Short term outcome of thoracic endovascular aortic repair in patients with thoracic aortic diseases

Aim and background

Open surgical repair for thoracic aortic diseases is associated with a high perioperative mortality and morbidity. Most of type B aortic dissections are uncomplicated and are medically treated which carries a high mortality rate. Thoracic endovascular aortic repair is the first-line therapy for isolated aneurysms of the descending aorta and complicated type B aortic dissection. The aim of this study is to test the safety of early thoracic endovascular aortic repair in patients with uncomplicated type B aortic dissection and patients with thoracic aortic aneurysms.

Lengthening of proximal implantation site during endovascular repair of thoracic aortic aneurysm: Preservation of carotid patency with retrograde trans endograft deployment of a carotid stent

Endovascular repair of descending thoracic aortic aneurysms with a reduced proximal implantation site represents a technical challenge. Surgical procedures before endovascular exclusion can be necessary to increase the length of the proximal landing site to avoid type 1 endoleaks. We present a case of endovascular exclusion of a descending thoracic aortic aneurysm with the endograft placed proximal to the left common carotid artery. Flow to this arch was preserved reconstructing the carotid ostium with the retrograde implantation of a carotid stent that was placed extending across an orifice created in the deployed endograft by puncture and balloon dilatation. © 2008 Wiley‐Liss, Inc.     

Clinical and patho-anatomical factors affecting expansion of thoracic aortic aneurysms

OBJECTIVE—To examine the expansion of aneurysmal aortic segments ( 35 mm) and to assess the impact of clinical and patho-anatomical factors on aneurysm expansion.
DESIGN—87 consecutive patients (mean age 63.6 years, range 22-84 years) were studied using serial (six month intervals) computed tomographic or magnetic resonance imaging to monitor progression of thoracic aortic aneurysms. Aortic diameter was measured at seven predetermined segments and at the site of maximum aortic dilatation (MAX).
RESULTS—780 segment intervals were identified. The median overall aneurysm expansion rate was 1.43 mm/year. This increased exponentially with incremental aortic diameter (p < 0.01) and varied by anatomical segment (p < 0.05). The presence of intraluminal thrombus (p < 0.01) but not dissection or calcification was associated with accelerated growth. Univariate analysis identified thrombus (p < 0.001), previous stroke (p < 0.002), smoking (p < 0.01), and peripheral vascular disease (p < 0.05) as factors associated with accelerated growth in MAX. Dissection, wall calcification, and history of hypertension did not affect expansion. β Blocker treatment was not associated with protection. Multivariate analysis confirmed the positive effect of intraluminal thrombus and previous cerebral ischaemia, and the negative effect of previous aortic surgery on aneurysm growth. These findings translated into a mathematical equation describing exponential aneurysm expansion.
CONCLUSIONS—Aneurysmal thoracic aortic segments expand exponentially according to their initial size and their anatomical position within the aorta. The presence of intraluminal thrombus, atherosclerosis, and smoking history is associated with accelerated growth and may identify a high risk patient group for close surveillance.


Keywords: thoracic aortic aneurysm; expansion rate     

管腔内支架人工血管治疗急性胸降主动脉夹层动脉瘤

目的 探讨管腔内支架替代传统手术治疗急性胸降主动脉夹层动脉瘤的可行性及效果.方法 从2003年6月至2005年6月,12例急性胸降主动脉夹层动脉瘤患者接受管腔内支架人工血管治疗.结果 12例患者无死亡.共放支架12支,胸降主动脉受压夹层真腔全部恢复正常管径,无中转手术.术后3个月、1年随访,行CTA检查未发现与支架有关的并发症.结论管腔内支架人工血管治疗急性胸降主动脉夹层动脉瘤是一种有效的治疗方法.     

高危胸降主动脉瘤腔内修复治疗

目的总结高危患者行胸降主动脉瘤(descending thoracic aortic aneurysm,DTAA)腔内修复治疗(endovascular aneurysm repair,EVAR)的经验。方法回顾分析2001年1月至2007年7月我科24例高危DTAA患者行EVAR诊治经过、结果和并发症。所有患者因动脉瘤部位、破裂、高龄或严重合并症而不适合行开放手术。EVAR术后1个月、3个月、6个月、12个月和每年行螺旋CT血管造影、三维重建随访。结果所有患者均获技术成功(100%)。围手术期死亡2例(8.3%),分别死于多系统器官功能衰竭和急性心肌梗死。2例(8.3%)术后发生严重并发症(1例缺血性脑卒中和1例急性肾功能不全)。11例(46%)术后即时造影显示近端Ⅰ型内漏,其中3例内漏量大,行球囊扩张后内漏消失;另8例随访观察。19例患者获随访,随访时间为1~60个月(平均18.6±4.2个月)。1例患者术后4年发生支架型人工血管移位并发Ⅰ型内漏,1例术后2年出现迟发性Ⅲ型内漏,均成功行EVAR。1例死于结肠癌。其余患者术后3个月CT证实瘤腔内完全血栓形成,无支架移位和内漏。随访期间动脉瘤最大直径缩小0~18 mm(平均6.3±3.1 mm),4例辅助性动脉旁路在随访期间人工血管均通畅。结论EVAR治疗高危DTAA早期死亡率和并发症发生率尚可接受,对某些病例可能是首选治疗方法。     

An update on the 'fast-track' abdominal aortic aneurysm repair

Patients who have unfavourable anatomy for endovascular repair of an abdominal aortic aneurysm require open repair. This is particularly the case for juxtarenal aortic aneurysms, or those patients with small or occluded iliac access vessels.An experience of 'fast-track' abdominal aortic aneurysm repair that was previously reported is updated in the present case. A retroperitoneal approach to the aorta is taken, using a small incision, and is followed by a patient care pathway protocol that demonstrated excellent results and a shortened length of stay. The present update on 56 patients is approximately double the previously reported experience.     

Endovascular treatment of thoracic aortic disease: mid-term follow-up.

OBJECTIVE: The aim of this study was to evaluate the mid-term follow-up in a cohort of patients with acute or chronic descending aortic disease treated by stent-graft repair. BACKGROUND: Since 1999, endovascular stent-graft placement has been reported as an alternative treatment to surgical approach for a variety of thoracic aortic diseases; however, results beyond initial short-term follow-up are not widely available for the broad range of applications. METHODS: From March 2001, 43 consecutive patients with traumatic aortic transection (group A = 16) and complicated type B aortic dissection or aneurysm (group B = 27) underwent stent-graft implantation. All patients underwent computed tomography (CT) scan as preoperative assessment and in 26 a transesophageal echo (TEE) exam was performed. RESULTS: Technically successful stent-graft deployment was achieved in all patients. No patient required surgical conversion and no cases of paraplegia occurred. The overall in-hospital mortality was 9.3%. A residual endoleak (type II) was detected in one group B patient who was managed conservatively. The mean follow-up was 29 +/- 8 months (range 10-48 months). No patient died during late follow-up after hospital discharge. At 12 months, one patient (2.5%) who had stent graft repair of an aortic dissection developed an asymptomatic type I endoleak. Three asymptomatic patients with chronic dissection had a persistent retrograde perfusion of the thoracic false lumen via a distal tear(s) in the dissection septum. CONCLUSION: Our results of stent-graft treatment of complicated and uncomplicated diseases of the descending aorta confirms that this alternative to open repair is a safe, less invasive, and relatively low risk approach. Medium-term follow-up results suggest that it is effective and durable therapy with low associated mortality and morbidity rates.     

传统及改良全胸腹主动脉替换术的临床疗效及术后并发症分析

目的探讨胸腹主动脉瘤(TAAA)患者行全胸腹主动脉替换术(tTAAAR)的临床疗效及术后并发症。方法回顾性分析2010年4月至2019年4月期间本院收治的14例行开放手术治疗的TAAA患者,11例为CrawfordⅡ型,3例为CrawfordⅢ型。男12例,女2例,年龄28～54岁,平均(36.1±7.1)岁。手术方式4例采用传统深低温体外循环tTAAAR,10例采用改良常温非体外循环tTAAAR。传统方式于深低温体外循环下建立动静脉通路进行体外转流,改良方式在常温非体外循环下建立降主动脉-髂动脉旁路循环。结果 14例患者均完成手术。降主动脉阻断时间为(22.2±9.6)min;脊髓缺血时间为(23.0±7.3)min。术后早期死亡2例,急性肾功能不全4例,双下肢截瘫3例,肺部感染4例,一过性脑功能障碍4例。1例患者术中行脾切除术,1例患者术后行气管切开术。结论开放性行tTAAAR是一种相对安全、有效的手术方式,是目前针对部分复杂TAAA的有效治疗手段。     

胸主动脉腔内修复术治疗Stanford B型主动脉夹层

目的 总结胸主动脉腔内修复术（thoracic endovascular aortic repair,TEVAR）治疗Stanford B型主动脉夹层的临床经验.方法 回顾性分析134例Stanford B型主动脉夹层患者的临床资料,分析并发症发生的原因及随访近、远期效果.结果 术前死亡4例,未手术1例,施行TEVAR 129例,手术操作均成功,部分封堵左锁骨下动脉27例（20.9％）,完全封闭左锁骨下动脉12例（9.3％）;Ⅰ型内漏13例（10.1％）,夹层逆剥为Stanford A型1例,低氧血症23例（17.8％）,肾功能衰竭需血液滤过9例（7.1％）,术后精神症状37例（28.7％）,脑梗死3例.随访2个月～5年,随访110例,随访率85.7％,1例术后1年和1.5年出现支架远端夹层,两次手术植入覆膜支架,部分封闭了腹腔干动脉,1例术后2个月时因肠梗阻在外院行手术治疗,1例术后4年时支架远端发生夹层破裂死亡,1例术后3个月突然死亡.Ⅰ型内漏消失11例,持续存在2例.结论 急诊TEVAR治疗Stanford B型主动脉夹层安全、可靠,近期效果良好,加强并发症的防治,可进一步改善临床效果.     

Troubleshooting techniques for the EndurantTM device in endovascular aortic aneurysm repair

Endovascular aortic aneurysm repair with the Endurant^TM stent-graft system has been shown to be safe and effective in high-risk surgical patients with complex suprarenal and/or infrarenal abdominal aortic aneurysm anatomy. The wireformed M-shaped stent architecture and proximal springs with anchoring pins theoretically permit optimal sealing in shorter and more angulated proximal aneurysm necks even under off-label conditions. Nonetheless, extremely difficult anatomical situations and inherent graft system-related limitations must be anticipated. Herein, we describe our techniques to overcome the capture of the tip sleeve within the suprarenal bare-stent anchoring pins, other endograft segments, and native vessels.     

Preoperative disseminated intravascular coagulation complicated by thoracic aortic aneurysm treated using recombinant human soluble thrombomodulin: A case report

Rationale:Chronic disseminated intravascular coagulation (DIC) associated with thoracic aortic aneurysm is characterized by enhanced fibrinolysis and is thought to be stable in the compensated/asymptomatic stage, with few bleeding symptoms. However, DIC can lead to decompensated/hemorrhagic stage disseminated intravascular coagulation, resulting in severe bleeding diathesis, and there is currently no established strategy for treatment of DIC in aortic aneurysms.Patient concerns:A 77-year-old woman underwent angiography and cardiac catheterization, before descending aortic replacement surgery. She developed DIC in postprocedure week 2 with extensive, uncontrollable massive subcutaneous hemorrhage.Diagnoses:Her acute-phase DIC score was 7 points, and the risk of mortality within 30 days after surgery according to the JapanSCORE was estimated to be 33.6%.Interventions:Therapy was a combination of recombinant human soluble thrombomodulin (rhTM) and an aortic stent-graft treatment.Outcomes:Short-term improvements were seen in both DIC and bleeding diathesis. The thoracic aortic aneurysm with severe DIC was eventually corrected by administration of rhTM.Lessons:We report the use of rhTM as an effective, novel anticoagulant drug with anti-inflammatory activity for treating DIC with suppressed fibrinolysis, which is typically associated with sepsis. In patients with a high hemorrhagic diathesis, in whom preoperative control of DIC cannot be achieved with conventional anticoagulation and radical surgical repair cannot be performed, a combination of rhTM and endovascular therapy may be a powerful new treatment option.     

Melatonin protects against thoracic aortic aneurysm and dissection through SIRT1-dependent regulation of oxidative stress and vascular smooth muscle cell loss

Melatonin functions as an endogenous protective molecule in multiple vascular diseases, whereas its effects on thoracic aortic aneurysm and dissection (TAAD) and underlying mechanisms have not been reported. In this study, TAAD mouse model was successfully induced by β-aminopropionitrile fumarate (BAPN). We found that melatonin treatment remarkably prevented the deterioration of TAAD, evidenced by decreased incidence, ameliorated aneurysmal dilation and vascular stiffness, improved aortic morphology, and inhibited elastin degradation, macrophage infiltration, and matrix metalloproteinase expression. Moreover, melatonin blunted oxidative stress damage and vascular smooth muscle cell (VSMC) loss. Notably, BAPN induced a decrease in SIRT1 expression and activity of mouse aorta, whereas melatonin treatment reversed it. Further mechanistic study demonstrated that blocking SIRT1 signaling partially inhibited these beneficial effects of melatonin on TAAD. Additionally, the melatonin receptor was involved in this phenomenon. Our study is the first to report that melatonin exerts therapeutic effects against TAAD by reducing oxidative stress and VSMC loss via activation of SIRT1 signaling in a receptor-dependent manner, thus suggesting a novel therapeutic strategy for TAAD.     

累及弓部的B型夹层及弓部动脉瘤处理手术方式的探讨

目的 讨论累及弓部的B型夹层及弓部动脉瘤处理手术方式及疗效。方法总结15例病例,其中男性13人,女性1人;年龄32-75岁,平均年龄48.17±10.62;发病时间3日-3月。13例为复杂型Standford B型夹层;2例行Hybrid手术,其中1例累及无名动脉,升主动脉未累及,予以在体外循环并行下行头臂干及左颈总动脉与三分支血管转移至升主动脉;1例累及左锁骨下动脉但左侧椎动脉起源于主动脉弓部,予以在非体外循环下行头臂干及左颈总动脉转移至升主动脉。11例行TEVAR 烟囱手术,其中一例累及左颈总动脉,予以行双烟囱手术治疗。2例主动脉弓部瘤,均行Hybrid手术;其中1例为主动脉多发弓部瘤,瘤体位于无名动脉近心端,升主动脉无受累,予以在非体外循环并行下行头臂干及左颈总动脉与三分支血管转移至升主动脉;1例瘤体累及左颈总动脉,予以行右侧腋动脉-左侧颈总动脉转流术。结果 15例手术均成功,手术时间142±53分钟,1例体外循环时间75分钟。1例“烟囱”术后出现II型内漏(9.1%),术后3月复查CTA提示内漏闭合。术后均无特殊并发症,治愈出院,现均存活,术后住院时间(16±5天)出院。术后1月,3月,6月,1年,2年予以行CTA复查,显示夹层假腔内血栓机化,真腔内径扩人,旁路血管通畅,无狭窄或闭塞。结论 TEVAR 烟囱技术及Hybrid技术的综合应用可以给我们很多处理复杂累及弓部主动脉瘤的方法,并且可以在损伤较小的情况下减少致残律及死亡率,但远期的疗效需要进一步观察。     

Giant dissecting aortic aneurysm with concealed perforation in an 81-year-old female

This paper describes the history of an 81-year-old female suffering from a giant dissecting aortic aneurysm with concealed perforation within the thorax. The patient had suffered from arterial hypertension for about 10 years and had been treated with thiazide. Nine months prior to admission the patient was in a state of collapse, and ultrasound examination revealed an intra-abdominal aortic aneurysm. At this time thoracic x-ray showed aortic sclerosis and elongation of the aorta but no signs of aneurysm formation. After this episode the patient was symptom-free for the next 9 months. Following a further syncopal attack with severe thoracic pain, the patient was hospitalized at the intensive care unit. Both in thoracic x-ray and computed tomography of the thorax, a pronounced dissecting aortic aneurysm with perforation of the thoracic aorta into the mediastinum could be established. Because of the patient's poor general condition and advanced age, as well as far reaching pathological findings, surgery was not advised by either the heart and vascular surgeon or the anesthetist. Following 1 week's intensive therapy, the patient's general condition improved greatly, with stabilization of thoracic pain, blood pressure, and respiratory action. On the other hand, thoracic x-ray, computed tomography, and magnetic resonance imaging produced a distinct progression of the aneurysm with consequent mild displacement of mediastinum and left lung. Laboratory examinations for syphilis showed no evidence of that disease. After further improvement the patient was discharged 4 weeks after admission and has been symptom-free for 6 months in spite of the extensive pathological findings described herein. This case demonstrates the efficacy of conventional therapy when surgery is not recommended.