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Bertoglio L, Oderich G, Melloni A, Gargiulo M, Kölbel T, Adam DJ, Di Marzo L, Piffaretti G, Agrusa CJ, Van den Eynde W. Multicentre International Registry of Open Surgical Versus Percutaneous Upper Extremity Access During Endovascular Aortic Procedures. Eur J Vasc Endovasc Surg 2023; 65:729-737. [PMID: 36740094 DOI: 10.1016/j.ejvs.2023.01.046] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 09/08/2022] [Accepted: 01/27/2023] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To investigate access failure (AF) and stroke rates of aortic procedures performed with upper extremity access (UEA), and compare results of open surgical vs. percutaneous UEA techniques with closure devices. METHODS A physician initiated, multicentre, ambispective, observational registry (SUPERAXA - NCT04589962) was carried out of patients undergoing aortic procedures requiring UEA, including transcatheter aortic valve replacement, aortic arch, and thoraco-abdominal aortic endovascular repair, pararenal parallel grafts, renovisceral and iliac vessel repair. Only vascular procedures performed with an open surgical or percutaneous (with a suture mediated vessel closure device) UEA were analysed. Risk factors and endpoints were classified according to the Society for Vascular Surgery and VARC-3 (Valve Academic Research Consortium) reporting standards. A logistic regression model was used to identify AF and stroke risk predictors, and propensity matching was employed to compare the UEA closure techniques. RESULTS Sixteen centres registered 1 098 patients (806 men [73.4%]; median age 74 years, interquartile range 69 - 79 years) undergoing vascular procedures using open surgical (76%) or percutaneous (24%) UEA. Overall AF and stroke rates were 6.8% and 3.0%, respectively. Independent predictors of AF by multivariable analysis included pacemaker ipsilateral to the access (odds ratio [OR] 3.8, 95% confidence interval [CI] 1.2 - 12.1; p = .026), branched and fenestrated procedure (OR 3.4, 95% CI 1.2 - 9.6; p = .019) and introducer internal diameter ≥ 14 F (OR 6.6, 95% CI 2.1 - 20.7; p = .001). Stroke was associated with female sex (OR 3.4, 95% CI 1.3 - 9.0; p = .013), vessel diameter > 7 mm (OR 3.9, 95% CI 1.1 - 13.8; p = .037), and aortic arch procedure (OR 7.3, 95% CI 1.7 - 31.1; p = .007). After 1:1 propensity matching, there was no difference between open surgical and percutaneous cohorts. However, a statistically significantly higher number of adjunctive endovascular procedures was recorded in the percutaneous cohort (p < .001). CONCLUSION AF and stroke rates during complex aortic procedures employing UEA are non-negligible. Therefore, selective use of UEA is warranted. Percutaneous access with vessel closure devices is associated with similar complication rates, but more adjunctive endovascular procedures are required to avoid surgical exposure.
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Affiliation(s)
- Luca Bertoglio
- Division of Vascular Surgery, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy.
| | - Gustavo Oderich
- Department of Cardiothoracic and Vascular Surgery, The University of Texas Health Science Centre at Houston, McGovern Medical School, Houston, TX, USA
| | - Andrea Melloni
- Division of Vascular Surgery, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Mauro Gargiulo
- Vascular Surgery, Department of Experimental, Diagnostic and Speciality Medicine, University of Bologna, IRCCS S. Orsola Hospital, Bologna, Italy
| | - Tilo Kölbel
- Department of Vascular Medicine, German Aortic Centre, University Heart and Vascular Centre, Hamburg, Germany
| | - Donald J Adam
- Department of Vascular Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Luca Di Marzo
- Vascular and Endovascular Surgery Division, Department of Surgery "Paride Stefanini", Policlinico Umberto I, "Sapienza" University, Rome, Italy
| | - Gabriele Piffaretti
- Vascular Surgery and Interventional Radiology, Department of Medicine and Surgery, University of Insubria School of Medicine, Varese, Italy
| | - Christopher J Agrusa
- Division of Vascular Surgery, New York-Presbyterian Hospital/Weill Cornell Medical Centre, New York, NY, USA
| | - Wouter Van den Eynde
- Department of Vascular and Thoracic Surgery, Imelda Hospital, Bonheiden, Belgium
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Yoon JA, Ahmad MM, Husain A, Walson LA, Syed MN, Tajik AJ, Ammar KA. Hypertrophic cardiomyopathy is associated with dilated sinus of Valsalva: A case-control study. Int J Cardiol Heart Vasc 2023; 45:101180. [PMID: 36785849 DOI: 10.1016/j.ijcha.2023.101180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 01/18/2023] [Accepted: 01/22/2023] [Indexed: 02/03/2023]
Abstract
Background We aimed to test the hypothesis that there is an association between hypertrophic cardiomyopathy and dilated aorta in a case-control, matched-design fashion. Methods Of 65,843 studies done from November 2011 to December 2015, we found, after detailed evaluation by a single author, 153 cases of hypertrophic cardiomyopathy and 3,213 controls who were classified as normal clinically and echocardiographically. Controls were defined as normal patients referred to the echocardiography laboratory with no diagnoses and no known risk factors for dilated aorta (e.g., aortic stenosis, hypertension, aortic regurgitation). Clinical chart review showed none of the risk factors for dilated aorta, and echocardiography did not reveal any abnormalities. Of these 3,213 patients, 153 controls were matched to cases by age and sex by propensity score. Dilated aorta was defined according to clinical, Goldstein, and Lang's criteria. Results The prevalence of a dilated sinus of Valsalva was 9 times higher in hypertrophic cardiomyopathy patients than controls (OR = 9.4, P = 0.003). The 9-fold higher prevalence in hypertrophic cardiomyopathy patients persisted after adjusting for height, weight, and aortic pathology. Association of dilated mid-ascending aorta with hypertrophic cardiomyopathy was significant after adjustment for height and body surface area but became borderline insignificant after adjusting for weight and aortic valve pathology. Conclusion Hypertrophic cardiomyopathy appears to be associated with a dilated sinus of Valsalva, even after adjusting for height, weight, and aortic valve pathology.
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Bertoglio L, Conradi L, Howard DPJ, Kaki A, Van den Eynde W, Rio J, Montorfano M, Dias NV, Ronchey S, Parlani G, Chiesa R, Schewel J; of the PAXA Collaborators. Percutaneous transAXillary access for endovascular aortic procedures in the multicenter international PAXA registry. J Vasc Surg 2021:S0741-5214(21)02154-6. [PMID: 34600031 DOI: 10.1016/j.jvs.2021.08.089] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 08/23/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND The aim of the study was to demonstrate the safety and effectiveness of a suture-mediated vascular closure device to perform hemostasis after an axillary artery access during endovascular procedures on the aortic valve, the aorta and its side branches. METHODS A physician-initiated, international, multicenter, retrospective registry was designed to evaluate the success rate (VARC-2 reporting standards) of percutaneous transaxillary access closure with a suture-mediated closure device. Secondary end points were minor access vascular complications, transient peripheral nerve injury, stroke, and influence on periprocedural outcomes of puncture technique. RESULTS Three hundred thirty-one patients (median age, 76 years; 69.2% males) in 11 centers received a percutaneous transaxillary access during endovascular cardiac (n = 166) or vascular (n = 165) procedures. The closure success rate was 84.6%, with 5 open conversions (1.5%), 45 adjunctive endovascular procedures (13.6%), and 1 nerve injury (0.3%). Secondary closure success was obtained in 325 patients (98%) after 7 bare stenting, 37 covered stenting, and 1 thrombin injection. Introducer sheaths 16F or larger (odds ratio, 3.70; 95% confidence interval, 1.22-11.42) and balloon-assisted hemostasis (odds ratio, 4.45; 95% confidence interval, 1.27-15.68) were associated with closure failure. A threshold of five percutaneous axillary accesses was associated with decreased rates of open conversion, but not with increased primary closure success. Primary closure success was 90.3% in the 175 patients with sheaths smaller than 16F, performed after the first 5 procedures in each center. Temporary nerve injury and stroke were observed in 2% and 4% of patients, respectively. CONCLUSIONS Percutaneous transaxillary aortic procedures, in selected patients, can be performed with low rates of open conversion. The need for additional endovascular bailout procedures is not negligible when introducers sheaths 16F or larger are required.
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Piazza M, Squizzato F, Xodo A, Saviane G, Forcella E, Dal Pont C, Grego F, Antonello M. Determination of Optimal and Safest Proximal Sealing Length During Thoracic Endovascular Aortic Repair. Eur J Vasc Endovasc Surg 2021:S1078-5884(21)00427-5. [PMID: 34247901 DOI: 10.1016/j.ejvs.2021.05.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 04/26/2021] [Accepted: 05/08/2021] [Indexed: 01/12/2023]
Abstract
OBJECTIVE To determine the optimal and safest proximal sealing length (PSL) during thoracic endovascular aortic repair (TEVAR), depending on anatomical aortic arch types and proximal landing zones (LZs). METHODS This was a single centre retrospective observational study of consecutive TEVAR patients (2008-2020). All aortic pathologies requiring Ishimaru landing zone (LZ) 0 - 3 were included; results were stratified by aortic arch type. The PSL was measured as the length of complete aortic wall to endograft apposition at the level of the proximal neck. The primary endpoint was proximal failure (type 1A endoleak, endograft migration, or re-intervention requiring proximal graft extension). Freedom from proximal failure was estimated with Kaplan-Meier curves. An "optimal" sealing length (PSL cutoff maximising sensitivity + specificity for proximal failure) and "safest length" (PSL cutoff determining ≥ 90% sensitivity) were identified using receiver operating characteristic curve analysis. RESULTS One hundred and forty patients received TEVAR; mean ± standard deviation PSL was 29 ± 9 mm. Freedom from proximal endograft failure at five years (median 31 months) was 82.4% (95% confidence interval [CI] 72 - 95); the shorter the PSL, the greater was the risk of failure (hazard ratio 0.90, 95% CI 0.84 - 0.97; p = .004). Overall optimal and safest PSL were 25 mm (sensitivity 78%, specificity 66%) and 30 mm (sensitivity 92%, specificity 30%), respectively. In type I arch, the optimal PSL was 22 mm (sensitivity 50%, specificity 87%). In type II, the optimal PSL was 25 mm (sensitivity 89%, specificity 59%) overall and 27 mm for type II/LZ 2 - 3 (sensitivity 31%, specificity 68%). For type III, the optimal PSL was 27 mm (sensitivity 80%, specificity 87%); the safest was 30 mm (sensitivity 100%, specificity 61%) In type III/LZ 2 - 3, the optimal PSL was 27 mm (sensitivity 31%, specificity 68%) and safest was 30 mm (sensitivity 100%, specificity 55%). CONCLUSION A 20 mm PSL may be acceptable only for type I arches. For types II/III, that represent the majority of cases, a 25 - 30 mm PSL may be required for a safe and durable TEVAR.
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Amemiya K, Ishibashi-Ueda H, Mousseaux E, Achouh P, Ochiai M, Bruneval P. Comparison of the damage to aorta wall in aortitis versus noninflammatory degenerative aortic diseases. Cardiovasc Pathol 2021; 52:107329. [PMID: 33621670 DOI: 10.1016/j.carpath.2021.107329] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 01/22/2021] [Accepted: 02/14/2021] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Not rarely aortitis is firstly identified in thoracic aorta aneurysm/dissection specimens only by histopathology in the absence of clinical evidence of systemic inflammatory disease emphasizing the importance of histology for the diagnosis of aortitis. Regardless of the improvement of the pathological assessment of aortic diseases by the recent consensus statements on surgical pathology of the aorta, histology can be confusing since medial degenerative changes (MDC) can be prominent in a background where inflammation is sometimes limited. This raises the question of the role of aging or other degenerative process versus the role of inflammation in the damage to aorta wall. PATIENTS AND METHODS In this study, besides inflammation, we evaluated aorta samples from aortitis cases focusing on the histological scoring of MDC. In this retrospective single center study, we retrieved 719 cases of ascending aorta aneurysms or dissections operated on from January 2010 until June 2018. MDC (elastic fiber fragmentation and/or loss, smooth muscle nuclei loss, mucoid extracellular matrix accumulation intralemellar or translamellar) were estimated using a scoring system derived from that of the consensus statement. Noninfectious aortitis group versus age-matched non-inflammatory degenerative aortic disease group were compared. RESULTS Noninfectious aortitis was pathologically diagnosed in 62 patients (8.6%). Among the 62 noninfectious aortitis patients, 47 patients (75.8%) had aortitis identified pathologically prior to the clinical diagnosis. Higher MDC scores were observed at all aortic sizes in aortitis group versus non-aortitis group, especially for elastic fiber damage and smooth muscle cell loss. CONCLUSIONS Aortitis is remarkably associated with severe damage to the aorta wall resulting in advanced MDC scores. Inflammatory process is responsible for higher MDC in the aorta wall than aging or other degenerative process.
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Affiliation(s)
- Kisaki Amemiya
- Department of Cardiology, Showa University Northern Yokohama Hospital, Yokohama, Japan; Department of Pathology, National Cerebral and Cardiovascular Center, Osaka, Japan; INSERM U970-PARCC, Paris, France
| | | | - Elie Mousseaux
- Department of Radiology, Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Paris, France
| | - Paul Achouh
- Department of Cardiovascular Surgery, Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Paris, France
| | - Masahiko Ochiai
- Department of Cardiology, Showa University Northern Yokohama Hospital, Yokohama, Japan
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Abstract
Thoracic aortic aneurysms are typically asymptomatic and discovered incidentally on an imaging study ordered for other indications. Small aneurysms are managed with antihypertensive therapy and surveillance imaging, using either echocardiography, computed tomographic angiography (CTA), or magnetic resonance angiography (MRA). Aneurysms are repaired when the risk of rupture or dissection exceeds the risk of repair; size thresholds for repair are determined by the underlying etiology of the aneurysm, with lower thresholds for those with genetic aortopathies. In contrast to the silent and asymptomatic nature of aneurysms, acute aortic syndromes-which include aortic dissection, intramural hematoma, and penetrating atherosclerotic ulcer-are usually associated with recognizable symptoms and signs. Acute aortic syndromes involving the ascending aorta are treated with emergent surgery, whereas those involving the descending aorta are now often treated with endovascular stent-grafting techniques. After acute aortic syndromes have been successfully treated, prognosis is favorable with close follow-up that includes optimal medical management and regular surveillance imaging.
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Affiliation(s)
- David M Dudzinski
- Thoracic Aortic Center, Massachusetts General Hospital, Yawkey 5, Boston, MA, 02114, USA.
| | - Eric M Isselbacher
- Thoracic Aortic Center, Massachusetts General Hospital, Yawkey 5, Boston, MA, 02114, USA.
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Yildiz S, Boyaci N, Yildiz A. A morbid coexistence: thrombosed descending thoracic aorta aneurysm and aortic insufficiency with aortic diastolic reverse flow. Quant Imaging Med Surg 2014; 4:437-8. [PMID: 25392831 DOI: 10.3978/j.issn.2223-4292.2014.10.01] [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] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2014] [Accepted: 03/15/2014] [Indexed: 11/14/2022]
Abstract
A 76-year-old woman presented with difficulty in speech and weakness on right arm and leg. Her medical history was remarkable only for uncontrolled hypertension for a long period. Dysarthria, right central facial paralysis, right hemiparesis and hypoactive deep tendon reflexes were noticed on neurological examination. Moderate degree aortic insufficiency with aortic diastolic reverse flow was detected on transthoracic echocardiography. Thrombosed aortic aneurysm on descending thoracic aorta, and an acute hemorrhagic infarction in the distribution of the left middle cerebral artery were depicted on thorax, and brain computed tomography scans, respectively. Cerebrovascular event was medically managed and whereas conservative management was offered for thrombosed descending thoracic aorta aneurysm.
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Affiliation(s)
- Sema Yildiz
- 1 Department of Radiology, 2 Department of Cardiology, Harran University School of Medicine, 63100, Sanliurfa, Turkey
| | - Nurefsan Boyaci
- 1 Department of Radiology, 2 Department of Cardiology, Harran University School of Medicine, 63100, Sanliurfa, Turkey
| | - Ali Yildiz
- 1 Department of Radiology, 2 Department of Cardiology, Harran University School of Medicine, 63100, Sanliurfa, Turkey
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Pradere P, Mordant P, Alsac JM, Sanchez O, Riquet M, Fabiani JN. [Massive hemoptysis following thoracic aortic rupture: an advancing field]. Rev Pneumol Clin 2014; 70:118-121. [PMID: 24566027 DOI: 10.1016/j.pneumo.2013.10.002] [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] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/18/2013] [Revised: 10/28/2013] [Accepted: 10/28/2013] [Indexed: 06/03/2023]
Abstract
We report the case of a 57-year-old woman who presented with massive hemoptysis and thoracic pain 3 years after the endovascular treatment of a thoracic aortic aneurysm. Emergency work up revealed the presence of an endoleak, leading to the pressurization of the aneurysm sac and its subsequent rupture into the lung parenchyma. The discussion includes presentation, clinical course, diagnosis, complications and new therapeutic options in the management of a massive hemoptysis secondary to aortic rupture. All together, the case and discussion highlight the classical rules of critical care and the recent advances in endovascular treatment of thoracic aortic rupture.
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Affiliation(s)
- P Pradere
- Service de pneumologie et soins intensifs, hôpital européen Georges-Pompidou, université Paris Descartes, 20, rue Leblanc, 75015 Paris, France
| | - P Mordant
- Service de chirurgie thoracique, hôpital européen Georges-Pompidou, université Paris Descartes, 20, rue Leblanc, 75015 Paris, France.
| | - J-M Alsac
- Service de chirurgie cardiovasculaire, hôpital européen Georges-Pompidou, université Paris Descartes, 20, rue Leblanc, 75015 Paris, France
| | - O Sanchez
- Service de pneumologie et soins intensifs, hôpital européen Georges-Pompidou, université Paris Descartes, 20, rue Leblanc, 75015 Paris, France
| | - M Riquet
- Service de chirurgie thoracique, hôpital européen Georges-Pompidou, université Paris Descartes, 20, rue Leblanc, 75015 Paris, France
| | - J-N Fabiani
- Service de chirurgie cardiovasculaire, hôpital européen Georges-Pompidou, université Paris Descartes, 20, rue Leblanc, 75015 Paris, France
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