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Annals of Vascular Surgery Apr 2021Ascending aortic thrombus (AAT) in a nonaneurysmal aorta is an extremely rare event and has potentially catastrophic complications, with a life-threatening risk of... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Ascending aortic thrombus (AAT) in a nonaneurysmal aorta is an extremely rare event and has potentially catastrophic complications, with a life-threatening risk of myocardial infarction and cerebral embolization. This systematic review aims to elucidate the clinical manifestations and to compare the outcomes of anticoagulation therapy versus open aortic surgery for AAT.
METHODS
The MEDLINE/PubMed databases were extensively searched between 1995 and 2019. All relevant publications on AAT in adults were reviewed, and individual patient data were pooled in this meta-analysis. The primary outcome was AAT resolution. The adverse outcome variables were recurrent arterial embolic events, complications related to open aortic surgery, and mortality during the study period. Chi-squared test and logistic regression analysis were used to compare groups and identify any predictors of mortality.
RESULTS
Overall, 107 patients from 101 articles were included, of whom 29 patients who received anticoagulation therapy and 59 who underwent open aortic surgery were included in the outcome analysis. Among 29 patients treated with initial anticoagulation therapy, the persistence of AAT was observed in 11 patients (38%) and recurrent arterial embolization was developed in 6 patients (21%). All 11 patients in the anticoagulation group underwent secondary aortic surgery for the persistence of AAT with uneventful postoperative course. Compared with patients treated with primary aortic surgery, patients treated with initial anticoagulation therapy had higher risk of recurrent embolization (P = 0.002). No significant difference existed in the mortality rates between the groups (P = 0.106). Hemodynamic instability was an independent predictor of mortality (P = 0.008).
CONCLUSIONS
Anticoagulation therapy and open aortic surgery for AAT show similar results; however, open aortic surgery reliably removes AAT and reduces the risk of recurrent embolization compared with anticoagulation therapy. Furthermore, the preoperative hemodynamic status significantly influences the clinical outcome and is a strong predictor of prognosis.
Topics: Adult; Aged; Aged, 80 and over; Anticoagulants; Aorta; Aortic Diseases; Female; Fibrinolytic Agents; Hemodynamics; Humans; Male; Middle Aged; Postoperative Complications; Recurrence; Risk Assessment; Risk Factors; Thrombosis; Treatment Outcome; Vascular Surgical Procedures
PubMed: 33249131
DOI: 10.1016/j.avsg.2020.10.031 -
Journal of Vascular Surgery Aug 2023To investigate the long-term reinterventions of thoracic endovascular repair (TEVAR) after blunt traumatic aortic injury. (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
To investigate the long-term reinterventions of thoracic endovascular repair (TEVAR) after blunt traumatic aortic injury.
METHODS
MEDLINE, EMBASE, and Cochrane databases were interrogated until June 2021. Inclusion criteria were blunt traumatic aortic injury treated with TEVAR and mean follow-up of more than 60 months. A systematic review was conducted and data were pooled using a random effects model of proportions applying the Freeman-Tukey transformation. Late reintervention was the primary outcome. Secondary outcomes were procedure-related complications (endoleak, in-stent thrombosis, occlusion, infolding/collapse, bird-beak, migration, and left arm claudication), overall and aortic-related mortality, and aortic diameter changes.
RESULTS
Eleven studies with a low quality assessment were included. Four hundred eight patients were collected and the 389 surviving more than 30 days were included. The mean follow-up was 8.2 years (95% confidence interval [CI], 5.7-10.8; I = 40.2%). Late reintervention was 2.1% (95% CI, 0.6-3.9; I = 0.0%; 11/389 cases) with 0.1% (95% CI, 0.0-1.2; I = 0.0%; 3/389) occurring after 5 years. Bird-beak was identified in 38.7% (95% CI, 16.4-63.6; I = 86.6%). Left arm claudication occurring after 30 days was 3.1% (95% CI, 0.1-8.6; I = 26.9%; 11/140 cases). In-stent thrombosis was 1.9% (95% CI, 0.1-5.2; I = 51.8%; 11/389 cases). Endoleak was 0.5% (95% CI, 0.0-1.9; I = 0.0%; 5/389 cases). Infolding, occlusion, and migration were reported in 2 of 389, 1 of 389, and 0 of 389 patients, respectively. Overall late survival was 95.6% (95% CI, 88.1-99.8; I = 84.7%; 358/389 patients) and only one patient accounted for aortic related mortality. The increase in proximal and distal aortic diameters was estimated at 2.7 mm (95% CI, 1.2-4.3; I = 0.0%) and 2.5 mm (95% CI, 1.1-3.9; I = 0.0%), respectively.
CONCLUSIONS
TEVAR demonstrates remarkably good long-term results and reinterventions are rarely required. Aortic reinterventions tend to occur within the first and after the fifth year.
Topics: Humans; Blood Vessel Prosthesis; Blood Vessel Prosthesis Implantation; Aorta, Thoracic; Stents; Endoleak; Treatment Outcome; Endovascular Procedures; Retrospective Studies; Wounds, Nonpenetrating
PubMed: 36754248
DOI: 10.1016/j.jvs.2023.01.196 -
Annals of Vascular Surgery Sep 2022To provide a contemporary review on endovascular false lumen (FL) embolization for thoracic aortic dissection (AD) and evaluate its early outcome. (Review)
Review
BACKGROUND
To provide a contemporary review on endovascular false lumen (FL) embolization for thoracic aortic dissection (AD) and evaluate its early outcome.
METHODS
A systematic literature review on FL embolization for thoracic AD from January 2003 to December 2020 was performed under the instruction of Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Each article was analyzed using a standardized protocol including predefined demographic characteristics, perioperative mortality, and major complications.
RESULTS
A total of 29 papers with 229 patients were included into the analysis. The methods of FL occlusion used were the candy-plug technique, the knickerbocker technique, the "cork in the bottleneck" technique, and direct FL embolization with a combination of stent-grafts, coils, onyx, plugs, and glue. FL embolization procedure was performed in 79 patients (34.5%) with type A AD and 150 (65.5%) with type B AD. FL direct embolization was the most frequently used technique and it was applied in 198 (86.5%) patients. Candy-plug, knickerbocker, and "cork in the bottleneck" techniques were used in 26 (11.4%), 3 (1.3%), and 2 (0.9%) patients, respectively. Technical success was achieved in all patients except one (228/229, 99.6%) in which implantation of a stent to celiac trunk was not possible. There were 4 hospital deaths (1.7%). Neurological complications occurred in 6 patients (2.6%), including 4 (1.7%) spinal cord ischemia and 2 (0.9%) ischemic stroke. There were 1 (0.4%) iatrogenic retrograde dissection and 2 (0.9%) renal failure reported. The mean duration of follow-up was 16.5 months. There were 21 deaths (9.3%) during follow-up and 8 (3.6%) were aorta-related. Thirty three (14.7%) secondary interventions were performed. Five patients (2.2%) required an open completion thoracoabdominal procedure incorporating the stent-graft into the repair. Complete FL thrombosis was observed in 181 (80.4%) patients, 34 (15.1%) had partial thrombosis, and 10 (4.4%) had FL progression.
CONCLUSIONS
FL embolization of the distal thoracic aorta is a promising technique in a group of patients to promote FL thrombosis and aortic remodeling in thoracic aorta.
Topics: Aortic Dissection; Aortic Aneurysm, Thoracic; Blood Vessel Prosthesis; Blood Vessel Prosthesis Implantation; Endovascular Procedures; Humans; Retrospective Studies; Stents; Thrombosis; Time Factors; Treatment Outcome
PubMed: 35339592
DOI: 10.1016/j.avsg.2022.03.020 -
Seminars in Thoracic and Cardiovascular... 2022Thoracic aortic aneurysms (TAA) may grow asymptomatically until they rupture, with a mortality over 90%. The true incidence and prevalence of this condition is uncertain... (Meta-Analysis)
Meta-Analysis
Thoracic aortic aneurysms (TAA) may grow asymptomatically until they rupture, with a mortality over 90%. The true incidence and prevalence of this condition is uncertain and epidemiologic data is scarce, understudied and dispersed. Therefore, we aimed to conduct a systematic review and meta-analysis of the incidence and prevalence of TAAs in population-based studies. We searched MEDLINE, EMBASE and CENTRAL from inception to October 2020 for all population-based studies reporting on incidence and/or prevalence of TAAs. Data were pooled using a random effects model. The main outcome was the overall available worldwide incidence and prevalence of TAAs. The secondary outcomes were to evaluate the incidence of ruptured TAAs, differences in the location of these aneurysms (either ascending, arch or descending aorta) and differences in prevalence/incidence across different study designs. Twenty-two studies were included in the review and meta-analysis. The pooled incidence and prevalence of TAAs was 5.3 per 100,000 individuals/year (95% confidence interval [CI]: 3.0; 8.3) and 0.16% (95% CI: 0.12; 0.20), respectively. The pooled incidence of ruptured aneurysms was 1.6 per 100,000 individuals/year (95% CI: 1.3; 2.1). We found a significant difference of the prevalence in autopsy-only studies, which was 0.76% (95% CI: 0.47; 1.13) and the prevalence of TAAs dropped down to 0.07% (95% CI: 0.05;0.11) when these studies were excluded from the overall analysis. The current epidemiologic information provided serve as a base for future public-health decisions. The lack of well-design population-base studies and the limitations encountered serve as calling for future research in this field.
Topics: Aortic Aneurysm; Aortic Aneurysm, Thoracic; Humans; Incidence; Prevalence; Treatment Outcome
PubMed: 33705940
DOI: 10.1053/j.semtcvs.2021.02.029 -
Journal of Endovascular Therapy : An... Mar 2023To gain insight into safety and efficacy of in situ and ex-situ fenestration techniques for total endovascular arch repair. The term ex-situ fenestration is referring to... (Review)
Review
PURPOSE
To gain insight into safety and efficacy of in situ and ex-situ fenestration techniques for total endovascular arch repair. The term ex-situ fenestration is referring to physician-modified stent-graft technique where fenestration is performed on a back table.
METHODS
Electronic search was conducted according to PRISMA (Preferred Reporting Items for Systematic review and Meta-analyses) guidelines from 2000 to 2020. The main outcomes measured were 30-day mortality, stroke, aortic-related mortality, and reintervention rates.
RESULTS
Fifteen studies were eligible: 7 ex-situ fenestration (189 patients) and 8 in-situ fenestration (149 patients). In ex-situ group, dissection was the main pathology treated and proximal sealing zones were Z0 or 1 in 53.5% of patients. In in-situ group, dissection and aneurysm were equally represented in around 40% of cases and proximal sealing zones were Z0 or 1 in 46.5% of patients. Cumulative 30-day all-cause mortality was similar in both groups: 3.8% (95% confidence interval [CI]: 1.7%-8.2%) and 3.8% (95% CI: 1.6%-8.9%), respectively, in ex-situ and in-situ groups and stroke rate of 2.8% (95% CI: 1.1%-7%) and 5.3% (95% CI: 2.6%-10.5%). After a 11.1 ± 2.6 months mean follow-up for ex-situ and 16.7 ± 2.3 months for in-situ group, there were 5.2 and 1.4 reinterventions per 100 patients-years, respectively, for ex-situ and in situ groups. Aortic-related mortality rates of, respectively, 3.2% (95% CI: 1.3%-7.4%) and 2.6% (95% CI: 0.9%-7.3%) were noted in ex-situ and in situ groups.
CONCLUSION
The reported data show favorable short-term results of both ex-situ and in-situ fenestration techniques with low mortality and strokes rates. However, durability is still questionable given the lack of long-term data. Both options may have their place in arch repair beyond the spectrum of emergent and urgent cases, on condition that results stand the test of time.
CLINICAL IMPACT
In situ and ex-situ fenestration techniques have been initially developed to overcome emergency or as a bail out techniques however giving the promessing favorable short term results indications of these techniques may be extended to elective patients ineligible to customized stent-grafts and possibly in the futur to more elective cases as an option for total endovascular arch repair.
PubMed: 36896884
DOI: 10.1177/15266028231157639 -
Annals of Vascular Surgery Oct 2021The aim of this study was to evaluate the safety, applicability and outcomes of the endovascular in situ fenestration (ISF) technique for patients with aortic arch... (Meta-Analysis)
Meta-Analysis
BACKGROUND
The aim of this study was to evaluate the safety, applicability and outcomes of the endovascular in situ fenestration (ISF) technique for patients with aortic arch pathologies by performing a systematic review.
METHODS
We conducted a systematic search using the PubMed, Embase, and Cochrane databases to identify English language articles between January 2004 and March 2019 on the management of aortic arch pathologies using an in situ fenestration technique. Two independent observers selected studies for inclusion in the study, assessed the methodological quality of the included studies, and extracted the data. The studies included all investigated the clinical outcomes and postprocedural complications of using ISF techniques.
RESULTS
Seven studies reported on a total of 117 aortic arch pathologies patients. Including 52 dissection patients, 47 aneurysm patients, 18 intramural hematomas and penetrating ulcers patients. Needle fenestration and laser fenestration were performed in 62 and 45 patients respectively, and the rest 10 patients received radiofrequency fenestration. The follow-up period ranged from 1 to 55 months. The pooled technical success rates were 94% (95% confidence interval [CI]: 79-98%). The stroke rate was 6% (95% CI: 3-13%). The 30-day MAE was 11% (95% CI: 6-18%).
CONCLUSION
The results of the study showed that using the in-situ fenestration technique for treating patients with aortic arch pathologies produced encouraging mid-outcomes. Long-term outcomes remain undefined.
Topics: Adult; Aged; Aged, 80 and over; Aorta, Thoracic; Aortic Diseases; Blood Vessel Prosthesis; Blood Vessel Prosthesis Implantation; Endovascular Procedures; Female; Humans; Male; Middle Aged; Postoperative Complications; Time Factors; Treatment Outcome
PubMed: 33508460
DOI: 10.1016/j.avsg.2020.12.021 -
Diagnostics (Basel, Switzerland) Jun 2023(1) Background. The anatomical variations of the vertebral arteries (VAs) have a significant impact both in neurosurgery and forensic pathology. The purpose of this... (Review)
Review
(1) Background. The anatomical variations of the vertebral arteries (VAs) have a significant impact both in neurosurgery and forensic pathology. The purpose of this study was to evaluate the variational anatomy of the vertebral artery. We evaluated anatomical aspects regarding the V1 and V2 segments of the VA: origin, course, tortuosity, hypoplasia, and dominance, and established the prevalence of each variation. (2) Methods. We conducted a systematic search in PubMed and Google Scholar databases, up to December 2022. Sixty-two studies, comprising 32,153 vessels, were included in the current meta-analysis. We used a random-effects model with a DerSimonian-Laird estimator. The confidence intervals were set at 95%. The heterogeneity between studies was assessed using I. The funnel plot and Egger's regression test for plot asymmetry were used for the evaluation of publication bias. Statistical significance was considered at < 0.05. (3) Results. The most common site for the origin of both VAs was the subclavian artery. The aortic arch origin of the left VA had a prevalence of 4.81%. Other origins of the right VAs were noted: aortic arch (0.1%), right common carotid artery (0.1%), and brachiocephalic trunk (0.5%). Ninety-two percent of the VAs entered the transverse foramen (TF) of the C6 vertebra, followed by C5, C7, C4, and least frequently, C3 (0.1%). Roughly one out of four (25.9%) VAs presented a sort of tortuosity, the transversal one representing the most common variant. Hypoplasia occurred in 7.94% of the vessels. Left VA dominance (36.1%) is more common, compared to right VA dominance (25.3%). (4) Conclusions. The anatomy of the VA is highly irregular, and eventual intraoperative complications may be life-threatening. The prevalence of VA origin from the subclavian artery is 94.1%, 92.0% of the VAs entered the TF at C6, 26.6% were tortuous, and 7.94% were hypoplastic.
PubMed: 37370931
DOI: 10.3390/diagnostics13122036 -
Vascular Aug 2022To elucidate the epidemiology, anatomical, presentation, classification, pathology, investigative modalities, management and prognosis of primary angiosarcoma of the...
PURPOSE
To elucidate the epidemiology, anatomical, presentation, classification, pathology, investigative modalities, management and prognosis of primary angiosarcoma of the aorta.
MATERIAL AND METHODS
A systematic review of literature from the database inception to January 2021 in PubMed and Embase, CINAHL and Cochrane Library in accordance to PRISMA was conducted. Retrieval and extraction was performed by two independent reviewers. The hierarchy of the evidence was assessed through the National Institute for Health and Care Excellence Checklist. Data were subjected to pooled prevalence analysis, Kaplan-Meier survival and test of probability using log-rank analysis. This review is registered with International Prospective Register of Systematic Reviews: RD42021231314.
RESULTS
82 studies with = 123 cases met the inclusion criterion. Abdominal (45%) aorta was the commonest anatomical site with female predominance in ascending aorta (4:1) and aortic arch (2:1). The longest survival was in the ascending aorta and the shortest in the abdominal aorta [540 (interquartile range [IQR], 7-1560 days vs. 180 (IQR, 1-5730 days)], respectively. The overall median survival was 210 days (IQR, 1-5730 days) or 7 months. Lack of metastasis (47%) was a marker of longer survival ( < 0.03) irrespective of other attributes.
CONCLUSION
The pathophysiology appears to be a trend of increasing fatigue, fever and weight loss associated with segmental dysfunction of the aorta projecting occlusive or destructive phenotypes. Computed tomography angiography features of volume-occupying, bulky, polypoid (intraluminal), protrusive vegetation, hyper vascular without atherosclerotic lesions are extremely suggestive of PA of the aorta at 5th and 6th decades of life.
Topics: Aorta, Abdominal; Aorta, Thoracic; Computed Tomography Angiography; Female; Hemangiosarcoma; Humans; Male; Tomography, X-Ray Computed
PubMed: 34238080
DOI: 10.1177/17085381211026491 -
European Journal of Vascular and... May 2022To synthesise and present all available evidence regarding the surgical treatment of patients with aberrant subclavian artery (aSA) pathologies during the last 30 years.... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
To synthesise and present all available evidence regarding the surgical treatment of patients with aberrant subclavian artery (aSA) pathologies during the last 30 years. The study also aimed to create a checklist of suggested reporting items to help increase reporting homogeneity.
METHODS
A systematic search of medical databases was performed to identify all studies published between 1990 and 2020 reporting on the outcomes of patients undergoing surgery for an aSA pathology. Patients were divided into two groups; Group A included patients undergoing open or hybrid surgery through sternotomy/thoracotomy and Group B included patients undergoing endovascular or hybrid treatment without chest access. The % crude rates (CR) of all variables of interest were calculated. A proportion meta-analysis was performed reporting pooled rates with 95% confidence intervals (CIs).
RESULTS
Three hundred and fourteen studies were identified reporting on the surgical outcomes of 732 patients (60.1% males; 440/732). The quality of evidence was generally low, with 286 studies including fewer than four patients and 28 studies with five or more cases. Aberrant right subclavian artery (aRSA) in a left sided aortic arch was present in 71.4% of the patients and a Kommerell's diverticulum was present in 50.1% of the cases. A total of 68% of the patients were symptomatic on presentation, with the majority complaining of dysphagia (49.6%). Group A included 453 and Group B 279 patients. Studies reporting on five or more patients were included in the main meta-analysis. The pooled early mortality rate was 1.62% (95% CI 0.05% - 4.53%) in Group A and 1.96% (95% CI 0 - 6.34%) in Group B. Pooled rates of symptom relief were 99.52% (95% CI 92.05% - 100.00%) in Group A and 95.79% (95% CI 83.96% - 100.00%) in Group B.
CONCLUSION
The surgical techniques used to treat aSA and aortic pathologies involving an aSA had remarkably low mortality rates and high clinical success, regardless of the technique used.
Topics: Aorta, Thoracic; Cardiovascular Abnormalities; Diverticulum; Female; Humans; Male; Subclavian Artery
PubMed: 35459610
DOI: 10.1016/j.ejvs.2022.02.027 -
Cardiovascular and Interventional... Oct 2023To compare the technical and clinical outcomes of fenestrated thoracic endovascular aortic repair (F-TEVAR) and chimney thoracic endovascular aortic repair (CH-EVAR) of... (Meta-Analysis)
Meta-Analysis Review
Comparison of Chimney and Fenestrated Techniques for Supra-Aortic Branch Revascularization During Thoracic Endovascular Aortic Repair: A Systematic Review and Meta-Analysis.
PURPOSE
To compare the technical and clinical outcomes of fenestrated thoracic endovascular aortic repair (F-TEVAR) and chimney thoracic endovascular aortic repair (CH-EVAR) of aortic disease.
METHODS
PubMed, Embase and Cochrane databases were systematically searched to identify studies on the management of thoracic aortic pathologies using chimney or fenestrated techniques published between 2000 and 2022. Individual studies provided at least one of the following essential outcomes: technical success, immediate and follow-up type I endoleak, 30-day and aorta-related mortality, cerebral events and supra-aortic branch patency.
RESULTS
24 chimney (1106 patients) and 21 fenestrated technique studies (1040 patients) were included. The scope of the study encompassed various thoracic aortic conditions, such as thoracic aortic dissection, thoracic aortic aneurysm, thoracic aortic ulcer, and other thoracic aortic diseases. Technical success was defined as the handling of the principal ailment affecting the aorta, devoid of any instances of complications. The technical success rates were higher in fenestrated group compared with chimney group (98.0% vs. 95.8% p < 0.001), and the rate of type I endoleak either immediately or during follow-up was higher in the chimney technique group (9.3% vs. 1.3% p < 0.001, 4.0% vs. 0.0% p < 0.001). The chimney technique group had higher 30-day mortality and aorta-related mortality than those in the fenestrated technique group (2.1% vs. 0.3% p < 0.001, 0.4% vs. 0.0% p < 0.001). Morbidity rates of cerebral events and supra-aortic branch patency were same in both groups (2.2% vs. 1.1% p = 0.116, 98.2% vs. 99.4% p = 0.094). The chimney technique group had longer operative time (110.0 min vs. 90.8 min p < 0.001). Two groups had same fluoroscopy time (34.0 min vs. 33.4 min p = 0.614).
CONCLUSIONS
The finding suggest that both the chimney and fenestrated techniques are efficacious in supra-aortic branch reconstruction. However, the fenestrated technique exhibits potential superiority as an interventional strategy, as it demonstrates a lower incidence of type 1 Endoleak, 30-day mortality, and aorta-related death following TEVAR.
Topics: Humans; Blood Vessel Prosthesis; Blood Vessel Prosthesis Implantation; Endovascular Aneurysm Repair; Stents; Endoleak; Treatment Outcome; Endovascular Procedures; Risk Factors; Aorta, Thoracic; Aortic Diseases; Retrospective Studies
PubMed: 37684487
DOI: 10.1007/s00270-023-03537-4