A review of the literature was conducted for incidence, outcomes, and risk factors for distal stent graft-induced new entry (SINE) after thoracic endovascular aortic repair (TEVAR) of aortic ...dissection.
The review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.
Seven articles reporting on 1415 patients with thoracic aortic dissection undergoing TEVAR without supplemental distal bare stenting were included. In this cohort, 86 patients were treated for a residual type A aortic dissection and 1329 for a complicated type B aortic dissection. Distal SINE occurred in 112 patients (7.9%). The mean time to identification of distal SINE was 19 ± 7 months. The incidence of distal SINE after TEVAR for type B aortic dissection differed on the basis of whether it was a chronic or acute dissection repair and was, respectively, 12.9% (43/331) and 4.3% (12/273). Successful secondary interventions were performed in 54% of the patients. All the studies analyzing the relationship between distal stent graft oversizing and incidence of distal SINE reported a significantly higher rate of SINE with oversizing.
The successful management of complicated descending thoracic aortic dissections by TEVAR is well established. Whereas distal SINE is relatively frequent, if it does occur, the complication can generally be treated with additional TEVAR without a poor outcome. The main determinant of SINE seems to be excessive distal oversizing.
Purpose: To investigate the midterm outcomes of scalloped or fenestrated physician-modified endovascular grafts (PMEGs) for zone 2 thoracic endovascular aortic repairs (TEVAR). Materials and Methods: ...Between November 2013 and May 2019, 54 consecutive patients (mean age 63 years; 41 men) were treated with thoracic PMEGs modified with 7 scallops or 47 fenestrations for the left subclavian artery (LSA). Indications for aortic repair were acute complicated type B aortic dissection (17, 31%), degenerative aneurysm (13, 24%), acute traumatic rupture of the aortic isthmus (9, 16%), post chronic dissection aneurysmal evolution (8, 15%), penetrating aortic ulcer (3, 6%), intramural hematoma (2, 4%), and floating thrombus (2, 4%). Results: Technical success was 94%; 3 (6%) LSAs were unintentionally covered. An intraoperative type Ia endoleak was treated during the index procedure. One (2%) patient suffered spinal cord ischemia, with irreversible bilateral paraplegia. Three (6%) patients experience postoperative minor strokes with full neurological recovery. Four (7%) patients died in the perioperative period; 2 (2%) were due to aneurysm rupture. Mean follow-up was 26±16 months; 15 (28%) patients had at least 3 years of follow-up. Two (4%) type II endoleaks were identified and successfully treated (4% reintervention rate); no other endoleaks were identified. All the LSAs remained clinically and radiologically patent. There were no conversions to open repair, ruptures, retrograde dissection, stent fracture, migrations, or other aortic complications. Conclusion: Scalloped or single-fenestrated PMEGs for the LSA appear to be durable and safe in the midterm. Combined with low periprocedural morbidity and mortality, these results suggest that this approach can be considered as an off-label alternative to extend proximal seal to zone 2 for TEVAR. Further studies with a larger number of patients and long-term outcomes are needed to fully validate this approach.
To provide data regarding the etiology and timing of retrograde type A aortic dissection (RTAD) after thoracic endovascular aortic repair (TEVAR).
Details of patients who had RTAD after TEVAR were ...obtained from the MOTHER Registry supplemented by data from a systematic review of the literature. Univariate analysis and binary logistic regression analysis of patient or technical factors was performed.
In MOTHER, RTAD developed in 16 of the 1010 patients (1.6%). Binary logistic regression demonstrated that an indication of TEVAR for aortic dissection (acute P = 0.000212; chronic P = 0.006) and device oversizing (OR 1.14 per 1% increase in oversizing above 9%, P < 0.0001) were significantly more frequent in patients with RTAD. Data from the systematic review was pooled with MOTHER data and demonstrated that RTAD occurred in 1.7% (168/9894). Most of RTAD occurred in the immediate postoperative (58%) period and was associated with a high mortality rate (33.6%). The odds ratio of RTAD for an acute aortic dissection was 10.0 (CI: 4.7-21.9) and 3.4 (CI: 1.3-8.8) for chronic aortic dissection. The incidence of RTAD was not significantly different for endografts with proximal bare stent (2.8%) or nonbare stent (1.9%) (P = 0.1298).
Although RTAD after TEVAR is an uncommon complication, it has a high mortality rate. RTAD is significantly more frequent in patients treated for acute and chronic type B dissection, and when the endograft is significantly oversized. The proximal endograft configuration was not associated with any difference in the incidence of RTAD.
Objective This study assessed predictive factors for reintervention after thoracic endovascular aortic repair (TEVAR) for complicated aortic dissection (C-AD). Methods An institutional review of ...consecutive TEVAR for C-AD was performed. Results Between 2000 and 2011, 41 patients underwent TEVAR for a C-AD involving the descending thoracic aorta. Primary indications included aneurysm >55 mm in 24, rapid aneurysmal enlargement or impending rupture in 6, saccular aneurysm >20 mm in 1, malperfusion in 1, intractable chest pain in 3, and rupture in 6. Technical success was achieved in 100%. The 30-day mortality rate was 5% (n = 2). Fourteen secondary procedures were performed in 13 patients (32%) for indications of device migration in 2, proximal type I endoleak in 5, distal type I endoleak in 2, type II endoleak in 1, aneurysmal evolution of the descending thoracic aorta in 2, aneurysmal expansion of the dissected abdominal aorta in 1, and retrograde dissection in 1. Multivariate analysis demonstrated that oversizing ≥20% (odds ratio OR, 16; P = .011), bare-spring stent in the proximal landing zone of the stent graft (OR, 12; P = .032), and anticoagulant therapy (OR, 78; P = .03) were significant factors for reintervention. On univariate analysis, large aneurysm was a risk factor for reintervention ( P = .002), whereas complete false lumen thrombosis at the stent graft level was protective ( P < .05). Conclusions This study confirms the feasibility of TEVAR for C-AD, although the rate of reintervention is high. Excessive oversizing, a bare-spring stent graft in the proximal landing zone, large aortic dilatation, and anticoagulant therapy were factors associated with reintervention. Complete false lumen thrombosis at the stent graft level was protective.
Hybrid aortic arch repair for dissecting aneurysm Faure, Elsa Madeleine, MD; Canaud, Ludovic, MD, PhD; Marty-Ané, Charles, MD, PhD ...
The Journal of thoracic and cardiovascular surgery,
07/2016, Letnik:
152, Številka:
1
Journal Article
Recenzirano
Odprti dostop
Abstract Objective This study analyzed the outcome of a combined endovascular and debranching procedure for hybrid aortic arch repair in patients with chronic dissecting aortic aneurysms involving ...the aortic arch. Methods We reviewed all consecutive patients who underwent hybrid aortic arch repair for dissecting aneurysm at the Arnaud de Villeneuve Hospital. Results A total of 33 consecutive patients between March 2005 and September 2015 were included. Patients' mean age was 65.1 ± 12.2 years. Mean aneurysm diameter was 60.3 ± 14.2 mm. Patients were treated for aneurysm diameter 55 mm or greater (n = 28), aortic growth more than 1 cm/year (n = 3), or rupture (n = 2). Eleven complete supra-aortic debranchings were performed in zone 0, with 2 concomitant replacements of the ascending aorta. Partial aortic arch debranching was performed in 22 patients (zone 1 = 8; zone 2 = 14). Technical success was achieved in 97% of patients. There was no in-hospital death. One patient died of decompensated cirrhosis on day 20, resulting in a 30-day mortality of 3%. One patient had major cerebrovascular complications (3%). Spinal cord ischemia was observed in 1 patient (3%), with complete recovery after spinal fluid drainage. Retrograde dissection occurred in 1 patient (3%). After a mean follow-up of 24.3 months (range, 0.6-104.8 months), the overall mortality was 12% (n = 4) with 3 additional deaths. Endoleak was reported in 6 patients (18%), of whom 2 required reintervention. Overall, 8 reinterventions were performed (24%), with a mean time from intervention of 8.7 months (range, 1.2-24.6 months). Conclusions Hybrid aortic arch repair for dissecting aneurysm is associated with acceptable early and midterm major morbidity and mortality, even for patients treated in zone 0. However, given the high rate of reintervention and endoleak, close follow-up is required.
Abstract Objective To assess factors predisposing patients to retrograde type A aortic dissection (RTAD) who have undergone hybrid aortic arch repair. Methods From 2001 to 2013, 32 patients underwent ...hybrid aortic arch repair in our department: 19 in zone 1 and 13 in zone 0. Among these patients, 6 experienced RTAD (18.7%): 3 in zone 0 (23%), 3 in zone 1 (15.8%). Preoperative computed tomography scans of these 32 patients were evaluated. A morphologic assessment of the aortic arch, ascending aorta, and aortic root was performed. Other potential risk factors were investigated. Binary logistic regression was performed to test for possible associations with RTAD. Results Five patients were successfully converted to open repair. Patients who had RTAD were similar to those who did not, across pertinent variables, including age, type of device, diameter of the ascending aorta, and presence of a bicuspid aortic valve (all P > .1). Incidence of RTAD was observed to be higher among women ( P = .034), patients with stent-graft oversizing ≥10% ( P = .018), and patients treated with a stent-graft of diameter >42 mm ( P = .01). Aortic morphology analysis showed that an indexed aortic diameter of ≥20 mm/m2 ( P = .003); aortic root morphology, specifically loss of the sinotubular junction ( P = .004); and presence of an aortic arch malformation ( P = .03) were correlated with risk of RTAD. Two patients in the zone-0 group with severe angulation (>120°) between the ascending and the transverse aorta suffered RTAD. Conclusions The occurrence of RTAD after hybrid aortic arch repair is common. To prevent this complication, preoperative screening of the aortic arch, ascending aorta, and aortic root morphology is critical.
Purpose: To evaluate outcomes of physician-modified thoracic stent-grafts for the treatment of aortic arch aneurysms. Methods: A retrospective dual-center analysis was performed involving 36 patients ...(mean age 74.7±9 years, range 58–91; 27 men) with an aortic arch lesion who were treated between November 2013 and June 2016 using physician-modified thoracic stent-grafts. Half of the patients had a degenerative aneurysm; the remainder had type B dissection (n=9), traumatic transection (n=3), type Ia endoleak after previous endografting (n=5), or aortoesophageal fistula (n=1). All patients were considered to be at high surgical risk. Patients were treated using an aortic arch stent-graft with a single fenestration (n=24) or a proximal scallop (n=12); zone 0 was involved in 16 patients, zone 1 in 9, and zone 2 in 11. The modified thoracic stent-graft was deployed after supra-aortic branch revascularization in 24 (67%) patients. Results: Mean time required for stent-graft modifications was 18 minutes (range 14–21). Technical success was obtained in all cases with no type I endoleak. One (3%) patient had a stroke without permanent sequelae. The 30-day mortality was 6%. During a mean follow-up of 11.4±6 months (range 2–36), there were no conversions to open repair. The overall mortality was 14%; aorta-related mortality was 6%. Conclusion: Our experience suggests that physician-modified thoracic stent-grafts are feasible for aortic arch lesions and provide encouraging results in the short term. Durability concerns will need to be assessed.
Objective To provide a systematic review of the outcomes of thoracic endovascular aortic repair (TEVAR) for aortoesophageal fistula (AEF) and to identify prognostic factors associated with poor ...outcomes. Methods Literature searches of the Embase, Medline, and Cochrane databases identified relevant articles reporting results of TEVAR for AEF. The main outcome measure was the composite of aortic mortality, recurrence of the AEF, and stent graft explantation. The secondary outcome measure was aortic-related mortality. Results Fifty-five articles were integrated after a literature search identified 72 patients treated by TEVAR for AEFs. The technical success rate of TEVAR was 87.3%. The overall 30-day mortality was 19.4%. Prolonged antibiotics (>4 weeks) were administered in 80% of patients. Concomitant or staged resection or repair of the esophagus was performed in 44.4% of patients. Stent graft explantation was performed within the first month after TEVAR as a planned treatment in 11.1%. After a mean follow-up of 7.4 months (range, 1-33 months), the all-cause mortality was 40.2%, and the aortic-related mortality was 33.3. Prolonged antibiotic treatment ( P = .001) and repair of AEFs due to a foreign body ( P = .038) were associated with a significant lower aortic mortality. On univariate analysis, TEVAR and concomitant or staged adjunctive procedures (resection, repair of the esophagus, or a planned stent graft explantation) were associated with a significantly lower incidence of aortic-related mortality ( P = .0121). When entered into a binary logistic regression analysis, prolonged antibiotic treatment was the only factor associated with a significant lower incidence of the endpoint ( P = .003). Conclusions Late infection or recurrence of the AEF and associated mortality rates are high when TEVAR is used as a sole therapeutic strategy. Prolonged antibiotic treatment has a strong negative association with mortality. A strategy of a temporizing endovascular procedure to stabilize the patient in extremis, and upon recovery, an open surgical esophageal repair with or without stent graft explantation is advocated.
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