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The Surgical Clinics of North America Aug 2023Aortic arch and descending thoracic pathology have historically remained in the realm of open surgical repair. Technology is quickly pushing to bring these under the... (Review)
Review
Aortic arch and descending thoracic pathology have historically remained in the realm of open surgical repair. Technology is quickly pushing to bring these under the endovascular umbrella, with lower morbidity repairs proving safe in their early experience. Much work remains particularly for acute aortic syndromes, however, to understand who is best treated medically, surgically, endovascularly, or with hybrid approaches.
Topics: Aortic Aneurysm, Thoracic; Aortic Dissection; Blood Vessel Prosthesis Implantation; Endovascular Procedures; Stents; Treatment Outcome; Aorta, Thoracic; Aortic Arch Syndromes
PubMed: 37455028
DOI: 10.1016/j.suc.2023.04.013 -
No Shinkei Geka. Neurological Surgery May 2024A right aortic arch and aberrant subclavian artery result from an interruption in the remodeling of the pharyngeal arch arteries. We occasionally encounter this... (Review)
Review
A right aortic arch and aberrant subclavian artery result from an interruption in the remodeling of the pharyngeal arch arteries. We occasionally encounter this anatomical variation during angiography. Patients with disorders such as Down syndrome and congenital heart disease show a high incidence of an aberrant right subclavian artery, and this anomaly can cause symptomatic esophageal or tracheal compression. The root of the aberrant artery may show dilatation(referred to as a Kommerell diverticulum), dissection, intramural hematoma, or rupture necessitating cardiac intervention using a surgical or endovascular approach. Neurointerventionalists should have working knowledge of the anatomy to rapidly understand the anatomy and ensure a safe procedure. A left transradial approach should be considered if prior knowledge of the aberrant subclavian anatomy is available.
Topics: Humans; Aorta, Thoracic; Subclavian Artery; Vascular Remodeling; Cardiovascular Abnormalities
PubMed: 38783489
DOI: 10.11477/mf.1436204939 -
The Journal of Thoracic and... Feb 2024Cross-sectional imaging allows identification of rare patients with a vascular ring and circumflex aorta. The key diagnostic feature is crossing of the transverse aortic... (Review)
Review
OBJECTIVE
Cross-sectional imaging allows identification of rare patients with a vascular ring and circumflex aorta. The key diagnostic feature is crossing of the transverse aortic arch from right to left posterior to the trachea and superior to the carina in a patient with a right aortic arch. We evaluated our patients who received an aortic uncrossing procedure.
METHODS
We reviewed all patients who underwent aortic uncrossing from 2002 to 2022. All patients received preoperative computed tomography imaging and bronchoscopy.
RESULTS
Eleven patients ranging in age from 1.5 to 10 years (median 4 years) underwent aortic uncrossing. Two patients had prior left ligamentum division, and 3 patients had prior left aortic arch division. All had significant clinical symptoms. Eight patients had deep hypothermic circulatory arrest (mean 34 minutes), and 3 patients had antegrade cerebral perfusion (median, 28 minutes). Patch material was not used for aortic augmentation, and no patient underwent a posterior tracheopexy or rotational esophagoplasty. Postoperative length of stay ranged from 4 to 31 days (median, 5 days). One patient required a temporary tracheostomy for bilateral recurrent laryngeal nerve paresis, which recovered. One patient required an aortic extension graft to alleviate esophageal compression from an unusual ectatic esophageal course. All patients had relief of airway symptoms and dysphagia.
CONCLUSIONS
In properly selected patients with a right aortic arch and circumflex aorta, aortic uncrossing is a safe and effective therapy to treat airway and esophageal compression. The procedure can be conducted with deep hypothermic circulatory arrest or antegrade cerebral perfusion. Careful attention to the location of the esophagus and recurrent laryngeal nerves is required.
Topics: Humans; Infant; Child, Preschool; Child; Aorta; Aorta, Thoracic; Bronchoscopy; Vascular Surgical Procedures; Perfusion
PubMed: 37406764
DOI: 10.1016/j.jtcvs.2023.06.013 -
Clinical Imaging Sep 2023Imaging plays a crucial role in the postoperative monitoring of thoracic aortic repairs. With the development of multiple surgical techniques to repair the ascending... (Review)
Review
Imaging plays a crucial role in the postoperative monitoring of thoracic aortic repairs. With the development of multiple surgical techniques to repair the ascending aorta and aortic arch, it can be a daunting challenge for the radiologist to diagnose potential pathologies in this sea of various techniques, each with their own normal postoperative appearance and potential complications. In this paper, we will provide a comprehensive review of the postoperative imaging in the setting of thoracic aortic repairs, including the role of imaging, components of thoracic aortic repairs, the normal postoperative appearance, and potential complications.
Topics: Humans; Aorta, Thoracic; Postoperative Complications; Aorta; Diagnostic Imaging; Aortic Aneurysm, Thoracic; Blood Vessel Prosthesis Implantation; Treatment Outcome
PubMed: 37262963
DOI: 10.1016/j.clinimag.2023.05.010 -
Annals of Vascular Surgery Aug 2023Intramural hematoma (IMH) is one of the acute aortic syndromes along with acute aortic dissection and penetrating aortic ulcer. The three conditions can occur alone or... (Review)
Review
Intramural hematoma (IMH) is one of the acute aortic syndromes along with acute aortic dissection and penetrating aortic ulcer. The three conditions can occur alone or in combination with overlapping presentation. Medical, open surgical, and endovascular treatment is tailored depending on clinical presentation, timing, and location within the aorta. Among patients who present with acute IMH affecting the ascending aorta (Type A), urgent open surgical repair is considered the primary line of treatment in patients who are suitable candidates and unstable. The management of IMH in the descending aorta and aortic arch (Type B) is similar to that applied to treat acute dissections in the same segment. Medical treatment with sequential imaging is recommended in patients with uncomplicated course, and endovascular repair is indicated in patients with rupture, persistent pain, end-organ ischemia, or rapid aortic enlargement. This review discusses the ideal timing for treatment of IMH.
Topics: Humans; Aortic Intramural Hematoma; Treatment Outcome; Aortic Diseases; Aortic Dissection; Hematoma; Aorta, Thoracic
PubMed: 36309166
DOI: 10.1016/j.avsg.2022.09.041 -
European Journal of Cardio-thoracic... Dec 2023The aim of this study was to analyse the indications, surgical extent and results of treatment, as well as determine the risk factors for adverse outcomes after redo...
OBJECTIVES
The aim of this study was to analyse the indications, surgical extent and results of treatment, as well as determine the risk factors for adverse outcomes after redo arch surgery.
METHODS
Between January 1996 and December 2022, 120 patients underwent aortic arch reoperations after primary proximal aortic surgery. We retrospectively analysed perioperative data, as well as early and mid-term outcomes in these patients.
RESULTS
Indications for arch reintervention included new aortic aneurysm in 34 patients (28.3%), expanding post-dissection aneurysm in 36 (30.0%), aortic graft infection in 39 (32.5%) and new aortic dissection in 9 cases. Two patients underwent reoperation due to iatrogenic complications. Thirty-one patients (25.8%) had concomitant endocarditis. In-hospital and 30-day mortality rates were 11.7% and 15.0%, respectively. Stroke was observed in 11 (9.2%) and paraplegia in 1 patient. Prior surgery due to aneurysm [odds ratio 4.5; 95% confidence interval (CI) 1.4-17.3] and critical preoperative state (odds ratio 5.9; 95% CI 1.5-23.7) were independent predictors of 30-day mortality. Overall 1- and 5-year survival was 65.8 ± 8.8% and 51.2 ± 10.6%, respectively. Diabetes mellitus (hazard ratio 2.4; 95% CI 1.0-5.1) and peripheral arterial disease (hazard ratio 4.7; 95% CI 1.1-14.3) were independent predictors of late death. The cumulative incidence of reoperations was 12.6% (95% CI 6.7-20.4%) at 5 years. Accounting for mortality as a competing event, connective tissue disorders (subdistribution hazard ratio 4.5; 95% CI 1.6-15.7) and interval between primary and redo surgery (subdistribution hazard ratio 1.04; 95% CI 1.02-1.06) were independent predictors of reoperations after redo arch surgery.
CONCLUSIONS
Despite being technically demanding, aortic arch reoperations are feasible and can be performed with acceptable results.
Topics: Humans; Aorta, Thoracic; Retrospective Studies; Treatment Outcome; Aortic Dissection; Aortic Aneurysm; Risk Factors; Reoperation; Postoperative Complications; Blood Vessel Prosthesis Implantation; Aortic Aneurysm, Thoracic
PubMed: 38109680
DOI: 10.1093/ejcts/ezad419 -
Annals of Vascular Surgery Aug 2023The gold standard for aneurysmal repair of the ascending aorta and the aortic arch has been open surgery with an established track record of good results in suitable... (Review)
Review
The gold standard for aneurysmal repair of the ascending aorta and the aortic arch has been open surgery with an established track record of good results in suitable patients. In recent years, with innovations in the endovascular field alternative endovascular solutions for pathologies of the aortic arch and ascending aorta became available. At first reserved only for highly selected patients unfit for open surgery, endovascular aortic arch repair is now being offered to patients with suitable anatomy in high-volume referral centers after discussion in an interdisciplinary team. The present scoping review aims at providing an overview on indications, available devices, technical aspects, and feasibility studies of endovascular arch repair both in elective and emergent situations, including also experiences and considerations from our center.
Topics: Humans; Aorta, Thoracic; Aortic Aneurysm, Thoracic; Blood Vessel Prosthesis Implantation; Endovascular Procedures; Treatment Outcome; Stents; Blood Vessel Prosthesis
PubMed: 37328096
DOI: 10.1016/j.avsg.2023.06.004 -
Stroke Jan 2024Aortic arch plaques are associated with an increased risk of ischemic stroke in patients with cryptogenic stroke or prior embolic events. However, this relationship is...
BACKGROUND
Aortic arch plaques are associated with an increased risk of ischemic stroke in patients with cryptogenic stroke or prior embolic events. However, this relationship is unclear in the community. We investigated (1) the long-term risk of stroke and cardiovascular events associated with arch plaques and (2) whether statin therapy prescribed for any indication modified the association.
METHODS
A total of 934 stroke-free participants (72±9 years; 37% men) from the CABL study (Cardiovascular Abnormalities and Brain Lesion) were evaluated. Arch plaques were assessed by suprasternal transthoracic echocardiography; plaques ≥4 mm in thickness were classified as large plaques. The primary outcome was ischemic stroke; the secondary outcome was combined cardiovascular events (ischemic stroke, myocardial infarction, and cardiovascular death). The plaque-related risk of outcomes was also analyzed according to the presence of statin treatment. No plaque was used as a reference.
RESULTS
Aortic arch plaques were present in 645 participants (69.1%), with large plaques in 114 (12.2%). During a mean follow-up of 11.3±3.6 years, 236 (25.3%) cardiovascular events occurred (76 ischemic strokes, 27 myocardial infarctions, and 133 cardiovascular deaths). Large arch plaques were independently associated with combined events (adjusted hazard ratio, 2.19 [95% CI, 1.40-3.43]) but not stroke alone (adjusted hazard ratio, 1.09 [95% CI, 0.50-2.38]). The association between large plaques and cardiovascular events was significant in participants receiving statins (adjusted hazard ratio, 2.57 [95% CI, 1.52-4.37]) but not in others; however, participants on statin treatment also had a worse risk profile (higher body mass index, greater frequencies of hypertension, diabetes, and coronary artery disease).
CONCLUSIONS
Aortic arch plaques may be a marker of cardiovascular risk rather than a direct embolic stroke source in older adults without prior stroke. The efficacy of broader cardiovascular risk factors control, beyond cholesterol levels alone, for primary prevention of cardiovascular events in individuals with aortic arch plaques may require further investigation.
Topics: Male; Humans; Aged; Female; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Aorta, Thoracic; Risk Factors; Stroke; Plaque, Atherosclerotic; Myocardial Infarction; Ischemic Stroke
PubMed: 38063018
DOI: 10.1161/STROKEAHA.123.044546 -
Annals of Vascular Surgery Aug 2023Despite significant technological advancements in endovascular aortic repair, the aortic arch remains a challenge due to anatomic complexity including arch angulation...
BACKGROUND
Despite significant technological advancements in endovascular aortic repair, the aortic arch remains a challenge due to anatomic complexity including arch angulation and morphology as well as the location of brachiocephalic vessels in relation to landing zones. Total endovascular solutions are in development and being studied, in the meantime, hybrid thoracic endovascular aortic repair (TEVAR) is a viable alternative to traditional open total arch replacement.
METHODS
A retrospective case series was performed reviewing outcomes of 71 patients who underwent hybrid TEVAR in the aortic arch over the past 12 years at our facility.
RESULTS
Major morbidity in the first 30 days post procedure was experienced by 3 patients (15.7%) and included one patient with stroke (n = 1), and another who experienced paraplegia and pulmonary complications (n = 1). There was one in-hospital death as a result of respiratory failure in a patient with multiple underlying comorbidities including chronic obstructive pulmonary disease on postoperative day 5 resulting in a 30-day mortality of 5.2%. After a mean follow-up of 30 months, the overall mortality remained 5.2%. Major morbidity occurred in one patient who developed retrograde type A dissection. There was no stenosis of bypass grafts identified on follow-up imaging. Endoleak was identified in 2 patients. One patient experienced persistent retrograde perfusion of the false lumen with interval aneurysmal degeneration which was managed with an Amplatz vascular plug at 120 months following the initial hybrid TEVAR (5.2%).
CONCLUSIONS
Single-stage hybrid TEVAR in the aortic arch is technically feasible with a good mid-term survival and a long-term freedom from reintervention.
Topics: Humans; Aortic Aneurysm, Thoracic; Blood Vessel Prosthesis Implantation; Retrospective Studies; Stents; Hospital Mortality; Aortic Dissection; Endovascular Procedures; Treatment Outcome; Risk Factors; Aortic Diseases; Aorta, Thoracic
PubMed: 36377067
DOI: 10.1016/j.avsg.2022.10.002 -
Expert Review of Medical Devices Mar 2024With the incidence of thoracic aortic disease on the rise, total arch replacement (TAR) with frozen elephant trunk (FET) remains the gold-standard management strategy... (Review)
Review
INTRODUCTION
With the incidence of thoracic aortic disease on the rise, total arch replacement (TAR) with frozen elephant trunk (FET) remains the gold-standard management strategy due to optimal results. Several FET devices exist commercially on the global market. However, the mainstay and most commonly used and reported device is the Thoraflex Hybrid Prosthesis (THP), with several recent reports suggesting its superiority.
AREAS COVERED
This review aims to collate and summarize the evidence in the literature on the clinical outcomes of TAR with FET using THP, with a focus on mortality, neurological complications, endoleak, distal stent-induced new entry (dSINE), aortic remodeling, coagulopathy, and graft kinking. In addition, the design features of THP is discussed, and an overview of market competitors is also highlighted.
EXPERT OPINION
THP consistently demonstrates its effectiveness in treating complex thoracic aortic pathology through favorable clinical outcomes, which can be attributed to its unique and innovative design. Rates of early mortality ranged 0.6-14.2%, neurological complications 0-25%, endoleak 0-8.4% and dSINE 0-14.5%, with minimal incidence of graft kinking and coagulopathy. Aortic remodeling is favorable and comparable to competitors. All this evidence solidifies THP as the leading FET device, particularly when combined with appropriate patient selection and surgical planning.
Topics: Humans; Blood Vessel Prosthesis; Blood Vessel Prosthesis Implantation; Aortic Dissection; Endoleak; Stents; Aorta, Thoracic; Retrospective Studies; Treatment Outcome
PubMed: 38431273
DOI: 10.1080/17434440.2024.2326539