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Irqsusi M, Rodepeter FR, Günther M, Kirschbaum A, Vogt S. Matrix metalloproteinases and their tissue inhibitors as indicators of aortic aneurysm and dissection development in extracellular matrix remodeling. World J Exp Med 2025; 15:100166. [DOI: 10.5493/wjem.v15.i2.100166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2024] [Revised: 01/04/2025] [Accepted: 01/15/2025] [Indexed: 04/16/2025] Open
Abstract
Aneurysms and dissections represent some of the most serious cardiovascular diseases. The prevailing theory posits that mechanical overloading of the vessel wall is the underlying cause. Inspired by Barkhordarian et al, the authors present matrix metalloproteinases (MMPs) and their inhibitors in immunohistological analyses as contributing factors in the pathophysiology of aortic aneurysms (AA). Data analysis of MMP-1, MMP-9, tissue inhibitors of metalloproteinases (TIMPs), including TIMP-1 and TIMP-2 expression reveals a varied distribution between the adventitia and media and a non-uniform expression of the investigated markers. These elements, as key components of the extracellular matrix (ECM), indicate that the formation of AA is not solely driven by endoluminal pressure loading of the aortic wall. Instead, degenerative processes within ECM elements contribute significantly. Importantly, AA do not necessarily imply dissection. Tissue destruction, allowing blood flow entry, arises from reduced oxygen supply to the media, primarily due to incomplete capillarization or neocapillarization.
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Affiliation(s)
- Marc Irqsusi
- Department of Heart Surgery, Universitätsklinikum Marburg and Gießen GmbH, Marburg 35043, Hesse, Germany
| | - Fiona R Rodepeter
- Institute of Pathology, Philipps-University Marburg, Marburg 35043, Hesse, Germany
| | - Madeline Günther
- Department of Heart Surgery, Cardiovascular Research Laboratory, Philipps-University Marburg, Marburg 35043, Hesse, Germany
| | - Andreas Kirschbaum
- Department of Visceral Surgery, University Hospital Giessen and Marburg GmbH, Marburg 35043, Hesse, Germany
| | - Sebastian Vogt
- Department of Heart Surgery, Philipps-University Marburg, Marburg 35043, Hesse, Germany
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de Magalhães ACPS, Gurgel GDA, de Barros SMW, Valente MLS, Aquino MDA, Bessa SDS, Baquette RF, Castro AA, Pitta GBB. Gastrointestinal histological injury in pigs subjected to triple stent interposition in the thoracoabdominal aorta. Acta Cir Bras 2025; 40:e402425. [PMID: 40105604 PMCID: PMC11908737 DOI: 10.1590/acb402425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2024] [Accepted: 01/10/2025] [Indexed: 03/20/2025] Open
Abstract
PURPOSE To evaluate gastrointestinal histological injury in pigs subjected to triple stent interposition versus a control group, hypothesizing no significant injury increase with triple stents. METHODS A prospective study with 15 pigs divided into a control group (G0, n = 5) undergoing arteriography only, and a triple stent group (G3, n = 10) undergoing arteriography and three stent implantations in the thoracoabdominal aorta. After an eight-day observation, arteriography, euthanasia, and en bloc gastrointestinal harvesting were performed. Lesions were graded using the Park/Chiu classification, and serum markers were analyzed pre- and post-procedure. RESULTS Arteriography confirmed mesenteric artery patency in all animals. Histological analysis showed ischemic lesions in 88.9% of G3, mainly in the colon (89%), compared to 60% in G0, primarily in the colon (60%) and stomach (40%). Most G3 lesions were grade 1, while G0 had higher-grade lesions. Serum markers showed no significant intergroup differences. CONCLUSION Triple stent interposition did not significantly increase gastrointestinal injury, indicating its safety for maintaining gastrointestinal perfusion in this model.
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Affiliation(s)
| | - Gutenberg do Amaral Gurgel
- Universidade Federal do Rio Grande do Sul – Faculdade de Medicina – Departamento de Cirurgia – Porto Alegre (RS) – Brazil
| | | | - Miguel Lucas Silva Valente
- Universidade Federal do Acre – Faculdade de Medicina – Departamento de Cirurgia – Rio Branco (AC) – Brazil
| | - Maurício de Amorim Aquino
- Universidade Federal do Rio Grande do Sul – Faculdade de Medicina – Departamento de Cirurgia – Porto Alegre (RS) – Brazil
| | - Sthefanie da Silva Bessa
- Centro Universitário São Lucas – Faculdade de Medicina – Departamento de Cirurgia – Porto Velho (RO) – Brazil
| | | | - Aldemar Araújo Castro
- Universidade Estadual de Ciências da Saúde de Alagoas – Faculdade de Medicina – Departamento de Cirurgia – Maceió (AL) – Brazil
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Teasdale A. Dissecting the Medical Student Approach to Chest Pain: A Cross-Sectional Study Focusing on Aortic Dissection. Cureus 2022; 14:e29050. [PMID: 36237814 PMCID: PMC9553203 DOI: 10.7759/cureus.29050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/10/2022] [Indexed: 11/08/2022] Open
Abstract
Background and purpose: To understand if medical students consider rarer, but highly fatal conditions, such as acute aortic dissection, when assessing chest pain. Methods:An online virtual clinical case (in two 'stages') was distributed to medical students. Stage one presented a chest pain scenario, asking participants to give relevant questions, clinical findings, investigations, and differential diagnoses. In the second stage, students were given a detailed case, populated with the aortic dissection ‘red flags’ and asked to re-evaluate their differential diagnosis and investigations. A total of 113 students in their final two years of study, across six United Kingdom (UK) medical schools, were accepted into the study. Results: During stage one, students were able to assess chest pain with radiation (93%), character (83%), and onset (89%), which were asked commonly. However, students failed to enquire on severity (38%) and important risk factors such as connective tissue disorders (4%) and hypertension (46%), or clinical signs such as blood pressure differences (5%). Myocardial infarction (97%) and pulmonary embolism (78%) were the most considered differentials with acute aortic dissection only considered by 31%. However, in stage two, 73% recognised the acute aortic dissection and 76% were able to request a CT thorax. Conclusions: Students effectively consider myocardial infarction and pulmonary embolism when assessing chest pain, but often fail to examine acute aortic dissection. This could lead to delayed treatment of a cataclysmic event and may be due to a deficiency in diagnostic synthesis rather than a lack of knowledge. More can be done to ensure these conditions form part of their diagnostic workup.
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Liu Y, Li Q, Zhang Y, Zhao R, Pang R, Ren H. Application of the national early warning score (NEWS) in patients with acute aortic dissection: A case-control study. J Clin Nurs 2021; 31:1620-1627. [PMID: 34459049 DOI: 10.1111/jocn.16016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 08/16/2021] [Accepted: 08/16/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND The vital-sign monitoring strategy of patients with acute aortic dissection in the emergency department is mainly based on traditional experience. This study attempts to explore the significance of the national early warning score (NEWS) in monitoring the condition of patients with acute aortic dissection during emergency observation and to provide evidence for emergency nurses in optimal and scientific monitoring of patients. METHODS The case-control method was used to continuously enrol patients with acute aortic dissection who had been in the emergency department; the STROBE checklist was used in this process. Based on patients' clinical deterioration, they were divided into two groups: clinical deterioration and non-clinical deterioration. The NEWS at each time point was compared by independent-samples t-test, and the predictive power of NEWS was evaluated according to the area under the receiver operating characteristic curve. RESULTS A total of 290 patients with acute aortic dissection were included: 46 patients showed clinical deterioration and 244 did not. There were significant differences in the NEW scores of the two groups at admission time and at 12, 8, 4 and 0.5 h before clinical deterioration. The NEW scores of the clinical deterioration group showed an upward trend, while the non-clinical deterioration group showed a relatively stable trend. The NEWS can be used to predict the occurrence of clinical deterioration earlier at 4 h before clinical deterioration. Simultaneously, the patient's respiration rate and SpO2 had better predictive performance than other vital signs. CONCLUSION The NEWS can be used to triage patients with acute aortic dissection admitted to the emergency department. Continuous use of the NEWS for monitoring can play a vital role in early warning of clinical deterioration in patients with acute aortic dissection. In clinical care, attention should also be paid when patients with acute aortic dissection have abnormal respiration rate and SpO2 .
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Affiliation(s)
- Yuwen Liu
- Department of Nursing, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Qingyin Li
- Department of Nursing, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yanjuan Zhang
- Emergency Department, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Rui Zhao
- Emergency Department, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ran Pang
- Emergency Department, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hua Ren
- Emergency Department, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Hynes N, Berguer R, Parodi JC, Acharya Y, Sultan S. Management of complicated aortic dissection: natural history, translational research, simulation, bioconvergence, clinical evidence and literature review. ITALIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY 2020. [DOI: 10.23736/s1824-4777.20.01473-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Harmon TS, Ghannam A, Meyer TE, Concepcion C, Pirris J, Matteo J. Covered or Not, Here I Come: Stanford Type B Aortic Dissection Repair With a Covered and Uncovered Stent Hybrid Technique. Cureus 2020; 12:e11729. [PMID: 33391956 PMCID: PMC7772157 DOI: 10.7759/cureus.11729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
The complications resulting from aortic dissections are often devastating. Historically, when a Stanford B aortic dissection extended into the visceral abdominal aorta, only surgical management was considered to limit visceral organ malperfusion. Complications of surgical management for Stanford B aortic dissections are as high as 50%. The inherently high complication and mortality rate for any acute aortic dissection, in addition to the complication rates resulting from surgical management, have demonstrated poor outcomes. This is especially true when aortic dissections involve the visceral segment, where thoracic endovascular aortic repair (TEVAR) becomes limited or contraindicated. In the last two decades, various approaches for TEVAR have improved in both endograft design and interventional technique. The current literature demonstrates improved outcomes for patients that receive TEVAR for Stanford B aortic dissections, including those that involve the visceral segment. Despite favorable prognostic advancement in TEVAR, the proven management complexity of Stanford B aortic dissections continue to reflect the pitfalls of the endovascular devices that are currently available. We describe a covered and uncovered stent hybrid technique in patients with complicated Stanford B aortic dissections involving the visceral segment, considering these deficiencies. Hundred percent technical success was demonstrated in the short and mid-term surveillance periods.
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Affiliation(s)
- Taylor S Harmon
- Radiology, University of Florida College of Medicine, Jacksonville, USA
| | - Alexander Ghannam
- Cardiothoracic Surgery, University of Florida College of Medicine, Jacksonville, USA
| | - Travis E Meyer
- Radiology, University of Florida College of Medicine, Jacksonville, USA
| | | | - John Pirris
- Cardiothoracic Surgery, University of Florida College of Medicine, Jacksonville, USA
| | - Jerry Matteo
- Radiology, University of Florida College of Medicine, Jacksonville, USA
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Patel TV, Canario DAH, Isaacson AJ, Mauro DM. Vascular Etiologies of the Acute Abdomen. Semin Roentgenol 2020; 55:417-426. [PMID: 33220787 DOI: 10.1053/j.ro.2020.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Tirth V Patel
- Department of Radiology, University of North Carolina School of Medicine, Chapel Hill, NC
| | | | - Ari J Isaacson
- Department of Radiology, University of North Carolina School of Medicine, Chapel Hill, NC
| | - David M Mauro
- Department of Radiology, University of North Carolina School of Medicine, Chapel Hill, NC.
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Aslanidou L, Trachet B, Sasset L, Lovric G, Stergiopulos N, Di Lorenzo A. Early Morphofunctional Changes in AngII-Infused Mice Contribute to Regional Onset of Aortic Aneurysm and Dissection. J Vasc Res 2020; 57:367-375. [PMID: 32937637 DOI: 10.1159/000509545] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 06/15/2020] [Indexed: 12/20/2022] Open
Abstract
Aortic aneurysms and dissections are silent and lethal conditions, whose pathogenesis remains incompletely understood. Although angiotensin II (AngII)-infused ApoE-/- mice have been widely used to study aortic aneurysm and dissection, early morphofunctional alterations preceding the onset of these conditions remain unknown. The goal of this study was to unveil early morphofunctional changes underlying the onset of aneurysm and dissection. At 3 days post-AngII infusion, suprarenal abdominal aorta presented significant volumetric dilatation and microstructural damage. Ex vivo assessment of vascular reactivity of the suprarenal dissection-prone aorta and its side branches, showed an endothelial and contractile dysfunctions that were severe in the suprarenal aorta, moderate distally, and absent in the side branches, mirroring the susceptibility to dissection of these different vascular segments. Early and specific morphofunctional changes of the suprarenal aorta may contribute to the regional onset of aortic aneurysm and dissection by exacerbating the biomechanical burden arising from its side branches.
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Affiliation(s)
- Lydia Aslanidou
- Institute of Bioengineering, École Polytechnique Fédérale de Lausanne, Lausanne, Switzerland.,Department of Pathology and Laboratory Medicine, Cardiovascular Research Institute, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York, USA
| | - Bram Trachet
- Institute of Bioengineering, École Polytechnique Fédérale de Lausanne, Lausanne, Switzerland.,BioMMeda, Ghent University, Ghent, Belgium
| | - Linda Sasset
- Department of Pathology and Laboratory Medicine, Cardiovascular Research Institute, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York, USA
| | - Goran Lovric
- Centre d'Imagerie BioMédicale, École Polytechnique Fédérale de Lausanne, Lausanne, Switzerland.,Swiss Light Source, Paul Scherrer Institute, Villigen, Switzerland
| | - Nikolaos Stergiopulos
- Institute of Bioengineering, École Polytechnique Fédérale de Lausanne, Lausanne, Switzerland
| | - Annarita Di Lorenzo
- Department of Pathology and Laboratory Medicine, Cardiovascular Research Institute, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York, USA,
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Shen Y, Rao W, Liu J, Zhu G, Chen Z, Song C, Lu Q, Jing Z. A Promising Treatment of Distal Entry Tears Located in Branched Area of Abdominal Aorta With Coil-Stent Tear Occlusion Device: an Animal Experiment. J Cardiovasc Transl Res 2019; 12:338-346. [PMID: 30915624 DOI: 10.1007/s12265-019-09869-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Accepted: 01/27/2019] [Indexed: 11/28/2022]
Abstract
This study aims to evaluate the effect of coil-stent tear occlusion device in treating entry tears located in branched area of abdominal aorta. An abdominal aortic dissection animal model was constructed by mesh suturing method. The animal models were treated by the occlusion device and were evaluated by computed tomography angiography (CTA) 1 month later. Eighteen pigs were adopted in the abdominal aortic dissection modeling experiment, two of them died of cardiopulmonary arrest during the operation. Sixteen models survived, two of them were found complete false lumen thrombosis by CTA 3 days after the operation. The false lumen kept patency in the remaining 14 cases which were then implanted with the occlusion device. The procedure was successful in 13 cases except for one. The coil-stent tear occlusion device provides a novel method for tears located in the branched area of abdominal aorta, and is worth of further study.
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Affiliation(s)
- Yu Shen
- Department of Vascular Surgery, Changhai Hospital, Second Military Medical University, 168 Changhai Road, Shanghai, 200433, China
| | - Wenquan Rao
- Department of Vascular Surgery, Changhai Hospital, Second Military Medical University, 168 Changhai Road, Shanghai, 200433, China
| | - Junjun Liu
- Department of Vascular Surgery, The Affiliated Hospital of Qingdao University, 16 Jiangshu Road, Qingdao, 266003, China
| | - Guanglang Zhu
- Department of Vascular Surgery, Changhai Hospital, Second Military Medical University, 168 Changhai Road, Shanghai, 200433, China
| | - Zheng Chen
- Department of Vascular Surgery, Changhai Hospital, Second Military Medical University, 168 Changhai Road, Shanghai, 200433, China
| | - Chao Song
- Department of Vascular Surgery, Changhai Hospital, Second Military Medical University, 168 Changhai Road, Shanghai, 200433, China
| | - Qingsheng Lu
- Department of Vascular Surgery, Changhai Hospital, Second Military Medical University, 168 Changhai Road, Shanghai, 200433, China.
| | - Zaiping Jing
- Department of Vascular Surgery, Changhai Hospital, Second Military Medical University, 168 Changhai Road, Shanghai, 200433, China.
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Stelzmueller ME, Nolz R, Mahr S, Beitzke D, Wolf F, Funovics M, Laufer G, Loewe C, Hutschala D, Ehrlich MP. Thoracic endovascular repair for acute complicated type B aortic dissections. J Vasc Surg 2019; 69:318-326. [DOI: 10.1016/j.jvs.2018.05.234] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Accepted: 05/31/2018] [Indexed: 10/27/2022]
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Giles KA, Beck AW, Lala S, Patterson S, Back M, Fatima J, Arnaoutakis DJ, Arnaoutakis GJ, Beaver TM, Berceli SA, Upchurch GR, Huber TS, Scali ST. Implications of secondary aortic intervention after thoracic endovascular aortic repair for acute and chronic type B dissection. J Vasc Surg 2018; 69:1367-1378. [PMID: 30553732 DOI: 10.1016/j.jvs.2018.07.080] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Accepted: 07/29/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND Thoracic endovascular aortic repair (TEVAR) has become a mainstay of therapy for acute and chronic type B aortic dissection (TBAD). Dynamic aortic morphologic changes, untreated dissected aorta, and persistent false lumen perfusion have significant consequences for reintervention after TEVAR for TBAD. However, few reports contrast differences in secondary aortic intervention (SAI) after TEVAR for TBAD or describe their influence on mortality. This analysis examined incidence, timing, and types of SAI after TEVAR for acute and chronic TBAD and determined their impact on survival. METHODS All TEVAR procedures for acute and chronic TBAD (2005-2016) were retrospectively reviewed. Patients with staged (<30 days) or concomitant ascending aortic arch repair or replacement were excluded. Acuity was defined by symptom onset (0-30 days, acute; >30 days, chronic). SAI procedures were grouped into open (intended treatment zone or remote aortic site), major endovascular (TEVAR extension or endograft implanted at noncontiguous site), and minor endovascular (side branch or false lumen embolization) categories. Kaplan-Meier methodology was used to estimate freedom from SAI and survival. Cox proportional hazards were used to identify SAI predictors. RESULTS TEVAR for TBAD was performed in 258 patients (acute, 49% [n = 128]; chronic, 51% [n = 130]). Mean follow-up was 17 ± 22 months with an overall SAI rate of 27% (n = 70; acute, 22% [28]; chronic, 32% [42]; odds ratio, 1.7; 95% confidence interval, 0.9-2.9; P = .07]. Median time to SAI was significantly less after acute than after chronic dissection (0.7 [0-12] vs 7 [0-91] months; P < .001); however, freedom from SAI was not different (1-year: acute, 67% ± 4%, vs chronic, 68% ± 5%; 3-year: acute, 65% ± 7%, vs chronic, 52% ± 8%; P = .7). Types of SAI were similar (acute vs chronic: open, 61% vs 55% [P = .6]; major endovascular, 36% vs 38% [P = .8]; minor endovascular, 21% vs 21% [P = 1]). The open conversion rate (either partial or total endograft explantation: acute, 10% [13/128]; chronic, 15% [20/130]; P = .2) and incidence of retrograde dissection (acute, 6% [7/128]; chronic, 4% [5/130]; P = .5) were similar. There was no difference in survival for SAI patients (5-year: acute + SAI, 55% ± 9%, vs acute without SAI, 67% ± 8% [P = .3]; 5-year: chronic + SAI, 72% ± 6%, vs chronic without SAI, 72% ± 7% [P = .7]). Factors associated with SAI included younger age, acute dissection with larger maximal aortic diameter at presentation, Marfan syndrome, and use of arch vessel adjunctive procedures with the index TEVAR. Indication for the index TEVAR (aneurysm, malperfusion, rupture, and pain or hypertension) or remote preoperative history of proximal arch procedure was not predictive of SAI. CONCLUSIONS SAI after TEVAR for TBAD is common. Acute TBAD has a higher proportion of early SAI; however, chronic TBAD appears to have ongoing risk of remediation after the first postoperative year. SAI types are similar between groups, and the occurrence of aorta-related reintervention does not affect survival. Patients' features and anatomy predict need for SAI. These data should be taken into consideration for selection of patients, device design, and surveillance strategies after TEVAR for TBAD.
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Affiliation(s)
- Kristina A Giles
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Fla.
| | - Adam W Beck
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama, Birmingham, Ala
| | - Salim Lala
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Fla
| | - Suzannah Patterson
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Fla
| | - Martin Back
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Fla
| | - Javairiah Fatima
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Fla
| | - Dean J Arnaoutakis
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Fla
| | - George J Arnaoutakis
- Division of Thoracic and Cardiovascular Surgery, University of Florida, Gainesville, Fla
| | - Thomas M Beaver
- Division of Thoracic and Cardiovascular Surgery, University of Florida, Gainesville, Fla
| | - Scott A Berceli
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Fla
| | - Gilbert R Upchurch
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Fla
| | - Thomas S Huber
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Fla
| | - Salvatore T Scali
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Fla
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Abstract
Stanford type B aortic dissections (TBADs) involve the descending aorta and can present with complications, including malperfusion syndrome or aortic rupture, which are associated with significant morbidity and mortality if left untreated. Clinical diagnosis is straightforward, typically confirmed using CT angiography. Treatment begins with immediate anti-impulse medical therapy. Acute TBAD with complications should be repaired with emergent thoracic endovascular aortic repair (TEVAR). Uncomplicated TBAD with high-risk features should undergo TEVAR in the subacute phase. Open surgical repair is seldom required and reserved only for select cases. It is critical to follow these patients clinically and radiographically in the outpatient setting.
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Affiliation(s)
- Daniel B Alfson
- Division of Vascular Surgery, Department of Surgery, Keck School of Medicine of USC, University of Southern California, 1520 San Pablo Street, HCC II, Suite 4300, Los Angeles, CA 90033-5330, USA
| | - Sung W Ham
- Division of Vascular Surgery, Department of Surgery, Keck School of Medicine of USC, University of Southern California, 1520 San Pablo Street, HCC II, Suite 4300, Los Angeles, CA 90033-5330, USA.
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13
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Tuncer A, Akbulut M, Adademir T, Tas S, Ak A, Arslan Ö, Erden B, Şişmanoğlu M. Frozen Elephant Trunk and Antegrade Visceral Debranching in the Surgical Treatment of Type B Aortic Dissection: An Alternative Method. AORTA : OFFICIAL JOURNAL OF THE AORTIC INSTITUTE AT YALE-NEW HAVEN HOSPITAL 2017; 4:167-171. [PMID: 28516092 DOI: 10.12945/j.aorta.2016.15.040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/12/2015] [Accepted: 07/15/2016] [Indexed: 11/18/2022]
Abstract
Intervention is inevitable in complicated Type B aortic dissections. Classical surgical procedures and endovascular interventions are far from ideal treatments due to their high risk of periprocedural complications and mortality. There is often a need for alternative method in cases of difficult anatomy. We present the combined use of frozen elephant trunk and antegrade visceral debranching methods in the treatment of a 54-year-old male patient with complicated Type B aortic dissection.
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Affiliation(s)
- Altug Tuncer
- Kartal Kosuyolu Heart and Research Hospital, Department of Cardiovascular Surgery, Istanbul, Turkey
| | - Mustafa Akbulut
- Kartal Kosuyolu Heart and Research Hospital, Department of Cardiovascular Surgery, Istanbul, Turkey
| | - Taylan Adademir
- Kartal Kosuyolu Heart and Research Hospital, Department of Cardiovascular Surgery, Istanbul, Turkey
| | - Serpil Tas
- Kartal Kosuyolu Heart and Research Hospital, Department of Cardiovascular Surgery, Istanbul, Turkey
| | - Adnan Ak
- Kartal Kosuyolu Heart and Research Hospital, Department of Cardiovascular Surgery, Istanbul, Turkey
| | - Özgür Arslan
- Kartal Kosuyolu Heart and Research Hospital, Department of Cardiovascular Surgery, Istanbul, Turkey
| | - Benay Erden
- Kartal Kosuyolu Heart and Research Hospital, Department of Cardiovascular Surgery, Istanbul, Turkey
| | - Mesut Şişmanoğlu
- University of Duzce, Faculty of Medicine, Department of Cardiovascular Surgery, Duzce, Turkey
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14
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Wojciechowski J, Znaniecki L, Bury K, Chwojnicki K, Rogowski J. Traumatic aortic injury: does the anatomy of the aortic arch influence aortic trauma severity? Surg Today 2016; 47:328-334. [PMID: 27858166 PMCID: PMC5288446 DOI: 10.1007/s00595-016-1443-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Accepted: 06/14/2016] [Indexed: 11/25/2022]
Abstract
Purpose Traumatic aortic injury (TAI) is a rare but life-threatening type of injury. We investigate whether the anatomy of the aortic arch influences the severity of aortic injury. Methods This is a retrospective study of twenty-two cases treated with TEVAR for TAI in our department from 2009 to 2014. Aortic injury was assessed in accordance with the recommendations of the Society of Vascular Surgery. We measured the aortic arch angle and the aortic arch index, based on the initial angio-CT scan, in each of the analyzed cases. Results The mean aortic arch index and mean aortic arch angle were 6.8 cm and 58.3°, respectively, in the type I injury group; 4.4 cm and 45.9° in the type III group; 3.3 cm and 37° in the type IV group. There were substantial differences in both the aortic arch index and the aortic arch angle of the type III and IV groups. A multivariate analysis confirmed that the aortic arch angle was significantly associated with the occurrence of type III damage (OR 1.5; 95% CI 1.03–2.2). Conclusions The severity of TAI is influenced by the sharpness of the aortic arch. There is an inverse relationship between the severity of aortic injury and the aortic arch index.
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Affiliation(s)
- Jacek Wojciechowski
- Department of Cardiac and Vascular Surgery, Medical University of Gdansk, ul. Dębinki 7, 80-923, Gdansk, Poland
| | - Lukasz Znaniecki
- Department of Cardiac and Vascular Surgery, Medical University of Gdansk, ul. Dębinki 7, 80-923, Gdansk, Poland.
| | - Kamil Bury
- Department of Cardiac and Vascular Surgery, Medical University of Gdansk, ul. Dębinki 7, 80-923, Gdansk, Poland
| | - Kamil Chwojnicki
- Department of Neurology, Medical University of Gdansk, Gdansk, Poland
| | - Jan Rogowski
- Department of Cardiac and Vascular Surgery, Medical University of Gdansk, ul. Dębinki 7, 80-923, Gdansk, Poland
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Berguer R, Parodi JC, Schlicht M, Khanafer K. Experimental and Clinical Evidence Supporting Septectomy in the Primary Treatment of Acute Type B Thoracic Aortic Dissection. Ann Vasc Surg 2015; 29:167-73. [DOI: 10.1016/j.avsg.2014.10.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2014] [Revised: 10/02/2014] [Accepted: 10/02/2014] [Indexed: 10/24/2022]
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Mousa AY, Abu-Halimah S, Gill G, Yacoub M, Stone P, Hass S, Campbell JE, AbuRahma AF. Current Treatment Strategies for Acute Type B Aortic Dissection. Vasc Endovascular Surg 2015; 49:30-6. [PMID: 25571896 DOI: 10.1177/1538574414564580] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Acute type B aortic dissection (ATBAD) is a medical emergency that is a common occurrence in patients with atherosclerotic disease. The presentation is usually severe, with tearing pain that radiates to the back, and various levels of end-organ ischemia and malperfusion, even rupture, may occur. Everyone agrees that prompt and aggressive blood pressure control with β-blockers and nitroprusside is imperative, but when to surgically intervene is still not well characterized. However, the advent of minimally invasive stent graft placement has reshaped our thoughts regarding therapeutic intervention for ATBAD. This review is an attempt to define the current surgical indications for treating ATBAD.
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Affiliation(s)
- Albeir Y. Mousa
- Department of Vascular Surgery, West Virginia University/CAMC, Charleston, WV, USA
| | - Shadi Abu-Halimah
- Department of Vascular Surgery, West Virginia University/CAMC, Charleston, WV, USA
| | - Gurpreet Gill
- Department of Vascular Surgery, West Virginia University/CAMC, Charleston, WV, USA
| | - Michael Yacoub
- Department of Vascular Surgery, West Virginia University/CAMC, Charleston, WV, USA
| | - Patrick Stone
- Department of Vascular Surgery, West Virginia University/CAMC, Charleston, WV, USA
| | - Stephen Hass
- Department of Vascular Surgery, West Virginia University/CAMC, Charleston, WV, USA
| | - John E. Campbell
- Department of Vascular Surgery, West Virginia University/CAMC, Charleston, WV, USA
| | - Ali F. AbuRahma
- Department of Surgery, R. C. Byrd Health Sciences Center, West Virginia University, Charleston, WV, USA
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Song SW, Kim TH, Lim SH, Lee KH, Yoo KJ, Cho BK. Prognostic factors for aorta remodeling after thoracic endovascular aortic repair of complicated chronic DeBakey IIIb aneurysms. J Thorac Cardiovasc Surg 2014; 148:925-32, 933.e1; discussion 932-3. [DOI: 10.1016/j.jtcvs.2014.05.040] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2014] [Revised: 05/08/2014] [Accepted: 05/16/2014] [Indexed: 01/09/2023]
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Abstract
TEVAR is a new strategy for treating both acute and chronic type B aortic dissection. The JSC guidelines classify TEVAR as a Class I recommendation for cases of complicated acute type B dissection and a Class IIa recommendation for cases of chronic type B aortic dissection. While TEVAR has been primarily applied to treat complicated acute type B aortic dissection in Europe and the USA, the procedure remains an off-label treatment strategy for aortic dissection in Japan. The current state of TEVAR for type B aortic dissection in Japan from 2001 to 2011 is estimated in the annual reports of the Japanese Association for Thoracic Surgery. The number of acute type B aortic dissection patients treated with transluminal stent grafting increased rapidly after 2008, from 10 cases in 2001 to 76 cases in 2010. Meanwhile, the number acute type B aortic dissection patients treated with any type of surgery has increased gradually, from 100 cases in 2001 to 194 cases in 2009. The number of chronic type B aortic dissection patients treated with transluminal stent grafting increased abruptly in 2010, reaching 346 cases, which accounted for one-third of all surgical procedures for chronic type B aortic dissection. Furthermore, the number of open surgeries for chronic type B aortic dissection has also increased gradually, from 401 cases in 2001 to 947 cases in 2011. At present, open surgery, TEVAR and hybrid procedures are available to treat patients with type B aortic dissection. The use of a multidisciplinary team approach is mandatory when selecting the appropriate surgical strategy.
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Hanna JM, Andersen ND, Ganapathi AM, McCann RL, Hughes GC. Five-year results for endovascular repair of acute complicated type B aortic dissection. J Vasc Surg 2013; 59:96-106. [PMID: 24094903 DOI: 10.1016/j.jvs.2013.07.001] [Citation(s) in RCA: 114] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2013] [Revised: 07/08/2013] [Accepted: 07/10/2013] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Despite a current lack of U.S. Food and Drug Administration approval for the indication, thoracic endovascular aortic repair (TEVAR) has replaced open surgical management for acute complicated type B aortic dissection due to promising short- and midterm data. However, long-term results, with a view toward durability and need for secondary procedures, are limited. As such, the objective of the present study is to report long-term outcomes of TEVAR for acute (≤ 2 weeks from symptom onset) complicated type B dissection. METHODS Between July 2005 and September 2012, 50 consecutive patients underwent TEVAR for management of acute complicated type B dissection at a single referral institution. Patient records were retrospectively reviewed from a prospectively maintained clinical database. RESULTS Indications for intervention included rupture in 10 (20%), malperfusion in 24 (48%), and/or refractory pain/impending rupture in 17 (34%). One patient (2%) had both rupture and malperfusion indications. Ten (20%) patients required one or more adjunctive procedures, in addition to TEVAR, to treat malperfusion syndromes. In-hospital and 30-day rates of death were both 0%; 30-day/in-hospital rates of stroke, permanent paraplegia/paraparesis, and new-onset dialysis were 2% (n = 1), 2% (n = 1), and 4% (n = 2), respectively. Median follow-up was 33.8 months [interquartile range, 12.3-56.6 months]. Overall survival at 5 and 7 years was 84%, with no deaths attributable to aortic pathology. Thirteen (26%) patients required a total of 17 reinterventions over the study period for type I endoleak (n = 5), metachronous aortic pathology (n = 5), persistent false lumen pressurization via distal fenestrations (n = 4), type II endoleak (n = 2), or retrograde acute type A aortic dissection (n = 1). Median time to first reintervention was 4.5 months (range, 0 days-40.3 months). Of the 17 total reinterventions, six (35%) were performed using open techniques and 11 (65%) with endovascular or hybrid methods; there was no difference in survival between patients who did or did not require reintervention. CONCLUSIONS This study confirms the excellent short-term outcomes of TEVAR for acute complicated type B dissection and demonstrates the results to be durable and sustained over long-term follow-up. Although aortic reinterventions were required in one-quarter of patients, no aortic-related deaths were observed. These data support the use of TEVAR for acute complicated type B aortic dissection but also highlight the importance of life-long aortic surveillance by an experienced aortic referral center in order to identify and treat complications of the underlying disease process and treatment, as well as new aortic pathologies, as they arise.
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Affiliation(s)
- Jennifer M Hanna
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Nicholas D Andersen
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Asvin M Ganapathi
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Richard L McCann
- Division of Vascular Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - G Chad Hughes
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC.
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20
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Scali ST, Feezor RJ, Chang CK, Stone DH, Hess PJ, Martin TD, Huber TS, Beck AW. Efficacy of thoracic endovascular stent repair for chronic type B aortic dissection with aneurysmal degeneration. J Vasc Surg 2013; 58:10-7.e1. [PMID: 23561433 DOI: 10.1016/j.jvs.2012.12.071] [Citation(s) in RCA: 88] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2012] [Revised: 12/21/2012] [Accepted: 12/22/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND The Food and Drug Administration has approved devices for endovascular management of thoracic endovascular aortic aneurysm repair (TEVAR); however, limited data exist describing the outcomes of TEVAR for aneurysms attributable to chronic type B aortic dissection (cTBAD). This study was undertaken to determine the results of endovascular treatment of cTBAD with aneurysmal degeneration. METHODS A retrospective analysis of all patients treated for cTBAD with aneurysmal degeneration at the University of Florida from 2004 to 2011 was performed. Computed tomograms with centerline reconstruction were analyzed to determine change in aortic diameter, relative proportions of aortic treatment lengths, and false lumen perfusion status. Reintervention and mortality were estimated using life-tables. Cox regression analysis was completed to predict mortality. RESULTS Eighty patients underwent TEVAR for aneurysm due to cTBAD (mean age [± standard deviation], 60 ± 13 years [male, 87.5%; n = 70]; median follow-up, 26 [range, 1-74] months). Median time from diagnosis of TBAD to TEVAR was 16 (range, 1-72) months. Prior aortic root/arch replacement had been performed in 29% (n = 23) at a median interval of 28.5 (range, 0.5-312) months. Mean preoperative aneurysm diameter was 62.0 ± 9.9 mm. In 75% (n = 60) of cases, coverage was proximal to zone 3, and 24% (n = 19) underwent carotid-subclavian bypass or other arch debranching procedure. Spinal drains were used in 78% (pre-op 71%, n = 57; post-op 6%, n = 5). Length of stay was 6.5 ± 4.7 days with a composite morbidity of 26% and in-hospital mortality of 2.5% (n = 2). Overall neurologic event rate was 17% (spinal cord ischemia 10% [n = 8], with a permanent deficit observed in 6.2% [n = 5]; stroke 7.5%). Aneurysm diameter reduced or stabilized in 65%. The false lumen thrombosed completely within the thoracic aorta in 52%, and reintervention within the treated aortic segment was required in 16% (n = 13).One- and 3-year freedom from reintervention (with 95% confidence interval [CI]) was 80% (range, 68%-88%) and 70% (range, 57%-80%), respectively. Survival at 1 and 5 years was 89% (range, 80%-94%) and 70% (range, 55%-81%) and was not significantly different among patients requiring reintervention or experiencing favorable aortic remodeling. Multivariable analysis identified coronary artery disease (hazard ratio [HR], 6.4; 95% CI, 2.3-17.7; P < .005), prior infrarenal aortic surgery (HR, 8.6; 95% CI, 2.3-31.7; P = .001), and congestive heart failure (HR, 11.9; 95% CI, 1.9-73.8; P = .008) as independent risk factors for mortality. Hyperlipidemia was found to be protective (HR, 0.2; 95% CI, 0.05-0.6; P = .004). No significant difference in predictors of mortality were found between patients who underwent reintervention vs those who did not (P = .2). CONCLUSIONS TEVAR for cTBAD with aneurysmal degeneration can be performed safely but spinal cord ischemia rates may be higher than previously reported. Liberal use of procedural adjuncts to reduce this complication, such as spinal drainage, is recommended. Reintervention is common, but long-term survival does not appear to be impacted by remediation.
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Affiliation(s)
- Salvatore T Scali
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Florida College of Medicine, Gainesville, FL 32610, USA.
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Management of acute type B aortic dissection. J Thorac Cardiovasc Surg 2013; 145:S202-7. [PMID: 23267526 DOI: 10.1016/j.jtcvs.2012.11.078] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2012] [Revised: 10/10/2012] [Accepted: 11/28/2012] [Indexed: 11/20/2022]
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Simring D, Raja J, Morgan-Rowe L, Hague J, Harris PL, Ivancev K. Placement of a branched stent graft into the false lumen of a chronic type B aortic dissection. J Vasc Surg 2011; 54:1784-7. [DOI: 10.1016/j.jvs.2011.05.053] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2011] [Revised: 05/19/2011] [Accepted: 05/20/2011] [Indexed: 10/18/2022]
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Lu Q, Jing Z, Zhao Z, Bao J, Feng X, Feng R, Mei Z. Endovascular Stent Graft Repair of Aortic Dissection Type B Extending to the Aortic Arch. Eur J Vasc Endovasc Surg 2011; 42:456-63. [DOI: 10.1016/j.ejvs.2011.06.050] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2010] [Accepted: 06/28/2011] [Indexed: 11/15/2022]
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Management of acute complicated and uncomplicated type B dissection of the aorta: focus on endovascular stent grafting. Cardiol Rev 2011; 18:234-9. [PMID: 20699671 DOI: 10.1097/crd.0b013e3181e883c9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Endovascular repair of aortic dissection is the subject of multiple studies. This article aims to review the current literature on Type B complicated and uncomplicated dissection, including indications for medical therapy, open surgical therapy, and endovascular therapy. The review suggests a benefit for thoracic endovascular aortic repair in complicated dissection and medical therapy for uncomplicated dissection. Upcoming trials may shed more light on this issue.
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Mangialardi N, Costa P, Bergeron P, Serrao E, Ronchey S. Staged Hybrid Repair of Thoracoabdominal Aortic Aneurysm after Chronic Type B Aortic Dissection. Vascular 2010; 18:336-43. [DOI: 10.2310/6670.2010.00061] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The purpose of this study was to evaluate clinical outcomes of combined endovascular and open techniques to eradicate false lumen dilatation in the visceral aortic segment after type B aortic dissection associated with aortic aneurysm. We reviewed eight patients with distal thoracic and abdominal false lumen dilatation treated with a staged procedure. These included arch debranching as needed, proximal thoracic endovascular repair, and open surgical correction with abdominal aortic replacement of the visceral and infrarenal aorta. False lumen eradication was successful in all patients. There were no operative deaths, and paraplegia or paraparesis occurred in two patients. During a mean follow-up of 30 months, no complications or secondary interventions were necessary. The thoracic false lumen remained thrombosed in all patients, with no evidence of aortic dilatation or stent graft complications. Complete thrombosis and eradication of the false lumen can be achieved through a three-stage repair of chronic type B aortic dissection with aneurysmal dilatation. A prospective randomized trial is needed to establish the viability of this approach versus standard open repair of type II thoracoabdominal aortic aneurysms.
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Affiliation(s)
- Nicola Mangialardi
- *Department of Vascular Surgery, San Filippo Neri Hospital, Rome, Italy; †Department of Thoracic and Cardiovascular Surgery, Saint Joseph Hospital, Marseille, France
| | - Pierluigi Costa
- *Department of Vascular Surgery, San Filippo Neri Hospital, Rome, Italy; †Department of Thoracic and Cardiovascular Surgery, Saint Joseph Hospital, Marseille, France
| | - Patrice Bergeron
- *Department of Vascular Surgery, San Filippo Neri Hospital, Rome, Italy; †Department of Thoracic and Cardiovascular Surgery, Saint Joseph Hospital, Marseille, France
| | - Eugenia Serrao
- *Department of Vascular Surgery, San Filippo Neri Hospital, Rome, Italy; †Department of Thoracic and Cardiovascular Surgery, Saint Joseph Hospital, Marseille, France
| | - Sonia Ronchey
- *Department of Vascular Surgery, San Filippo Neri Hospital, Rome, Italy; †Department of Thoracic and Cardiovascular Surgery, Saint Joseph Hospital, Marseille, France
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Bhamidipati CM, Ailawadi G. Acute complicated and uncomplicated type III aortic dissection: an endovascular perspective. Semin Thorac Cardiovasc Surg 2010; 21:373-86. [PMID: 20226352 DOI: 10.1053/j.semtcvs.2009.11.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/24/2009] [Indexed: 11/11/2022]
Abstract
Type III aortic dissection is associated with high morbidity and mortality. There is a shifting paradigm in the treatment of complicated and uncomplicated acute type III aortic dissection toward earlier endovascular repair. In this review, the authors present the current perspective on the endovascular management of acute complicated and uncomplicated type III aortic dissection.
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Affiliation(s)
- Castigliano M Bhamidipati
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia School of Medicine, Charlottesville, Virginia, USA
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Torsello GB, Torsello GF, Osada N, Teebken OE, Ratusinski CM, Nienaber CA. Midterm Results From the TRAVIATA Registry: Treatment of Thoracic Aortic Disease With the Valiant Stent Graft. J Endovasc Ther 2010; 17:137-50. [PMID: 20426628 DOI: 10.1583/09-2905.1] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Feezor RJ, Martin TD, Hess PJ, Beaver TM, Klodell CT, Lee WA. Early outcomes after endovascular management of acute, complicated type B aortic dissection. J Vasc Surg 2009; 49:561-6; discussion 566-7. [PMID: 19268759 DOI: 10.1016/j.jvs.2008.09.071] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2008] [Revised: 09/17/2008] [Accepted: 09/17/2008] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Surgical management of acute, complicated type B aortic dissection is associated with significant morbidity and mortality. This study examined the feasibility and safety of endovascular treatment of this pathology. METHODS We reviewed a prospectively maintained thoracic endovascular database and medical records at a single institution from 2005 to 2007. The study group comprised of acute, complicated type B dissections, defined as duration of symptoms <or=14 days and involving either false lumen rupture, malperfusion, intractable pain, or uncontrolled hypertension. All repairs were performed using the TAG device (W. L. Gore and Associates, Flagstaff, Ariz). Select 30-day or in-hospital outcomes were reported. RESULTS Of the 216 thoracic endovascular aortic aneurysm repairs performed during the study period, 33 (15%) were for acute, complicated type B dissections. There were eight women (24%). The mean age was 61 +/- 15 years. The average duration of symptoms was 2.9 +/- 4.1 (median, 1) days. The indications for repair included rupture in 15 patients (46%) and mesenteric/renal/lower extremity malperfusion in 11 (33%). Mean fluoroscopy time and contrast volume were 30 +/- 16 minutes and 176 +/- 55 mL, respectively. Eight (73%) of 11 patients with malperfusion required branch vessel stenting. The 30-day in-hospital mortality was 21% (7 of 33). Causes of death included cardiac arrest in 3, progressive multisystem organ failure in 2, rupture in 1 and unknown in 1. At least one major complication occurred in 76% of the patients, including respiratory failure in 11 (33%), permanent spinal cord ischemia in 5 (15%), renal failure requiring dialysis in 4 (12%), and stroke in 4 (12%). The mean postoperative length of stay was 17.2 +/- 16.5 days, and only 14 (42%) were discharged to home. CONCLUSIONS Emergency endovascular repair of acute, complicated type B dissection is associated with significant mortality and morbidity. The overall role of this therapy in the treatment of this lethal problem should be better defined and compared with other surgical or interventional options before being generally adopted.
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Affiliation(s)
- Robert J Feezor
- Division of Vascular Surgery and Endovascular Therapy, University of Florida College of Medicine, Gainesville, Fla., USA
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Parsa CJ, Hughes GC. Surgical Options to Contend with Thoracic Aortic Pathology. Semin Roentgenol 2009; 44:29-51. [PMID: 19064070 DOI: 10.1053/j.ro.2008.10.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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30
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Ting AC, Cheng SW, Ho P, Chan YC, Poon JT, Cheung GC. Endovascular Repair for Thoracic Aortic Pathologies—Early and Midterm Results. Asian J Surg 2009; 32:39-46. [DOI: 10.1016/s1015-9584(09)60007-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Lin PH, Huynh TT, Kougias P, Huh J, LeMaire SA, Coselli JS. Descending Thoracic Aortic Dissection: Evaluation and Management in the Era of Endovascular Technology. Vasc Endovascular Surg 2008; 43:5-24. [DOI: 10.1177/1538574408318475] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Acute aortic dissection is a relatively uncommon but highly lethal condition. Without proper treatment, devastating consequences can occur due to aortic rupture, cardiac tamponade, or irreversible ischemia involving the spinal cord or the visceral organs. The treatment strategy of this condition is in part influenced by the location and the severity of aortic dissection as immediate surgical intervention is necessary in acute ascending aortic dissection, whereas medical therapy is the initial treatment approach in uncomplicated descending aortic dissection. Recent advances of endovascular technology have broadened the potential application of this catheter-based therapy in aortic pathologies, including descending thoracic aortic dissection. In this article, the etiology, pathogenesis, and classification of this condition are discussed. The diagnostic benefits of various imaging modalities for descending aortic dissection are also discussed. Current treatment strategies, including medical, surgical, and catheter-based interventions, are reviewed. Lastly, clinical experiences of endovascular treatment for descending aortic dissection and various endovascular devices potentially applicable for this condition are discussed.
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Affiliation(s)
- Peter H. Lin
- Michael E. DeBakey Department of Surgery, Division of Vascular Surgery and Endovascular Therapy, Baylor College of Medicine, and Michael E. DeBakey VA Medical Center,
| | - Tam T. Huynh
- Michael E. DeBakey Department of Surgery, Division of Vascular Surgery and Endovascular Therapy, Baylor College of Medicine, and Michael E. DeBakey VA Medical Center
| | - Panagiotis Kougias
- Michael E. DeBakey Department of Surgery, Division of Vascular Surgery and Endovascular Therapy, Baylor College of Medicine, and Michael E. DeBakey VA Medical Center
| | - Joseph Huh
- Michael E. DeBakey Department of Surgery, Division of Cardiothoracic Surgery, Baylor College of Medicine, and Texas Heart Institute at St. Luke's Episcopal Hospital Houston, Texas
| | - Scott A. LeMaire
- Michael E. DeBakey Department of Surgery, Division of Cardiothoracic Surgery, Baylor College of Medicine, and Texas Heart Institute at St. Luke's Episcopal Hospital Houston, Texas
| | - Joseph S. Coselli
- Michael E. DeBakey Department of Surgery, Division of Cardiothoracic Surgery, Baylor College of Medicine, and Texas Heart Institute at St. Luke's Episcopal Hospital Houston, Texas
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Vallely MP, Semsarian C, Bannon PG. Management of the ascending aorta in patients with bicuspid aortic valve disease. Heart Lung Circ 2008; 17:357-63. [PMID: 18514024 DOI: 10.1016/j.hlc.2008.01.007] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2007] [Revised: 12/05/2007] [Accepted: 01/23/2008] [Indexed: 01/11/2023]
Abstract
Bicuspid aortic valve (BAV) disease is the most common form of congenital heart disease, affecting 1-2% of the population. Only 20% of patients will maintain normal valve function throughout their life and more than 30% of patients will develop serious morbidity. It is a highly heritable condition, with transmission likely to be autosomal dominant. Patients with BAV have a 10-fold risk of aortic dissection when compared to the normal population. Management of BAV associated aortopathy represents a significant clinical challenge.
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Abstract
Thoracic aortic dissection is associated with substantial morbidity and mortality, and it requires timely and accurate diagnosis and treatment. Long-term antihypertensive therapy remains critical for the treatment of this disease. Surgical intervention, although still a formidable undertaking, has evolved to better address both acute and chronic dissection, and the results have improved. Basic and clinical research, as well as technological advances, have increased our understanding of this challenging disease state.
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Affiliation(s)
- Daniel R. Wong
- From the Texas Heart Institute, St. Luke's Episcopal Hospital and the Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Scott A. Lemaire
- From the Texas Heart Institute, St. Luke's Episcopal Hospital and the Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Joseph S. Coselli
- From the Texas Heart Institute, St. Luke's Episcopal Hospital and the Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
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Riambau V, Guerrero F, Murillo I, Rivadeneira M, Montaña X, Matute P. Stent Grafting–Related Acute Type B Redissection. Vascular 2008; 16:101-5. [DOI: 10.2310/6670.2008.00004] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The purpose of this article is to report two distal dissections resulting as a complication of endovascular aneurysm repair (EVAR) in two cases of type B aortic dissection (TBAD) and its relationship with prosthetic alignment at the distal landing zone. Two patients affected by aneurysm formation of a chronic type B dissection underwent EVAR. During postoperative follow-up, at 48 and 39 months, respectively, a new chest pain episode recommended a new computed tomographic angiography examination. New false lumen reperfusion and increased aortic diameter distally to the prosthesis were demonstrated. The distal end of each stent graft showed an angulated alignment to the proximal descending aorta at the point of the secondary entry site. Both patients were successfully treated after deployment of a distal endograft. Prosthetic alignment with the aortic axis is important to avoid wall stress and secondary perforation in patients treated for TBAD. The distal landing point at the descending aortic straight segment is recommended.
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Affiliation(s)
- Vincent Riambau
- *Vascular Surgery Division, Thorax Institute; †Interventional Radiology; and ‡Anaesthesiology, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Francisco Guerrero
- *Vascular Surgery Division, Thorax Institute; †Interventional Radiology; and ‡Anaesthesiology, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Ivan Murillo
- *Vascular Surgery Division, Thorax Institute; †Interventional Radiology; and ‡Anaesthesiology, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Miguel Rivadeneira
- *Vascular Surgery Division, Thorax Institute; †Interventional Radiology; and ‡Anaesthesiology, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Xavier Montaña
- *Vascular Surgery Division, Thorax Institute; †Interventional Radiology; and ‡Anaesthesiology, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Purificación Matute
- *Vascular Surgery Division, Thorax Institute; †Interventional Radiology; and ‡Anaesthesiology, Hospital Clinic, University of Barcelona, Barcelona, Spain
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Karmy-Jones R, Simeone A, Meissner M, Granvall B, Nicholls S. Descending thoracic aortic dissections. Surg Clin North Am 2007; 87:1047-86, viii-ix. [PMID: 17936475 DOI: 10.1016/j.suc.2007.08.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Type B dissection has traditionally been managed medically if uncomplicated and surgically if associated with complications. This practice has resulted in most centers reporting significant morbidity and mortality if open repair is required. In the setting of malperfusion, operative repair has been conjoined with fenestration or visceral stenting to improve outcomes. Endovascular stent grafts seem to offer an attractive alternative in the acute complicated type B dissection, with reduced mortality and morbidity, particularly paralysis, compared with open repair. It is reasonable to consider endovascular stent grafts as another tool in managing dissection, but to recognize that open surgical repair still plays an important role, and that the data that define indications and outcomes are still emerging.
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Affiliation(s)
- Riyad Karmy-Jones
- Division of Thoracic Surgery, Heart and Vascular Institute, Southwest Washington Medical Center, P.O. Box 1600 Vancouver, WA 98668, USA.
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