腔内修复术治疗非复杂性急性B型主动脉夹层及随访结果

目的评价覆膜支架胸主动脉腔内修复术(TEVAR)治疗非复杂性急性Stanford B型主动脉夹层(ATBAD)的近中期效果,并与复杂性ATBAD作比较。方法回顾性分析2003年5月至2012年6月收治的122例ATBAD患者临床资料。根据临床特征,分为非复杂性ATBAD组(A组,n=73)和复杂性ATBAD组(B组,n=49)。TEVAR术后随访5年,对比两组围手术期并发症、30 d死亡率、5年主动脉相关事件、免于主动脉相关事件发生率和中期生存率。结果 A组与B组相比,围手术期并发症发生率(8.2%对42.9%,P<0.01)、30 d死亡率(0%对12.2%,P=0.008)均显著降低;5年中期随访显示,主动脉相关事件发生率(5.5%对7.0%,P=1.000)、中期死亡率(2.7%对7.0%,P=0.352)均相似,免于主动脉相关事件发生率(P=0.661)、中期生存率(P=0.245)差异均无统计学意义。结论 TEAVR治疗非复杂ATBAD可行、有效。与复杂ATBAD相比,非复杂ATBAD经TEVAR治疗获得了更好的近期效果,中期效果相似。     

Midterm Outcomes of Open Surgical Repair Compared with Thoracic Endovascular Repair for Isolated Descending Thoracic Aortic Disease

Objective

This study aimed to assess the surgical morbidity and mortality of thoracic endovascular repair (TEVAR) as compared with open surgical repair (OSR) for isolated descending thoracic aortic disease.

Materials and Methods

From January 1, 2006 through May 31, 2010, a total of 68 patients with isolated descending thoracic aortic disease were retrospectively reviewed for the presence of perioperative complication, 30-day mortality, and clinical success. The patients were divided into two groups (group 1, OSR, n = 40 vs. group 2, TEVAR, n = 28) and these groups were compared for major variables and late outcomes.

Results

The mean age was 58 years (group I = 54 vs. group II = 63 years, p = 0.011). Significant perioperative complications occurred in 12 patients: 8 (20%) in group I and 4 (13%) in group II (p = 0.3). There were five 30 day mortalities of which 4 occurred in group I and 1 in group II (p = 0.23). Clinical success (effective aortic remodeling and complete false lumen obliteration or thrombosis) was achieved in 20 patients (71%). Mean Kaplan-Meier survival rate at 1 year was similar for both groups (group 1 = 87% vs. group 2 = 80%, p = 0.65).

Conclusion

Thoracic endovascular repair for isolated thoracic aortic disease shows comparable results to OSR. However, the potential for endoleak or rupture remains a challenge that needs to be addressed in the future. Therefore, close follow-up study is needed for the evaluation of satisfactory long-term outcomes.     

MDCT angiography before and after thoracic endovascular aortic repair (TEVAR) in patients with thoracic traumatic aortic injuries

Objective

The objective of this study was to outline the role of multidetector computed tomography angiography (MDCTA) in the evaluation of patients with thoracic traumatic aortic injuries (TTAIs) pre- and post-thoracic endovascular aortic repair (TEVAR)

腔内修复术治疗113例主动脉夹层瘤的临床分析

目的 评价腔内修复术治疗主动脉夹层的疗效,探讨主动脉夹层的治疗策略.方法 回顾分析2002年3月 - 2010年6月,113 例采用腔内修复术治疗的主动脉夹层患者的临床资料、治疗和随访结果.结果 腔内修复术治疗主动脉夹层的手术成功率99.1%(112/113),围手术期无严重并发症发生,术后30 d病死率1.8%(2/...     

Endovascular Outcomes in Aortic Arch Repair with Double and Triple Parallel Stent Grafts

PurposeTo report early and midterm outcomes of treating thoracic aortic aneurysm (TAA) and aortic dissection (AD) involving zone 1 and zone 0 with multiple parallel stent grafts (PSGs).Materials and MethodsFrom February 2011 to August 2018, 31 of 1,806 patients (1.7%) who underwent thoracic endovascular aortic repair (TEVAR) with double PSGs (DPSGs) (n = 20) or triple PSGs (TPSGs) (n = 11) were retrospectively reviewed. Procedures were performed in high-risk patients who had TAA or AD involving zone 1 or zone 0.ResultsFifteen patients (48.4%) who presented with symptomatic or impending rupture underwent urgent or emergent TEVAR with DPSGs or TPSGs. Nineteen patients (61.3%) were treated for zone 0 disease. Technical and clinical success rates were 70.0% for DPSG cohort and 45.5% for TPSG cohort. Intraoperative type Ia endoleak was observed in 30% of DPSG cohort and 45.5% of TPSG cohort. One patient in the DPSG cohort died of aortic sinus rupture intraoperatively. Minor stroke during the 30-day postoperative period was more frequent in the TPSG cohort (P = .042). Mean duration of follow-up was 28.9 months ± 17.7. The TPSG cohort had a higher incidence of major adverse events (72.7% vs 25.0%, P = .021). The most common adverse events were endoleaks (12.9%), endograft migration (9.7%), PSG stenosis or occlusion (6.5%), retrograde dissection (6.5%), and stroke (3.2%). Endograft migrations were more common in TPSG cohort (27.3%, P = .037). Overall mortality rate was 16.1% (5/31) perioperatively and during follow-up. There were no statistical differences in overall survival and reintervention-free survival.ConclusionsIn the context of TEVAR with multiple PSGs for aortic arch repair, TPSGs may have a high risk of major complications.     

“Cheese Wire” Fenestration of Dissection Intimal Flap to Facilitate Thoracic Endovascular Aortic Repair in Chronic Dissection

Thoracic endovascular aortic repair (TEVAR) for aneurysmal chronic dissection is often complicated by retrograde filling of the false lumen and dissected distal landing zone. A “cheese wire”-style fenestration of the dissection intimal flap can create a landing zone facilitating TEVAR. This technique successfully aided TEVAR in 3 patients with an average age of 57.3 years. Complications included type III endoleak requiring relining and renal artery occlusion requiring stent placement. Average duration of clinical follow-up was 19 ± 4 months. Imaging follow-up was 8 ± 10 months. All patients have survived for more than 1 year without aneurysm enlargement.     

Endovascular abdominal aortic aneurysm repair in 144 patients: correlation of aneurysm size, proximal aortic neck length, and procedure-related complications.

PURPOSE: During endovascular abdominal aortic aneurysm (AAA) repair, larger aneurysms often present formidable anatomic challenges to the insertion of the delivery catheter and graft deployment. The authors sought to evaluate whether large-diameter aneurysms and those with short proximal aortic necks might be associated with a higher frequency of insertion-related and short-term complications. MATERIALS AND METHODS: From October 1999 to August 2000, 144 patients underwent elective endovascular graft placement for infrarenal AAA disease at the authors' institution. These patients were treated with use of the AneuRx bifurcated endoprosthesis. AAA size (maximum aneurysm diameter) and proximal aortic neck length were compared to estimated blood loss, operative time, accuracy of graft placement, presence of endoleak, intraoperative and postoperative complications (such as limb occlusion or vascular injury), length of hospital stay, and mortality. Statistical methods included correlation analysis and logistic regression. RESULTS: There were 121 men and 23 women whose aneurysms ranged in size from 3 cm to 9.8 cm (mean, 5.6 cm; 95% CI, 5.4-5.8 cm). Endograft insertion was successful in all cases. There were three deaths within 30 days (2.1%) and seven deaths overall (4.9%). There were 43 intraoperative complications (29.9%) in 31 patients (21.5%), most of them minor. Patients with major intraoperative complications had significantly longer procedure times than those without complications (337 vs. 149 min; P <.0001). In the postoperative period (within 30 days), 31 complications (21.5%) occurred in 28 patients (19.4%), again most of them minor. AAA size was unrelated in any way to the rate of complications, but short proximal aortic neck length was associated with more serious intraoperative and postoperative complications (P =.0404 and P =.0230, respectively), and decreased 30-day and overall survival (P =.0240 and P =.0152, respectively). CONCLUSIONS: Endovascular repair of large AAAs can be challenging; however, the size of the AAA does not influence the rate of complications. A short proximal aortic neck is the only significant risk factor for more serious complications.     

腔内修复术治疗Stanford B型主动脉夹层:单中心长期疗效分析

目的探讨胸主动脉腔内修复术(TEVAR)治疗Stanford B型主动脉夹层的长期疗效。方法回顾性搜集300例行TEVAR治疗的Stanford B型主动脉夹层患者的临床及影像学资料,分析患者短期(在院/术后30天)及长期死亡率、并发症发生率及主动脉重塑情况。结果技术成功率100%。左锁骨下动脉完全覆盖29例,烟囱支架重建左锁骨下动脉11例,烟囱支架重建左颈总动脉7例。患者在院/术后30天死亡率0.7%(2/300),并发症发生率14%(42/300)。中位随访时间35个月(6~126个月)。1、3、5年累积全因死亡率分别为2.0%、6.7%、12.8%,主动脉夹层相关死亡率分别为1.7%、4.5%、8.4%;晚期并发症发生率14.7%(44/300),胸主动脉段假腔完全血栓化率83.7%(251/300)。结论应用覆膜血管内支架行TEVAR是治疗Stanford B型夹层安全有效的方法,长期疗效令人满意。     

Endovascular repair of inflammatory abdominal aneurysm: a retrospective analysis of CT follow-up

Retrospective radiologic and clinical midterm follow-up is reported for 10 patients with inflammatory abdominal aortic aneurysm (IAAA) after endovascular aortic aneurysm repair (EVAR). At a mean follow-up of 33 months, regression of the thickness of the perianeurysmal fibrosis (PAF) and decrease of aneurysmal sac diameter was observed in nine patients. Four EVAR-associated complications were observed: periinterventional dissection of femoral artery (n = 1), blue toe syndrome (n = 1), and stent-graft disconnection (n = 2). EVAR is the less invasive method of aneurysm exclusion in patients with IAAA with a comparable evolution of the PAF as reported after open repair.     

Midterm follow-up of a single-center experience of endovascular repair of abdominal aortic aneurysms with use of the Talent stent-graft

PURPOSE: To review the midterm results of endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms (AAAs) with the Talent stent-graft. MATERIALS AND METHODS: All patients who underwent EVAR of AAAs with Talent stent-grafts from February 1998 to April 2002 at a single institution were monitored for a minimum of 2 years or until an endpoint of death or rupture was reached. RESULTS: There were 68 eligible patients, who were monitored for a mean period of 39 months (range, 24-72 months). Forty-nine (72.9%) were alive at 2 years; among the 19 deaths, two resulted from aneurysm rupture and the other 17 were unrelated to EVAR. There was one immediate conversion to open repair and five primary proximal endoleaks; the remaining 62 patients (91.2%) all had a technically successful procedure. There were 33 endoleaks during follow-up: 23 (69.7%) were treated conservatively and 10 (30.3%) underwent secondary intervention in the form of embolization (n=2), attempted embolization (n=2), endovascular stent-graft placement (n=3), combined stent-graft placement and embolization (n=1), or surgical conversion (n=2). Overall, there were five persistent endoleaks, and the remaining patients were free of endoleak at their last review or endpoint. Three stent-grafts migrated and required further endovascular intervention. Wire fracture was seen in two stents but presented no clinical sequelae. There was one case of graft limb thrombosis that required surgical thrombectomy. CONCLUSIONS: EVAR of AAAs with use of the Talent stent-graft is a promising and acceptable alternative to open surgery. Our 30-day mortality rate of zero compares extremely well with historical data from open surgery and the findings of more recently published trials. The risk of endoleak and uncertainty over durability require long-term surveillance.     

Stanford B型主动脉夹层腔内修复术治疗体会

目的:探讨腔内修复术治疗Stanford B型主动脉夹层的效果。方法:对2005-09~2010-02期间18例Stanford B型主动脉夹层患者实行血管造影和血管腔内带膜支架植入手术治疗,术后3、6、12个月行CTA检查,观察手术疗效以及有无狭窄、移位和扭曲等术后并发症。结果:无中转开胸手术。除1例再发Stanford A型夹层破裂死亡外,其余患者均顺利出院。结论:主动脉夹层腔内修复术治疗Stanford B型主动脉夹层是一种安全有效的方法,早期结果满意,中远期效果还有待观察。     

Clinical Outcomes for Endovascular Repair of Thoracic Aortic Disease Using the Seal Thoracic Stent Graft: A Korean Multicenter Retrospective Study

Purpose

To investigate the midterm outcomes of thoracic endovascular aneurysm repair (TEVAR) with the use of the Seal stent graft for four categories of thoracic aortic disease.

Acute Intramural Hematoma of the Descending Aorta Treated with Stent Graft Repair Is Associated with a Better Prognosis

Purpose

To compare midterm outcomes of optimal medical treatment (OMT) alone with OMT and thoracic endovascular aortic repair (TEVAR) of acute type B intramural hematoma (IMHB).

Midterm Outcomes of Endovascular Repair for Stanford Type B Aortic Dissection with Aberrant Right Subclavian Artery

PurposeTo evaluate the early and midterm outcomes of endovascular repair of Stanford type B aortic dissection (TBAD) with an aberrant right subclavian artery (ARSA).Materials and MethodsFrom November 2012 to July 2018, 15 patients (13 male, 2 female) who had TBAD with ARSA underwent total endovascular repair, including thoracic endovascular aortic repair (TEVAR), left subclavian artery (LSA) chimney technique, LSA fenestration technique, and double chimney technique (LSA chimney and ARSA periscope). The mean age was 55 years. Kommerell diverticulum (KD) occurred in 2 patients, which were covered by means of oversized aortic stents. All patients had preoperative imaging examinations for assessing cerebral blood flow and the dominant vertebral arteries.ResultsAll procedures were completed successfully. There was no in-hospital mortality. The mean procedural time was 98 ± 40 minutes (range 50–190). The mean preoperative diameters of the maximum descending aorta, false lumen, and true lumen in the descending aorta versus postoperative were 37 ± 10 mm (range 28–67), 18 ± 9 mm (range 9–41), and 19 ± 6 mm (range 10–35) versus 34 ± 9 mm (range 25–64), 5 ± 8 mm (range 0–28), and 28 ± 5 mm (range 19–37), respectively. Right upper extremity weakness was observed in 2 patients, which recovered gradually during follow-up. Immediate type Ia endoleak was detected in 1 patient. The mean follow-up time was 33 ± 20 months. During follow-up, no ARSA steal syndrome, spinal cord ischemia, or strokes were not observed.ConclusionsEndovascular treatment for TBAD with ARSA was feasible and safe with a satisfactory midterm follow-up outcome.     

腔内修复或药物治疗稳定型B型主动脉夹层

目的 比较胸主动脉腔内修复术(TEVAR)联合药物及单纯药物在稳定型Standford B型主动脉夹层治疗中的价值,探讨稳定型B型主动脉夹层治疗策略.方法 回顾性分析2004年至2015年收治的118例明确诊断为稳定型B型主动脉夹层患者临床资料,其中接受TEVAR联合药物治疗(TEVAR组)57例,单纯药物治疗(药物组)61例.分别统计1个月内、随访期并发症和死亡率,Kaplan-Meier生存曲线比较两组生存率.结果 术后1个月内及住院期间主要并发症发生率、死亡率,TEVAR组分别为5.2％、0％,药物组均为0％.术后随访1～110个月,平均(43.3±36.7)个月,主要并发症、死亡率在TEVAR组分别为7.0％、5.3％,药物组分别为6.6％、8.1％;术后1、2、4、7年累积生存率在TEVAR组分别为100％、97.1％、93.5％、78.0％,药物组分别为98.4％、96.4％、90.8％、72.7％,两组间差异无统计学意义(x2=0.019,P=0.890).结论 与单纯药物治疗相比,TEVAR术治疗稳定型Standford B型主动脉夹层可降低假腔扩展率,但有手术相关并发症,并不能提高生存率.     

Endovascular treatment of late in-stent-graft dissection after thoracic endovascular aneurysm repair

Complications after endovascular repair of thoracic aortic pathologies may be devastating. We report the case of endovascular treatment of late in–stent-graft dissection after thoracic endovascular aneurysm repair (TEVAR). A 25-year-old man was admitted to our hospital 2 years after endovascular treatment of posttraumatic aortic pseudoaneurysm using stent-graft implantation with an acute sudden onset of ischemia in both legs with absent femoral pulses, numbness, and renal functions deterioration. Multidetector computed tomography (MDCT) angiography showed an intimal flap in the distal part of the stent-graft with critical stenosis of the residual lumen. The patient was successfully treated with stent-graft implantation by way of percutaneous approach while under local anesthesia. The risk of this late complication after TEVAR should be considered during follow-up, especially in young patients with increased physical activity. Endovascular treatment can be the method of choice for these patients.     

CT appearance of complications related to thoracic endovascular aortic repair (TEVAR): a pictorial essay

Thoracic endovascular aortic repair (TEVAR) is a recognized treatment for various diseases involving the thoracic aorta. Patients treated with TEVAR require lifelong surveillance for potential complications, with CT being highly utilized in most centres. Endoleak is the most common complication and can be detected using CT. However, other complications such as stent strut perforations and end organ ischemia can also be detected on CT. The purpose of this pictorial essay is to illustrate the CT appearance of post-TEVAR complications encountered in our institution and to highlight their significance.     

Stanford B型夹层覆膜支架血管腔内修复术后围术期死亡原因分析

目的分析Stanford B型主动脉夹层覆膜支架血管腔内修复术(TEVAR)后围术期患者死亡情况及可能的死亡原因。 方法2004年2月—2012年9月,254例症状性Stanford B型主动脉夹层患者在本中心接受覆膜支架血管腔内修复术(TEVAR)治疗,其中,男性214例,女性40例,平均(51.5±12.5)岁。统计TEVAR术后围术期患者死亡情况,并分析可能的死亡原因。 结果TEVAR术后围术期患者死亡7例(7/254,2.76﹪),其中男性5例,女性2例。可能的死亡原因中,破裂所致死亡3例(3/254,1.18﹪),肠道缺血死亡2例(2/254,0.79﹪),呼吸功能衰竭死亡1例(1/254,0.39﹪),心源性猝死1例(1/254,0.39﹪)。 结论TEVAR术治疗症状性Stanford B型主动脉夹层安全、有效,但TEVAR术后围术期患者死亡情况仍需重视,在引起死亡的各种原因中,破裂和肠道缺血引起的死亡尤其值得关注。     

Outcomes of endovascular treatment of thoracic aorta pathologies: 10-year single-center results

PURPOSE Thoracic endovascular aortic repair (TEVAR) is a safe and effective treatment method for a variety of thoracic aortic pathologies. We aimed to investigate the mortality and complication outcomes and associated factors of TEVAR treatment in Turkey.METHODS In this single-centered retrospective study, patients with thoracic aorta pathologies treated with TEVAR at Gazi University School of Medicine, Department of Radiology, between January 2009 and January 2020 were included. Perioperative, early, and late mortality, complications, and technical success were the outcomes.RESULTS The sample comprised 58 patients with 68 TEVAR interventions. Eleven (16.2%) patients were female, the mean age was 60.1 ± 13.4 years. Emergent TEVAR was required in 20.7% of the patients. The main indications of TEVAR were intact descending aorta aneurysms in 37.9% of the sample, 31.0% Stanford type-B dissection, and 12.1% traumatic transections. The technical success rate of primary and secondary interventions was 98.3% and 100%, respectively. The mortality rate in the first 30 days was 8.6%. Seventeen (29.3%) cases had at least 1 complication related to TEVAR treatment. The most common complication was type-1A endoleak (10.3%). Having acute symptoms, stroke, and acute renal failure were significantly associated with mortality (P = .020, .049, and .009, respectively).CONCLUSION This study reported the outcomes of TEVAR treatment from a tertiary medical center in Turkey over a decade. Patients presenting with acute symptoms and who developed stroke and acute renal failure after the procedure should be carefully followed up as these factors were found to be associated with mortality.

Main points

• Thoracic endovascular aortic repair (TEVAR) procedure is associated with increased mortality.
• This study showed the mortality and complication outcomes of TEVAR treatment for various aortic pathologies in a single tertiary center in Turkey over a 10-year period.
• Presenting with acute symptoms and developing stroke and acute renal failure after the TEVAR procedure were associated with mortality.

Thoracic aorta pathologies are a spectrum of diseases composed of aneurysms, dissections, traumatic injuries, penetrating atherosclerotic ulcers (PAU), and intramural hematomas. Thoracic endovascular aortic repair (TEVAR) is a safe and effective treatment method described and used with increased frequency. Lower rates of complications like renal failure, paraplegia, stroke, lower blood transfusion requirement, and lower mortality rates, as well as shorter hospitalization time, make TEVAR a successful treatment alternative to open surgery regarding thoracic aortic pathologies.^1-3 TEVAR has become the treatment of choice for descending aortic aneurysm,^4-6 complicated type-B dissections,⁷ and traumatic transections.⁸While TEVAR has been used widely around the world, mortality and complications such as endoleak, stroke, renal failure, myocardial infarction, hemorrhage, thrombus, migration, and loss of graft integrity have been reported during follow-up.^4-6,9-14 This study aimed to investigate the mortality and complication outcomes in the first year after the TEVAR procedure and associated factors in patients with a variety of thoracic aorta pathologies.     

Percutaneous In Situ Microneedle Puncture Fenestration via the Left Subclavian Artery for branched Thoracic Endovascular Aortic Repair

This study explored the feasibility of a totally percutaneous approach to perform in situ microneedle puncture fenestration during thoracic endovascular aortic repair (TEVAR) via access from the left subclavian artery (LSA). In total, 23 patients with either thoracic aortic dissection or thoracic aortic aneurysm were treated with in situ LSA fenestration during TEVAR. The procedure was technically successful in all the patients. No serious complications occurred during a mean 9-month follow-up period. In situ microneedle puncture fenestration during TEVAR via the LSA is a feasible and effective method for LSA reconstruction.