Pub Date : 2023-06-01Epub Date: 2023-08-24DOI: 10.1055/s-0043-1770960
Akshat C Pujara, Marijan Koprivanac, Filip Stembal, Ashley M Lowry, Edward R Nowicki, Mina Chung, David V Wagoner, Eugene H Blackstone, Eric E Roselli
Background: As risks of repairing the descending thoracic and thoracoabdominal aorta diminish, common complications that may prolong hospital stay, or actually increase risk, require attention. One such complication is postoperative atrial fibrillation (AF). Therefore, we characterized prevalence of, risk factors for, and effects of postoperative atrial fibrillation (PoAF) after descending and thoracoabdominal aorta repair.
Methods: From January 2000 to January 2011, 696 patients underwent open descending or thoracoabdominal aorta repair at Cleveland Clinic. Operations approached via median sternotomy (n = 178) and patients treated preoperatively for arrhythmias (32 amiodarone, 9 paced) or in AF on preoperative electrocardiogram (n = 14) were excluded, leaving 463. Logistic regression analysis identified risk factors for PoAF. Temporal relation of PoAF with postoperative morbidities was determined, and outcomes following PoAF were compared between propensity-matched pairs.
Results: New-onset PoAF occurred in 101 patients (22%) at a median 68 hours of postincision. Risk factors included older age (p = 0.002) and history of remote AF (p = 0.0004) but not operative details, such as pericardiotomy for cardiac cannulation. Hypoperfusion and neurologic complications tended to precede PoAF, whereas sepsis, respiratory failure, and dialysis followed. Among 94 propensity-matched patient pairs, those developing PoAF were more likely to experience hypoperfusion (p = 0.006), respiratory failure (p = 0.009), dialysis (p = 0.04), paralysis (p < 0.0001), longer intensive care unit stay (median 7 vs. 5 d, p = 0.02), and longer postoperative hospital stay (median 15 vs. 13 d, p = 0.004). However, hospital death was similar (6/94 PoAF [6.4%] vs. 7/94 no PoAF [7.4%], p = 0.8).
Conclusion: PoAF after descending thoracic aorta surgery is relatively common and a part of a constellation of other serious complications prolonging postoperative recovery. While PoAF was associated with adverse events, it did not impact postoperative cost and mortality. Descending thoracic aorta surgery is by itself comorbid enough, which is likely why PoAF does not have a more significant effect on postoperative recovery and cost.
{"title":"Atrial Fibrillation after Descending Aorta Repair: Occurrence, Risk Factors, and Impact on Outcomes.","authors":"Akshat C Pujara, Marijan Koprivanac, Filip Stembal, Ashley M Lowry, Edward R Nowicki, Mina Chung, David V Wagoner, Eugene H Blackstone, Eric E Roselli","doi":"10.1055/s-0043-1770960","DOIUrl":"10.1055/s-0043-1770960","url":null,"abstract":"<p><strong>Background: </strong> As risks of repairing the descending thoracic and thoracoabdominal aorta diminish, common complications that may prolong hospital stay, or actually increase risk, require attention. One such complication is postoperative atrial fibrillation (AF). Therefore, we characterized prevalence of, risk factors for, and effects of postoperative atrial fibrillation (PoAF) after descending and thoracoabdominal aorta repair.</p><p><strong>Methods: </strong> From January 2000 to January 2011, 696 patients underwent open descending or thoracoabdominal aorta repair at Cleveland Clinic. Operations approached via median sternotomy (<i>n</i> = 178) and patients treated preoperatively for arrhythmias (32 amiodarone, 9 paced) or in AF on preoperative electrocardiogram (<i>n</i> = 14) were excluded, leaving 463. Logistic regression analysis identified risk factors for PoAF. Temporal relation of PoAF with postoperative morbidities was determined, and outcomes following PoAF were compared between propensity-matched pairs.</p><p><strong>Results: </strong> New-onset PoAF occurred in 101 patients (22%) at a median 68 hours of postincision. Risk factors included older age (<i>p =</i> 0.002) and history of remote AF (<i>p =</i> 0.0004) but not operative details, such as pericardiotomy for cardiac cannulation. Hypoperfusion and neurologic complications tended to precede PoAF, whereas sepsis, respiratory failure, and dialysis followed. Among 94 propensity-matched patient pairs, those developing PoAF were more likely to experience hypoperfusion (<i>p =</i> 0.006), respiratory failure (<i>p =</i> 0.009), dialysis (<i>p =</i> 0.04), paralysis (<i>p</i> < 0.0001), longer intensive care unit stay (median 7 vs. 5 d, <i>p =</i> 0.02), and longer postoperative hospital stay (median 15 vs. 13 d, <i>p =</i> 0.004). However, hospital death was similar (6/94 PoAF [6.4%] vs. 7/94 no PoAF [7.4%], <i>p =</i> 0.8).</p><p><strong>Conclusion: </strong> PoAF after descending thoracic aorta surgery is relatively common and a part of a constellation of other serious complications prolonging postoperative recovery. While PoAF was associated with adverse events, it did not impact postoperative cost and mortality. Descending thoracic aorta surgery is by itself comorbid enough, which is likely why PoAF does not have a more significant effect on postoperative recovery and cost.</p>","PeriodicalId":52392,"journal":{"name":"AORTA","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://ftp.ncbi.nlm.nih.gov/pub/pmc/oa_pdf/8b/57/10-1055-s-0043-1770960.PMC10449568.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"10127249","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Rodrigo Piltcher-da-Silva, Pedro S M Soares, Debora O Hutten, Cláudia C Schnnor, Isabelle G Valandro, Bruno B Rabolini, Brenda M Medeiros, Rafaela G Duarte, Bernardo S Volkweis, Marco A Grudtner, Leandro T Cavazzola
Background: Incisional hernia (IH) is an important surgical complication that has several ways of prevention, including modifications in the surgical technique of the initial procedure. Its incidence can reach 69% in high-risk patients and long-term follow-up. Of the risky procedures, open abdominal aortic aneurysmectomy is the one with the highest risk. Ways to reduce this morbid complication were suggested, and prophylactic mesh rises as an important tool to prevent recurrence.
Methods: A retrospective cohort study review of medical records of patients undergoing vascular surgery for abdominal aortoiliac aneurysm (AAA) or vascular bypass surgery due to aortoiliac occlusive disease. We identified 193 patients treated between 2010 and 2020. We further performed a one-to-nine matching analysis between the use of prophylactic mesh and control groups, based on estimated propensity scores for each patient.
Results: Prophylactic mesh group had a 18% lower risk of IH, compared with the control group (relative risk: 0.82; 95% confidence interval [CI] = 0.74-0.93). The difference in IH rates between the groups compared was 2.6% (95% CI: -19.8 to 25.5). From the perspective of the number needed to treat, it would be necessary to use prophylactic mesh in 39 (95% CI: 35-44) patients to avoid one IH in this population.
Conclusion: Use of prophylactic mesh in the repair of AAA significantly reduces the incidence of IH in nearly one in five cases. Our data suggest that there is benefit in the use of prophylactic mesh in open aneurysmectomy surgery regarding postoperative IH development.
{"title":"Incisional Hernias after Vascular Surgery for Aortoiliac Aneurysm and Aortoiliac Occlusive Arterial Disease: Has Prophylactic Mesh Changed This Scenario?","authors":"Rodrigo Piltcher-da-Silva, Pedro S M Soares, Debora O Hutten, Cláudia C Schnnor, Isabelle G Valandro, Bruno B Rabolini, Brenda M Medeiros, Rafaela G Duarte, Bernardo S Volkweis, Marco A Grudtner, Leandro T Cavazzola","doi":"10.1055/s-0043-1771475","DOIUrl":"https://doi.org/10.1055/s-0043-1771475","url":null,"abstract":"<p><strong>Background: </strong> Incisional hernia (IH) is an important surgical complication that has several ways of prevention, including modifications in the surgical technique of the initial procedure. Its incidence can reach 69% in high-risk patients and long-term follow-up. Of the risky procedures, open abdominal aortic aneurysmectomy is the one with the highest risk. Ways to reduce this morbid complication were suggested, and prophylactic mesh rises as an important tool to prevent recurrence.</p><p><strong>Methods: </strong> A retrospective cohort study review of medical records of patients undergoing vascular surgery for abdominal aortoiliac aneurysm (AAA) or vascular bypass surgery due to aortoiliac occlusive disease. We identified 193 patients treated between 2010 and 2020. We further performed a one-to-nine matching analysis between the use of prophylactic mesh and control groups, based on estimated propensity scores for each patient.</p><p><strong>Results: </strong> Prophylactic mesh group had a 18% lower risk of IH, compared with the control group (relative risk: 0.82; 95% confidence interval [CI] = 0.74-0.93). The difference in IH rates between the groups compared was 2.6% (95% CI: -19.8 to 25.5). From the perspective of the number needed to treat, it would be necessary to use prophylactic mesh in 39 (95% CI: 35-44) patients to avoid one IH in this population.</p><p><strong>Conclusion: </strong> Use of prophylactic mesh in the repair of AAA significantly reduces the incidence of IH in nearly one in five cases. Our data suggest that there is benefit in the use of prophylactic mesh in open aneurysmectomy surgery regarding postoperative IH development.</p>","PeriodicalId":52392,"journal":{"name":"AORTA","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://ftp.ncbi.nlm.nih.gov/pub/pmc/oa_pdf/c7/aa/10-1055-s-0043-1771475.PMC10449565.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"10072895","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-04-01Epub Date: 2023-05-12DOI: 10.1055/s-0043-1766114
John A Elefteriades, Bulat A Ziganshin, Mohammad A Zafar
For decades, aortic surgery has relied on size criteria for intervention on the ascending aorta. While diameter has served well, diameter alone falls short of an ideal criterion. Herein, we examine the potential application of other, nondiameter criteria in aortic decision-making. These findings are summarized in this review. We have conducted multiple investigations of specific alternate nonsize criteria by leveraging our extensive database, which includes complete, verified anatomic, clinical, and mortality data on 2,501 patients with thoracic aortic aneurysm (TAA) and dissections (198 Type A, 201 Type B, and 2102 TAAs). We examined 14 potential intervention criteria. Each substudy had its own specific methodology, reported individually in the literature. The overall findings of these studies are presented here, with a special emphasis on how the findings can be incorporated into enhanced aortic decision-making-above and beyond sheer diameter. The following nondiameter criteria have been found useful in decision-making regarding surgical intervention. (1) Pain: In the absence of other specific cause, substernal chest pain mandates surgery. Well-developed afferent neural pathways carry warning signals to the brain. (2) Aortic length/tortuosity: Length is emerging as a mildly better predictor of impending events than diameter. (3) Genes: Specific genetic aberrations provide a powerful predictor of aortic behavior; malignant genetic variants obligate earlier surgery. (4) Family history: Aortic events closely follow those in relatives with a threefold increase in likelihood of aortic dissection for other family members once an index family dissection has occurred. (5) Bicuspid aortic valve: Previously thought to increase aortic risk (as a "Marfan light" situation), current data show that bicuspid valve is not a predictor of higher risk. (6) Diabetes actually protects against aortic events, via mural thickening and fibrosis. (7) Biomarkers: A specialized "RNA signature test" identifies aneurysm-bearing patients in the general population and promises to predict impending dissection. (8) Aortic stress: Blood pressure (BP) elevation from anxiety/exertion precipitates dissection, especially with high-intensity weightlifting. (9) Root dilatation imposes higher dissection risk than supracoronary ascending aneurysm. (10) Inflammation on positron emission tomography (PET) imaging implies high rupture risk and merits surgical intervention. (11) A KIF6 p.Trp719Arg variant elevates aortic dissection risk nearly two-fold. (12) Female sex confers some increased risk, which can be largely accommodated by using body-size-based nomograms (especially height nomograms). (13) Fluoroquinolones predispose to catastrophic dissection events and should be avoided rigorously in aneurysm patients. (14) Advancing age makes the aorta more vulnerable, increasing likelihood of dissection. In conclusion, nondiameter criteria can beneficially be brought to bear on the
{"title":"Nonsize Criteria for Surgical Intervention on the Ascending Thoracic Aorta.","authors":"John A Elefteriades, Bulat A Ziganshin, Mohammad A Zafar","doi":"10.1055/s-0043-1766114","DOIUrl":"10.1055/s-0043-1766114","url":null,"abstract":"<p><p>For decades, aortic surgery has relied on size criteria for intervention on the ascending aorta. While diameter has served well, diameter alone falls short of an ideal criterion. Herein, we examine the potential application of other, nondiameter criteria in aortic decision-making. These findings are summarized in this review. We have conducted multiple investigations of specific alternate nonsize criteria by leveraging our extensive database, which includes complete, verified anatomic, clinical, and mortality data on 2,501 patients with thoracic aortic aneurysm (TAA) and dissections (198 Type A, 201 Type B, and 2102 TAAs). We examined 14 potential intervention criteria. Each substudy had its own specific methodology, reported individually in the literature. The overall findings of these studies are presented here, with a special emphasis on how the findings can be incorporated into enhanced aortic decision-making-above and beyond sheer diameter. The following nondiameter criteria have been found useful in decision-making regarding surgical intervention. (1) Pain: In the absence of other specific cause, substernal chest pain mandates surgery. Well-developed afferent neural pathways carry warning signals to the brain. (2) Aortic length/tortuosity: Length is emerging as a mildly better predictor of impending events than diameter. (3) Genes: Specific genetic aberrations provide a powerful predictor of aortic behavior; malignant genetic variants obligate earlier surgery. (4) Family history: Aortic events closely follow those in relatives with a threefold increase in likelihood of aortic dissection for other family members once an index family dissection has occurred. (5) Bicuspid aortic valve: Previously thought to increase aortic risk (as a \"Marfan light\" situation), current data show that bicuspid valve is not a predictor of higher risk. (6) Diabetes actually protects against aortic events, via mural thickening and fibrosis. (7) Biomarkers: A specialized \"RNA signature test\" identifies aneurysm-bearing patients in the general population and promises to predict impending dissection. (8) Aortic stress: Blood pressure (BP) elevation from anxiety/exertion precipitates dissection, especially with high-intensity weightlifting. (9) Root dilatation imposes higher dissection risk than supracoronary ascending aneurysm. (10) Inflammation on positron emission tomography (PET) imaging implies high rupture risk and merits surgical intervention. (11) A <i>KIF6</i> p.Trp719Arg variant elevates aortic dissection risk nearly two-fold. (12) Female sex confers some increased risk, which can be largely accommodated by using body-size-based nomograms (especially height nomograms). (13) Fluoroquinolones predispose to catastrophic dissection events and should be avoided rigorously in aneurysm patients. (14) Advancing age makes the aorta more vulnerable, increasing likelihood of dissection. In conclusion, nondiameter criteria can beneficially be brought to bear on the","PeriodicalId":52392,"journal":{"name":"AORTA","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10232037/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9551836","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Emma A Roberts, Andrew Pistner, Oyinkansola Osobamiro, Stephanie Banning, Sherene Shalhub, Catherine Albright, Ofir Horovitz, Jonathan Buber
Background: Pregnant patients with Marfan's syndrome (MFS) are at an increased risk for adverse aortic outcomes. While beta-blockers are used to slow aortic root dilatation in nonpregnant MFS patients, the benefit of such therapy in pregnant MFS patients remains controversial. The purpose of this study was to investigate the effect of beta-blockers on aortic root dilatation during pregnancy in MFS patients.
Methods: This was a longitudinal single-center retrospective cohort study of females with MFS who completed a pregnancy between 2004 and 2020. Clinical, fetal, and echocardiographic data were compared in patients on- versus off-beta-blockers during pregnancy.
Results: A total of 20 pregnancies completed by 19 patients were evaluated. Beta-blocker therapy was initiated or continued in 13 (65%) of the 20 pregnancies. Pregnancies on-beta-blocker therapy experienced less aortic growth compared with those off-beta-blockers (0.10 [interquartile range, IQR: 0.10-0.20] vs. 0.30 cm [IQR: 0.25-0.35]; p = 0.03). Using univariate linear regression, maximum systolic blood pressures (SBP), increase in SBP, and absence of beta-blocker use in pregnancy were found to be significantly associated with greater increase in aortic diameter during pregnancy. There were no differences in rates of fetal growth restriction between pregnancies on- versus off-beta-blockers.
Conclusion: This is the first study that we are aware of to evaluate changes in aortic dimensions in MFS pregnancies stratified by beta-blocker use. Beta-blocker therapy was found to be associated with less aortic root growth during pregnancy in MFS patients.
背景:妊娠马凡氏综合征(MFS)患者发生主动脉不良结局的风险增加。虽然β受体阻滞剂用于减缓非妊娠MFS患者的主动脉根扩张,但这种治疗对妊娠MFS患者的益处仍存在争议。本研究的目的是探讨-受体阻滞剂对妊娠期MFS患者主动脉根扩张的影响。方法:这是一项纵向单中心回顾性队列研究,研究对象为2004年至2020年期间完成妊娠的MFS女性。临床,胎儿和超声心动图的数据比较患者在怀孕期间使用β受体阻滞剂和关闭。结果:19例患者共完成20例妊娠。20例妊娠中有13例(65%)开始或继续使用β受体阻滞剂治疗。与未使用受体阻滞剂的孕妇相比,接受受体阻滞剂治疗的孕妇主动脉生长较少(0.10[四分位数间距,IQR: 0.10-0.20] vs. 0.30 cm [IQR: 0.25-0.35];p = 0.03)。使用单变量线性回归,发现最大收缩压(SBP)、SBP升高和妊娠期未使用β受体阻滞剂与妊娠期主动脉直径增加显著相关。在使用受体阻滞剂和不使用受体阻滞剂的妊娠中,胎儿生长受限率没有差异。结论:这是我们所知的第一个评估使用-受体阻滞剂分层MFS妊娠主动脉尺寸变化的研究。研究发现-受体阻滞剂治疗与妊娠期MFS患者主动脉根生长减少有关。
{"title":"Beta-Blocker Use during Pregnancy Correlates with Less Aortic Root Dilatation in Patients with Marfan's Syndrome.","authors":"Emma A Roberts, Andrew Pistner, Oyinkansola Osobamiro, Stephanie Banning, Sherene Shalhub, Catherine Albright, Ofir Horovitz, Jonathan Buber","doi":"10.1055/a-2072-0469","DOIUrl":"https://doi.org/10.1055/a-2072-0469","url":null,"abstract":"<p><strong>Background: </strong> Pregnant patients with Marfan's syndrome (MFS) are at an increased risk for adverse aortic outcomes. While beta-blockers are used to slow aortic root dilatation in nonpregnant MFS patients, the benefit of such therapy in pregnant MFS patients remains controversial. The purpose of this study was to investigate the effect of beta-blockers on aortic root dilatation during pregnancy in MFS patients.</p><p><strong>Methods: </strong> This was a longitudinal single-center retrospective cohort study of females with MFS who completed a pregnancy between 2004 and 2020. Clinical, fetal, and echocardiographic data were compared in patients on- versus off-beta-blockers during pregnancy.</p><p><strong>Results: </strong> A total of 20 pregnancies completed by 19 patients were evaluated. Beta-blocker therapy was initiated or continued in 13 (65%) of the 20 pregnancies. Pregnancies on-beta-blocker therapy experienced less aortic growth compared with those off-beta-blockers (0.10 [interquartile range, IQR: 0.10-0.20] vs. 0.30 cm [IQR: 0.25-0.35]; <i>p</i> = 0.03). Using univariate linear regression, maximum systolic blood pressures (SBP), increase in SBP, and absence of beta-blocker use in pregnancy were found to be significantly associated with greater increase in aortic diameter during pregnancy. There were no differences in rates of fetal growth restriction between pregnancies on- versus off-beta-blockers.</p><p><strong>Conclusion: </strong> This is the first study that we are aware of to evaluate changes in aortic dimensions in MFS pregnancies stratified by beta-blocker use. Beta-blocker therapy was found to be associated with less aortic root growth during pregnancy in MFS patients.</p>","PeriodicalId":52392,"journal":{"name":"AORTA","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://ftp.ncbi.nlm.nih.gov/pub/pmc/oa_pdf/85/e6/10-1055-a-2072-0469.PMC10232026.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9558974","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Khawaja A Ammar, Matthew McDiarmid, Lauren Richards, Mark W Mewissen, M Fuad Jan, Eric S Weiss, Tanvir Bajwa
Background: Although uncomplicated Type B aortic dissection (uTBAD) is traditionally treated with optimal medical therapy (OMT) as per guidelines, recent studies, performed primarily in interventional radiology or surgical operating rooms, suggest superiority of thoracic endovascular aortic repair (TEVAR) over OMT due to recent advancements in endovascular technologies. We report a large, single-center, case control study of TEVAR versus OMT in this population, undertaken solely in a cardiac catheterization laboratory (CCL) with a cardiologist and surgeon. We aimed to determine if TEVAR for uTBAD results in better outcomes compared with OMT.
Methods: This was a retrospective chart review of all patients with uTBAD during the last 13 years, with 46 cases (TEVAR group) and 56 controls (OMT group).
Results: In the TEVAR group, the procedure duration of 2.5 hours resulted in 100% procedural success for stent placement, with 63% undergoing protective left subclavian artery bypass, 0% mortality or stroke, and a lower readmission rate (1 vs. 2%; p = 0.04 in early TEVAR cases), but a longer length of stay (12.9 vs. 8.5 days: p = 0.006). The risk of all-cause long-term mortality was markedly reduced in the TEVAR group (RR = 0.38; p = 0.01), irrespective of early (<14 days) versus late intervention. On follow-up computed tomography imaging, the false lumen stabilized or decreased in 85% of cases, irrespective of intervention timing.
Conclusion: TEVAR performed solely in the CCL is safe and effective, with lower all-cause mortality than OMT. These data, in collaboration with previous data on TEVAR in different settings, call for consideration of an update of practice guidelines.
背景:尽管无并发症的B型主动脉夹层(uTBAD)传统上按照指南采用最佳药物治疗(OMT)治疗,但最近主要在介入放射学或外科手术室进行的研究表明,由于血管内技术的最新进展,胸廓血管内主动脉修复(TEVAR)优于OMT。我们报告了一项大型单中心病例对照研究,该研究仅在心导管实验室(CCL)与心脏病专家和外科医生进行TEVAR与OMT的比较。我们的目的是确定TEVAR治疗uTBAD的结果是否比OMT更好。方法:回顾性分析13年来所有uTBAD患者,其中TEVAR组46例,OMT组56例为对照。结果:在TEVAR组中,手术时间为2.5小时,支架置入术成功率为100%,63%的患者接受了保护性左锁骨下动脉搭桥术,死亡率或卒中为0%,再入院率较低(1比2%;早期TEVAR病例p = 0.04),但住院时间较长(12.9 vs. 8.5天:p = 0.006)。TEVAR组全因长期死亡风险显著降低(RR = 0.38;结论:仅在CCL中进行TEVAR是安全有效的,其全因死亡率低于OMT。这些数据与以前在不同环境下的TEVAR数据相结合,要求考虑更新实践指南。
{"title":"Early Thoracic Endovascular Aortic Repair of Uncomplicated Type B Thoracic Aortic Dissection: An Aorta Team Approach.","authors":"Khawaja A Ammar, Matthew McDiarmid, Lauren Richards, Mark W Mewissen, M Fuad Jan, Eric S Weiss, Tanvir Bajwa","doi":"10.1055/s-0043-1768201","DOIUrl":"https://doi.org/10.1055/s-0043-1768201","url":null,"abstract":"<p><strong>Background: </strong> Although uncomplicated Type B aortic dissection (uTBAD) is traditionally treated with optimal medical therapy (OMT) as per guidelines, recent studies, performed primarily in interventional radiology or surgical operating rooms, suggest superiority of thoracic endovascular aortic repair (TEVAR) over OMT due to recent advancements in endovascular technologies. We report a large, single-center, case control study of TEVAR versus OMT in this population, undertaken solely in a cardiac catheterization laboratory (CCL) with a cardiologist and surgeon. We aimed to determine if TEVAR for uTBAD results in better outcomes compared with OMT.</p><p><strong>Methods: </strong> This was a retrospective chart review of all patients with uTBAD during the last 13 years, with 46 cases (TEVAR group) and 56 controls (OMT group).</p><p><strong>Results: </strong> In the TEVAR group, the procedure duration of 2.5 hours resulted in 100% procedural success for stent placement, with 63% undergoing protective left subclavian artery bypass, 0% mortality or stroke, and a lower readmission rate (1 vs. 2%; <i>p</i> = 0.04 in early TEVAR cases), but a longer length of stay (12.9 vs. 8.5 days: <i>p</i> = 0.006). The risk of all-cause long-term mortality was markedly reduced in the TEVAR group (RR = 0.38; <i>p</i> = 0.01), irrespective of early (<14 days) versus late intervention. On follow-up computed tomography imaging, the false lumen stabilized or decreased in 85% of cases, irrespective of intervention timing.</p><p><strong>Conclusion: </strong> TEVAR performed solely in the CCL is safe and effective, with lower all-cause mortality than OMT. These data, in collaboration with previous data on TEVAR in different settings, call for consideration of an update of practice guidelines.</p>","PeriodicalId":52392,"journal":{"name":"AORTA","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://ftp.ncbi.nlm.nih.gov/pub/pmc/oa_pdf/4f/f4/10-1055-s-0043-1768201.PMC10232024.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9920146","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Nikolaos Kontopodis, Konstantinos Lasithiotakis, Ioannis Kasiolas, Alexandros Kafetzakis, Emmanuel Chrysos, Christos V Ioannou
Background: Abdominal compartment syndrome (ACS) often complicates ruptured abdominal aortic aneurysm (rAAA) repair. We report results with routine skin-only abdominal wound closure after rAAA surgical repair.
Methods: This was a single-center retrospective study including consecutive patients undergoing rAAA surgical repair for the duration of 7 years. Skin-only closure was routinely performed, and if possible, secondary abdominal closure was performed during the same admission. Demographic information, preoperative hemodynamic condition, and perioperative information (ACS, mortality, rate of abdominal closure, and postoperative outcomes) were collected.
Results: During the study period, 93 rAAAs were recorded. Ten patients were too frail to undergo repair or refused treatment. Eighty-three patients underwent immediate surgical repair. The mean age was 72.4 ± 10.5 years, and the vast majority were male (82:1). Preoperative systolic blood pressure <90 mm Hg was recorded in 31 patients. Intraoperative mortality was recorded in nine cases. Overall in-hospital mortality was 34.9% (29/83). Primary fascial closure was performed in five patients, while skin-only closure was performed in 69. ACS was recorded in two cases in whom skin sutures were removed and negative pressure wound treatment was applied. Secondary fascial closure was feasible in 30 patients during the same admission. Among 37 patients not undergoing fascial closure, 18 died and 19 survived and were discharged with a planned ventral hernia repair. Median length of intensive care unit and hospital stay were 5 (1-24) and 13 (8-35) days, respectively. After a mean follow-up of 21 months, telephone contact was possible with 14/19 patients who left the hospital with an abdominal hernia. Three reported hernia-related complications mandating surgical repair, while in 11, this was well tolerated.
Conclusion: Routine skin-only closure during rAAA surgical repair results in low rates of ACS at the expense of a high rate of patients being discharged with a planned ventral hernia which, however, seems to be well tolerated by the majority of patients.
{"title":"Does the Routine Skin-Only Closure in Ruptured Abdominal Aortic Aneurysm Repair Safely Diminish Abdominal Compartment Syndrome? A Hypothesis Generating Retrospective Study.","authors":"Nikolaos Kontopodis, Konstantinos Lasithiotakis, Ioannis Kasiolas, Alexandros Kafetzakis, Emmanuel Chrysos, Christos V Ioannou","doi":"10.1055/a-2066-8480","DOIUrl":"https://doi.org/10.1055/a-2066-8480","url":null,"abstract":"<p><strong>Background: </strong> Abdominal compartment syndrome (ACS) often complicates ruptured abdominal aortic aneurysm (rAAA) repair. We report results with routine skin-only abdominal wound closure after rAAA surgical repair.</p><p><strong>Methods: </strong> This was a single-center retrospective study including consecutive patients undergoing rAAA surgical repair for the duration of 7 years. Skin-only closure was routinely performed, and if possible, secondary abdominal closure was performed during the same admission. Demographic information, preoperative hemodynamic condition, and perioperative information (ACS, mortality, rate of abdominal closure, and postoperative outcomes) were collected.</p><p><strong>Results: </strong> During the study period, 93 rAAAs were recorded. Ten patients were too frail to undergo repair or refused treatment. Eighty-three patients underwent immediate surgical repair. The mean age was 72.4 ± 10.5 years, and the vast majority were male (82:1). Preoperative systolic blood pressure <90 mm Hg was recorded in 31 patients. Intraoperative mortality was recorded in nine cases. Overall in-hospital mortality was 34.9% (29/83). Primary fascial closure was performed in five patients, while skin-only closure was performed in 69. ACS was recorded in two cases in whom skin sutures were removed and negative pressure wound treatment was applied. Secondary fascial closure was feasible in 30 patients during the same admission. Among 37 patients not undergoing fascial closure, 18 died and 19 survived and were discharged with a planned ventral hernia repair. Median length of intensive care unit and hospital stay were 5 (1-24) and 13 (8-35) days, respectively. After a mean follow-up of 21 months, telephone contact was possible with 14/19 patients who left the hospital with an abdominal hernia. Three reported hernia-related complications mandating surgical repair, while in 11, this was well tolerated.</p><p><strong>Conclusion: </strong> Routine skin-only closure during rAAA surgical repair results in low rates of ACS at the expense of a high rate of patients being discharged with a planned ventral hernia which, however, seems to be well tolerated by the majority of patients.</p>","PeriodicalId":52392,"journal":{"name":"AORTA","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://ftp.ncbi.nlm.nih.gov/pub/pmc/oa_pdf/bd/e7/10-1055-a-2066-8480.PMC10232023.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9558976","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Efstratios Georgakarakos, Konstantinos Dimitriadis, Christos Argyriou, Gioultzan Memet Efenti, Damianos Doukas, George S Georgiadis
The Ovation Alto design repositions the maximum diameter of the proximal sealing ring at 7 mm below the lowermost renal artery. Although it has been introduced to address abdominal aortic aneurysms with short necks ≥7 mm, we present further applications of Alto in other neck irregularities, presenting four representative challenging cases with a short, wide, and conical neck, as well a juxtarenal aneurysm. At 1-month follow-up, there was 100% technical and clinical success.
{"title":"Technical Characteristics of the Ovation Alto for the Treatment of Abdominal Aortic Aneurysms: Application to Challenging Anatomies.","authors":"Efstratios Georgakarakos, Konstantinos Dimitriadis, Christos Argyriou, Gioultzan Memet Efenti, Damianos Doukas, George S Georgiadis","doi":"10.1055/a-2051-2520","DOIUrl":"https://doi.org/10.1055/a-2051-2520","url":null,"abstract":"<p><p>The Ovation Alto design repositions the maximum diameter of the proximal sealing ring at 7 mm below the lowermost renal artery. Although it has been introduced to address abdominal aortic aneurysms with short necks ≥7 mm, we present further applications of Alto in other neck irregularities, presenting four representative challenging cases with a short, wide, and conical neck, as well a juxtarenal aneurysm. At 1-month follow-up, there was 100% technical and clinical success.</p>","PeriodicalId":52392,"journal":{"name":"AORTA","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://ftp.ncbi.nlm.nih.gov/pub/pmc/oa_pdf/d7/85/10-1055-a-2051-2520.PMC10232035.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9558805","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Spyros Papadoulas, Anastasia Zotou, Natasa Kouri, Andreas Tsimpoukis, Petros Zampakis, Nikolaos Koutsogiannis, Elisabeth Chroni
Abdominal aortic aneurysm in a patient with myasthenia gravis (MG) is extremely rare. We present a 64-year-old male with MG and an asymptomatic abdominal aortic aneurysm treated endovascularly. After extubation, he suffered a cardiac arrest due to an acute myocardial infarction. Cardiopulmonary resuscitation and a primary coronary angioplasty led to a satisfactory outcome. Special care is needed due to higher rates of postoperative complications in these patients.
{"title":"Myasthenia Gravis and Abdominal Aortic Aneurysm: A Rare Combination.","authors":"Spyros Papadoulas, Anastasia Zotou, Natasa Kouri, Andreas Tsimpoukis, Petros Zampakis, Nikolaos Koutsogiannis, Elisabeth Chroni","doi":"10.1055/a-2051-7678","DOIUrl":"https://doi.org/10.1055/a-2051-7678","url":null,"abstract":"<p><p>Abdominal aortic aneurysm in a patient with myasthenia gravis (MG) is extremely rare. We present a 64-year-old male with MG and an asymptomatic abdominal aortic aneurysm treated endovascularly. After extubation, he suffered a cardiac arrest due to an acute myocardial infarction. Cardiopulmonary resuscitation and a primary coronary angioplasty led to a satisfactory outcome. Special care is needed due to higher rates of postoperative complications in these patients.</p>","PeriodicalId":52392,"journal":{"name":"AORTA","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://ftp.ncbi.nlm.nih.gov/pub/pmc/oa_pdf/39/ad/10-1055-a-2051-7678.PMC10232032.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9562429","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Nowadays, despite the rapid advancements in interventional cardiology, open surgery still deals with aortic root diseases, to assure the best "ad hoc" treatment. In case of middle-aged adult patients, the optimal operation still represents a matter of debate. A review of the last 10-year literature was conducted, focusing on patients below 65 to 70 years of age. Because of the small sample and the heterogeneity of the papers, no metanalysis was possible. Bentall-de Bono procedure, valve sparing, and Ross operations are the surgical options currently available. The main issues in the Bentall - de Bono operation are lifelong anticoagulation therapy and cavitation in case of mechanical prosthesis implantation and structural valve degeneration in case of biological Bentall. As transcatheter procedures are currently performed as valve in valve, biological prosthesis may be preferable, if the diameter may prevent postoperative high gradients. Conservative techniques, such as remodeling and reimplantation, preferred in the young, guarantee physiologic aortic root dynamics and impose surgical analysis of the aortic root structures to get a durable result. The Ross operation, which shows excellent performance, involves autologous pulmonary valve implantation and is performed only in experienced and high-volume centers. Due to its technical difficulty, it requires a steep learning curve and presents some limitations in specific aortic valve diseases. All three have advantages and downsides, and no ideal solution has still been reported.
{"title":"Aortic Root Surgery in Adults: An Unsolved Problem.","authors":"Carlotta Brega, Alberto Albertini","doi":"10.1055/s-0042-1757949","DOIUrl":"https://doi.org/10.1055/s-0042-1757949","url":null,"abstract":"<p><p>Nowadays, despite the rapid advancements in interventional cardiology, open surgery still deals with aortic root diseases, to assure the best \"ad hoc\" treatment. In case of middle-aged adult patients, the optimal operation still represents a matter of debate. A review of the last 10-year literature was conducted, focusing on patients below 65 to 70 years of age. Because of the small sample and the heterogeneity of the papers, no metanalysis was possible. Bentall-de Bono procedure, valve sparing, and Ross operations are the surgical options currently available. The main issues in the Bentall - de Bono operation are lifelong anticoagulation therapy and cavitation in case of mechanical prosthesis implantation and structural valve degeneration in case of biological Bentall. As transcatheter procedures are currently performed as valve in valve, biological prosthesis may be preferable, if the diameter may prevent postoperative high gradients. Conservative techniques, such as remodeling and reimplantation, preferred in the young, guarantee physiologic aortic root dynamics and impose surgical analysis of the aortic root structures to get a durable result. The Ross operation, which shows excellent performance, involves autologous pulmonary valve implantation and is performed only in experienced and high-volume centers. Due to its technical difficulty, it requires a steep learning curve and presents some limitations in specific aortic valve diseases. All three have advantages and downsides, and no ideal solution has still been reported.</p>","PeriodicalId":52392,"journal":{"name":"AORTA","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://ftp.ncbi.nlm.nih.gov/pub/pmc/oa_pdf/72/86/10-1055-s-0042-1757949.PMC9970757.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"10822735","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Andrea Stadlbauer, Jing Li, Natascha Platz Batista da Silva, Christian Stadlbauer, Christof Schmid, Bernhard Floerchinger
We present the case of a 52-year-old with a history of aortic valve replacement and replacement of the ascending aorta with the graft inclusion technique presenting with dizziness and collapse. Computed tomography and coronary angiography revealed pseudoaneurysm formation at the anastomotic site causing aortic pseudostenosis. Due to severe calcification of the graft inclusion surrounding the ascending aorta, we performed a redo ascending aortic replacement using a two-circuit cardiopulmonary bypass to avoid deep hypothermic cardiac arrest.
{"title":"Ascending Aortic Pseudostenosis following the Classic Bentall Inclusion Technique.","authors":"Andrea Stadlbauer, Jing Li, Natascha Platz Batista da Silva, Christian Stadlbauer, Christof Schmid, Bernhard Floerchinger","doi":"10.1055/s-0042-1757871","DOIUrl":"https://doi.org/10.1055/s-0042-1757871","url":null,"abstract":"<p><p>We present the case of a 52-year-old with a history of aortic valve replacement and replacement of the ascending aorta with the graft inclusion technique presenting with dizziness and collapse. Computed tomography and coronary angiography revealed pseudoaneurysm formation at the anastomotic site causing aortic pseudostenosis. Due to severe calcification of the graft inclusion surrounding the ascending aorta, we performed a redo ascending aortic replacement using a two-circuit cardiopulmonary bypass to avoid deep hypothermic cardiac arrest.</p>","PeriodicalId":52392,"journal":{"name":"AORTA","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9970756/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"10822736","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}