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1.
Yoshimasa Seike Hitoshi Matsuda Yosuke Inoue Atsushi Omura Kyokun Uehara Tetsuya Fukuda Junjiro Kobayashi 《The Journal of thoracic and cardiovascular surgery》2019,157(4):1336-1345.e1
Objectives
Since 2012, we have routinely applied balloon protection of the proximal left subclavian artery to prevent embolic events through the left vertebral artery during debranching thoracic endovascular aortic repair. This study aimed to study the effectiveness of balloon protection of the proximal left subclavian artery.Methods
We reviewed the medical records of 157 patients who underwent debranching thoracic endovascular aortic repair between 2007 and 2017. Of these, 71 patients for whom balloon protection of the proximal left subclavian artery was used were assigned to the balloon protection of the proximal left subclavian artery group (58 men; age: 78 ± 6.7 years), and 86 patients were assigned to the control group (66 men; age: 78 ± 8.9 years). A total of 51 patients from each group were matched by their propensity scores to adjust for differences in the patients’ characteristics.Results
Perioperative stroke was significantly lower in the balloon protection of the proximal left subclavian artery group than in the control group (0%: 0/71 vs 7.9%: 7/86, P = .014). Freedom from all causes of mortality at 2 and 4 years was significantly higher in the balloon protection of the proximal left subclavian artery group compared with the control group (93%/76% vs 77%/59%, P = .015). Freedom from aortic death at 2 and 4 years was similar in both groups (97%/97% vs 91%/86%, P = .094). Propensity score matching yielded similar results of better freedom from all causes of mortality in the balloon protection of the proximal left subclavian artery group (93%/93% vs 81%/63%, P = .017) and equivalent aortic death in both groups (95%/95% vs 92%/88%, P = .30).Conclusions
Debranching thoracic endovascular aortic repair using balloon protection of the proximal left subclavian artery demonstrated more appropriate early and late outcomes. Evaluation using propensity score matching enhanced the efficacy of balloon protection of the proximal left subclavian artery. 相似文献2.
Ayman Saeyeldin Mohammad A. Zafar Yupeng Li Maryam Tanweer Mohamed Abdelbaky Anton Gryaznov Adam J. Brownstein Camilo A. Velasquez Joelle Buntin Kabir Thombre Wei-Guo Ma Young Erben John A. Rizzo Bulat A. Ziganshin John A. Elefteriades 《The Journal of thoracic and cardiovascular surgery》2019,157(5):1733-1745
Objective
The risk of rupture and dissection in ascending thoracic aortic aneurysms increases as the aortic diameter exceeds 5 cm. This study evaluates the clinical effectiveness of a specific algorithm based on size and symptoms for preemptive surgery to prevent complications.Methods
A total of 781 patients with nondissecting ascending thoracic aortic aneurysms who presented electively for evaluation to our institution from 2011 to 2017 were triaged to surgery (n = 607, 77%) or medical observation (n = 181, 24%) based on a specific algorithm: surgery for large (>5 cm) or symptomatic aneurysms. A total of 309 of 781 patients did not undergo surgery. Of these, 128 (16%) had been triaged to prompt repair but did not undergo surgery for a variety of reasons (“surgery noncompliant and overwhelming comorbidities” group). Another 181 patients (24%) were triaged to medical management (“medical” group).Results
In the “surgery noncompliant and overwhelming comorbidities” versus the “medical” group, mean aortic diameters were 5 ± 0.5 cm versus 4.45 ± 0.4 cm and aortic events (rupture/dissection) occurred in 17 patients (13.3%) versus 3 patients (1.7%), respectively (P < .001). Later elective surgeries (representing late compliance in the “surgery noncompliant and overwhelming comorbidities group” or onset of growth or symptoms in the “medical” group) were conducted in 21 patients (16.4%) versus 15 patients (8.3%) (P = .04), respectively. Death ensued in 20 patients (15.6%) versus 6 patients (3.3%) (P < .001), respectively. In the “surgery noncompliant and overwhelming comorbidities” group, 7 of 20 patients died of definite aortic causes compared with none in the “medical” group.Conclusions
Patients with ascending thoracic aortic aneurysms who did not follow surgical recommendations experienced substantially worse outcomes compared with medically triaged candidates. The specific algorithm based on size and symptoms functioned effectively in the clinical setting, correctly identifying both at-risk and safe patients. 相似文献3.
Shinichi Iwakoshi Shigeo Ichihashi Takeshi Inoue Takashi Inoue Futoshi Sakuragi Shoji Sakaguchi Kimihiko Kichikawa 《Journal of vascular surgery》2019,69(4):1021-1027
Objective
The objective of this study was to assess the accuracy of predicting stent graft position for thoracic endovascular aortic repair by measuring three lengths of the virtual stent graft: smaller curvature (SC), center lumen line (CL), and greater curvature (GC).Methods
From January 2012 to December 2016, patients treated at our institution were analyzed retrospectively. Patients who were treated with more than two devices, patients treated for aortic dissection, and cases without complete preoperative or postoperative computed tomography (CT) data were excluded. From the preoperative CT data, the virtual stent graft image based on the SC (SCVS) was created so that its SC length matched that of the stent graft actually used. In the same manner, virtual stent graft images based on the CL (CLVS) and GC (GCVS) were created. These virtual stent graft images were created using SYNAPSE VINCENT software (Fujifilm Co, Tokyo, Japan) and superimposed on the postoperative CT image to measure the misalignment between these virtual stent graft images and the actual stent graft. These misalignments were compared using Wilcoxon signed rank sum test. In addition, the actual length (AL) of the stent graft was measured on the basis of the CL from postoperative CT data and compared with its original length (OL).Results
A total of 35 cases were analyzed. Twenty-six patients were men. The average age of the patients was 72.4 ± 13.0 years. The proximal landing zone were located at the descending aorta (n = 11) and the aortic arch (n = 24). The misalignment between SCVS, CLVS, and GCVS and actual stent graft position was ?47.8 ± 18.1 mm, ?21.5 ± 9.4 mm, and 5.3 ± 7.4 mm, respectively. The difference in means between the three groups was significant (P < .001). The relationship between the AL based on CL and OL was represented by the formula AL = OL * 0.92 ? 0.05 (in the descending aorta) and AL = OL * 0.77 + 9.85 (in the aortic arch).Conclusions
Compared with CLVS and SCVS, GCVS was the most accurate predictor of stent graft position for thoracic endovascular aortic repair. 相似文献4.
Theodoros Kratimenos Constantine N. Antonopoulos Dimitrios Tomais Panagiotis Dedeilias Vasileios Patris Ilias Samiotis John Kokotsakis Dimosthenis Farsaris Michalis Argiriou 《Journal of vascular surgery》2019,69(4):996-1002.e3
Objective
The aim of the study was to present the results for patients with atherosclerotic aneurysm of the descending thoracic aorta (DTA) treated with a novel thoracic stent graft.Methods
A single-center retrospective review of prospectively collected data was performed. We extracted demographic variables as well as atherosclerotic comorbidities and operation-related and imaging-related data from patients' medical records. We estimated technical success rate, in-hospital and 30-day mortality, and mortality at the end of follow-up as well as complication and reintervention rate in our study cohort. Follow-up computed tomography angiography was performed after 1 month and 6 months and yearly thereafter.Results
A total of 30 patients (80% male; mean age, 73.7 ± 6.33 years) were treated with Ankura Thoracic Stent Graft (Lifetech, Shenzhen, China) for DTA aneurysm from February 2014 until June 2017. Technical success of the thoracic endovascular aortic repair (TEVAR) was 97% (29/30 patients). A surgical conduit was required in one patient; in three patients, we intentionally covered the left subclavian artery because of insufficient proximal landing zone. No aorta-related deaths were recorded during follow-up. During the early postoperative period, two patients (7%) with long DTA coverage developed paralysis or paraparesis, which immediately resolved after lumbar drainage. No renal complications requiring dialysis were observed. One patient (3%) developed postoperative pulmonary infection, whereas access site complications were 7%. Two symptomatic patients treated outside instructions for use (7%) developed early type IA endoleak and one patient (3%) developed type IB endoleak; type II endoleak was recorded in 3% of the study cohort. During the 30-day postoperative period, two patients died of non-TEVAR-related causes, one of gastrointestinal bleeding and the other of pulmonary infection. During a median follow-up of 31.7 (range, 38.4) months, two more patients also died of non-TEVAR-related causes, one of stroke from carotid artery disease and the other of motor vehicle trauma. In the rest of the cohort, no other adverse events were noted.Conclusions
This novel endograft showed early evidence of a safe, effective, and durable endoprosthesis for the treatment of DTA aneurysms. 相似文献5.
Fernando Motta Raghuveer Vallabhaneni Corey A. Kalbaugh George Alyateem William A. Marston Mark A. Farber 《Journal of vascular surgery》2019,69(3):645-650
Objective
To evaluate and compare the early outcomes of patients treated for complex aortic aneurysms using a commercially available Zenith fenestrated endograft (ZFEN) or an advanced customized fenestrated-branched endovascular repair, which includes custom-made device or off-the-shelf p-branch devices available for use in a physician-sponsored investigational device exemption (PSIDE).Methods
Between July 2012 and July 2015, patients who underwent to complex aortic aneurysms repair at University of North Carolina-Chapel Hill were retrospectively analyzed using data prospectively collected in electronically maintained aortic database. Patients were separated in two groups: ZFEN and PSIDE (custom-made device and p-branch). Demographics data, cardiac risk factors, comorbidities, computed tomography angiography anatomic measurements (aneurysm diameter, length of aortic coverage above the celiac artery), procedural data (operative time, estimated blood loss, intraoperative complications), and 30-day outcomes (mortality, major adverse cardiac events, stroke/transient ischemic attack, paraplegia, gastrointestinal complications, visceral branch complications, and endoleak) were analyzed.Results
Among the 131 repairs for complex aortic aneurysms (juxtarenal or thoracoabdominal), there were 60 ZFEN and 71 PSIDE devices. Demographics and risk factors had similar distribution between groups, except that PSIDE patients more commonly had a history of previous aortic surgery (33% vs 5% [ZFEN]; P = .0001). PSIDE patients had a greater number of stented vessels (3.4 vs 2.2; P < .001) and length of aortic coverage (72 mm vs ?13.4 mm) than ZFEN; however, no differences were seen in operative time, estimated blood loss or fluoroscopic time. Early outcomes were similar between groups, except for duration of hospital stay, which was significantly longer in PSIDE cohort (4.4 days vs 3.3 days; P = .05).Conclusions
More advanced fenestrated-branched endovascular repair does not seem to increase the complications associated with repair compared with patients receiving a ZFEN device in an experienced treatment center. Although mortality and morbidity were comparable between the groups, further studies evaluating long-term outcomes are needed. 相似文献6.
Biao Zhou Wei Li Guizhen Zhao Bing Yu Baihui Ma Zhujiang Liu Nan Xie Yi Fu Ze Gong Rongbo Dai Xiaoming Zhang Wei Kong 《Journal of vascular surgery》2019,69(3):921-932.e3
Objective
The purpose of this study was to investigate whether rapamycin inhibits the development of thoracic aortic aneurysm and dissection (TAAD) in mice.Methods
Three-week-old C57BL/6J male mice were fed a normal diet and randomized into a control group (n = 6), β-aminopropionitrile fumarate (BAPN) group (Gp A; n = 15), BAPN plus rapamycin (5 mg) group (Gp B; n = 8), and BAPN plus rapamycin (10 mg) group (Gp C; n = 8). Gp A, Gp B, and Gp C were administered BAPN (1 g/kg/d) for 4 weeks. One week after BAPN administration, Gp B and Gp C were treated with rapamycin (5 mg/kg/d or 10 mg/kg/d) through gavage for 21 days. Thoracic aortas were harvested for Western blot and immunofluorescence staining at day 14 and for morphologic and histologic analyses at day 28.Results
BAPN treatment induced TAAD formation in mice. The incidence of TAAD in control, Gp A, Gp B, and Gp C mice was 0%, 80%, 25%, and 37.5%, respectively. Smaller thoracic aortic diameters (ascending aorta and arch) were observed in Gp B and Gp C mice than in Gp A mice (Gp B vs Gp A: ascending aorta, ex vivo, 1.07 ± 0.21 mm vs 1.80 ± 0.67 mm [P < .05]; aortic arch, ex vivo, 1.51 ± 0.40 mm vs 2.70 ± 1.06 mm [P < .05]; Gp C vs Gp A: ascending aortas, ex vivo, 1.10 ± 0.33 mm vs 1.80 ± 0.67 mm [P < .05]; aortic arch, ex vivo, 1.55 ± 0.56 mm vs 2.70 ± 1.06 mm [P < .05]). TAAD mice exhibited elastin fragmentation, abundant inflammatory cell infiltration, and significantly increased matrix metalloproteinase production in the aorta, and rapamycin treatment alleviated these changes. The protein levels of p-S6K and p-S6 in TAAD aortic tissues increased significantly, whereas they were suppressed by rapamycin.Conclusions
Rapamycin suppressed TAAD formation, probably by inhibition of mechanistic target of rapamycin signaling and reduction of inflammatory cell infiltration and matrix metalloproteinase 9 production. Targeting of the mechanistic target of rapamycin signaling pathway using rapamycin may be a favorable modulation for the clinical treatment of TAAD. 相似文献7.
Soraya L. Voigt Muath Bishawi David Ranney Babatunde Yerokun Richard L. McCann G. Chad Hughes 《Journal of vascular surgery》2019,69(3):701-709
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. 相似文献8.
Eric C. Kuo Narek Veranyan Cali E. Johnson Fred A. Weaver Sung Wan Ham Vincent L. Rowe Fernando Fleischman Michael Bowdish Sukgu M. Han 《Journal of vascular surgery》2019,69(4):987-995
Objective
Thoracic endovascular aortic repair (TEVAR) has become standard treatment of complicated type B aortic dissections (TBADs). Whereas adequate proximal seal is a fundamental requisite for TEVAR, what constitutes “adequate” in dissections and its impact on outcomes remain unclear. The goal of this study was to describe the proximal seal zone achieved with associated clinical outcomes and aortic remodeling.Methods
A retrospective review was performed of TEVARs for TBAD at a single institution from 2006 to 2016. Three-dimensional centerline analysis of preoperative computed tomography was used to identify the primary entry tear, dissection extent, distances between arch branches, and intramural hematoma (IMH) involvement of the proximal seal zone. Patients were categorized into group A, those with proximal extent of seal zone in IMH/dissection-free aorta, and group B, those with landing zone entirely within IMH. Clinical outcomes including retrograde type A dissection (RTAD), death, and aortic reinterventions were recorded. Postoperative computed tomography scans were analyzed for remodeling of the true and false lumen volumes of the thoracic aorta.Results
Seventy-one patients who underwent TEVAR for TBAD were reviewed. Indications for TEVAR included malperfusion, aneurysm, persistent pain, rupture, uncontrolled hypertension, and other. Mean follow-up was 14 months. In 26 (37%) patients, the proximal extent of the seal zone was without IMH, whereas 45 (63%) patients had proximal seal zone entirely in IMH. Proximal seal zone of 2-cm IMH-free aorta was achieved in only six (8.5%) patients. Review of arch anatomy revealed that to create a 2-cm landing zone of IMH-free aorta, 31 (43.7%) patients would have required coverage of all three arch branch vessels. Postoperatively, two patients developed image-proven RTADs requiring open repair, and one patient had sudden death. All three of these patients had TEVAR with the proximal seal zone entirely in IMH. No RTADs occurred in patients whose proximal seal zone involved healthy aortic segment. At 24 months, overall survival was 93% and freedom from aorta-related mortality was 97.4%. Complete thoracic false lumen thrombosis was seen in 46% of patients. Aortic remodeling, such as true lumen expansion, false lumen regression, and false lumen thrombosis, was similar in both groups of patients.Conclusions
Whereas achieving 2 cm of IMH-free proximal seal zone during TEVAR for TBAD would often require extensive arch branch coverage, failure to achieve any IMH-free proximal seal zone may be associated with higher incidence of RTAD. The length and quality of the proximal seal zone did not affect the subsequent aortic remodeling after TEVAR. 相似文献9.
Sabin J. Bozso Jeevan Nagendran Roderick G.G. MacArthur Michael W.A. Chu Bob Kiaii Ismail El-Hamamsy Raymond Cartier Ali Shahriari Michael C. Moon 《The Journal of thoracic and cardiovascular surgery》2019,157(5):1763-1771
Objectives
We describe the Canadian results of the Ascyrus Medical Dissection Stent (AMDS), a novel partially uncovered aortic arch hybrid graft implanted antegrade during hypothermic circulatory arrest to promote true lumen expansion and enhance aortic remodeling.Methods
From March 2017 to February 2018, 16 consecutive patients (66 ± 12 years; 38% female) presented with acute type A aortic dissections and underwent emergent surgical aortic repair with AMDS implantation. All patients presented with DeBakey I aortic dissection, with evidence of malperfusion in 50% (n = 8) of patients. All cases were performed under hypothermic circulatory arrest with an additional average duration for AMDS implantation time of 2.1 minutes.Results
All 16 device implantations were successful. Overall 30-day mortality was 6.3% (n = 1) and stroke occurred in 6.3% (n = 1) of cases. There was no incidence of device-related aortic injury or aortic arch branch vessel occlusion. During the follow-up period, 12 patients had completed at least 1 postoperative computed tomography scan. At initial follow-up computed tomography scan, complete or partial thrombosis, and remodeling of the aortic arch occurred in 91.7% of cases (n = 11/12) and in the proximal descending thoracic aorta, complete or partial thrombosis, and remodeling occurred in 91.7% (n = 11/12).Conclusions
Preliminary results suggest that the AMDS is a safe, feasible and reproducible adjunct to current surgical approaches for acute DeBakey I aortic dissection repair. Further, the AMDS manages malperfusion and promotes early positive remodeling in the aortic arch and distal dissected segments, with favorable FL closure rates at follow-up. Ongoing follow-up will provide additional insight into the long-term effects of the AMDS. 相似文献10.
Christian-Alexander Behrendt Art Sedrakyan Thea Schwaneberg Tilo Kölbel Konstantinos Spanos Eike Sebastian Debus Henrik Christian Rieß 《Journal of vascular surgery》2019,69(3):792-799.e2
Objective
There is some evidence that weekend admission to the hospital is associated with worse outcomes compared with weekday admission. However, only a few studies have focused on weekend vs weekday surgery outcomes. This study aimed to determine whether there is a weekend effect on outcomes in the treatment of ruptured aortic aneurysms in Germany.Methods
Health insurance claims of Germany's third largest insurance provider, DAK-Gesundheit, were used to investigate short-term and long-term mortality after weekend vs weekday treatment of ruptured aortic aneurysm. Patients undergoing endovascular repair (ER) or open surgical repair (OSR) between January 2008 and December 2016 were included in the study. Both propensity score matching and regression methods were used to adjust for confounding.Results
There were 1477 patients in the cohort, of whom 517 (35.0%) underwent ER and 960 (65.0%) OSR. Overall, 995 (67.4%) patients underwent an operation on weekdays (Monday to Thursday), and 482 (32.6%) patients underwent an operation on a weekend (Friday to Sunday). In multivariable models, patients who underwent an operation on a weekend were at higher risk of in-hospital death after OSR (49.2% vs 38.0%; odds ratio [OR], 1.61; P = .001), and there was a trend toward higher in-hospital mortality after ER (29.5% vs 21.2%; OR, 1.55; P = .056). The ER of thoracic or thoracoabdominal aortic ruptures was associated with significantly higher in-hospital mortality compared with ER of abdominal aortic aneurysm (OR, 1.69; P = .026).Conclusions
Weekend repairs of ruptured aortic aneurysms are associated with worse in-hospital survival compared with weekday surgery. ER of thoracic or thoracoabdominal aortic ruptures is associated with worse in-hospital survival compared with ER of ruptured abdominal aortic ruptures. This might be an international phenomenon requiring joint learning and action in times of centralization of aortic procedures. 相似文献11.
Leonard N. Girardi Jeremy R. Leonard Christopher Lau Lucas B. Ohmes Ivancarmine Gambardella Erin M. Iannacone Monica Munjal Alexandra N. Schwann Mario F.L. Gaudino 《Journal of vascular surgery》2019,69(4):1028-1035.e1
Objective
Female sex has been associated with greater morbidity and mortality for a variety of major cardiovascular procedures. We sought to determine the influence of female sex on early and late outcomes after open descending thoracic aortic aneurysm (DTA) and thoracoabdominal aortic aneurysm (TAAA) repair.Methods
We searched our aortic surgery database to identify patients having open DTA or TAAA repair. Logistic regression and Cox regression analyses were used to assess the effect of sex on perioperative and long-term outcomes.Results
From 1997 until 2017, there were 783 patients who underwent DTA or TAAA repair. There were 462 male patients and 321 female patients. Female patients were significantly older (67.6 ± 13.9 years vs 62.6 ± 14.7 years; P < .001), had more chronic pulmonary disease (47.0% vs 35.7%; P = .001) and forced expiratory volume in 1 second <50% (28.3% vs 18.2%; P < .001), and were more likely to have degenerative aneurysms (61.7% vs 41.6%; P < .001). Operative mortality was not different between women and men (5.6% vs 6.2%; P = .536). However, women were more likely to require a tracheostomy after surgery (10.6% vs 5.0%; P = .003) despite a reduced incidence of left recurrent nerve palsy (3.4% vs 7.8%; P = .012). Logistic regression found female sex to be an independent risk factor for a composite of major adverse events (odds ratio, 2.68; confidence interval, 1.41-5.11) and need for tracheostomy (odds ratio, 3.73; confidence interval, 1.53-9.10). Women also had significantly lower 5-year survival.Conclusions
Women undergoing open DTA or TAAA repair are not at greater risk for operative mortality than their male counterparts are. Reduced preoperative pulmonary function may contribute to an increased risk for respiratory failure in the perioperative period. 相似文献12.
Christopher A. Latz Virendra I. Patel Richard P. Cambria Emel A. Ergul R. Todd Lancaster Glenn M. LaMuraglia Mark F. Conrad W. Darrin Clouse 《Journal of vascular surgery》2019,69(3):661-670
Objective
Perioperative outcomes and late mortality after open type IV thoracoabdominal aortic aneurysm (TAAA) repair are known, yet risk of late graft and subsequent aortic events is infrequently described. Such data are increasingly important as endovascular repair becomes an option and are the subject of this study.Methods
During a 27-year interval, 233 patients underwent open surgical repair of type IV TAAA. Surviving patients were monitored for late aortic or graft-related events. Late aortic events were defined as native aortic disease unrelated to the prior reconstruction leading to death or further intervention. Graft-related complications included anastomotic aneurysm, graft infection, and branch occlusion. Variables were assessed for association with study end points using univariate log-rank methods and Cox proportional hazards regression. Time-to-event analysis was performed using Kaplan-Meier techniques.Results
In-hospital mortality occurred in 7 patients (3%), leaving 226 available for surveillance. Mean age was 72 ± 9 years; 50 patients (21%) had 52 synchronous, noncontiguous aortic aneurysms at time of repair (n = 11 ascending aorta/arch; n = 41 descending thoracic aorta). Mean follow-up was 4.3 ± 3.7 years (median, 3.5 years; interquartile range, 5 years). Aortic events (n = 19 [8%]) included elective aortic repair (n = 15), emergent repair (n = 2), and atheroembolic embolization (n = 2) at a mean of 2.6 ± 2.2 years after type IV TAAA repair. There were 17 patients (8%) who experienced graft-related events (renovisceral occlusion [n = 10; 4% of cohort], anastomotic aneurysm repair [n = 5], graft infection [n = 1], and graft-caval fistula [n = 1]) occurring at 1.7 ± 1.9 years after repair. Variables independently predictive of an aortic event were initial rupture (hazard ratio, 5.6; P = .02) and native aortic expansion during surveillance (hazard ratio, 3.9; P = .04). No independent predictors of graft-related complication were identified. Freedom from an aortic or graft-related event was 93% at 1 year and 66% at 5 years. Freedom from graft or aortic reintervention was 86% at 5 years. Aortic-related mortality in follow-up was 2% and estimated to be 5% at 5 years after type IV TAAA repair. Overall survival was 92% and 66% at 1 year and 5 years, respectively.Conclusions
After open type IV TAAA repair, late aortic and graft-related events are uncommon. Native aortic disease sequelae and graft complications occur with equal frequency and with similar temporal relation to repair. Need for reintervention is infrequent, and aortic-related mortality is low. These findings verify durability of open type IV TAAA repair and serve as long-term comparative results for endovascular repair. 相似文献13.
Bo Yang Elizabeth L. Norton Terry Shih Linda Farhat Xiaoting Wu Whitney E. Hornsby Karen M. Kim Himanshu J. Patel G. Michael Deeb 《The Journal of thoracic and cardiovascular surgery》2019,157(4):1313-1321.e2
Objective
To compare perioperative and long-term outcomes in patients undergoing hemiarch and aggressive arch replacement for acute type A aortic dissection (ATAAD).Methods
From 1996 to 2017, we compared outcomes of hemiarch (n = 322) versus aggressive arch replacements (zones 2 and 3 arch replacement with implantation of 2-4 arch branches, n = 150) in ATAAD. Indications for aggressive arch were arch aneurysm >4 cm or intimal tear in the aortic arch that was not resectable by hemiarch replacement, or dissection of arch branches with malperfusion.Results
Patients in the aggressive arch group were significantly younger (mean age: 57 vs 61 years old) and had significantly longer hypothermic circulatory arrest, cardiopulmonary bypass, and aortic crossclamp times. There were no significant differences in perioperative outcomes between hemiarch and aggressive arch groups, including 30-day mortality (5.3% vs 7.3%, P = .38) and postoperative stroke rate (7% vs 7%, P = .96). Over 15 years, Kaplan–Meier survival was similar between hemiarch and aggressive arch groups (log-rank P = .55, 10-year survival 70% vs 72%). Given death as a competing factor, incidence rates of reoperation over 15 years (2.1% vs 2.0% per year, P = 1) and 10-year cumulative incidence of reoperation (14% vs 12%, P = .89) for arch and distal aorta pathology were similar between the 2 groups.Conclusions
Both hemiarch and aggressive arch replacement are appropriate approaches for select patients with ATAAD. Aggressive arch replacement should be considered for an arch aneurysm >4 cm or an intimal tear at the arch unable to be resected by hemiarch replacement, or dissection of the arch branches with malperfusion. 相似文献14.
Amine Mazine Louis-Mathieu Stevens Aly Ghoneim Jennifer Chung Maral Ouzounian Francois Dagenais Ismail El-Hamamsy Munir Boodhwani John Bozinovski Mark D. Peterson Michael W.A. Chu 《The Journal of thoracic and cardiovascular surgery》2019,157(4):1360-1368.e8
Objectives
To examine the performance curves of 8 early-career aortic surgeons with the use of hypothermic circulatory arrest (HCA) and to analyze the impact of the learning curve on perioperative outcomes.Methods
A total of 1025 consecutive patients who underwent aortic reconstruction with HCA between 2002 and 2017 were analyzed for mortality and 5 other complications (stroke, reoperation for bleeding, dialysis, prolonged ventilation, and sternal wound complications), subdivided into 3 consecutive time periods. This cohort represents the complete inaugural experience of 8 Canadian academic aortic surgeons. A risk-adjusted cumulative sum analysis was used to evaluate the performance curve with respect to predetermined 80% alert and 95% alarm boundary lines.Results
Mean age was 62 ± 13 years, 71% of patients were male, and 24% presented nonelectively. Hemiarch repair was performed in 80% and total arch replacement in 20%. There was a reduction in the incidence of the primary composite outcome over time (P1: 26%, P2: 23%, and P3: 16%; P = .010). Overall in-hospital mortality was 5% and remained stable throughout the 3 periods. Rates of stroke were lower in the late period (P1: 4%, P2: 6%, and P3: 2%; P = .035). Risk-adjusted cumulative sum analysis demonstrated that all surgeons remained within the 95% reassurance boundary throughout their experience, with 6 surgeons performing as expected and 2 performing better than expected.Conclusions
Early-career surgeons can safely perform operations with HCA from the initiation of their practice. The cumulative sum analysis method is valuable for monitoring competence in aortic surgery and could prove useful in structuring training programs. 相似文献15.
Jean Porterie Nicolas Mayeur Thibaut Lhermusier Nicolas Dumonteil Thomas Chollet Olivier Lairez Bertrand Marcheix 《The Journal of thoracic and cardiovascular surgery》2019,157(4):1393-1401.e7
Objectives
This study aimed at evaluating the efficacy and safety of the transaortic approach for the transcatheter aortic valve implantation procedure using balloon-expandable and self-expanding devices.Methods
From January 2012 to December 2016, the transaortic-transcatheter aortic valve implantation procedure was performed in 206 consecutive patients at the Rangueil University Hospital. All procedures were performed by a multidisciplinary heart team. The ascending aorta (27%) or innominate artery (73%) was exposed through a J-type manubriotomy. Events were adjudicated according to Valve Academic Research Consortium-2 criteria.Results
Mean age and logistic European System for Cardiac Risk Evaluation II were 83.9 ± 6.7 years and 16.8% ± 10.8%, respectively. Balloon-expandable and self-expanding valves were implanted in 59.7% and 40.3% of patients, respectively. Device success rate was 98.1%. Thirty-day overall mortality, cardiovascular mortality, cerebrovascular event, myocardial infarction, and permanent pacemaker implantation rates were 5.3%, 4.4%, 1.5%, 1.0%, and 9.7%, respectively (1-year rates: 15.5%, 9.2%, 3.9%, 3.4%, and 10.2%, respectively). Life-threatening bleeding and major vascular complications (7.3% and 3.9%, respectively) were not related to the central access site in approximately half of the cases. Multivariable Cox regression analysis identified preoperative renal failure as an independent predictor of overall mortality (odds ratio, 2.82; 95% confidence interval, 1.73-4.59; P < .0001). At the 1-year follow-up, most patients had experienced improved functional status and 98.4% of them were free of moderate to severe paravalvular leak.Conclusions
In a higher-risk subgroup within the patient population receiving transcatheter aortic valve implantation, transaortic-transcatheter aortic valve implantation was successfully performed in 98.1% of cases, with high functional improvement and low rates of mortality and adverse events, especially neurologic complications. 相似文献16.
Stephan Koter Tina U. Cohnert Korbinian B. Hindermayr Jörg Lindenmann Maximilian Brückner Wolfgang K. Oswald Georg Werkgartner Doris Wagner 《Journal of vascular surgery》2019,69(4):1227-1232
Objective
Low psoas muscle area is shown to be an indicator for worse postoperative outcome in patients undergoing vascular surgical. Additionally, it has been associated with longer durations of hospital stay in patients with cancer who undergo surgery and subsequently greater health care costs in Europe and the United States. We sought to evaluate this effect on hospital expenditure for patients undergoing vascular repair in a health care system with universal access.Methods
Skeletal muscle mass was assessed on preoperative abdominal computed tomography scans of patients undergoing open aortic aneurysm repair in a retrospective fashion. The skeletal muscle index (SMI) was used to define low muscle mass. Health care costs were obtained for all patients and the relationship between a low SMI and higher costs was explored using linear regression and cross-sectional analysis.Results
We included 156 patients (81.5% male) with a median age of 72 years undergoing elective surgery for infrarenal abdominal aortic aneurysm in this analysis. The median SMI for patients with low skeletal muscle mass was 53.21 cm2/kg and for patients without, 70.07 cm2/kg. Hospital duration of stay was 2 days longer in patients with low skeletal muscle mass as compared with patients with normal (14 days vs 11 days; P = .001), as was duration of intensive care stay (3 days vs 1 day; P = .01). The median overall hospital costs were €10,460 higher for patients with a low SMI as compared with patients with a normal physical constitution (€53,739 [interquartile range, €45,007-€62,471] vs €43,279 [interquartile range, €39,509-€47,049]; P = .001). After confounder adjustment, a low SMI was associated with a 14.68% cost increase in overall hospital costs, for a cost increase of €6521.Conclusions
Low skeletal muscle mass is independently associated with higher hospital as well as intensive care costs in patients undergoing elective aortic aneurysm repair. Strategies to reduce this risk factor are warranted for these patients. 相似文献17.
Francesco Pollari Angelo Maria Dell&#x;Aquila Claudius S?hn Jill Marianowicz Pia Wiehofsky Johannes Schwab Matthias Pauschinger Wolfgang Hitzl Theodor Fischlein Steffen Pfeiffer 《The Journal of thoracic and cardiovascular surgery》2019,157(4):1406-1415.e3
Objective
To assess risk factors for paravalvular leak (PVL) after transcatheter aortic valve implantation in a large single-center cohort, including measurement of aortic valve calcification using a reproducible method.Methods
We retrospectively analyzed preoperative contrast-enhanced multidetector computed tomography scans of patients who underwent transcatheter aortic valve implantation in our center between 2009 and 2016. Calcium volume was calculated for each aortic cusp in the aortic valve, left ventricular outflow tract, and device landing zone.Results
Overall, 539 patients were included in the study who had experience with 4 prothesis types (SapienXT [Edwards Lifesciences, Irvine, Calif] [n = 192], Sapien3 [Edwards Lifesciences] [n = 206], CoreValve EvolutR [Medtronic, Minneapolis, Minn] [n = 44], and Acurate [Symetis, Ecublens, Switzerland] [n = 97]). Median calcium volume in the device landing zone was 757 mm3, with no significant differences among the 4 prosthesis groups. None of the patients had severe PVL. The overall incidence of mild-to-moderate PVL was 15.8% (95% confidence interval [CI], 12.8%-19.1%). On multivariate logistic regression, device landing zone calcification (P = .00006; odds ratio for an increase of 100 mm3, 1.08; 95% CI, 1.04-1.13) and use of the CoreValve (P = .0028; odds ratio, 4.1; 95% CI, 1.6-10 with SapienXT as reference) prosthesis were found to be associated with mild or greater PVL. In contrast, degree of oversizing (P = .002; odds ratio, 0.97; 95% CI, 0.95-0.99), and use of Sapien3 (P = .00005; odds ratio, 0.23; 95% CI, 0.11-0.47 with SapienXT as reference) were associated with a lower incidence of mild or greater PVL.Conclusions
Aortic calcification volume in the device landing zone is associated with residual PVL after transcatheter aortic valve implantation. When taking calcification into account, the balloon-expandable prosthesis Sapien3 seems to be associated with a lower incidence of PVL. 相似文献18.
Shailee Shah Alaa Alashi Gosta B. Pettersson L. Leonardo Rodriguez A. Marc Gillinov Richard A. Grimm Jose Navia Samir R. Kapadia Lars G. Svensson Brian P. Griffin Milind Y. Desai 《The Journal of thoracic and cardiovascular surgery》2019,157(5):1785-1792.e1
Background
Paravalvular leak (PVL) is often seen after aortic (AV) and mitral valve (MV) surgery, either due to infection or valve dehiscence. We sought to describe predictors of longer-term outcomes in patients who developed PVL after AV and MV surgery and were considered eligible for reoperative cardiac surgery (RCS).Methods
We studied 495 such patients (65 ± 14 years, 65% men, 47% with MV PVL) who presented at our center between January 2003 and December 2011. Patients with severe mitral/aortic stenosis, patients with less than mild PVL, and those with prohibitive risk precluding RCS were excluded. Society of Thoracic Surgeons (STS) score was calculated. Primary endpoint was mortality.Results
At baseline, mean STS score and left ventricular ejection fraction were 5.8 ± 4% and 52 ± 12%, respectively. In total, 105 (21%) had infective PVL and 72% had moderate or greater PVL. At a median of 8 days, 351 (71%) patients underwent RCS to repair PVL (3% in-hospital postoperative mortality), and at 6.6 ± 4 years, 230 (47%) patients died. On multivariable Cox survival analysis, greater STS score (hazard ratio or HR 1.35), mitral versus aortic PVL (HR 1.66), infectious etiology (HR 2.05), and greater right ventricular systolic pressure (HR 1.09) were associated with greater longer-term mortality, whereas surgery (HR 0.58) was associated with improved longer-term survival (all P < .05).Conclusions
Patients who develop mild or greater PVL after AV/MV surgery have a high rate of longer-term mortality, despite excellent perioperative outcomes. Greater STS score, right ventricular systolic pressure, infectious etiology, and MV (vs AV) involvement were all independently associated with long-term mortality, whereas RCS for PVL closure was associated with improved longer-term survival. 相似文献19.
Thomas Sénage Florence Gillaizeau Thierry Le Tourneau Basile Marie Jean-Christian Roussel Yohann Foucher 《The Journal of thoracic and cardiovascular surgery》2019,157(4):1383-1390.e5
Objectives
Structural valve deterioration (SVD) remains a major bioprosthesis-related complication, as recently described for the Mitroflow valve (models LX and 12A) (LivaNova, London, United Kingdom). The real incidence of the SVD risk remains unclear, often due to methodologic pitfalls by systematically using the Kaplan-Meier estimator and/or the Cox model. In this report, we propose for the first time a precise statistical modeling of this issue.Methods
Five hundred sixty-one patients who underwent aortic valve replacement with the aortic Mitroflow valve between 2002 and 2007 were included. We used an illness–death model for interval-censored data. Median follow-up was 6.6 years; 103 cases of SVD were diagnosed.Results
The 4-year and 7-year SVD cumulative incidences after the first anniversary of surgery were 15.2% (95% confidence interval, 11.9-19.1) and 31.0% (95% confidence interval, 25.8-37.2), respectively. Female gender, dyslipidemia, chronic obstructive pulmonary disease, and severe patient-prosthesis mismatch were significant risk factors of SVD. The occurrence of SVD was associated with a 2-fold increase in the risk of death.Conclusions
Appropriate statistical models should be used to avoid underestimating the SVD complication associated with worse long-term survival. 相似文献20.
Seyed M. Qaderi Nam T. Tran Billi Tatum Jan D. Blankensteijn Niten Singh Benjamin W. Starnes 《Journal of vascular surgery》2019,69(4):1059-1065