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European Journal of Vascular and... 2022To perform a systematic review and meta-analysis of the outcomes of physician modified endografts (PMEG) for the treatment of thoraco-abdominal (TAAA) and complex... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
To perform a systematic review and meta-analysis of the outcomes of physician modified endografts (PMEG) for the treatment of thoraco-abdominal (TAAA) and complex abdominal aortic aneurysms (C-AAA).
DATA SOURCES
MEDLINE, CENTRAL, Web of Science Core Collection, Scielo, and Open Grey.
REVIEW METHODS
The databases were searched from inception to July 2021 for studies reporting on outcomes of PMEGs for TAAA or C-AAA repair. A systematic review was conducted (protocol CRD42021267856) and data were pooled using a random effects model of proportions. The outcomes analysed were major adverse events at 30 days (30 day mortality, myocardial infarction, respiratory failure requiring prolonged ventilation [> 24 hours or re-intubation], renal failure requiring dialysis, bowel ischaemia requiring surgery, major stroke, or definitive paraplegia); technical success; 30 day mortality; ruptures; spinal cord ischaemia; endoleaks; re-interventions; and target vessel patency.
RESULTS
Twenty studies were included. Overall study quality assessment was found to be low. Overall, 909 PMEGs were reported and analysed. Regarding aneurysm location (n = 867), 222 patients had extent I - III TAAAs and 645 had C-AAA or extent IV TAAA. Regarding presentation, 14 studies reported whether the patients were treated in an elective or urgent setting (n = 782). Overall, 500 (63.9%) patients were treated in an elective setting and 282 (36.1%) in an urgent setting. Major adverse events (at 30 days) occurred in 15.5% of patients (95% confidence interval [CI] 10.8 - 20.8; I = 63%, 135/832 cases): 11.6% (95% CI 8.1 - 15.7; I = 0%, 23/280 cases) for elective patients and 24.6% for urgent (95% CI 14.1 - 36.6; I = 65%, 50/192 cases). Overall technical success was 97.2% (95% CI 95.4 - 98.7; I = 0%, 587/611 cases): 98.0% (95% CI 92.1 - 100; I = 0%, 106/113cases) for extent I - III TAAAs and 99.4% (95% CI 97.5 - 100; I = 0%, 317/324 cases) for C-AAA and extent IV TAAAs. Regarding technique, technical success was 96.1% for fenestrated endovascular repair (FEVAR; 95% CI 93.2 - 98.4; I = 0%, 313/329 cases) and 99.8% for FEVAR/branched endovascular repair (95% CI 99.8 - 100; I = 0%, 17/18 cases).
CONCLUSION
Physician modified fenestrated or branched grafts for endovascular aortic repair seem feasible and safe in the short term. However, the quality of the available data is low, which highlights the need for better and more accurate data regarding this technique.
Topics: Humans; Aortic Aneurysm, Abdominal; Blood Vessel Prosthesis; Aortic Aneurysm, Thoracic; Blood Vessel Prosthesis Implantation; Endovascular Procedures; Prosthesis Design; Treatment Outcome; Retrospective Studies; Postoperative Complications; Risk Factors; Time Factors; Physicians
PubMed: 35483575
DOI: 10.1016/j.ejvs.2022.04.015 -
Journal of Cardiothoracic Surgery Feb 2022Prior studies on ascending thoracic aortic aneurysm (ATAA) growth rates have reported approximately 1 mm of growth per year but these studies are based on...
BACKGROUND
Prior studies on ascending thoracic aortic aneurysm (ATAA) growth rates have reported approximately 1 mm of growth per year but these studies are based on referral-based study populations which are biased towards the highest risk patients who may not represent the true natural history of aortic aneurysm disease. We aimed to characterize the growth rate of ATAAs in a non-referral-based population, using a large institutional database of computed tomography (CT) scans.
METHODS
We queried the 21,325 CT scans performed at our institution between 2013 and 2016 on patients ages 50-85 years old for radiologic diagnosis of aortic aneurysm or dilatation. 560 patients were identified to have aortic dilatation > 4 cm, of which 207 had follow-up scan intervals > 6 months. This comprised our non-referral-based study population. Linearized annual aneurysm growth rates were calculated by dividing the change in aortic size by the time interval between CT scans.
RESULTS
The median time interval between scans was 2.7 years (interquartile range [IQR] 1.5-4.2) for the 207 patients included in the study. The median initial aneurysm size was 4.3 cm (IQR 4.1-4.5). 38.2% (n = 79) of patients did not experience aortic dilatation. The median growth rate was 0.13 mm/year (IQR - 0.24 to 0.49). Of patients in the top quartile of growth rates, 26.9% of patients were female whereas 12.9% of patients were female in the bottom three quartiles of growth rates.
CONCLUSION
While some patients' ATAAs may grow at previously published rates of around 1 mm/year, this is not the predominant pattern in a non-referral-based population and may over-estimate the overall growth rate of ATAAs.
Topics: Aged; Aged, 80 and over; Aorta; Aortic Aneurysm; Aortic Aneurysm, Thoracic; Female; Humans; Middle Aged; Referral and Consultation; Tomography, X-Ray Computed
PubMed: 35109884
DOI: 10.1186/s13019-022-01761-6 -
Heart (British Cardiac Society) Oct 2014Elective root replacement in Marfan syndrome has improved life expectancy in affected patients. Three forms of surgery are now available: total root replacement (TRR)... (Review)
Review
Elective root replacement in Marfan syndrome has improved life expectancy in affected patients. Three forms of surgery are now available: total root replacement (TRR) with a valved conduit, valve sparing root replacement (VSRR) and personalised external aortic root support (PEARS) with a macroporous mesh sleeve. TRR can be performed irrespective of aortic dimensions and a mechanical replacement valve is a secure and near certain means of correcting aortic valve regurgitation but has thromboembolic and bleeding risks. VSRR offers freedom from anticoagulation and attendant risks of bleeding but reoperation for aortic regurgitation runs at 1.3% per annum. A prospective multi-institutional study has found this to be an underestimate of the true rate of valve-related adverse events. PEARS conserves the aortic root anatomy and optimises the chance of maintaining valve function but average follow-up is under 5 years and so the long-term results are yet to be determined. Patients are on average in their 30s and so the cumulative lifetime need for reoperation, and of any valve-related complications, are consequently substantial. With lowering surgical risk of prophylactic root replacement, the threshold for intervention has reduced progressively over 30 years to 4.5 cm and so an increasing number of patients who are not destined to have a dissection are now having root replacement. In evaluation of these three forms of surgery, the number needed to treat to prevent dissection and the balance of net benefit and harm in future patients must be considered.
Topics: Aortic Aneurysm; Cardiac Surgical Procedures; Humans; Marfan Syndrome
PubMed: 24986892
DOI: 10.1136/heartjnl-2013-305132 -
Interactive Cardiovascular and Thoracic... Jun 2022Ascending thoracic aortic aneurysms (aTAAs) carry a risk of acute type A dissection. Elective repair guidelines are based on diameter, but complications often occur...
OBJECTIVES
Ascending thoracic aortic aneurysms (aTAAs) carry a risk of acute type A dissection. Elective repair guidelines are based on diameter, but complications often occur below diameter threshold. Biomechanically, dissection can occur when wall stress exceeds wall strength. Aneurysm wall stresses may better capture dissection risk. Our aim was to investigate patient-specific aTAA wall stresses associated with a tricuspid aortic valve (TAV) by anatomic region.
METHODS
Patients with aneurysm diameter ≥4.0 cm underwent computed tomography angiography. Aneurysm geometries were reconstructed and loaded to systemic pressure while taking prestress into account. Finite element analyses were conducted to obtain wall stress distributions. The 99th percentile longitudinal and circumferential stresses were determined at systole. Wall stresses between regions were compared using one-way analysis of variance with post hoc Tukey HSD for pairwise comparisons.
RESULTS
Peak longitudinal wall stresses on aneurysms (n = 204) were 326 [standard deviation (SD): 61.7], 246 (SD: 63.4) and 195 (SD: 38.7) kPa in sinuses of Valsalva, sinotubular junction (STJ) and ascending aorta (AscAo), respectively, with significant differences between AscAo and both sinuses (P < 0.001) and STJ (P < 0.001). Peak circumferential wall stresses were 416 (SD: 85.1), 501 (SD: 119) and 340 (SD: 57.6) kPa for sinuses, STJ and AscAo, respectively, with significant differences between AscAo and both sinuses (P < 0.001) and STJ (P < 0.001).
CONCLUSIONS
Circumferential and longitudinal wall stresses were greater in the aortic root than AscAo on aneurysm patients with a TAV. Aneurysm wall stress magnitudes and distribution relative to respective regional wall strength could improve understanding of aortic regions at greater risk of dissection in a particular patient.
Topics: Aorta; Aortic Aneurysm; Aortic Aneurysm, Thoracic; Aortic Valve; Humans; Stress, Mechanical; Tricuspid Valve
PubMed: 34718581
DOI: 10.1093/icvts/ivab269 -
Brazilian Journal of Cardiovascular... Feb 2021Although aortic valve replacement remains the gold standard treatment for aortic valve diseases like stenosis (AS) or insufficiency, new surgical methods have been...
Although aortic valve replacement remains the gold standard treatment for aortic valve diseases like stenosis (AS) or insufficiency, new surgical methods have been developed with a focus in the reconstruction of the aortic valve rather than replacing it. The Ozaki procedure involves a tailored replacement of each individual valvular leaflet with glutaraldehyde-treated autologous pericardium and aims to reproduce the normal anatomy of the aortic valve. Cases of patients with unicuspid aortic valve treated with the Ozaki procedure are uncommon in the litrature and become even more rare when it comes to concomitant diseases like AS and ascending aorta aneurysm. We present the case of a 21-year-old, fit and asymptomatic male, with unicuspid aortic valve with severe stenosis and ascending aorta dilatation, surgically treated with tricuspidization of the aortic valve with glutaraldehyde-treated autologous pericardium and replacement of the ascending aorta with a straight synthetic graft. Postoperative studies showed a fully functional, neo-tailored tricuspid aortic valve with trivial regurgitation. The patient had an uncomplicated recovery, stayed in the intensive care unit for 2 days and was discharged on the 7th postoperative day.
Topics: Adult; Aorta; Aortic Aneurysm; Aortic Valve; Heart Valve Diseases; Humans; Male; Young Adult
PubMed: 33355794
DOI: 10.21470/1678-9741-2020-0150 -
The Journal of Thoracic and... Dec 2020
Topics: Aortic Aneurysm; Aortic Aneurysm, Abdominal; Aortic Aneurysm, Thoracic; Atherosclerosis; Humans; Inflammation
PubMed: 31627956
DOI: 10.1016/j.jtcvs.2019.09.037 -
Journal of Vascular Surgery Nov 2016Cardiac arrest in patients with ruptured abdominal aortic aneurysm (rAAA) is not uncommon and associated with significantly increased mortality. Although it has been... (Review)
Review
OBJECTIVE
Cardiac arrest in patients with ruptured abdominal aortic aneurysm (rAAA) is not uncommon and associated with significantly increased mortality. Although it has been suggested as a contraindication to aortic repair, the prognostic implications of preoperative cardiac arrest in the face of rAAA are controversial. The purpose of this structured review is to analyze the reported outcomes of patients with rAAA and preoperative cardiac arrest.
METHODS
English language single- and multi-institutional series reporting outcomes of patients with rAAA and cardiac arrest were identified by systematic literature search and review. An aggregate analysis and structured review of outcomes after subsequent aortic repair was performed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology. The primary outcome was short-term overall mortality.
RESULTS
Sixteen studies involving 2669 patients with rAAA were analyzed, including 334 (13%) with preoperative cardiac arrest. Cardiac arrest was associated with significantly increased mortality compared with patients with rAAA without arrest (86% vs 44%; P < .0001), although cardiac arrest in isolation was poorly predictive of mortality. Four patients were treated by endovascular aortic repair, and all survived. Shorter resuscitation times and return of signs of life prior to aortic repair are associated with improved survival, and long-term functional outcomes among survivors have been reported.
CONCLUSIONS
Mortality among patients with rAAA and preoperative cardiac arrest is high but not prohibitive. Aortic repair should not be withheld from such patients who are otherwise reasonable candidates for intervention, provided resources for emergent aortic repair are available.
Topics: Aortic Aneurysm, Abdominal; Aortic Rupture; Blood Vessel Prosthesis Implantation; Endovascular Procedures; Heart Arrest; Hemodynamics; Humans; Patient Selection; Risk Factors; Treatment Outcome
PubMed: 27473775
DOI: 10.1016/j.jvs.2016.05.085 -
The Journal of Thoracic and... Nov 2019
Topics: Aortic Dissection; Aorta, Abdominal; Aortic Aneurysm, Abdominal; Aortic Aneurysm, Thoracic; Humans
PubMed: 30902472
DOI: 10.1016/j.jtcvs.2019.02.063 -
Radiologia Mar 2023Abdominal aortic aneurysm is defined as a dilatation of the abdominal aorta greater than 3cm. Its prevalence is between 1 and 1.5 cases per 100 people, constituting an...
Abdominal aortic aneurysm is defined as a dilatation of the abdominal aorta greater than 3cm. Its prevalence is between 1 and 1.5 cases per 100 people, constituting an important cause of morbidity and mortality. Rare in women, its frequency increases with age and its most frequent location is between the renal arteries and the aorto-iliac bifurcation. Approximately 5% of cases will involve the visceral branches. It is a silent pathological process whose natural evolution is rupture, which often has a fatal outcome and whose diagnosis is part of the pathology that we will find in emergency radiology. The involvement of the radiologist and the preparation of an accurate diagnostic report, as soon as possible, is essential for decision-making by the team in charge of the patient's surgery.
Topics: Humans; Female; Aortic Rupture; Aortic Aneurysm, Abdominal; Prevalence; Radiologists; Surgeons
PubMed: 37024231
DOI: 10.1016/j.rxeng.2022.11.003 -
Medicine Sep 2022Although surgical treatment strategies for patients with extensive thoracic aortic disease involving the aortic arch have improved considerably, the impact of stent...
RATIONALE
Although surgical treatment strategies for patients with extensive thoracic aortic disease involving the aortic arch have improved considerably, the impact of stent graft length and placement site on aortic remodeling at long-term follow-up is not fully understood, and the protection of the Adamkiewicz artery (AKA) using the frozen elephant trunk (FET) method is also unclear.
PATIENT CONCERNS
The patient was a 69-year-old man with diabetic nephropathy who became increasingly fatigued and started maintenance hemodialysis 6 months prior to admission. At 64 years, he underwent clipping of a right cerebellar artery aneurysm. In addition, a 1.8 cm aneurysm was found in the contralateral extracranial internal carotid artery. He also had an atrial septal defect and moderate aortic regurgitation and was receiving continuous positive airway pressure therapy for sleep apnoea syndrome.
DIAGNOSIS
He had aneurysms in the aortic arch (4.8 cm in diameter) and descending aorta (6 cm in diameter), which was located at T6-9. Preoperative 3-dimensional computed tomography showed that the (AKA) bifurcated at T10-11.
INTERVENTIONS
Considering the patient's several comorbidities and frailty, we planned to perform 1-stage extended aortic arch repair using the FET procedure. However, we performed 2-stage aortic surgery to prevent spinal ischemia, anticipating substantial cardiac enlargement and blood pressure instability due to dialysis treatment. Aortic valve replacement, atrial septal defect patch closure, and aortic arch surgery were performed. A 7-cm elephant trunk was inserted in the descending aorta. Postoperatively, the patient continued rehabilitation until his blood pressure stabilized during dialysis therapy. At postoperative week 4, he underwent thoracic endovascular aortic repair for a descending aortic aneurysm.
OUTCOMES
After surgery, his physical strength decreased; however, he recovered and was discharged 1 month later without any complications. One year after the second operation, he is living a healthy life.
LESSONS
Extensive aortic arch surgery using the FET procedure is effective for distal aortic arch and descending aortic aneurysms. Nevertheless, in cases in which the position of the AKA is close to the aortic aneurysm and blood pressure control is difficult, a 2-stage procedure and accurate positioning of thoracic endovascular aortic repair are both desirable.
Topics: Aged; Aortic Aneurysm; Aortic Aneurysm, Thoracic; Blood Vessel Prosthesis Implantation; Heart Septal Defects, Atrial; Humans; Male
PubMed: 36086696
DOI: 10.1097/MD.0000000000030342