocytopenia. During a 6 month period, we identified six patients with heparin induced thrombocytopenia who required an alternative parenteral anticoagulant, four as primary treatment for specific medical problem, and two as anticoagulation during a necessary surgical procedure. Heparinoid was used successfully in both medical and surgical patients requiring parenteral anticoagulation. In no case was there an exacerbation of the thrombocytopenia nor thromboembolic complications while on heparinoid therapy. Three of our patients sustained hemorrhagic complications, predominantly in the post-surgical setting in association with elevated anti-factor Xa levels and additional anticoagulant agents. We feel that these results confirm the utility of heparinoid anticoagulation in a select subset of patients with heparin induced thrombocytopenia who require continued parenteral anticoagulation.
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Affiliation(s)
- Thomas L Ortel
- The Divisions of Hematology/Oncology, Duke University Medical Center, Durham, North Carolina, USA
| | - Jon P Gockerman
- The Divisions of Hematology/Oncology, Duke University Medical Center, Durham, North Carolina, USA
| | - Robert M Califf
- The Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Richard L McCann
- The Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Christopher M O’Connor
- The Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Diane M Metzler
- The Division of Gastroenterology, Duke University Medical Center, Durham, North Carolina, USA
| | - Charles S Greenberg
- The Divisions of Hematology/Oncology, Duke University Medical Center, Durham, North Carolina, USA
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Gilmore BF, Fang C, Turner MC, Nag UP, Turley R, McCann RL, Cox MW. Jejunal arterial access for retrograde mesenteric stenting. J Vasc Surg 2018; 67:1613-1617. [PMID: 29567024 DOI: 10.1016/j.jvs.2017.12.041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Accepted: 12/17/2017] [Indexed: 11/25/2022]
Abstract
Endovascular approaches have replaced open surgical revascularization in most patients with mesenteric ischemia; however, flush ostial occlusions may not be amenable to traditional antegrade access. Retrograde mesenteric stenting has been previously described, but this technique requires a formal laparotomy and dissection of the proximal superior mesenteric artery. We present here a modification of this technique that requires only a "mini-laparotomy" and no open vascular repair of the superior mesenteric artery as well as a review of our initial institutional experience with this procedure. Our approach differs from previously described work by minimizing mesenteric dissection, avoiding the need for repair of an arteriotomy, and limiting the size of the laparotomy incision in this population of profoundly comorbid patients.
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Affiliation(s)
- Brian F Gilmore
- Department of Surgery, Duke University Medical Center, Durham, NC.
| | | | - Megan C Turner
- Department of Surgery, Duke University Medical Center, Durham, NC
| | - Uttara P Nag
- Department of Surgery, Duke University Medical Center, Durham, NC
| | - Ryan Turley
- Cardiothoracic and Vascular Surgeons, Austin, Tex
| | - Richard L McCann
- Department of Surgery, Duke University Medical Center, Durham, NC
| | - Mitchell W Cox
- Department of Surgery, Duke University Medical Center, Durham, NC
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Ranney DN, Cox ML, Yerokun BA, Benrashid E, McCann RL, Hughes GC. Long-term results of endovascular repair for descending thoracic aortic aneurysms. J Vasc Surg 2018; 67:363-368. [PMID: 28847657 PMCID: PMC9799071 DOI: 10.1016/j.jvs.2017.06.094] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Accepted: 06/15/2017] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Since thoracic endovascular aortic repair (TEVAR) received U.S. Food and Drug Administration approval for the treatment of descending thoracic aneurysms in March 2005, excellent 30-day and midterm outcomes have been described. However, data on long-term outcomes are lacking with Medicare data suggesting that TEVAR has worse late survival compared with open descending repair. As such, the purpose of this study was to examine the long-term outcomes for on-label use of TEVAR for repair of descending thoracic aneurysms. METHODS Of 579 patients undergoing TEVAR between March 2005 and April 2016 at a single referral center for aortic surgery, 192 (33.2%) were performed for a descending thoracic aneurysm indication in accordance with the device instructions for use, including 106 fusiform (55.2%), 80 saccular (41.7%), and 6 with both saccular and fusiform (3.1%) aneurysms. All aneurysms were located distal to the left subclavian artery and proximal to the celiac axis, and hybrid procedures including arch or visceral debranching were excluded with the exception of left carotid-subclavian artery bypass. Aortic dissection and intramural hematoma as indications for TEVAR were also excluded. Primary 30-day and in-hospital outcomes included mortality, stroke, need for new permanent dialysis, and permanent paraparesis or paraplegia. Primary long-term outcomes included survival and rate of reintervention secondary to endoleak. The Kaplan-Meier method was used to estimate long-term overall and aorta-specific survivals. RESULTS The mean age was 71.1 ± 10.4 years. All aneurysms in this series were degenerative in nature and no patients with a connective tissue disorder were included. The mean aortic diameter was 5.9 ± 1.5 cm at time of intervention. Rates of 30-day and in-hospital mortality, stroke, permanent dialysis, and permanent paraparesis and paraplegia were 4.7%, 2.1%, 0.5%, and 0.5%, respectively. At a mean follow-up of 69 ± 44 months (range, 3-141 months), there were 68 late deaths (35.4%), two of which were due to aortic rupture. Overall and aorta-specific survivals at 141 months (11.8 years) were 45.7% and 96.2%, respectively. Endovascular reintervention was required in 14 patients (7.3%) owing to type I (n = 10), type II (n = 2), and type III (n = 2) endoleak, all of which subsequently resolved. No patient required open reintervention for any cause. CONCLUSIONS Long-term (12-year) aorta-specific survival after on-label endovascular repair of degenerative descending thoracic aneurysms in nonsyndromic patients is excellent (96%) with sustained protection from rupture, and a low rate of reintervention owing to endoleak (7%). Endovascular repair should be considered the treatment of choice for this pathology.
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Affiliation(s)
- David N Ranney
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Morgan L Cox
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Babatunde A Yerokun
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Ehsan Benrashid
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Richard L McCann
- Division of Vascular Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - G Chad Hughes
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC.
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Wang H, Wagner M, Benrashid E, Keenan J, Wang A, Ranney D, Yerokun B, Gaca JG, McCann RL, Hughes GC. Outcomes of Reoperation After Acute Type A Aortic Dissection: Implications for Index Repair Strategy. J Am Heart Assoc 2017; 6:JAHA.117.006376. [PMID: 28974497 PMCID: PMC5721847 DOI: 10.1161/jaha.117.006376] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background The optimal surgical approach for management of acute type A aortic dissection remains controversial. This study aimed to assess outcomes of reoperation after acute type A dissection repair to help guide decision making around index operative strategy. Methods and Results All aortic reoperations (n=129) at a single referral institution from August 2005 to April 2016 after prior acute type A dissection repair were reviewed. The primary outcome was 30‐day or in‐hospital mortality. Secondary outcomes included organ‐specific morbidity and 1‐ and 5‐year outcomes as estimated using the Kaplan–Meier method. The majority of initial reoperations were proximal aortic (aortic valve, aortic root, or ascending) or aortic arch procedures (62.5%, n=55); most initial reoperations were performed in the elective setting (83.1%, n=74). Additional nonstaged second or more reoperations were required in 21 patients (23.6%) after the initial reoperation, during a median follow‐up of 2.5 years after the initial reoperation. Thirty‐day or in‐hospital mortality for all reoperations was 7.0% (elective: 6.3%; nonelective: 11.1%) with acceptable rates of organ‐specific morbidity, given the procedural complexity. One‐ and 5‐year overall survival after initial reoperation was 85.9% and 64.9%, respectively, with aorta‐specific survival of 88% at 5 years. Conclusions Reoperation after acute type A aortic dissection repair is associated with low rates of mortality and morbidity. These data support more limited index repair for acute type A dissection, especially for patients undergoing index repair in lower volume centers without expertise in extensive repair, because reoperations, if needed, can be performed safely in referral aortic centers.
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Affiliation(s)
- Hanghang Wang
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Matthew Wagner
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Ehsan Benrashid
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Jeffrey Keenan
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Alice Wang
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - David Ranney
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Babatunde Yerokun
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Jeffrey G Gaca
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Richard L McCann
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - G Chad Hughes
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
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Yerokun BA, Bishawi M, Williams AR, Ranney DN, Benrashid E, McCann RL, Hughes GC. Impact of Early versus Late Timing of TEVAR on Aortic Remodeling and Long-Term Survival Following Type B Aortic Dissection. J Vasc Surg 2017. [DOI: 10.1016/j.jvs.2016.10.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Bishawi M, Shah AA, McCann RL, Milano CA. Concomitant Thoracic Aortobifemoral Bypass With Left Ventricular Assist Device Implantation. Ann Thorac Surg 2016; 102:e413-e415. [PMID: 27772595 DOI: 10.1016/j.athoracsur.2016.03.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Revised: 03/07/2016] [Accepted: 03/14/2016] [Indexed: 10/20/2022]
Abstract
Improved quality of life for patients after left ventricular assist device (LVAD) implantation can be greatly limited by peripheral vascular disease even if heart failure symptoms are resolved by LVAD support. We present a case of concomitant thoracic aortobifemoral bypass and LVAD implantation in a patient with ischemic cardiomyopathy, severe peripheral vascular disease, and multiple previous failed revascularization attempts. In this patient, we used the LVAD outflow to provide the inflow to the femoral artery bypass graft. This graft has remained patent at a 2-year follow-up, without claudication symptoms. Performing concomitant major vascular operations safely and successfully is feasible in patients with LVADs. Quality of life after ventricular assist device placement can be limited by vascular disease, but it can be markedly improved after vascular surgical intervention.
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Affiliation(s)
- Muath Bishawi
- Division of Cardiothoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina.
| | - Asad A Shah
- Division of Cardiothoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Richard L McCann
- Division of Vascular Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Carmelo A Milano
- Division of Cardiothoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
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O'Donohoe MK, Radic ZS, Stein AD, Schwartz LB, McCann RL, Hagen PO. Loss of Tachyphylaxis and Increased Sensitivity to Angiotensin II in Experimental Vein Grants. ACTA ACUST UNITED AC 2016. [DOI: 10.1177/153857449102500405] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Intimal hyperplasia and atherosclerosis have been implicated in the pathophysiology of vein graft failure. Several recent studies have also reported alterations in the vasoreactivity of vein grafts. These alterations in vasoreactivity could contribute to vein graft spasm and lead to graft occlusion. This study examined the vasomotor responses of experimental vein grafts to angiotensin II, the most potent natural vasoconstrictor known. The right carotid artery was divided and bypassed in 12 rabbits with use of the right external jugular vein. The left external jugular vein was used as a control. Eight vein grafts and jugular veins were harvested after fourteen days and 4 vein grafts after twenty-eight days. Segments of vein graft and control vein were mounted under isometric tension in an organ bath, and the dose response curves to angiotensin II obtained. On day 14, the response of the jugular veins was triphasic, while the respnse of the vein grafts was sigmoidal. The vein grafts were hypersensitive to angiotensin II. The ED50 was reduced from 8.4 ± 2.5 x 10-6 M in the jugular veins to 1.62 ± 0.24 x 10-8 M in the vein grafts (p < 0.005). The maximal response to angiotensin II was also increased from 342 ± 24 mg in the jugular veins to 558 ± 108 mg in the vein grafts on day 14 (p < 0.05). There was no significant difference in either the ED50 or the maximal response of the vein grafts on day 14 or 28. Tachyphylaxis (desensitization with repeated doses of agonist) was observed in the jugular veins but not in the vein grafts. The results show that experimental vein grafts are hypersensitive to angiotensin II, with either single or repeated exposure. This increased vasoreactivity to angiotensin II may have important clinical implications, particularly when vein grafts are used in patients with renovascular hypertension.
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Affiliation(s)
| | | | - Adam D. Stein
- Department of Surgery, Duke University Medical Center
| | | | | | - Per-Otto Hagen
- Department of Surgery, Duke University Medical Center, Department of Biochemistry, Duke University Medical Center, Durham, North Carolina
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Schwartz LB, Haines LJ, Massey MF, Kerfoot WW, McCann RL, Hagen PO. Dependence of Rabbit External Jugular Vein Vasoreactivity on Segment Size and Location. ACTA ACUST UNITED AC 2016. [DOI: 10.1177/153857449402800103] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
In this study, the dependence of vein segment length, weight, and location on vasore activity was examined. Twenty-four segments from 12 external jugular veins from 6 New Zealand White rabbits were harvested from the proximal (near the thoracic inlet) or distal (near the linguofacial vein/external jugular vein bifurcation) external jugular vein with in vivo lengths of either 3 or 8 mm. Segments were studied in vitro at their resting tension in an organ bath system. The results showed that bradykinin (BK)- and histamine (HIST)-induced maximal active tension was dependent on vessel size (BK: 3 mm segments 0.54 ±0.10 g vs 8 mm segments 1.42 ±0.23 g, P = 0.0003 by paired t test; HIST: 3 mm segments 0.49 ±0.15 vs 8 mm segments 1.10 ±0.24, P = 0.018) and weight (BK: P < 0.0001 by linear regression; HIST: P = 0.0031). In contrast, BK sensi tivity was dependent on location (proximal segments, -logED50 7.81 ±0.15 vs distal segments 8.48 ±0.14, P = 0.0006) but was not dependent on size (3 mm segments 8.24 ±0.22 vs 8 mm segments 8.05 ±0.11, P = 0.33) or weight (P = 0.58). HIST sensi tivity, acetylcholine-induced relaxation (endothelium dependent), and sodium nitro prusside-induced relaxation (endothelium independent) were not dependent on segment length, weight, or location. Because significant differences in vasoreactivity exist along the short length of the external jugular vein, vein segment length and location should be rigorously standardized during vasoreactivity experiments. Increased agonist sensitivity from distal to proximal along the length of a vein may provide an additional mechanism for venous return.
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Affiliation(s)
- Lewis B. Schwartz
- Atherosclerosis Research Laboratory, Department of Surgery, Duke University Medical Center
| | - Laurel J. Haines
- Atherosclerosis Research Laboratory, Department of Surgery, Duke University Medical Center
| | - Marga F. Massey
- Atherosclerosis Research Laboratory, Department of Surgery, Duke University Medical Center
| | - William W. Kerfoot
- Atherosclerosis Research Laboratory, Department of Surgery, Duke University Medical Center
| | - Richard L. McCann
- Atherosclerosis Research Laboratory, Department of Surgery, Duke University Medical Center
| | - Per-Otto Hagen
- Atherosclerosis Research Laboratory, Department of Surgery, Duke University Medical Center, Department of Biochemistry, Duke University Medical Center, Durham, North Carolina
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Benrashid E, Wang H, Andersen ND, Keenan JE, McCann RL, Hughes GC. Complementary roles of open and hybrid approaches to thoracoabdominal aortic aneurysm repair. J Vasc Surg 2016; 64:1228-1238. [PMID: 27444368 DOI: 10.1016/j.jvs.2016.04.022] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Accepted: 04/15/2016] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Thoracoabdominal aortic aneurysm (TAAA) repair remains a significant challenge with considerable perioperative morbidity and mortality. A hybrid approach utilizing visceral debranching with endovascular aneurysm exclusion has been used to treat high-risk patients and therefore allow repair in more patients. Limited data exist regarding long-term outcomes with this procedure as well as comparison to conventional open repair. This study describes our institutional algorithmic approach to TAAA repair using both open and hybrid techniques. METHODS Hybrid and open TAAA repairs performed between July 2005 and August 2015 were identified from a prospectively maintained institutional aortic surgery database. Perioperative morbidity and mortality, freedom from reintervention, and long-term and aorta-specific survival were calculated and compared between the two groups. RESULTS During the study period, 165 consecutive TAAA repairs were performed, including 84 open repairs and 81 hybrid repairs. Patients in the hybrid repair group were significantly older, were more frequently female, and had a generally greater comorbid disease burden, including significantly more chronic kidney disease. Despite the older and sicker cohort, there was no difference in in-hospital mortality between the two groups (9.9% hybrid vs 7.1% open; P = .59). Major morbidity rates differed by procedure, with patients undergoing open repair having a significantly higher rate of postoperative stroke (9.5% open vs 0% hybrid; P = .017), whereas patients undergoing hybrid repair had a higher rate of new permanent dialysis (14.8% hybrid vs 3.6% open; P = .043). There was no difference between groups in the rate of postoperative permanent paraplegia/paresis (8.3% open vs 7.4% hybrid; P = .294). There was a significantly increased rate of reintervention in the hybrid repair group (12.3% hybrid vs 1.2% open, P = .004), with all hybrid reinterventions performed because of endoleak. One-year survival was similar between groups at 69% in hybrid repairs vs 77% in open repairs. Long-term survival was worse in the hybrid group (5-year survival, 32% hybrid vs 56% open), although late survival appeared to be influenced mainly by comorbid disease burden, given the similar long-term aorta-specific survival between groups. CONCLUSIONS Use of an algorithmic approach whereby higher risk patients with TAAA are treated by a hybrid approach and lower risk patients with conventional open repair yields satisfactory short- and long-term outcomes. The availability of multiple options for TAAA repair within a single center likely allows repair in more patients with consequent decrease in the risk of aorta-related death, at the expense of increased reinterventions for endoleak.
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Affiliation(s)
- Ehsan Benrashid
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Hanghang Wang
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Nicholas D Andersen
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Jeffrey E Keenan
- Division of Vascular Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Richard L McCann
- Division of Vascular Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - G Chad Hughes
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC.
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Benrashid E, Wang H, Andersen ND, Keenan JE, McCann RL, Hughes GC. An Integrated Approach to Thoracoabdominal Aortic Aneurysm Repair: Complimentary Roles of Open and Hybrid Approaches. J Vasc Surg 2016. [DOI: 10.1016/j.jvs.2015.10.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Benrashid E, Wang H, Keenan JE, Andersen ND, Meza JM, McCann RL, Hughes GC. Evolving practice pattern changes and outcomes in the era of hybrid aortic arch repair. J Vasc Surg 2015; 63:323-31. [PMID: 26518097 DOI: 10.1016/j.jvs.2015.09.004] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2015] [Accepted: 09/14/2015] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The role of hybrid repair in the management of aortic arch pathology, and long-term outcomes with these techniques, remains uncertain. We report a decade of experience with hybrid arch repair (HAR) and assess institutional practice patterns with regard to the use of hybrid and open techniques. METHODS Hybrid and open total and distal arch procedures performed between July 2005 and January 2015 were identified from a prospectively maintained, institutional aortic surgery database. Perioperative morbidity and mortality, freedom from reintervention, and long-term survival were calculated. Hybrid and open procedural volumes over the study period were assessed to evaluate for potential practice pattern changes. RESULTS During the study period 148 consecutive procedures were performed for repair of transverse and distal aortic arch pathology, including 101 hybrid repairs and 47 open total or distal arch repairs. Patients in the hybrid repair group were significantly older with a greater incidence of chronic kidney disease, peripheral vascular disease, and chronic lung disease. Perioperative mortality and outcomes were not significantly different between the hybrid and open groups, aside from decreased median length of stay after hybrid repair. Need for subsequent reintervention was significantly greater after hybrid repair. Unadjusted long-term survival was superior after open repair (70% 5-year survival open vs 47% hybrid; P = .03), although aorta-specific survival was similar (98% 5-year aorta-specific survival open vs 93% hybrid; P = .59). Institutional use of HAR decreased over the final 3 years of the study, with an associated increased use of open total or distal arch repairs. This was primarily the result of decreased use of native zone 0 hybrid procedures. Concurrent with this apparent increased stringency around patient selection for HAR, perioperative morbidity and mortality was reduced, including avoidance of retrograde type A dissection. CONCLUSIONS HAR remains a viable option for higher-risk patients with transverse arch pathology with perioperative outcomes and long-term aorta-specific survival similar to open repair, albeit at a cost of increased reintervention. This observational single-institution study would suggest decreased use in more recent years in favor of open repair due to avoidance of native zone 0 hybrid procedures. This decline in the institutional use of native zone 0 hybrid repairs was associated with improved perioperative outcomes.
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Affiliation(s)
- Ehsan Benrashid
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Hanghang Wang
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Jeffrey E Keenan
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Nicholas D Andersen
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - James M Meza
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Richard L McCann
- Division of Vascular Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - G Chad Hughes
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC.
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Schechter MA, Ganapathi AM, Englum BR, Keenan JE, Wang H, Hughes GC, McCann RL. PC46. Improved Long-Term Survival of EVAR Compared to Open Repair. J Vasc Surg 2015. [DOI: 10.1016/j.jvs.2015.04.247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Benrashid E, Wang H, Keenan JE, Andersen ND, Meza JM, McCann RL, Hughes GC. SS7. Hybrid Repair of the Aortic Arch: Long-Term Outcomes After a Decade of Intervention. J Vasc Surg 2015. [DOI: 10.1016/j.jvs.2015.04.077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Williams JA, Hanna JM, Shah AA, Andersen ND, McDonald MT, Jiang YH, Wechsler SB, Zomorodi A, McCann RL, Hughes GC. Adult surgical experience with Loeys-Dietz syndrome. Ann Thorac Surg 2015; 99:1275-81. [PMID: 25678502 DOI: 10.1016/j.athoracsur.2014.11.021] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Revised: 11/02/2014] [Accepted: 11/17/2014] [Indexed: 12/20/2022]
Abstract
BACKGROUND Loeys-Dietz syndrome (LDS) results from mutations in receptors for the cytokine transforming growth factor-β leading to aggressive aortic pathology sometimes accompanied by specific phenotypic features including bifid uvula, hypertelorism, cleft palate, and generalized arterial tortuosity. We reviewed our adult surgical experience with LDS in order to validate current recommendations regarding management of this newly described disease. METHODS All adult (≥ 18 years old) patients with LDS undergoing surgical treatment at a single referral institution from September 1999 to May 2013 were retrospectively reviewed. RESULTS Eleven adult LDS patients were identified by clinical criteria and genotyping. Seven (64%) experienced acute type A dissection at some point in their lives. All eventually required aortic root replacement, and 73% required multiple vascular surgical interventions. Over a mean follow-up of 65 ± 49 months, 2.8 cardiovascular procedures per patient were performed. In patients with type A dissection, a mean of 3.4 operations were performed versus 1.8 operations for patients without dissection. Total aortic replacement was required in 5 patients (45%) and 2 (18%) required neurosurgical intervention for cerebrovascular pathology. There was 1 late death from infectious complications, and no deaths from vascular catastrophe. CONCLUSIONS These results confirm the aggressive nature of LDS aortic pathology. However, the improved survival compared with earlier LDS reports suggest that aggressive treatment strategies may alter outcomes and improve the natural history of this syndrome.
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Affiliation(s)
- Jason A Williams
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Jennifer M Hanna
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Asad A Shah
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Nicholas D Andersen
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Marie T McDonald
- Department of Pediatrics, Division of Medical Genetics, Duke University Medical Center, Durham, North Carolina
| | - Yong-Hui Jiang
- Department of Pediatrics, Division of Medical Genetics, Duke University Medical Center, Durham, North Carolina
| | - Stephanie Burns Wechsler
- Department of Pediatrics, Division of Medical Genetics, Duke University Medical Center, Durham, North Carolina; Department of Pediatrics, Division of Cardiology, Duke University Medical Center, Durham, North Carolina
| | - Ali Zomorodi
- Division of Neurosurgery, Duke University Medical Center, Durham, North Carolina
| | - Richard L McCann
- Division of Vascular Surgery, Duke University Medical Center, Durham, North Carolina
| | - G Chad Hughes
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, North Carolina.
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McGinigle KL, Pascarella L, Shortell CK, Cox MW, McCann RL, Mureebe L. Spliced arm vein grafts are a durable conduit for lower extremity bypass. Ann Vasc Surg 2015; 29:716-21. [PMID: 25638725 DOI: 10.1016/j.avsg.2014.11.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2014] [Revised: 10/29/2014] [Accepted: 11/07/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Many patients with peripheral vascular disease (PAD) requiring revascularization do not have adequate ipsilateral great saphenous vein (GSV) for constructing a bypass because of intrinsic vein disease or prior harvesting for limb or coronary bypass. Prosthetic conduits have poor long-term patency, especially for distal bypass. With advancing endovascular sophistication, tibial angioplasty may be a good revascularization option, but we hypothesize that using spliced arm vein for distal lower extremity bypass is still a well-tolerated and more durable solution. METHODS A retrospective chart review was conducted of all PAD patients undergoing lower extremity bypass or tibial angioplasty for lifestyle-limiting claudication or critical limb ischemia at a single institution over a 7-year period. Statistical analysis was conducted by Kaplan-Meier survival analysis and Cox proportional hazards model. Statistical significance was set at P = 0.05. RESULTS From 2005 to 2012, there were 120 patients who underwent infrageniculate revascularization with conduit other than GSV. Over half of the patients (66 patients, 71.2% male, mean age 62 years) underwent bypass operations using arm vein conduit, and 88% of those bypasses were to tibial vessels. Patency was 100% at 1 year and 85% at 2 years. There was no impact on patency or amputation rate based on the source of vein or the number of splices. Forty-three patients underwent tibial angioplasty and patency was 70% at 1 year and 50% at 2 years. CONCLUSIONS When GSV is not available, spliced arm vein grafts provide durable lower extremity revascularization with favorable patency and limb preservation rates. Spliced arm vein grafts should be considered over prosthetic grafts and angioplasty alone in patients with distal occlusive disease.
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Affiliation(s)
- Katharine L McGinigle
- Division of Vascular Surgery, Department of General Surgery, Duke Univeristy Medical Center, Duke University, Durham, NC
| | - Luigi Pascarella
- Division of Vascular Surgery, Department of General Surgery, Duke Univeristy Medical Center, Duke University, Durham, NC
| | - Cynthia K Shortell
- Division of Vascular Surgery, Department of General Surgery, Duke Univeristy Medical Center, Duke University, Durham, NC
| | - Mitchell W Cox
- Division of Vascular Surgery, Department of General Surgery, Duke Univeristy Medical Center, Duke University, Durham, NC
| | - Richard L McCann
- Division of Vascular Surgery, Department of General Surgery, Duke Univeristy Medical Center, Duke University, Durham, NC
| | - Leila Mureebe
- Division of Vascular Surgery, Department of General Surgery, Duke Univeristy Medical Center, Duke University, Durham, NC.
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Turley RS, Unger J, Cox MW, Lawson J, McCann RL, Shortell CK. Atypical Aortic Thrombus: Should Nonoperative Management Be First Line? Ann Vasc Surg 2014; 28:1610-7. [DOI: 10.1016/j.avsg.2014.03.028] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2014] [Accepted: 03/12/2014] [Indexed: 11/25/2022]
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Hughes GC, Ganapathi AM, Keenan JE, Englum BR, Hanna JM, Schechter MA, Wang H, McCann RL. Thoracic endovascular aortic repair for chronic DeBakey IIIb aortic dissection. Ann Thorac Surg 2014; 98:2092-7; discussion 2098. [PMID: 25282168 DOI: 10.1016/j.athoracsur.2014.06.066] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2014] [Revised: 06/01/2014] [Accepted: 06/09/2014] [Indexed: 11/25/2022]
Abstract
BACKGROUND Thoracic endovascular aortic repair (TEVAR) for chronic DeBakey IIIb dissection with associated descending aneurysm remains controversial. This study examines long-term results of TEVAR for this disorder including examination of anatomic features associated with TEVAR outcomes. METHODS Between July 2005 and January 2013, 32 patients underwent TEVAR for chronic (>30 days) DeBakey IIIb dissection involving the descending thoracic aorta at a single institution and constituted the study cohort. RESULTS The mean interval from dissection to TEVAR was 32 ± 44 months (range, 1 to 146 months). There were no 30-day or in-hospital deaths, strokes, or paraplegia. During a 54-month median follow-up, there were no aortic-related deaths. Significant thoracic aneurysm sac regression (>1 cm) in the intervened segment was observed in 89%. Thoracic remodeling was not correlated with the number of visceral vessels arising from the true lumen or the number or size of residual distal fenestrations; failure of thoracic remodeling was associated with fenestrations distal to the endograft(s) in the descending thoracic aorta, most often stent graft-induced new entry tears. Complete resolution of the thoracic and abdominal false lumen after TEVAR was observed in 15.6% (n = 5). All patients in this group had all visceral vessels arising from the true lumen and fewer than three residual distal fenestrations. CONCLUSIONS Thoracic endovascular aortic repair is effective for chronic DeBakey IIIb dissection with associated descending aneurysm, with excellent 30-day and long-term outcomes and significant aortic remodeling in the vast majority of patients. Thoracic remodeling does not appear dependent on distal anatomic characteristics of the true and false lumens, although care should be taken to cover all thoracic fenestrations and avoid creation of stent graft-induced new entry tears to ensure clinical success. Complete aortic remodeling was observed only in the setting of all visceral vessels off the true lumen with fewer than three residual distal fenestrations, and this would appear the ideal anatomy for TEVAR in this scenario.
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Affiliation(s)
- G Chad Hughes
- Department of Surgery, Duke University Medical Center, Durham, North Carolina.
| | - Asvin M Ganapathi
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Jeffrey E Keenan
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Brian R Englum
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Jennifer M Hanna
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Matthew A Schechter
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Hanghang Wang
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Richard L McCann
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
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Andersen ND, Keenan JE, Ganapathi AM, Gaca JG, McCann RL, Hughes GC. Current management and outcome of chronic type B aortic dissection: results with open and endovascular repair since the advent of thoracic endografting. Ann Cardiothorac Surg 2014; 3:264-74. [PMID: 24967165 DOI: 10.3978/j.issn.2225-319x.2014.05.07] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Accepted: 05/20/2014] [Indexed: 11/14/2022]
Abstract
BACKGROUND Thoracic endovascular aortic repair (TEVAR) has become the preferred treatment for chronic type B aortic dissection (CTBAD) at our institution. However, it remains incapable of treating all patients with CTBAD. The present study aims to review our contemporary results with open and endovascular CTBAD repairs since the advent of thoracic endografting. METHODS The records of all patients undergoing index repair of CTBAD (chronic DeBakey type IIIA, IIIB and repaired type I) at our institution between June 2005 and December 2013, were retrospectively reviewed. RESULTS A total of 107 patients underwent CTBAD repair, of whom 70% (n=75) underwent endovascular-based procedures [44 TEVAR, 27 hybrid arch and four hybrid thoracoabdominal aortic aneurysm (TAAA) repair] and 30% (n=32) underwent open procedures (nine open descending and 23 open TAAA). Connective tissue disease (CTD), prior aortic surgery and DeBakey dissection type were strongly associated with the choice of operation. The rates of stroke, paraplegia and operative mortality following endovascular-based repairs were 0%, 0% and 4% (n=3), respectively. Adverse neurologic events were higher following open repair, and rates of stroke, paraplegia, and operative mortality were 16% (n=5), 9% (n=3), and 6% (n=2), respectively. However, 1- and 5-year survival rates were similar for endovascular-based repairs (86% and 65%, respectively), and open repairs (88% and 79%, respectively). Over a median follow-up interval of 34 months, the rate of descending aortic reintervention was 24% (n=18) following endovascular-based repairs and 0% following open repairs (P=0.001). Forty-four percent (n=8) of descending aortic reinterventions were required to treat stent graft complications (five endoleak, two stent graft collapse and one stent graft-induced new entry tear) and the remainder were required to treat metachronous pathology (n=2) or progressive aneurysmal disease related to persistent distal fenestrations (n=8). CONCLUSIONS Endovascular repair of CTBAD was associated with excellent procedural and survival outcomes, but at the expense of further reinterventions. Open repair remains relevant for patients who are not candidates for endovascular repair and was associated with higher procedural morbidity but similar overall survival and fewer reinterventions.
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Affiliation(s)
- Nicholas D Andersen
- 1 Division of Cardiovascular and Thoracic Surgery, 2 Division of Vascular Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Jeffrey E Keenan
- 1 Division of Cardiovascular and Thoracic Surgery, 2 Division of Vascular Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Asvin M Ganapathi
- 1 Division of Cardiovascular and Thoracic Surgery, 2 Division of Vascular Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Jeffrey G Gaca
- 1 Division of Cardiovascular and Thoracic Surgery, 2 Division of Vascular Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Richard L McCann
- 1 Division of Cardiovascular and Thoracic Surgery, 2 Division of Vascular Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - G Chad Hughes
- 1 Division of Cardiovascular and Thoracic Surgery, 2 Division of Vascular Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
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Ganapathi AM, Englum BR, Keenan JE, Schechter MA, Wang H, Vavalle JP, Kevin Harrison J, McCann RL, Chad Hughes G. Role of Cardiac Evaluation Prior to Thoracic Endovascular Aortic Repair. J Vasc Surg 2013. [DOI: 10.1016/j.jvs.2013.10.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Hanna JM, Andersen ND, Ganapathi AM, McCann RL, Hughes GC. Five-year results for endovascular repair of acute complicated type B aortic dissection. J Vasc Surg 2013; 59:96-106. [PMID: 24094903 DOI: 10.1016/j.jvs.2013.07.001] [Citation(s) in RCA: 104] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2013] [Revised: 07/08/2013] [Accepted: 07/10/2013] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Despite a current lack of U.S. Food and Drug Administration approval for the indication, thoracic endovascular aortic repair (TEVAR) has replaced open surgical management for acute complicated type B aortic dissection due to promising short- and midterm data. However, long-term results, with a view toward durability and need for secondary procedures, are limited. As such, the objective of the present study is to report long-term outcomes of TEVAR for acute (≤ 2 weeks from symptom onset) complicated type B dissection. METHODS Between July 2005 and September 2012, 50 consecutive patients underwent TEVAR for management of acute complicated type B dissection at a single referral institution. Patient records were retrospectively reviewed from a prospectively maintained clinical database. RESULTS Indications for intervention included rupture in 10 (20%), malperfusion in 24 (48%), and/or refractory pain/impending rupture in 17 (34%). One patient (2%) had both rupture and malperfusion indications. Ten (20%) patients required one or more adjunctive procedures, in addition to TEVAR, to treat malperfusion syndromes. In-hospital and 30-day rates of death were both 0%; 30-day/in-hospital rates of stroke, permanent paraplegia/paraparesis, and new-onset dialysis were 2% (n = 1), 2% (n = 1), and 4% (n = 2), respectively. Median follow-up was 33.8 months [interquartile range, 12.3-56.6 months]. Overall survival at 5 and 7 years was 84%, with no deaths attributable to aortic pathology. Thirteen (26%) patients required a total of 17 reinterventions over the study period for type I endoleak (n = 5), metachronous aortic pathology (n = 5), persistent false lumen pressurization via distal fenestrations (n = 4), type II endoleak (n = 2), or retrograde acute type A aortic dissection (n = 1). Median time to first reintervention was 4.5 months (range, 0 days-40.3 months). Of the 17 total reinterventions, six (35%) were performed using open techniques and 11 (65%) with endovascular or hybrid methods; there was no difference in survival between patients who did or did not require reintervention. CONCLUSIONS This study confirms the excellent short-term outcomes of TEVAR for acute complicated type B dissection and demonstrates the results to be durable and sustained over long-term follow-up. Although aortic reinterventions were required in one-quarter of patients, no aortic-related deaths were observed. These data support the use of TEVAR for acute complicated type B aortic dissection but also highlight the importance of life-long aortic surveillance by an experienced aortic referral center in order to identify and treat complications of the underlying disease process and treatment, as well as new aortic pathologies, as they arise.
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Affiliation(s)
- Jennifer M Hanna
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Nicholas D Andersen
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Asvin M Ganapathi
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Richard L McCann
- Division of Vascular Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - G Chad Hughes
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC.
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Hughes GC, Andersen ND, Hanna JM, McCann RL. Thoracoabdominal aortic aneurysm: hybrid repair outcomes. Ann Cardiothorac Surg 2013; 1:311-9. [PMID: 23977513 DOI: 10.3978/j.issn.2225-319x.2012.08.13] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2012] [Accepted: 08/21/2012] [Indexed: 11/14/2022]
Abstract
BACKGROUND Thoracoabdominal aortic aneurysms (TAAA) remain amongst the most formidable of surgical challenges, particularly degenerative aneurysms in the elderly population with concomitant pulmonary disease. This report presents an update of our robust single-institution experience with "hybrid" TAAA repair including complete visceral debranching and endovascular aneurysm exclusion in high-risk patients. METHODS Between March 2005 and June 2012, 58 patients underwent extra-anatomic debranching of all visceral vessels followed by aneurysm exclusion via endovascular means at a single institution. The median number of visceral vessels bypassed was 4. The debranching and endovascular portions of the procedure were performed as a single stage in the initial 33 patients and as a staged approach in the most recent n=25 cases. RESULTS Median patient age was 69.0 years; 50% were female. All had significant co-morbidity and were considered suboptimal candidates for conventional open surgical repair. Mean aortic diameter was 6.7¡À1.2 cm. Thirty-day/in-hospital rates of death, stroke, and permanent paraparesis/paraplegia were 9%, 0%, and 4%, respectively; in the most recent 25 patients undergoing staged repair these rates were 4%, 0%, and 0%. Over a mean follow-up of 26¡À21 months, visceral graft patency is 95.3%; all occluded limbs were to renal vessels and none resulted in permanent dialysis. Two patients (3%) have required re-intervention, one for type Ib and one for type III endoleak. Five-year freedom from re-intervention was 94%. Kaplan-Meier overall survival was 78% at 1 year and 62% at 5 years, with a 5-year aorta-specific survival of 87%. CONCLUSIONS These updated results continue to support hybrid TAAA repair via complete visceral debranching and endovascular aneurysm exclusion as a good option for elderly high-risk patients less suited to conventional open repair. A staged approach to debranching and endovascular aneurysm exclusion appears to yield optimal results.
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Hanna JM, Andersen ND, Aziz H, Shah AA, McCann RL, Hughes GC. Results With Selective Preoperative Lumbar Drain Placement for Thoracic Endovascular Aortic Repair. Ann Thorac Surg 2013; 95:1968-74; discussion 1974-5. [DOI: 10.1016/j.athoracsur.2013.03.016] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2012] [Revised: 03/05/2013] [Accepted: 03/07/2013] [Indexed: 11/25/2022]
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Shah AA, McCann RL, Hughes GC. Conformable Gore®TAG®Thoracic Endoprosthesis for the treatment of thoracic aortic aneurysms. Interv Cardiol 2013. [DOI: 10.2217/ica.13.14] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Andersen ND, Barfield ME, Hanna JM, Shah AA, Shortell CK, McCann RL, Hughes GC. Intrathoracic subclavian artery aneurysm repair in the thoracic endovascular aortic repair era. J Vasc Surg 2013; 57:915-25. [DOI: 10.1016/j.jvs.2012.09.074] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2012] [Revised: 09/26/2012] [Accepted: 09/27/2012] [Indexed: 10/27/2022]
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Ganapathi AM, Andersen ND, Prastein DJ, Hashmi ZA, Rogers JG, Milano CA, McCann RL, Hughes GC. Endovascular Stent Grafting of a Left Ventricular Assist Device Outflow Graft Pseudoaneurysm. Circ Heart Fail 2013; 6:e16-8. [DOI: 10.1161/circheartfailure.112.971861] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Asvin M. Ganapathi
- From the Divisions of Cardiovascular and Thoracic Surgery (A.M.G., N.D.A., D.J.P., Z.A.H., C.A.M., G.C.H.), Cardiology (J.G.R.), and Vascular Surgery (R.L.M.), Duke University Medical Center, Durham, NC
| | - Nicholas D. Andersen
- From the Divisions of Cardiovascular and Thoracic Surgery (A.M.G., N.D.A., D.J.P., Z.A.H., C.A.M., G.C.H.), Cardiology (J.G.R.), and Vascular Surgery (R.L.M.), Duke University Medical Center, Durham, NC
| | - Deyanira J. Prastein
- From the Divisions of Cardiovascular and Thoracic Surgery (A.M.G., N.D.A., D.J.P., Z.A.H., C.A.M., G.C.H.), Cardiology (J.G.R.), and Vascular Surgery (R.L.M.), Duke University Medical Center, Durham, NC
| | - Zubair A. Hashmi
- From the Divisions of Cardiovascular and Thoracic Surgery (A.M.G., N.D.A., D.J.P., Z.A.H., C.A.M., G.C.H.), Cardiology (J.G.R.), and Vascular Surgery (R.L.M.), Duke University Medical Center, Durham, NC
| | - Joseph G. Rogers
- From the Divisions of Cardiovascular and Thoracic Surgery (A.M.G., N.D.A., D.J.P., Z.A.H., C.A.M., G.C.H.), Cardiology (J.G.R.), and Vascular Surgery (R.L.M.), Duke University Medical Center, Durham, NC
| | - Carmelo A. Milano
- From the Divisions of Cardiovascular and Thoracic Surgery (A.M.G., N.D.A., D.J.P., Z.A.H., C.A.M., G.C.H.), Cardiology (J.G.R.), and Vascular Surgery (R.L.M.), Duke University Medical Center, Durham, NC
| | - Richard L. McCann
- From the Divisions of Cardiovascular and Thoracic Surgery (A.M.G., N.D.A., D.J.P., Z.A.H., C.A.M., G.C.H.), Cardiology (J.G.R.), and Vascular Surgery (R.L.M.), Duke University Medical Center, Durham, NC
| | - G. Chad Hughes
- From the Divisions of Cardiovascular and Thoracic Surgery (A.M.G., N.D.A., D.J.P., Z.A.H., C.A.M., G.C.H.), Cardiology (J.G.R.), and Vascular Surgery (R.L.M.), Duke University Medical Center, Durham, NC
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Castleberry AW, White RR, De La Fuente SG, Clary BM, Blazer DG, McCann RL, Pappas TN, Tyler DS, Scarborough JE. The impact of vascular resection on early postoperative outcomes after pancreaticoduodenectomy: an analysis of the American College of Surgeons National Surgical Quality Improvement Program database. Ann Surg Oncol 2012; 19:4068-77. [PMID: 22932857 DOI: 10.1245/s10434-012-2585-y] [Citation(s) in RCA: 93] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2012] [Indexed: 12/15/2022]
Abstract
BACKGROUND Several single-center reports suggest that vascular resection (VR) during pancreaticoduodenectomy (PD) for patients with pancreatic adenocarcinoma is feasible without affecting early postoperative mortality or morbidity. Our objective is to review the outcomes associated with VR during PD using a large multicenter data source. METHODS A retrospective cohort analysis was performed using the National Surgical Quality Improvement Program Participant User Files for 2005-2009. All patients undergoing PD for a postoperative diagnosis of malignant neoplasm of the pancreas were included. Forward stepwise multivariate regression analysis was used to determine the association between VR during PD and 30-day postoperative mortality and morbidity after adjustment for patient demographics and comorbidities. RESULTS 3,582 patients were included for analysis, 281 (7.8 %) of whom underwent VR during PD. VR during PD was associated with significantly greater risk-adjusted 30-day postoperative mortality [5.7 % with VR versus 2.9 % without VR, adjusted odds ratio (AOR) 2.1, 95 % confidence interval (CI) 1.22-3.73, P = 0.008] and overall morbidity (39.9 % with VR versus 33.3 % without VR, AOR 1.36, 95 % CI 1.05-1.75, P = 0.02). There was no significant difference in risk-adjusted postoperative mortality or morbidity between those patients undergoing VR by the primary surgical team versus those patients undergoing VR by a vascular surgical team. CONCLUSIONS Contrary to the findings of several previously published single-center analyses, the current study demonstrates increased 30-day postoperative morbidity and mortality in PD with VR when compared with PD alone.
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Abstract
OBJECTIVE Hybrid repair of the transverse aortic arch may allow for aortic arch repair with reduced morbidity in patients who are suboptimal candidates for conventional open surgery. We present our results with an algorithmic approach to hybrid arch repair, based on the extent of aortic disease and patient comorbidities. METHODS Between August 2005 and January 2012, 87 patients underwent hybrid arch repair by three principal procedures: zone 1 endograft coverage with extra-anatomic left carotid revascularization (zone 1; n = 19), zone 0 endograft coverage with aortic arch debranching (zone 0; n = 48), or total arch replacement with staged stented elephant trunk completion (stented elephant trunk; n = 20). RESULTS The mean patient age was 64 years, and the mean expected in-hospital mortality rate was 16.3% as calculated by the EuroSCORE II. Of operations, 22% (n = 19) were nonelective. Sternotomy, cardiopulmonary bypass, and deep hypothermic circulatory arrest were required in 78% (n = 68), 45% (n = 39), and 31% (n = 27) of patients to allow for total arch replacement, arch debranching, or other concomitant cardiac procedures, including ascending with or without hemiarch replacement in 17% (n = 8) of patients undergoing zone 0 repair. All stented elephant trunk procedures (n = 20) and 19% (n = 9) of zone 0 procedures were staged, with 41% (n = 12) of patients undergoing staged repair during a single hospitalization. The 30-day/in-hospital rates of stroke and permanent paraplegia or paraparesis were 4.6% (n = 4) and 1.2% (n = 1). Of 27 patients with native ascending aorta zone 0 proximal landing zone, three (11.1%) experienced retrograde type A dissection after endograft placement. The overall in-hospital mortality rate was 5.7% (n = 5); however, 30-day/in-hospital mortality increased to 14.9% (n = 13) owing to eight 30-day out-of-hospital deaths. Native ascending aorta zone 0 endograft placement was found to be the only univariate predictor of 30-day in-hospital mortality (odds ratio, 4.63; 95% confidence interval, 1.35-15.89; P = .02). Over a mean follow-up period of 28.5 ± 22.2 months, 13% (n = 11) of patients required reintervention for type 1A (n = 4), type 2 (n = 6), or type 3 (n = 1) endoleak. Kaplan-Meier estimates of survival at 1 year, 3 years, and 5 years were 73%, 60%, and 51%. CONCLUSIONS Hybrid aortic arch repair can be tailored to patient anatomy and comorbid status to allow complete repair of aortic pathology, frequently in a single stage, with acceptable outcomes. However, endograft placement in the native ascending aorta is associated with high rates of retrograde type A dissection and 30-day/in-hospital mortality and should be approached with caution.
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Affiliation(s)
- Nicholas D Andersen
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA
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Shah AA, Barfield ME, Andersen ND, Williams JB, Shah JA, Hanna JM, McCann RL, Hughes GC. Results of thoracic endovascular aortic repair 6 years after United States Food and Drug Administration approval. Ann Thorac Surg 2012; 94:1394-9. [PMID: 22785216 PMCID: PMC4089907 DOI: 10.1016/j.athoracsur.2012.05.072] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2012] [Revised: 05/13/2012] [Accepted: 05/16/2012] [Indexed: 11/28/2022]
Abstract
BACKGROUND Since United States Food and Drug Administration approval in 2005, the short-term safety and efficacy of thoracic endovascular aortic repair (TEVAR) have been established. However, longer-term follow-up data remain lacking. The objective of this study is to report 6-year outcomes of TEVAR in clinical practice. METHODS A prospective cohort review was performed of all patients undergoing TEVAR at a single referral institution between March 2005 and May 2011. Rates of reintervention were noted. Overall and aortic-specific survival were determined using Kaplan-Meier methods. Log-rank tests were used to compare survival between groups. RESULTS During the study interval, 332 TEVAR procedures were performed in 297 patients. Reintervention was required after 12% of procedures at a mean of 8 ± 14 months after initial TEVAR and was higher in the initial tercile of patients (15.0% vs 9.9%). The 6-year freedom from reintervention was 84%. Type I endoleak was the most common cause of reintervention (5%). Six-year overall survival was 54%, and aorta-specific survival was 92%. Long-term survival was significantly lower than that of an age- and sex-matched United States population (p < 0.001). Survival was similar between patients requiring a reintervention vs those not (p = 0.26). Survival was different based on indication for TEVAR (p = 0.007), and patients with degenerative aneurysms had the lowest survival (47% at 6 years). Cardiopulmonary pathologies were the most common cause of death (27 of 93 total deaths). CONCLUSIONS Long-term aortic-related survival after TEVAR is high, and the need for reintervention is infrequent. However, overall long-term survival is low, particularly for patients with degenerative aneurysms, and additional work is needed to identify patients unlikely to derive a survival benefit from TEVAR.
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Affiliation(s)
- Asad A Shah
- Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
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Andersen ND, Hanna JM, Bhattacharya SD, Williams JB, Gaca JG, McCann RL, Hughes CG. Insurance status predicts non-elective case status but not outcomes of thoracic aortic operations. J Am Coll Surg 2012. [DOI: 10.1016/j.jamcollsurg.2012.06.136] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Hanna JM, Andersen ND, Shah AA, Harrison KJ, McCann RL, Hughes CG. Open femoral access for transcatheter aortic intervention leads to fewer major vascular complications. J Am Coll Surg 2012. [DOI: 10.1016/j.jamcollsurg.2012.06.128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Shah AA, Craig DM, Andersen ND, Williams JB, Bhattacharya SD, Shah SH, McCann RL, Hughes GC. Risk factors for 1-year mortality after thoracic endovascular aortic repair. J Thorac Cardiovasc Surg 2012; 145:1242-7. [PMID: 22698564 DOI: 10.1016/j.jtcvs.2012.05.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2012] [Revised: 04/13/2012] [Accepted: 05/04/2012] [Indexed: 12/01/2022]
Abstract
OBJECTIVE Thoracic endovascular aortic repair, although physiologically well tolerated, may fail to confer significant survival benefit in some high-risk patients. In an effort to identify patients most likely to benefit from intervention, the present study sought to determine the risk factors for 1-year mortality after thoracic endovascular aortic repair. METHODS A retrospective review was performed on prospectively collected data from all patients undergoing thoracic endovascular aortic repair from 2002 to 2010 at a single institution. Univariate analysis and multivariate Cox proportional hazards regression analysis were used to identify risk factors associated with mortality within 1 year after thoracic endovascular aortic repair. RESULTS During the study period, 282 patients underwent at least 1 thoracic endovascular aortic repair; index procedures included descending aortic repair (n = 189), hybrid arch repair (n = 55), and hybrid thoracoabdominal repair (n = 38). The 30-day/in-hospital mortality was 7.4% (n = 21) and the overall 1-year mortality was 19% (n = 54). Cardiopulmonary pathologies were the most common cause of nonperioperative 1-year mortality (22%, n = 12). Multivariate modeling demonstrated 3 variables independently associated with 1-year mortality: age older than 75 years (hazard ratio, 2.26; P = .005), aortic diameter greater than 6.5 cm (hazard ratio, 2.20; P = .007), and American Society of Anesthesiologists class 4 (hazard ratio, 1.85; P = .049). A baseline creatinine greater than 1.5 mg/dL (hazard ratio, 1.79; P = .05) and congestive heart failure (hazard ratio, 1.87; P = .08) were also retained in the final model. These 5 variables explained a large proportion of the risk of 1-year mortality (C statistic = 0.74). CONCLUSIONS Age older than 75 years, aortic diameter greater than 6.5 cm, and American Society of Anesthesiologists class 4 are independently associated with 1-year mortality after thoracic endovascular aortic repair. These clinical characteristics may help risk-stratify patients undergoing thoracic endovascular aortic repair and identify those unlikely to derive a long-term survival benefit from the procedure.
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Affiliation(s)
- Asad A Shah
- Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
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Andersen ND, Williams JB, Shah AA, McCann RL, Hughes GC. SS7. Results with an Algorithmic Approach to Hybrid Repair of the Aortic Arch. J Vasc Surg 2012. [DOI: 10.1016/j.jvs.2012.03.073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Barfield ME, Andersen ND, Shah AA, Shortell CK, McCann RL, Chad Hughes G. PS16. Intra-Thoracic Subclavian Artery Aneurysm Repair in the Thoracic Endovascular Era. J Vasc Surg 2012. [DOI: 10.1016/j.jvs.2012.03.101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Hughes GC, Barfield ME, Shah AA, Williams JB, Kuchibhatla M, Hanna JM, Andersen ND, McCann RL. Staged total abdominal debranching and thoracic endovascular aortic repair for thoracoabdominal aneurysm. J Vasc Surg 2012; 56:621-9. [PMID: 22575483 DOI: 10.1016/j.jvs.2011.11.149] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2011] [Revised: 09/26/2011] [Accepted: 11/12/2011] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Thoracoabdominal aortic aneurysms (TAAAs) occur most commonly in elderly individuals, who are often suboptimal candidates for open repair because of significant comorbidities. The availability of a hybrid option, including open visceral debranching with endovascular aneurysm exclusion, may have advantages in these patients who are at high-risk for conventional repair. This report details the evolution of our technique and results with complete visceral debranching and endovascular aneurysm exclusion for TAAA repair in high-risk patients. METHODS Between March 2005 and June 2011, 47 patients (51% women) underwent extra-anatomic debranching of all visceral vessels, followed by aneurysm exclusion by endovascular means at a single institution. A median of four visceral vessels were bypassed. The debranching procedure was initially performed through a partial right medial visceral rotation approach, leaving the left kidney posterior in the first 22 patients, and in the last 25 by a direct anterior approach to the visceral vessels. The debranching and endovascular portions of the procedure were performed in a single operation in the initial 33 patients and as a staged procedure during a single hospital stay in the most recent 14. RESULTS Median patient age was 71.0 ± 9.8 years. All had significant comorbidity and were considered suboptimal candidates for conventional repair: 55% had undergone previous aortic surgery, 40% were American Society of Anesthesiologists (ASA) class 4, and baseline serum creatinine was 1.5 ± 1.3 mg/dL. The 30-day/in-hospital rates of death, stroke, and permanent paraparesis/plegia were 8.5%, 0%, and 4.3%, respectively, but 0% in the most recent 14 patients undergoing staged repair. These patients had significantly shorter combined operative times (314 vs 373 minutes), decreased intraoperative red blood cell transfusions (350 vs 1400 mL), and were more likely to be extubated in the operating room (50% vs 12%) compared with patients undergoing simultaneous repair. Over a median follow-up of 19.3 ± 18.5 months, visceral graft patency was 97%; all occluded limbs were to renal vessels and clinically silent. There have been no type I or III endoleaks or reinterventions. Kaplan-Meier overall survival is 70.7% at 2 years and 57.9% at 5 years. CONCLUSIONS Hybrid TAAA repair through complete visceral debranching and endovascular aneurysm exclusion is a good option for elderly high-risk patients less suited to conventional repair in centers with the requisite surgical expertise with visceral revascularization. A staged approach to debranching and endovascular aneurysm exclusion during a single hospitalization appears to yield optimal results.
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Affiliation(s)
- G Chad Hughes
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
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Turley RS, Peterson K, Barbas AS, Ceppa EP, Paulson EK, Blazer DG, Clary BM, Pappas TN, Tyler DS, McCann RL, White RR. Vascular surgery collaboration during pancreaticoduodenectomy with vascular reconstruction. Ann Vasc Surg 2012; 26:685-92. [PMID: 22305864 DOI: 10.1016/j.avsg.2011.11.009] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2011] [Revised: 11/02/2011] [Accepted: 11/08/2011] [Indexed: 12/17/2022]
Abstract
BACKGROUND Once thought to have unresectable disease, pancreatic cancer patients with portal venous involvement are now reported to have comparable survival after pancreaticoduodenectomy (PD) with vascular reconstruction (VR) as compared with patients without vascular involvement. We hypothesize that a multidisciplinary approach involving a vascular surgeon will minimize morbidity and improve patency of VRs. METHODS We identified 204 patients who underwent PD for pancreatic adenocarcinoma from 1997 to 2008. Patients who underwent PD with VR (N = 42) were compared with those who underwent standard PD (N = 162). VRs were performed by a vascular surgeon and involved primary repair (N = 8), vein patch (N = 25), or interposition grafting (N = 9) with femoral or other venous conduit. RESULTS Patients undergoing PD with VR had larger tumors (3.0 cm vs. 2.5 cm, P < 0.01) but did not have different rates of tumor-free margins (73% vs. 72%, P = 0.84) or lymph nodes metastases (50% vs. 38%, P = 0.14). The VR group had higher median blood loss (875 mL vs. 550 mL, P = 0<0.01), but no differences in mortality, complication rates, length of stay, or readmission rates were found in a median follow-up of 29 months. Overall survival rates were similar. Predictors of mortality on multivariate analysis included increasing histological grade (P = 0.01), positive lymph nodes (P = 0.01), and increasing tumor size (P = 0.01), but not VR (P = 0.28). When evaluated by computed tomography scans within 6 months postoperatively, 97% of reconstructions remained patent. CONCLUSIONS The need for VR is not a contraindication to potentially curative resection in patients with pancreatic adenocarcinoma. Assistance of a vascular surgeon during VR may allow moderate-volume centers to achieve outcomes comparable with high-volume centers.
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Affiliation(s)
- Ryan S Turley
- Department of Surgery, Duke University, Durham, NC 27710, USA
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Lee TC, Andersen ND, Williams JB, Bhattacharya SD, McCann RL, Hughes GC. Results with a selective revascularization strategy for left subclavian artery coverage during thoracic endovascular aortic repair. Ann Thorac Surg 2011; 92:97-102; discussion 102-3. [PMID: 21718834 DOI: 10.1016/j.athoracsur.2011.03.089] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2010] [Revised: 03/14/2011] [Accepted: 03/15/2011] [Indexed: 11/29/2022]
Abstract
BACKGROUND The need for routine left subclavian artery (LSCA) revascularization when this vessel is covered during thoracic endovascular aortic repair remains controversial. We report our results with a selective LSCA revascularization strategy during thoracic endovascular aortic repair. METHODS Between May 2002 and March 2010, 287 thoracic endovascular aortic repair procedures were performed at our institution. LSCA coverage occurred in 145 (51%), which form the basis of this report. RESULTS Left subclavian artery revascularization was performed in 32 patients (22%) through a left common carotid-LSCA bypass. Indications for selective LSCA revascularization included spinal cord protection in 10, patent pedicled left internal mammary artery graft in 9, left arm ischemia after LSCA coverage in 5, origin of the left vertebral artery from the arch in 4, dialysis access in the left arm in 2, and vertebrobasilar insufficiency in 2. There were no instances of dominant left vertebral artery. The revascularized and non-revascularized groups had similar rates of death (6.3% vs 1.8%; p=0.21), stroke (3.1% vs 3.5%; p>0.99), permanent paraplegia or paraparesis (3.1% vs 0%; p=0.22), and type II endoleak (4.3% vs 6.5%; p>0.99). There were no instances of ischemic stroke related to left posterior circulation hypoperfusion. Four complications of carotid-subclavian bypass occurred in 3 patients (9.4%). CONCLUSIONS Selective LSCA revascularization is safe and does not appear to increase the risk of neurologic events. Further, subclavian revascularization is not without complications, which should be considered with regards to a nonselective revascularization strategy.
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Affiliation(s)
- Teng C Lee
- Department of Surgery, Duke University Medical Center, Durham, North Carolina 27710, USA
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Andersen ND, Bhattacharya SD, Williams JB, McCann RL, Hughes GC. Mycotic aneurysm of the thoracoabdominal aorta in a child with end-stage renal disease. J Vasc Surg 2011; 54:1161-3. [PMID: 21723063 DOI: 10.1016/j.jvs.2011.04.051] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2010] [Revised: 02/23/2011] [Accepted: 04/23/2011] [Indexed: 10/18/2022]
Abstract
A 5-year-old child with nephrotic syndrome developed a mycotic saccular thoracoabdominal aortic aneurysm (TAAA) involving the visceral segment within a 4-month period following pneumococcal bacteremia and presumed spontaneous bacterial peritonitis (SBP). Due to continued aneurysm growth and progression to end-stage renal disease, TAAA repair was performed, followed by cadaveric kidney transplantation. This is the first known instance of mycotic aortic aneurysm formation as a consequence of SPB and the first report of TAAA repair in preparation for kidney transplantation in a child.
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Affiliation(s)
- Nicholas D Andersen
- Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
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Williams JB, Piccini JP, Bhattacharya SD, Andersen ND, McCann RL, Hughes GC. PS28. Retrograde Ascending Aortic Dissection as an Early Complication of Thoracic Endovascular Aortic Repair. J Vasc Surg 2011. [DOI: 10.1016/j.jvs.2011.03.079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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McCann RL. VS4. Video Presentation Staged Total Abdominal Debranching and TEVAR for Thoracoabdominal Aneurysm. J Vasc Surg 2011. [DOI: 10.1016/j.jvs.2011.03.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Shah AA, Craig DM, Williams JB, Bhattacharya SD, Andersen ND, Shah SH, McCann RL, Hughes GC. PS24. Risk Factors for Non-Procedure Related Mortality One Year after Thoracic Endovascular Aortic Repair. J Vasc Surg 2011. [DOI: 10.1016/j.jvs.2011.03.077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Shah AA, Bhattacharya SD, McCann RL, Hughes GC. Pan-aortic hybrid treatment of mega-aorta syndrome. J Vasc Surg 2011; 53:1398-401. [DOI: 10.1016/j.jvs.2010.11.115] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2010] [Revised: 11/22/2010] [Accepted: 11/24/2010] [Indexed: 10/18/2022]
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Abstract
Loeys-Dietz syndrome (LDS) is a recently identified genetic complex characterized in part by rapidly progressive aortic and branch vessel disease. We now describe total aortic replacement using an open Extent II thoracoabdominal repair followed by second-stage redo-sternotomy for a valve-sparing aortic root replacement and hybrid aortic arch repair in a patient with this syndrome.
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Affiliation(s)
- Judson B Williams
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
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Parsa CJ, Williams JB, Bhattacharya SD, Wolfe WG, Daneshmand MA, McCann RL, Hughes GC. Midterm results with thoracic endovascular aortic repair for chronic type B aortic dissection with associated aneurysm. J Thorac Cardiovasc Surg 2011; 141:322-7. [PMID: 21241855 DOI: 10.1016/j.jtcvs.2010.10.043] [Citation(s) in RCA: 87] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2010] [Revised: 10/11/2010] [Accepted: 10/24/2010] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Thoracic endovascular aortic repair for chronic type B aortic dissection with associated descending thoracic aneurysm remains controversial. Concerns include potential ischemic complications due to branch vessel origin from the chronic false lumen and continued retrograde false lumen/aneurysm sac pressurization via fenestrations distal to implanted endografts. The present study examines midterm results with thoracic endovascular aortic repair for chronic (>2 weeks) type B aortic dissection with associated aneurysm to better understand the potential role of thoracic endovascular aortic repair for this condition. METHODS Between March 2005 and December 2009, 51 thoracic endovascular aortic repair procedures were performed at a single institution for management of chronic type B dissection. The indication for thoracic endovascular aortic repair was aneurysm in all cases. A subset of 7 patients (14%) underwent placement of the EndoSure wireless pressure measurement system (CardioMEMS, Inc, Atlanta, Ga) in the false lumen adjacent to the primary tear for monitoring aneurysm sac/false lumen pulse pressure after thoracic endovascular aortic repair. RESULTS Mean patient age was 57±12 years (range, 30-82 years); 14 patients (28%) were female. Mean aortic diameter was 6.2±1.4 cm. There were no in-hospital/30-day deaths, strokes, or permanent paraplegia/paresis. There were no complications related to compromise of downstream branch vessels arising from the false lumen. Two patients (3.9%) who had preexisting ascending aortic dilation had retrograde acute type A aortic dissection; both were repaired successfully. Median postoperative length of stay was 4 days. Mean follow-up is 27.0±16.5 months (range, 2-60 months). Actuarial overall survival is 77.7% at 60 months with an actuarial aorta-specific survival of 98% over this same time period. Actuarial freedom from reintervention is 77.3% at 60 months. All patients with the EndoSure wireless pressure measurement system exhibited a decrease in aneurysm sac/false lumen pulse pressure indicating a depressurized false lumen. The aneurysm sac/false lumen pulse pressure ratio decreased from 52%±27% at the predischarge measurement to 14%±5% at the latest follow-up reading (P=.029). CONCLUSIONS Thoracic endovascular aortic repair for chronic type B dissection with associated aneurysm is safe and effective at midterm follow-up. Aneurysm sac/false lumen pulse pressure measurements demonstrate a significant reduction in false lumen endotension, thus ruling out clinically significant persistent retrograde false lumen perfusion and provide proof of concept for a thoracic endovascular aortic repair-based approach. Longer-term follow-up is needed to determine the durability of thoracic endovascular aortic repair for this aortic pathology.
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Affiliation(s)
- Cyrus J Parsa
- Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
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Hughes GC, Lee SM, Daneshmand MA, Bhattacharya SD, Williams JB, Tucker SW, McCann RL. Endovascular repair of descending thoracic aneurysms: results with "on-label" application in the post Food and Drug Administration approval era. Ann Thorac Surg 2010; 90:83-9. [PMID: 20609753 DOI: 10.1016/j.athoracsur.2010.03.052] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2009] [Revised: 03/16/2010] [Accepted: 03/19/2010] [Indexed: 10/19/2022]
Abstract
BACKGROUND Most studies of thoracic endovascular aortic repair (TEVAR) published since the technology gained US Food and Drug Administration (FDA) approval in March 2005 have included multiple applications including dissection, trauma, and "hybrid" approaches, all of which are currently "off-label." However, little post-approval data exist for the only FDA-approved application, namely descending thoracic aneurysm (DTA). The purpose of this study was to examine our experience with TEVAR for aneurysms limited to the descending thoracic aorta. METHODS Between March 23, 2005 (date of initial FDA approval) and April 6, 2009, 210 TEVAR procedures were performed at our institution. Of these, 79 (38%) were for saccular (n = 31) or fusiform (n = 48) DTA and form the basis of this report. Patients requiring "hybrid" approaches other than carotid-subclavian bypass were excluded. Devices utilized were Gore TAG (W. L. Gore Associates, Flagstaff, AZ) (n = 67; 85%), Zenith TX2 (Cook Medical Incorporated, Bloomington, IN) (n = 10; 13%), and Medtronic Talent (Medtronic, Inc, Santa Rosa, CA) (n = 5; 6%); 3 (4%) patients received more than one type of device. RESULTS Median patient age was 73 +/- 4 years; 35 (44%) were female. Mean aortic diameter was 5.8 +/- 1.8 cm. Twenty-four (30%) procedures were urgent-emergent. Thirty-day in-hospital rates of death, stroke, and permanent paraplegia-paresis were 5.1% (n = 4; 1.9% elective mortality), 2.5% (n = 2), and 1.3% (n = 1), respectively. The median postoperative length of stay was 3.0 days (25th and 75th percentiles = 2 and 6, respectively). At a mean follow-up of 23 +/- 17 months (range, 6 to 55), there were 2 (2.5%) late aortic deaths from graft infection (n = 1) and aneurysm rupture (n = 1). Overall actuarial midterm survival is 73% at 55 months, with an aorta-specific actuarial survival of 86% during this same time interval. Five patients (6.3%) required late (>30 days) secondary endovascular re-intervention for type I (n = 4) or type II (n = 1) endoleak; re-intervention was successful in 4 of 5. CONCLUSIONS Despite the advanced age, comorbid conditions, and significant incidence of urgent-emergent status of patients presenting with DTA, on-label application of TEVAR yields excellent 30-day and midterm outcomes, especially when compared with historic rates of morbidity and mortality with open repair. However, "on-label" applications represent a minority of current TEVAR use, likely due to the relative scarcity of DTA. These data appear to support the increasing utilization of TEVAR as a treatment strategy for this pathology.
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Affiliation(s)
- G Chad Hughes
- Department of Surgery, Duke University Medical Center, Durham, North Carolina 27710, USA.
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Affiliation(s)
- Cyrus J Parsa
- Division of Thoracic and Cardiovascular Surgery, Duke University Medical Center, Durham, NC 27710, USA
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Rajagopal K, Rogers JG, Lodge AJ, Gaca JG, McCann RL, Milano CA, Hughes GC. Two-stage total cardioaortic replacement for end-stage heart and aortic disease in Marfan syndrome: case report and review of the literature. J Heart Lung Transplant 2010; 28:958-63. [PMID: 19716050 DOI: 10.1016/j.healun.2009.05.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2008] [Revised: 04/15/2009] [Accepted: 05/06/2009] [Indexed: 11/18/2022] Open
Abstract
A 24-year-old man with Marfan syndrome underwent mitral valve repair for prolapse at age 13. He sustained an acute type A aortic dissection at age 20 and underwent aortic root/ascending aortic replacement with a mechanical valved conduit. He initially did well after the latter procedure, but end-stage heart disease developed 4 years later, apparently secondary to primary cardiomyopathy. Pre-transplant evaluation revealed residual chronic dissection with aneurysmal dilatation of the distal ascending aorta, transverse arch, and descending thoracic aorta. He underwent combined orthotopic heart transplantation (OHT) and total arch replacement (stage I elephant trunk procedure). Subsequently, he underwent extent II thoracoabdominal aneurysm repair, leaving no residual aortic disease. The 2 procedures resulted in total cardioaortic replacement, thus definitively managing his cardiomyopathy and aortic disease resulting from Marfan syndrome. The operative strategies employed represent a novel approach in this clinical setting. This report emphasizes that patients with this disease should not be denied potentially life-saving OHT on the basis of concomitant aortic disease, but rather should be treated in centers offering expertise in both areas of surgical therapy.
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Affiliation(s)
- Keshava Rajagopal
- Department of Surgery (Division of Thoracic and Cardiovascular Surgery), Duke University Medical Center, Durham, North Carolina 27710, USA
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