Introduction. Thoracic aortic aneurysms (TAA) are the most common condition of the thoracic aorta requiring surgical treatment. Despite significant improvement in anesthetic, surgical techniques and ...postoperative care, the mortality and morbidity rate in TAA-repair remains high. The aim of this study was to assess the morbidity and mortality rate after endovascular stent-graft treatment of atherosclerotic (non-dissecting) TAAs.
Methods. Thirty-one patients, ASA-classification III–IV, with symptomatic or expanding atherosclerotic TAAs underwent endovascular stent-graft repair between May 1997 and August 2003. Procedures were performed on an emergency basis in 13 patients and elective in 18 patients. Patients were assessed postoperatively by routine CT-scan within 48 h. Further follow up investigations were performed after 3, 6, 12 months and annually thereafter.
Results. Stent-graft placement was successful in all but one patient in whom the stent-graft procedure had to be postponed due severe hemodynamic instability. Perioperative mortality rate was 19% including three haemorrhages, two cardiac events and one respiratory failure (6/31). Technical success rate was 55% (17/31). Completion CT scans performed in 30 patients within 2 days of stent-graft procedure showed type I leaks in seven patients (23%), type II leaks in four patients (13%) and type III leaks in two patients (6%). Further complications included one stroke, one paralysis, one spinalis anterior syndrome and five relevant access related complications. New onset endoleaks, all type I, were observed in seven patients (23%) occurring after 3, 4, 7, 8, 17, 25 and 26 months. Mean follow-up was 15 months (range 2–69 months).
Conclusion. Thoracic aortic atherosclerotic aneurysm stent-grafting is feasible but not without significant morbidity and mortality.
To evaluate the feasibility and safety of endovascular stent-graft placement in treating Stanford type B aortic dissection.
Seven patients underwent endovascular stent-graft placement for type B ...aortic dissection. Five patients had acute and two had chronic dissection. In five patients, the proximal entry tear was within 2 cm of the origin of the left subclavian artery, and in two patients it was beyond this site. In three patients, the noncovered proximal portion of the stent-graft was placed across the origin of the left subclavian artery. The efficacy of the procedure was assessed at follow-up studies 3, 6, 12, and 24 months after intervention.
The procedure was technically and clinically successful in six patients (86%). The left subclavian artery remained patent in all patients. In two patients with involvement of aortic branches, endovascular stent-graft placement restored adequate blood flow to the compromised branches. One patient was readmitted 1 month later because the dissection extended into the ascending aorta. In all but this patient, closure of the entry tear and thrombosis of the false lumen along the stent-graft were achieved. All false lumina shrank considerably. The mean follow-up time was 14 months (range, 1-25 months).
Type B aortic dissections within and beyond 2 cm of the origin of the left subclavian artery can be treated safely and effectively by means of endovascular stent-graft placement.
Traumatic rupture of the thoracic aorta is potentially life-threatening and leads to death in 75 to 90 per cent of cases at the time of injury. In high-risk patients, as traumatic injuries of the ...aorta combine with multiple associated injuries, endoluminal repair is now reported as a promising therapeutic strategy with encouraging results. This study determined the outcome of patients with traumatic thoracic aortic injury treated endovascularly during the past 7 years at our institution. Thirteen patients, 11 males and 2 females (mean age, 39 years; range, 19–82), with traumatic rupture of the otherwise unremarkable descending aorta (10 acute, 3 chronic), out of a series of 64 endovascular thoracic stent-graft procedures, were treated by implantation of Talent (n = 8), Vanguard (n = 5), and Excluder (n = 2) self-expanding devices between January 1996 and August 2003. The immediate technical success rate was 92 per cent (12/13). One patient showed a proximal endoleak type I, which was treated successfully by an additional stent-graft procedure. Secondary success rate was 100 per cent. The mortality rate was 0 per cent. Two additional stent-graft procedures were performed due to type I endoleaks after 18 and 28 months. There was no other intervention-related morbidity or mortality during the mean follow-up time of 26.4 months (range, 6–86). Endovascular stent-graft repair of traumatic thoracic aortic injuries is a safe, effective, and low-morbidity alternative to open thoracic surgery and has promising midterm results.
Objectives: to determine medium term technical and clinical success of kissing stents for aortoiliac occlusive disease. Design: retrospective study. Subjects: twenty-five patients presenting with ...intermittent claudication (IC) or critical limb ischaemia (CLI) due to aortoiliac disease (41 complex stenoses, 8 occlusions). Methods: balloon- or self-expanding kissing stents, with or without predilatation depending upon the nature of the disease, were inserted via bilateral retrograde femoral artery punctures. Clinical examination, ABPI, exercise testing and duplex ultrasound were performed at 1, 3, 6, and 12 months, and then annually. Results: technical success was achieved in 86% segments. All patients with CLI improved and 6 of 7 ulcerated limbs showed complete healing. During follow-up, 7 patients died and two patients required major amputation at 7 and 8 months. The primary assisted patency rate was 94, 91 and 65% at 6, 12, and 24 months, respectively. Conclusions: despite acceptable short-term technical and clinical success, as the medium term patency rates are clearly inferior to those of bypass surgery, the kissing stent technique should be reserved for high risk patients with a limited life expectancy.
Eur J Vasc Endovasc Surg 26, 161-165 (2003)
Abstract
OBJECTIVES
Only few studies compared the surgical morbidity and mortality of thoracoscopic segmentectomy versus lobectomy for non-small-cell lung cancer, in particular, by relating the ...segmental resections with the corresponding anatomical lobes.
METHODS
We enrolled a total of 7487 patients who underwent VATS lobectomy (7269) or segmentectomy (218) from January 2014 to July 2019. A propensity score matching approach was used to account for potential confounding factors between the 2 groups. After matching, 349 lobectomies and 208 segmentectomies were included in the analysis. We analysed the operative and postoperative outcomes of video-assisted anatomical segmentectomy compared with video-assisted lobectomy and, in details, the results of segmentectomy with its corresponding lobectomy in a large cohort of patients from the Italian VATS Group Registry.
RESULTS
The overall conversion rate to thoracotomy was not statistically different between the groups (27 patients 8% vs 7 patients 3%, P = 0.1). The lobectomy group had a greater number of resected lymph nodes (median 11 vs 8, P = 0.006). No significant differences were detected in 30-day mortality (1.4%, 5 patients vs 0.9%, 2 patients), overall complications (18%, 62 patients vs 14%, 29 patients) and prolonged air leakage (31 patients, 9% vs 12 patients, 6%) between lobectomy and segmentectomy, respectively. No statistical differences were found regarding the median duration of drainage (3.2 days, P = 1) and the overall median length of hospital stay (6.4 days, P = 0.1) between the 2 groups. In the context of segmentectomy versus corresponding lobectomy, the right upper lobectomy compared with right upper segmentectomy showed a higher number of resected lymph nodes (P = 0.027). No statistical differences were reported in terms of conversion rate and postoperative complication and mortality.
CONCLUSIONS
Segmentectomy could be considered a safe procedure without significant differences compared to thoracoscopic lobectomy in terms of postoperative morbidity and mortality.
Since 2000, many studies have been published, including randomized ones, which have demonstrated that anatomical segmentectomy for early-stage non-small-cell lung cancer (NSCLC) yields oncological equivalent results with respect to those of lobectomy, with a potential lung-sparing effect 1–4.
Abstract
OBJECTIVES
This study compares the uniportal with the 3-portal video-assisted thoracic surgery (VATS) by examining the data collected in the Italian VATS Group Database. The primary end ...point was early postoperative pain; secondary end points were intraoperative and postoperative complications, surgical time, number of dissected lymph nodes and length of stay.
METHODS
This was an observational, retrospective, cohort, multicentre study on data collected by 49 Italian thoracic units. Inclusion criteria were clinical stage I–II non-small-cell lung cancer, uniportal or 3-portal VATS lobectomy and R0 resection. Exclusion criteria were cT3 disease, previous thoracic malignancy, induction therapy, significant comorbidities and conversion to other techniques. The pain parameter was dichotomized: the numeric rating scale ≤3 described mild pain, whereas the numeric rating scale score >3 described moderate/severe pain. The propensity score-adjusted generalized estimating equation was used to compare the uniportal with 3-portal lobectomy.
RESULTS
Among 4338 patients enrolled from January 2014 to July 2017, 1980 met the inclusion criteria; 1808 patients underwent 3-portal lobectomy and 172 uniportal surgery. The adjusted generalized estimating equation regression model using the propensity score showed that over time pain decreased in both groups (P < 0.001). There was a statistical difference on the second and third postoperative days; odds ratio (OR) 2.28 95% confidence interval (CI) 1.62–3.21; P < 0.001 and OR 2.58 (95% CI 1.74–3.83; P < 0.001), respectively. The uniportal-VATS group had higher operative time (P < 0.001), shorter chest drain permanence (P < 0.001) and shorter length of stay (P < 0.001).
CONCLUSIONS
Data from the Italian VATS Group Database showed that in clinical practice uniportal lobectomy seems to entail a higher risk of moderate/severe pain on second and third postoperative days.
Purpose:
To describe our experience with endovascular stent-graft repairs in the thoracic aorta focusing on the secondary complication of type A dissection.
Methods:
Between January 1996 and April ...2004, 73 patients were treated for traumatic thoracic aortic rupture (n=15), type B dissection (n=22), or atherosclerotic descending thoracic aortic aneurysms (TAA, n=36). A retrospective review of the records found 5 (6.8%) patients (3 men; median age 64 years, range 43–87) who experienced a type A dissection at a median 20 days (range 2–124) after thoracic stent-graft repair for 3 type B dissections, 1 TAA, and a late type I endoleak that appeared 28 months after initial stent-graft repair of a traumatic dissection.
Results:
In 3 patients (2 dissections, 1 endoleak), a tear in the aortic wall at the proximal stent-graft was responsible for a retrograde type A dissection. Underlying disease was the cause of the type A dissection in the 2 other patients (1 dissection, 1 TAA) and was unrelated to the stent-grafts. Three patients underwent open surgery at 3, 26, and 124 days after stent-graft placement; 2 procedures were successful, but the third patient died 3 months later due to multiorgan failure. Two type A dissections were untreated: one patient died from cardiac tamponade 14 days after successful stent-graft exclusion of the type I endoleak; the other patient refused further treatment and survived. The procedure-related mortality following acute retrograde type A dissection was 40%.
Conclusions:
Endovascular stent-graft repair of the thoracic aorta is associated with lower morbidity and mortality rates than surgical repair, although potentially lethal complications, acute or delayed, may occur.
For patients with chronic non-reconstructible limb ischemia (chronic CLI), spinal-cord stimulation (SCS) has been advocated for the treatment of ischemic pain and prevention of amputation. The ...present clinical report was performed to evaluate the long-term effects of SCS on limb survival. A retrospective review was performed of 21 patients who had undergone SCS between December 1997 and July 2002 due to chronic CLI. The impulse generator used was the Itrel device (Medtronic, Inc). All conventional methods for revascularization and improvement of microcirculatory blood flow had been performed prior to SCS treatment. Patient selection was performed by clinical examination, pulse volume records, Doppler ankle brachial measurements, angiography, and thoracic spine and lumbar spine x-ray. Since July 2000, additional TcpO2 measurements at the dorsum of the foot have been performed. SCS implantation was performed as a one-stage procedure in all cases. Patients are followed up to 57 months. Of 21 patients with chronic CLI, 20 (95%) were available for follow-up investigations. Four patients died one to fifteen months after implantation due to acute renal failure or myocardial infarction (19%). Major amputation could be avoided in 15 (71%) of 21 patients. Two electrode dislocation, one pulse-generator dislocation, and one wire disconnection occurred; no other complications were observed. SCS represents a safe and effective therapy for patients with chronic non-reconstructible critical limb ischemia.
Endovascular stent graft repair of traumatic vessel injuries is gaining worldwide acceptance as a minimally invasive alternative to open surgical repair. However, effective endovascular repair fails ...if the aneurysm is not completely excluded. Conversion to open surgery may be unavoidable in such cases. Herein we describe the case of a 45-year-old man who was referred to our hospital with a pseudoaneurysm of the proximal brachiocephalic artery caused by biopsy during diagnostic medianoscopy. The pseudoaneurysm was primarily treated by stent-graft implantation into the proximal brachiocephalic artery. As a result of the unfavorable location of the lesion exclusion of the aneurysm failed and the initial therapy had to be extended to open reconstruction of the brachiocephalic artery. A bypass procedure from the aortic arch to the right common carotid artery was performed with reinsertion of the right subclavian artery to exclude the pseudoaneurysm.
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