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International Journal For Numerical... Oct 2023To explore the differences between fenestration technique and parallel grafts technique of thoracic endovascular aortic repair, and evaluate the risk of complications...
To explore the differences between fenestration technique and parallel grafts technique of thoracic endovascular aortic repair, and evaluate the risk of complications after interventional treatment of aortic arch aneurysms. A three-dimensional aortic model was established from the follow-up imaging data of patient who reconstructed the superior arch vessel by the chimney technique, which was called the chimney model. Based on the chimney model, the geometric of the reconstructed vessel was modified by virtual surgery, and the normal model, fenestration model and periscope model were established. The blood flow waveforms measured by 2D phase contrast magnetic resonance imaging were processed as the boundary conditions of the ascending aorta inlet and the superior arch vessels outlets of the normal model. The pressure waveform of descending aorta was obtained using three-element Windkessel model, and specific pressure boundary conditions were imposed at reconstructed branches for the postoperative models. Through computational fluid dynamics simulations, the hemodynamic parameters of each model were obtained. The reconstructed vessel flow rate of the periscope model and the fenestration model are 33% and 50% of that of the normal model, respectively. The pressure difference between the inner and outer walls of the fenestration stent and periscope stent is 3.15 times and 7.56 times that of the chimney stent. The velocity in the fenestration stent and periscope stent is uneven. The high relative residence time is concentrated in the region around the branch stents, which is prone to thrombosis. The "gutter" part of the chimney model may become larger due to the effect of the stent-graft DF, increasing the risk of endoleak. For patients with incomplete circle of Willis, the periscope technique to reconstruct the supra-arch vessels may affect blood perfusion. It is recommended to use balloon-expandable stent for fenestration stent and periscope stent, and self-expanding stent for chimney stent. For patients with aortic arch aneurysms, the fenestration technique may be superior to the parallel grafts technique.
Topics: Humans; Blood Vessel Prosthesis; Blood Vessel Prosthesis Implantation; Endovascular Aneurysm Repair; Aortic Aneurysm, Thoracic; Aneurysm, Aortic Arch; Treatment Outcome; Risk Factors; Endovascular Procedures; Aortography; Time Factors; Stents; Aorta, Thoracic; Prosthesis Design
PubMed: 36447341
DOI: 10.1002/cnm.3664 -
European Journal of Cardio-thoracic... Aug 2023The aim of this study was to evaluate the incidence and outcomes of ischaemic organ complications after thoracic endovascular aortic repair (TEVAR). (Observational Study)
Observational Study
OBJECTIVES
The aim of this study was to evaluate the incidence and outcomes of ischaemic organ complications after thoracic endovascular aortic repair (TEVAR).
METHODS
This is a multicentre, retrospective, observational cohort study. We analysed data from patients treated with TEVAR between 22 June 2001 and 10 December 2022. Primary outcomes were postoperative overall organ ischaemic complications and early (≤30 days) survival. Secondary outcomes were long-term survival and freedom from aorta-related mortality.
RESULTS
A total of 255 patients were included in this study. We performed 233 (91.4%) isolated TEVARs, 14 (5.5%) fenestrated or branched TEVARs and 8 (3.1%) TEVARs in combination with normal infrarenal stent graft. Overall, 31 organ ischaemic complications were detected in 29 (11.4%) cases, out of which 8 (3.1%) complications were cerebrovascular, 8 (3.1%) spinal cord, 6 (2.3%) visceral, 4 (1.6%) renal, 2 (0.8%) peripheral and 3 (1.2%) myocardial. Binary logistic regression analysis identified grade III-IV aortic arch atheroma [odds ratio (OR): 6.6, P = 0.001; 95% confidence interval: 2.9-14.9] and shaggy aorta (OR: 12.1, P = 0.003; 95% confidence interval: 2.3-64.1) to be associated with the development of organ ischaemic complications. In patients with organ ischaemia, we observed higher early (≤30 days) mortality (20.7% vs 6.2%; OR: 3.6, P = 0.016), prolonged hospitalization (P = 0.001) and inferior estimated survival (log-rank, P = 0.001).
CONCLUSIONS
Aortic arch atherosclerotic overload as well as the presence of shaggy aorta are predictors of organ ischaemic complications following TEVAR. They are neither uncommon nor negligible and are associated with perioperative mortality, prolonged hospitalization and a negative impact on long-term survival.
Topics: Humans; Endovascular Aneurysm Repair; Blood Vessel Prosthesis Implantation; Retrospective Studies; Endovascular Procedures; Aorta, Thoracic; Postoperative Complications; Ischemia; Aortic Aneurysm, Thoracic; Treatment Outcome; Risk Factors
PubMed: 37335859
DOI: 10.1093/ejcts/ezad238 -
Pediatric Cardiology Jun 2024Left ventricular outflow tract obstruction (LVOTO) remains a significant complication after primary repair of interrupted aortic arch with ventricular septal defect...
Left ventricular outflow tract obstruction (LVOTO) remains a significant complication after primary repair of interrupted aortic arch with ventricular septal defect (IAA-VSD). Clinical and echocardiographic predictors for LVOTO reoperation are controversial and procedures to prophylactically prevent future LVOTO are not reliable. However, it is important to identify the patients at risk for future LVOTO intervention after repair of IAA-VSD. Patients who underwent single-stage IAA-VSD repair at our center 2006-2021 were retrospectively reviewed, excluding patients with associated cardiac lesions. Two-dimensional measurements, LVOT gradients, and 4-chamber (4C) and short-axis (SAXM) strain were obtained from preoperative and predischarge echocardiograms. Univariate risk analysis for LVOTO reoperation was performed using unpaired t-test. Thirty patients were included with 21 (70%) IAA subtype B and mean weight at surgery 3.0 kg. Repair included aortic arch patch augmentation in 20 patients and subaortic obstruction intervention in three patients. Seven (23%) required reoperations for LVOTO. Patient characteristics were similar between patients who required LVOT reoperation and those who did not. Patch augmentation was not associated with LVOTO reintervention. Patients requiring reintervention had significantly smaller LVOT AP diameter preoperatively and at discharge, and higher LVOT velocity, smaller AV annular diameter, and ascending aortic diameter at discharge. There was an association between LVOT-indexed cross-sectional area (CSAcm/BSAm) ≤ 0.7 and reintervention. There was no significant difference in 4C or SAXM strain in patients requiring reintervention. LVOTO reoperation was not associated with preoperative clinical or surgical variables but was associated with smaller LVOT on preoperative echo and smaller LVOT, smaller AV annular diameter, and increased LVOT velocity at discharge.
Topics: Humans; Female; Retrospective Studies; Male; Reoperation; Aorta, Thoracic; Echocardiography; Ventricular Outflow Obstruction; Heart Septal Defects, Ventricular; Infant; Postoperative Complications; Infant, Newborn; Treatment Outcome; Cardiac Surgical Procedures
PubMed: 38480569
DOI: 10.1007/s00246-024-03419-7 -
Annals of Vascular Surgery Aug 2023Recently published experience has shown that endovascular management of the aortic arch, including sealing in the proximal zones, can be a viable option for patients... (Review)
Review
Recently published experience has shown that endovascular management of the aortic arch, including sealing in the proximal zones, can be a viable option for patients considered unfit for conventional open repair. Endograft designs vary and include single or multibranch devices, with or without the addition of surgical debranching. Initial reports show that both techniques can be performed with high technical success and acceptable perioperative morbidity and mortality rates in high volume centers. Single branch devices, available off-the-shelf, may provide a treatment option for emergent presentations where patients cannot wait for the design and manufacture of a customized endograft. Double or triple branched endografts are now increasingly implanted in high-volume aortic centers. The purpose of this review is to describe the single and multibranched endovascular devices currently available for aortic arch repair, their associated published outcomes, and to discuss their relative advantages and disadvantages.
Topics: Humans; Aorta, Thoracic; Blood Vessel Prosthesis; Blood Vessel Prosthesis Implantation; Aortic Aneurysm, Thoracic; Treatment Outcome; Prosthesis Design; Endovascular Procedures; Stents; Retrospective Studies
PubMed: 36309169
DOI: 10.1016/j.avsg.2022.09.044 -
Journal of Endovascular Therapy : An... Aug 2023The RelayBranch stent-graft (Terumo Aortic, Sunrise, FL, USA) offers a custom-made endovascular solution for complex aortic arch pathologies. In this technical note, a...
The RelayBranch stent-graft (Terumo Aortic, Sunrise, FL, USA) offers a custom-made endovascular solution for complex aortic arch pathologies. In this technical note, a modified electrocardiography (ECG)-gated computed tomography (CT)-based algorithm was applied to quantify cardiac-pulsatility-induced changes of the aortic arch geometry and motion before and after double-branched endovascular repair (bTEVAR) of an aortic arch aneurysm. This software algorithm has the potential to provide novel and clinically relevant insights in the influence of bTEVAR on aortic anatomy, arterial compliance, and stent-graft dynamics.
Topics: Humans; Aorta, Thoracic; Aortic Aneurysm, Thoracic; Stents; Treatment Outcome; Endovascular Procedures; Prosthesis Design; Blood Vessel Prosthesis; Blood Vessel Prosthesis Implantation; Retrospective Studies
PubMed: 35352980
DOI: 10.1177/15266028221086474 -
The Annals of Thoracic Surgery Jun 2024Although anomalous aortic origin of a coronary artery (AAOCA) is associated with risk of sudden cardiac arrest (SCA), there is a spectrum of disease, with the... (Review)
Review
BACKGROUND
Although anomalous aortic origin of a coronary artery (AAOCA) is associated with risk of sudden cardiac arrest (SCA), there is a spectrum of disease, with the appropriate management for many remaining unclear. Increasing data warrant review for an updated perspective on management.
METHODS
A panel of congenital cardiac surgeons, cardiologists, and imaging practitioners reviewed the current literature related to AAOCA and its management. Survey of relevant publications from 2010 to the present in PubMed was performed.
RESULTS
The prevalence of AAOCA is 0.4% to 0.8%. Anomalous left coronary artery is 3 to 8 times less common than anomalous right coronary, but carries a much higher risk of SCA. Nevertheless, anomalous right coronary is not completely benign; 10% demonstrate ischemia, and it remains an important cause of SCA. Decision-making regarding which patients should be recommended for surgical intervention includes determining anatomic features associated with ischemia, evidence of ischemia on provocative testing, and concerning cardiovascular symptoms. Ischemia testing continues to prove challenging with low sensitivity and specificity, but the utility of new modalities is an active area of research. Surgical interventions focus on creating an unobstructed path for blood flow and choosing the appropriate surgical technique given the anatomy to accomplish this. Nontrivial morbidity has been reported with surgery, including new-onset ischemia.
CONCLUSIONS
A proportion of patients with AAOCA demonstrate features and ischemia that warrant surgical intervention. Continued work remains to improve the ability to detect inducible ischemia, to risk stratify these patients, and to provide guidance in terms of which patients warrant surgical intervention.
Topics: Humans; Coronary Vessel Anomalies; Aorta, Thoracic
PubMed: 38302054
DOI: 10.1016/j.athoracsur.2024.01.016 -
Training in Aortic Arch Surgery as a Blueprint for a Structured Educational Team Approach: A Review.Medicina (Kaunas, Lithuania) Jul 2023The treatment of pathologies of the aortic arch is a complex field of cardiovascular surgery that has witnessed enormous progress recently. Such treatment is mainly... (Review)
Review
The treatment of pathologies of the aortic arch is a complex field of cardiovascular surgery that has witnessed enormous progress recently. Such treatment is mainly performed in high-volume centres, and surgeons gain great experience in mastering potential difficulties even under emergency circumstances, thereby ensuring the effective therapy of more complex pathologies with lower complication rates. As the numbers of patients rise, so does the need for well-trained surgeons in aortic arch surgery. But how is it possible to learn surgical procedures in a responsible way that, in addition to surgical techniques, also places particular demands on the overall surgical management such as perfusion strategy and neuro-protection? This is why a good training programme teaching young surgeons without increasing the risk for patients is indispensable. Our intention was to highlight the most challenging aspects of aortic arch surgery teaching and how young surgeons can master them. We analysed the literature to find out which methods are most suitable for such teaching goals and what result they reveal when serving as teaching procedures. Several studies were found comparing the surgical outcome of young trainees with that of specialists. It was found that the results were comparable whether the procedure was performed by a specialist or by a trainee assisted by the specialist. We thus came to the conclusion that even for such a complex type of intervention, the responsible training of young surgeons by experienced specialists is possible. However, it requires a clear strategy and team approach to ensure a safe outcome for the patient.
Topics: Humans; Aorta, Thoracic; Educational Status; Learning; Surgeons; Intention
PubMed: 37629681
DOI: 10.3390/medicina59081391 -
The Annals of Thoracic Surgery Aug 2023Aortic arch surgery necessitates interruption of perfusion, thus conferring higher morbidity and mortality compared with other aortic surgery. This report describes a...
BACKGROUND
Aortic arch surgery necessitates interruption of perfusion, thus conferring higher morbidity and mortality compared with other aortic surgery. This report describes a branch-first continuous perfusion aortic arch replacement (BF-CPAR) technique that overcomes these shortcomings and describes midterm results with this technique.
METHODS
This report represents the corresponding author's 15-year experience with BF-CPAR, which involves preliminary mobilization and branch reconstruction before circulatory arrest by using a modified trifurcation graft. Demographic, procedural, and outcome (mortality, reintervention, morbidity, and stroke) were analyzed with Kaplan-Meier and Cox regression.
RESULTS
Over 15 years (July 2005-February 2021), 155 patients underwent BF-CPAR, at a median age of 66.8 years, 106 (68.3%) on an elective basis and 49 (31.6%) on an emergency basis. There were no aortic deaths after the first postoperative year, thereby resulting in a 1- and 10-year freedom from aortic death constant at 95.6% in patients undergoing elective BF-CPAR and 93.3% in patients undergoing emergency BF-CPAR patients, respectively. Freedom from reintervention on the operated segment at 5 and 9 years was 93.2% and 93.2% in patients undergoing elective cases and 97.1% and 91.4% in emergency cases, respectively. The 10-year freedom from any aortic reintervention was 72.8% in elective patients and 29.2% in emergency patients; there were 38 reinterventions, 76.3% (n = 29/38) done for progression of aneurysmal or dissection disease, of which 79.3% (n = 23/29) were completed endovascularly. Freedom from cerebrovascular-related events at 5 and 10 years was 90.3% and 82.6% in patients undergoing elective BF-CPAR and 75.4% for both time points in patients undergoing emergency BF-CPAR, respectively.
CONCLUSIONS
BF-CPAR has excellent 10-year results for elective and emergency cases of arch replacement.
Topics: Humans; Aged; Aorta, Thoracic; Aortic Aneurysm, Thoracic; Treatment Outcome; Perfusion; Retrospective Studies; Blood Vessel Prosthesis Implantation; Postoperative Complications
PubMed: 36152878
DOI: 10.1016/j.athoracsur.2022.09.020 -
The Journal of Thoracic and... Mar 2024The study objective was to analyze the outcomes of reoperative thoracic aortic surgery at our institution from January 1986 to December 2018 to identify specific risk...
OBJECTIVE
The study objective was to analyze the outcomes of reoperative thoracic aortic surgery at our institution from January 1986 to December 2018 to identify specific risk factors for early and late mortality.
METHODS
Two groups of patients were identified: aortic root or ascending aorta repair (group 1: proximal repair, 218 patients, 48%) and arch surgery or descending thoracic aorta repair (group 2: distal repair, 235 patients, 52%). Primary end points were 30-day mortality, 10-year survival, and freedom from aortic reoperations.
RESULTS
The 30-day mortality (6.4% vs 8.1%) and in-hospital mortality (8.3% vs 11.9%) were similar (P > .05) in the 2 groups. Multivariable analysis identified female gender (odds ratio, 8.60, P < .01), endocarditis (odds ratio, 2.96, P = .04), and cardiopulmonary bypass time (odds ratio, 1.02, P < .01) as risk factors for 30-day mortality. Mean follow-up time was 163 months (confidence interval, 147-179). Long-term survival at 1, 5, and 10 years was 91.2%, 79.4%, and 66.3% in the proximal repair group and 80.7%, 68.8%, the and 55.3% in distal repair group, respectively (P = .03). According to the indication, 1-, 5-, and 10-year survivals were 92.1%, 82.3%, and 68.8% in degenerative aneurysms; 82.7%, 72.4%, and 56.3% in residual dissections; 80.9%, 65.4%, and 50.3% in endocarditis and pseudoaneurysms; 69.2%, 52.7%, and 42.2% in acute type A aortic dissections, respectively (P < .01). Competing risk analysis showed a significantly different cumulative incidence of reoperation at 1, 5, and 10 years between the 2 groups: 0.50%, 0.50%, and 0.90%, respectively, for the proximal repair group, and 0.40%, 4.30%, and 7.70%, respectively, the for distal repair group (P < .01).
CONCLUSIONS
In our experience, short- and long-term results of reoperative thoracic aortic surgery were satisfactory in chronic aneurysms but poor in aortic dissections, pseudoaneurysms, and active endocarditis. Reoperative aortic surgery carries a high risk, regardless of the anatomic extension of the procedure.
Topics: Humans; Female; Aorta, Thoracic; Retrospective Studies; Reoperation; Aneurysm, False; Treatment Outcome; Blood Vessel Prosthesis Implantation; Aortic Dissection; Aneurysm; Risk Factors; Endocarditis; Aortic Aneurysm, Thoracic
PubMed: 35690473
DOI: 10.1016/j.jtcvs.2022.03.039 -
Archives of Cardiovascular Diseases Nov 2023Bicuspid aortic valve (BAV) is frequently associated with dilatation of the thoracic aorta. Peculiar anatomical, histological and mechanical changes of the aortic wall... (Comparative Study)
Comparative Study
BACKGROUND
Bicuspid aortic valve (BAV) is frequently associated with dilatation of the thoracic aorta. Peculiar anatomical, histological and mechanical changes of the aortic wall in BAV aortopathy have been hypothesized to suggest an increased risk of acute aortic complications in patients with BAV.
AIM
In this study we tried to clarify any differences in the adaptability of the aortic wall to the mechanism of dilatation between patients with BAV and those with TAV.
METHODS
In total, 354 samples were taken from 71 patients undergoing elective aortic surgery and divided into two groups: BAV group (n=16; 101 samples); and TAV group (n=55; 253 samples). Aortic wall thickness was measured with a dedicated caliper. The relationship between aortic wall thickness and aortic dilatation and demographic variables was evaluated cumulatively and comparatively (BAV versus TAV). In patients with more than three samples available, intrapatient variability was also studied. Finally, potential risk factors for severely reduced aortic wall thickness were also assessed.
RESULTS
Analysis of preoperative characteristics revealed significant differences in patient age (54±16years for BAV and 66±11years for TAV; P=0.0011), with no differences in variables related to aortic dilatation (including phenotype). Cumulative aortic wall thickness was significantly thinner in the anterior than in the posterior wall. In the comparative analysis, aortic wall thickness was significantly thinner in patients with BAV in both the anterior and posterior regions. Furthermore, in patients with BAV, dilatation>51mm was a significant predictor of severely reduced aortic wall thickness.
CONCLUSIONS
In our experience, patients with BAV aortopathy reached the cut-off for the surgical indication at an early age. Careful monitoring in patients with BAV is mandatory when aortic dilatation has reached 51mm, as it is related to significant anatomical changes.
Topics: Humans; Middle Aged; Male; Bicuspid Aortic Valve Disease; Female; Aortic Valve; Aged; Adult; Risk Factors; Dilatation, Pathologic; Heart Valve Diseases; Tricuspid Valve; Retrospective Studies; Aortic Aneurysm, Thoracic; Aorta, Thoracic; Aortic Valve Disease; Aortic Aneurysm
PubMed: 37770332
DOI: 10.1016/j.acvd.2023.08.003