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Management of Adults With Anomalous Aortic Origin of the Coronary Arteries: State-of-the-Art Review.Journal of the American College of... Nov 2023As a result of increasing adoption of imaging screening, the number of adult patients with a diagnosis of anomalous aortic origin of the coronary arteries (AAOCA) has... (Review)
Review
As a result of increasing adoption of imaging screening, the number of adult patients with a diagnosis of anomalous aortic origin of the coronary arteries (AAOCA) has grown in recent years. Existing guidelines provide a framework for management and treatment, but patients with AAOCA present with a wide range of anomalies and symptoms that make general recommendations of limited applicability. In particular, a large spectrum of interventions can be used for treatment, and there is no consensus on the optimal approach to be used. In this paper, a multidisciplinary group of clinical and interventional cardiologists and cardiac surgeons performed a systematic review and critical evaluation of the available evidence on the interventional treatment of AAOCA in adult patients. Using a structured Delphi process, the group agreed on expert recommendations that are intended to complement existing clinical practice guidelines.
Topics: Adult; Humans; Coronary Vessels; Coronary Vessel Anomalies; Retrospective Studies; Aorta
PubMed: 37855757
DOI: 10.1016/j.jacc.2023.08.012 -
APMIS : Acta Pathologica,... Jan 2023HIV-associated infective native aortic aneurysms (INAA) constitute a subcategory of the disease INAA. This is a very rare group of patients. The aim of this systematic... (Review)
Review
HIV-associated infective native aortic aneurysms (INAA) constitute a subcategory of the disease INAA. This is a very rare group of patients. The aim of this systematic literature review was to compile a description of patient characteristics with HIV-associated INAA. A systematic literature review was performed using the search terms HIV and aortic aneurysm in Ovid MEDLINE and Embase databases, on articles published between 1981 and 2022. Using the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement, articles were scrutinized according to a predefined protocol including age, sex, comorbidities, microbiological pathogens, CD4-count, HIV/AIDS state, aortic segment involved, treatment and outcome. Thirty-three studies, all case reports with a total of 39 patients, were included. The median age was 48 years (range 27-79), most were male n = 35 (90%), and the median follow-up was n = 6 months (range 0-63). Cardiovascular comorbidity was present in n = 1 (3%), median CD4-count was 216 (range 6-1236), and n = 12 (31%) had AIDS. The most common microbiological pathogens were Treponema pallidum, n = 12 (31%), Salmonella spp. n = 10 (26%), Mycobacterium species n = 5 (12%) and Staphylococcal spp. n = 5 (13%). The HIV-associated INAAs were localized in the abdominal aorta n = 32 (82%), in the thoracic aorta n = 5 (13%) and in the thoraco-abdominal aorta n = 2 (5%). Open surgery was performed in n = 23 (59%) patients, endovascular aortic repair n = 6 (15%), and n = 7 (18%) did not receive surgery. Infection-related complications were reported in n = 2 (7%) patients, both with postoperative development of fatal sepsis. Patients with HIV-associated INAAs were younger, had lower rate of cardiovascular comorbidity, demonstrated low CD4 counts as a measure of immunosuppression, and demonstrated diverse microbiological pathogens compared with other INAAs. Treponema pallidum and Mycobacterium spp. were common pathogens, which are very rare microbiological pathogens in other INAAs.
Topics: Humans; Male; Adult; Middle Aged; Aged; Female; Acquired Immunodeficiency Syndrome; Aneurysm, Infected; Aortic Aneurysm; Treatment Outcome; Postoperative Complications
PubMed: 36106509
DOI: 10.1111/apm.13273 -
Interactive Cardiovascular and Thoracic... Aug 2022Consensus regarding optimal cerebral protection strategy in aortic arch surgery is lacking. We therefore performed a systematic review and meta-analysis to assess... (Meta-Analysis)
Meta-Analysis
Consensus regarding optimal cerebral protection strategy in aortic arch surgery is lacking. We therefore performed a systematic review and meta-analysis to assess outcome differences between unilateral antegrade cerebral perfusion (ACP), bilateral ACP, retrograde cerebral perfusion (RCP) and deep hypothermic circulatory arrest (DHCA). A systematic literature search was performed in Embase, Medline, Web of Science, Cochrane and Google Scholar for all papers published till February 2021 reporting on early clinical outcome after aortic arch surgery utilizing either unilateral, bilateral ACP, RCP or DHCA. The primary outcome was operative mortality. Other key secondary endpoints were occurrence of postoperative disabling stroke, paraplegia, renal and respiratory failure. Pooled outcome risks were estimated using random-effects models. A total of 222 studies were included with a total of 43 720 patients. Pooled postoperative mortality in unilateral ACP group was 6.6% [95% confidence interval (CI) 5.3-8.1%], 9.1% (95% CI 7.9-10.4%), 7.8% (95% CI 5.6-10.7%), 9.2% (95% CI 6.7-12.7%) in bilateral ACP, RCP and DHCA groups, respectively. The incidence of postoperative disabling stroke was 4.8% (95% CI 3.8-6.1%) in the unilateral ACP group, 7.3% (95% CI 6.2-8.5%) in bilateral ACP, 6.4% (95% CI 4.4-9.1%) in RCP and 6.3% (95% CI 4.4-9.1%) in DHCA subgroups. The present meta-analysis summarizes the clinical outcomes of different cerebral protection techniques that have been used in clinical practice over the last decades. These outcomes may be used in advanced microsimulation model. These findings need to be placed in the context of the underlying aortic disease, the extent of the aortic disease and other comorbidities. Prospero registration number: CRD42021246372 METC: MEC-2019-0825.
Topics: Aorta, Thoracic; Aortic Diseases; Cerebrovascular Circulation; Circulatory Arrest, Deep Hypothermia Induced; Humans; Perfusion; Retrospective Studies; Stroke; Treatment Outcome
PubMed: 35512204
DOI: 10.1093/icvts/ivac128 -
Innovations (Philadelphia, Pa.) 2022Early surgical intervention is critical for treatment of aortic arch aneurysms and dissections, but limited comprehensive data exist to define the optimal approach for...
Early surgical intervention is critical for treatment of aortic arch aneurysms and dissections, but limited comprehensive data exist to define the optimal approach for surgical management with respect to postoperative outcomes. We conducted a systematic review of the 2 most common surgical approaches-total arch replacement and hybrid arch repair. We referenced the electronic PubMed database reporting on outcomes for these surgical approaches from inception to June 2022. Our initial search query returned a total of 2,517 records. All records were independently screened for adherence to our inclusion criteria and a total of 12 retrospective cohort studies were identified as appropriate for inclusion. Across the included studies, a total of 618 patients underwent hybrid repair, as compared to 2,104 patients who underwent total arch replacement. We found that most of the literature supported the findings of similar rates of permanent neurologic dysfunction, acute kidney injury, and short-term mortality between approaches and higher postoperative reintervention rates following hybrid repair. Reported outcomes of studies included in this review often conflicted regarding midterm and long-term survival, as well as hospital and intensive care unit length of stay following open and hybrid repair. Future studies should address midterm and long-term survival with a prospective study design.
Topics: Aorta, Thoracic; Aortic Aneurysm, Thoracic; Blood Vessel Prosthesis Implantation; Endovascular Procedures; Humans; Postoperative Complications; Prospective Studies; Retrospective Studies; Risk Factors; Time Factors; Treatment Outcome
PubMed: 35934948
DOI: 10.1177/15569845221115355 -
Journal of Cardiac Surgery Dec 2022New temperature management concepts of moderate and mild hypothermic circulatory arrest during aortic arch surgery have gained weight over profound cooling. Comparisons... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVES
New temperature management concepts of moderate and mild hypothermic circulatory arrest during aortic arch surgery have gained weight over profound cooling. Comparisons of all temperature levels have rarely been performed. We performed direct and indirect comparisons of deep hypothermic circulatory arrest (DHCA) (≤20°C), moderate hypothermic circulatory arrest (MHCA) (20.1-25°C), and mild hypothermic circulatory arrest (mild HCA) (≥25.1°C) in a network meta-analysis.
METHODS
The literature was systematically searched for all papers published through February 2022 reporting on clinical outcomes after aortic arch surgery utilizing DHCA, MHCA and mild HCA. The primary outcome was operative mortality. The secondary outcomes were postoperative stroke and acute kidney failure (AKI).
RESULTS
A total of 34 studies were included, with a total of 12,370 patients. DHCA was associated with significantly higher postoperative incidence of stroke when compared with MHCA (odds ratio [OR], 1.46, 95% confidence interval [CI], 1.19-1.78) and mild HCA: (OR, 1.50, 95% CI, 1.14-1.98). Furthermore, DHCA and MHCA were associated with higher operative mortality when compared with mild HCA (OR 1.71, 95% CI, 1.23-2.39 and OR 1.50, 95% CI, 1.12-2.00, respectively). Separate analysis of randomized and propensity score matched studies showed sustained increased risk of stroke with DHCA in contrast to MHCA and mild HCA (OR, 1.61, 95% CI, 1.18-2.20, p value = .0029 and OR, 1.74, 95% CI, 1.09-2.77, p value = .019).
CONCLUSIONS
In the included studies, the moderate to mild hypothermia strategies were associated with decreased operative mortality and the risk of postoperative stroke. Large-scale prospective studies are warranted to further explore appropriate temperature management for the treatment of aortic arch pathologies.
Topics: Humans; Aorta, Thoracic; Aortic Aneurysm, Thoracic; Treatment Outcome; Temperature; Network Meta-Analysis; Retrospective Studies; Circulatory Arrest, Deep Hypothermia Induced; Stroke; Cerebrovascular Circulation; Perfusion
PubMed: 36378895
DOI: 10.1111/jocs.17206 -
The Canadian Journal of Cardiology Jan 2023Total endovascular aortic arch repair (TEAAR) represents an emerging alternative for the treatment of aortic arch disease in patients at prohibitive risk for open... (Review)
Review
BACKGROUND
Total endovascular aortic arch repair (TEAAR) represents an emerging alternative for the treatment of aortic arch disease in patients at prohibitive risk for open surgery. A systematic review of TEAAR was performed to delineate early outcomes with this new technology.
METHODS
All studies (excluding single-patient case reports) of CE-certified "custom made" or "off-the-shelf" zone 0 stent graft deployments were included. The primary search of Medline, Embase, CINAHL, and the Cochrane CENTRAL registry was supplemented with searches of Web of Science, ClinicalTrials.gov, and conference abstracts (within last 3 years), and a hand search of citations within relevant articles. Articles underwent 2-stage screening by 2 independent reviewers before inclusion.
RESULTS
Fifteen relevant investigations were identified. Indications for TEAAR were chronic arch dissection with degenerative aneurysmal disease (54%, 148/273), pure arch aneurysm (41%, 112/273), penetrating atherosclerotic ulcer (2%, 5/273), and type IA endoleak from a zone 2 thoracic endograft (1%, 3/273). Double-branch (70%, 192/273), triple-branch (19%, 53/273), and single-branch (into innominate artery; 10%, 28/273) devices were used. Adjunct left carotid-subclavian bypass occurred in 90% of double- and single-branch procedures. Procedural success with TEAAR was 93% (95% CI 85.8%-96.3%). The proportion of all-cause mortality was 16% (95% CI 8%-26%), stroke 14% (8%-24%), peripheral vascular events 7% (1%-33%), and myocardial infarction 4% (2%-7%). Endoleaks were identified in 13% (7%-25%) of the study population.
CONCLUSIONS
TEAAR represents an emerging option for the management of aortic arch disease wth high procedural success rates and acceptable early outcomes in a high-risk patient population.
Topics: Humans; Aorta, Thoracic; Blood Vessel Prosthesis; Aortic Aneurysm, Thoracic; Blood Vessel Prosthesis Implantation; Aortic Dissection; Treatment Outcome; Endovascular Procedures; Stents; Retrospective Studies
PubMed: 36395997
DOI: 10.1016/j.cjca.2022.11.003 -
Management of Adults With Anomalous Aortic Origin of the Coronary Arteries: State-of-the-Art Review.The Annals of Thoracic Surgery Dec 2023As a result of increasing adoption of imaging screening, the number of adult patients with a diagnosis of anomalous aortic origin of the coronary arteries (AAOCA) has... (Review)
Review
As a result of increasing adoption of imaging screening, the number of adult patients with a diagnosis of anomalous aortic origin of the coronary arteries (AAOCA) has grown in recent years. Existing guidelines provide a framework for management and treatment, but patients with AAOCA present with a wide range of anomalies and symptoms that make general recommendations of limited applicability. In particular, a large spectrum of interventions can be used for treatment, and there is no consensus on the optimal approach to be used. In this paper, a multidisciplinary group of clinical and interventional cardiologists and cardiac surgeons performed a systematic review and critical evaluation of the available evidence on the interventional treatment of AAOCA in adult patients. Using a structured Delphi process, the group agreed on expert recommendations that are intended to complement existing clinical practice guidelines.
Topics: Humans; Adult; Coronary Vessels; Coronary Vessel Anomalies; Aorta
PubMed: 37855783
DOI: 10.1016/j.athoracsur.2023.09.025 -
Journal of Cardiac Surgery Oct 2021Type B aortic dissection (TBAD), is defined as a dissection involving the aorta distal to left subclavian artery with the ascending aorta and the aortic arch not... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Type B aortic dissection (TBAD), is defined as a dissection involving the aorta distal to left subclavian artery with the ascending aorta and the aortic arch not affected. TBAD is classified due to the time frame and presence of complications. Complicated TBAD (co-TBAD) patients have a greater mortality rate than uncomplicated TBAD (un-TBAD) and thoracic endovascular aortic repair (TEVAR) is considered the gold-standard intervention for these clinical challenges.
METHODS
We undertook a systematic review of the literature regarding TEVAR intervention in co-TBAD and un-TBAD. A comprehensive search was undertaken across four major databases and was evaluated and assessed until June 2020.
RESULTS
A total of 16,104 patients were included in the study (7772 patients co-TBAD and 8352 un-TBAD). A significantly higher proportion of comorbidities were seen in co-TBAD patients compared with un-TBAD. Acute dissection was more frequent in the co-TBAD group (73.55% vs. 66.91%), while chronic dissection was more common in un-TBAD patients (33.8% vs. 70.73%). Postprocedure stroke was higher in co-TBAD (5.85% vs. 3.92%; p < .01), while postprocedural renal failure was higher in un-TBAD patients (7.23 vs. 11.38%; p < .01). No difference was observed in in-hospital mortality however the 30 days mortality was higher in the co-TBAD group. One-year survival was higher in the uncomplicated group but this difference was not observed in the 5-year survival.
CONCLUSION
In our analysis we can appreciate that despite significantly higher comorbidities in the co-TBAD cohort, there was no difference in in-hospital mortality between the two groups and the 5-year survival did not have any difference.
Topics: Aortic Dissection; Aorta, Thoracic; Aortic Aneurysm, Thoracic; Blood Vessel Prosthesis Implantation; Endovascular Procedures; Humans; Retrospective Studies; Risk Factors; Time Factors; Treatment Outcome
PubMed: 34310731
DOI: 10.1111/jocs.15827 -
European Journal of Vascular and... 2022Blunt thoracic aortic injury (BTAI) is a devastating condition that commonly occurs in healthy and young patients. Endovascular treatment is the first choice; however,... (Review)
Review
OBJECTIVE
Blunt thoracic aortic injury (BTAI) is a devastating condition that commonly occurs in healthy and young patients. Endovascular treatment is the first choice; however, it has also been demonstrated to alter cardiovascular haemodynamics. The aim of this systematic review was to describe the cardiovascular modifications after thoracic endovascular aortic repair (TEVAR) for BTAI.
DATA SOURCES
PubMed (MEDLINE), Scopus, and Web of Science were systematically searched for eligible studies reporting on modifications in aortic stiffness, blood pressure, cardiac mass, and aortic size.
REVIEW METHODS
The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement was followed. The Newcastle-Ottawa Scale was used to assess the methodological quality of included studies.
RESULTS
A total of 12 studies reporting on 265 patients were included. Severe heterogeneity existed among the included studies with regard to demographics, BTAI grade, endograft specifications, reported outcomes, and the method of evaluation. Regarding aortic stiffness, two studies found a significant increase in pulse wave velocity (PWV) in patients after TEVAR compared with a control group, while one did not find a significant increase in PWV and augmentation index after > 3 years of follow up. Five studies reported an increase in the incidence of post-TEVAR hypertension up to 55% (range 34.8% - 55.0%) vs. baseline. One study found a statistically significant increase in left ventricular mass and left ventricular mass index during follow up. Nine studies report data regarding aortic dilatation or remodelling after TEVAR. One found a 2.4 fold faster growth rate in ascending aortic diameter vs. controls, while other studies described significant changes in aortic size at different locations along the aorta and endograft after TEVAR.
CONCLUSION
This systematic review highlights adverse cardiac and aortic modifications after TEVAR for BTAI. The results stress the need for lifelong surveillance in these patients and the necessity of developing a more compliant endograft to prevent cardiovascular complications in the long term.
Topics: Humans; Blood Vessel Prosthesis Implantation; Endovascular Procedures; Pulse Wave Analysis; Vascular System Injuries; Retrospective Studies; Thoracic Injuries; Wounds, Nonpenetrating; Aorta, Thoracic; Treatment Outcome
PubMed: 35537638
DOI: 10.1016/j.ejvs.2022.05.004 -
Journal of Endovascular Therapy : An... Nov 2022Open repair remains the standard of care for aortic arch pathologies. However, endovascular management became an attractive alternative for high-risk patients. This... (Review)
Review
PURPOSE
Open repair remains the standard of care for aortic arch pathologies. However, endovascular management became an attractive alternative for high-risk patients. This study aimed to assess the outcomes of the available endovascular techniques for aortic arch pathology management.
MATERIALS AND METHODS
A search of the English literature (2000-2022) using PubMed, EMBASE, via Ovid, and CENTRAL databases (February 1, 2022) was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Studies reporting on patients with aortic arch pathologies managed with custom-made devices ([CMDs] fenestrated or branched thoracic endovascular aortic repair [F/BTEVAR]) and non-CMDs (parallel graft or surgeon-modified FTEVAR) were eligible. Studies reporting on hybrid or open repair were excluded. Studies' quality was assessed using the Newcastle-Ottawa Scale. Primary outcomes were technical success, 30 day mortality, and cerebrovascular events (CVEs). Secondary outcomes were re-intervention and mortality during follow-up.
RESULTS
Thirty studies (2135 patients) were included. Treatment indications were mainly dissections (652 cases [48.0%, 652/1358]; 90 type A, 506 type B; 364 acute, 163 chronic) and aneurysms (46.9%, 582/1239). Five studies (211 patients) reported on FTEVAR and 10 (388 patients) on BTEVAR. For FTEVAR, technical success rate was 98.3%. Thirty-day mortality was 3.8% and CVE rate was 12.3%. Ten deaths (9.7%) and 19 re-interventions (9%) were recorded during follow-up (24 months). Regarding BTEVAR, technical success rate was 98.7%, and 30 day mortality and CVE rates were 5.4% and 11.0%, respectively. During follow-up (27 months), 64 deaths (18.7%) and 33 re-interventions (9.6%) were recorded. Parallel graft technique was reported in 11 studies (901 patients). Technical success rate was 76.4%. Thirty-day mortality was 3.9% and 32 (4.3%) CVEs were recorded. Thirty-five deaths (4.4%) and 43 re-interventions (5.5%) were reported during follow-up (27 months). Surgeon-modified FTEVAR was described in 5 studies (635 patients). Technical success rate was 91.6%. At 30 days, 15 deaths (2.3%) and 22 CVEs (3.5%) were recorded. During follow-up (19 months), 26 deaths (4.2%) and 21 re-interventions (3.6%) were detected.
CONCLUSIONS
Endovascular arch repair presented a variable technical success; >95% for F/BTEVAR; ≤90% for non-CMDs. Acceptable 30 day mortality rates were reported. Cerebrovascular event rates ranged up to 10%. These findings, adjacent to the estimated midterm mortality and re-interventions, set the need for further improvement.
CLINICAL IMPACT
Endovascular arch repair gains popularity as a valuable alternative, especially in patients considered unfit for open repair. According the available literature, any endovascular technique, including custom-made or off-the-shelf solutions, may be applied successfully, with acceptable early mortality. However, the perio-operative cerebrovascular event rate is still an issue, indicating the need for further advancements.
PubMed: 36346051
DOI: 10.1177/15266028221133701