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Annals of Vascular Surgery Aug 2021Branched and fenestrated endografts (fEVAR/bEVAR) are complex techniques used to treat thoracic aorta pathologies involving the aortic arch. This systematic review aims...
OBJECTIVE
Branched and fenestrated endografts (fEVAR/bEVAR) are complex techniques used to treat thoracic aorta pathologies involving the aortic arch. This systematic review aims to determine all the reported results regarding these techniques in the aortic arch, in order to describe their clinical outcomes.
METHODS
A systematic review of the literature was performed, considering all articles published until October 2019. PubMed, Cochrane database resources were used. The protocol of the study was previously registered in the Prospero database (CRD42020147037). Primary exclusion criteria included opinion articles, merely technique descriptions, articles without the follow-up of at least 1 month, studies conducted on animals, mixed treatments, and ongoing trials without published data. Included variables were study design, aortic pathology, type of endovascular technique (fEVAR/bEVAR), endograft manufacturing, number of fenestrations/branches and type of bridge stents. Technical success, complications during surgery and follow-up were also described.
RESULTS
From a total of 164 articles, 29 (28 retrospective, 1 prospective) were analyzed with a total of 693 cases (341 fEVAR and 352 bEVAR). The most common indications for repair were aneurysm (54.8%) and dissection (40%). Only fEVAR and bEVAR were considered, but different endograft materials and techniques were used and, therefore, reported upon in the current review. Zenith Alpha Thoracic Endovascular Graft was the most representative (24% of cases). Custom made, off-the-shelf, physician modified and in situ fenestrated endografts were also used in 39%, 22.4%, 18.6% and 18.9% of cases, respectively. Bridge stents were implanted in the 50.5% of cases. Technical success rate was 96%. The main intraoperative complication was the endoleak (5.2%) followed by stroke (4.8%). The in-hospital mortality was 2.5%. The mean follow-up was 18.5 months. The mortality related to the main operation during follow-up was 3.2% and not directly related to the main operation was 11.3%. During the follow-up, 92 cases (13.3%) in total had to undergo through a reintervention, 46.7% with endovascular repair and 26.1% with open surgical repair (the rest were not specified).
CONCLUSION
published experience with bEVAR and fEVAR in the aortic arch showed acceptable short-term effectiveness and safety. More well-conducted prospective clinical studies with long term follow-up, combined with comparative meta-analysis, are needed to elucidate the real benefit of those endovascular techniques in the aortic arch pathology.
Topics: Aorta, Thoracic; Aortic Diseases; Blood Vessel Prosthesis; Blood Vessel Prosthesis Implantation; Endovascular Procedures; Female; Hospital Mortality; Humans; Male; Postoperative Complications; Prosthesis Design; Retreatment; Risk Assessment; Risk Factors; Stents; Time Factors; Treatment Outcome
PubMed: 33831530
DOI: 10.1016/j.avsg.2021.03.024 -
Interactive Cardiovascular and Thoracic... Mar 2022This study aims to systematically review published literature on male-female differences in presentation, management and outcomes in patients diagnosed with acute... (Meta-Analysis)
Meta-Analysis
OBJECTIVES
This study aims to systematically review published literature on male-female differences in presentation, management and outcomes in patients diagnosed with acute thoracic aortic dissection (AD).
METHODS
A systematic literature search was conducted for studies published between 1 January 1999 and 19 October 2020 investigating mortality and morbidity in adult patients diagnosed with AD. Patient and treatment characteristics were compared with odds ratios (ORs) and standardized mean differences and a meta-analysis using a random-effects model was performed for early mortality. Overall survival and reoperation were visualized by pooled Kaplan-Meier curves.
RESULTS
Nine studies investigating type A dissections (AD-A), 1 investigating type B dissections (AD-B) and 3 investigating both AD-A and AD-B were included encompassing 18 659 patients. Males were younger in both AD-A (P < 0.001) and AD-B (P < 0.001), and in AD-A patients males had more distally extended dissections [OR 0.57, 95% confidence interval (CI) 0.46-0.70; P < 0.001]. Longer operation times were observed for males in AD-A (standardized mean difference 0.29, 95% CI 0.17-0.41; P < 0.001) while male patients were less often treated conservatively in AD-B (OR 0.65, 95% CI 0.58-0.72; P < 0.001). The pooled early mortality risk ratio for males versus females was 0.94 (95% CI 0.84-1.06, P = 0.308) in AD-A and 0.92 (95% CI 0.83-1.03, P = 0.143) in AD-B. Pooled overall mortality in AD-A showed no male-female difference, whereas male patients had more reinterventions during follow-up.
CONCLUSIONS
This systematic review shows male-female differences in AD patient and treatment characteristics, comparable early and overall mortality and inconsistent outcome reporting. As published literature is scarce and heterogeneous, large prospective studies with standardized reporting of male-female characteristics and outcomes are clearly warranted. Improved knowledge of male-female differences in AD will help shape optimal individualized care for both males and females.
CLINICAL REGISTRATION NUMBER
PROSPERO, ID number: CRD42020155926.
Topics: Adult; Aortic Dissection; Aortic Aneurysm, Thoracic; Blood Vessel Prosthesis Implantation; Endovascular Procedures; Female; Humans; Male; Prospective Studies; Retrospective Studies; Risk Factors; Treatment Outcome
PubMed: 34664071
DOI: 10.1093/icvts/ivab270 -
Journal of Endovascular Therapy : An... Jul 2023The objective of this systematic review was to assess the incidences and associations of early postoperative stroke and death among patients undergoing inner branched... (Review)
Review
Incidence and Prognostic Associations of Early Postoperative Stroke and Death Among Patients Undergoing Inner Branched Thoracic Endovascular Repair of Aortic Arch Pathologies: A Systematic Review and Meta-Analysis.
OBJECTIVE
The objective of this systematic review was to assess the incidences and associations of early postoperative stroke and death among patients undergoing inner branched thoracic endovascular aortic repair (TEVAR) of arch pathologies.
METHODS
Electronic bibliographic sources (PUBMED, EMBASE, and CENTRAL) were searched up to February 2022 using a combination of thesaurus and free-text terms to identify the studies using branched TEVAR to treat aortic arch disease. The systematic review was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. All observational studies investigating the prognosis of inner branched TEVAR in the treatment of aortic arch pathologies were included. Independent extraction of articles was performed by two authors using predefined data fields, including study quality indications. All pooled analyses were based on a random-effects or fixed model according to the heterogeneity.
RESULTS
A total of 23 case series totaling 532 participants were included after screening. After optimized selection (largest sample size, most detailed data, lowest risk of bias) from the overlapping data, 12 studies with 289 participants were included in data synthesis. The pooled incidence of 30-day postoperative stroke was 10.6% (95% CI 7.0%-14.2%; p=.41, I=3%). Pooled 30-day mortality was 4.9% (95% CI 2.0%-7.8%; p=.38, I=7%). Combined early stroke/death was 15.7% (95% CI 11.2%-20.3%; p=.30, I=15%). Subgroup analyses of 11 studies (without data missing) showed that a higher incidence of 30-day postoperative stroke was found in studies with aged participants (age≥71.3 years, p=.010), the higher percentage of COPD (≥30%, p= .011) and non-dissection-related pathologies (≥60.8%, p=.011). The higher 30-day postoperative mortality was found in studies with a high percentage of previous coronary artery disease (≥34.5%, p=.023).
CONCLUSIONS
This review demonstrated that there were acceptable rates of 30-day postoperative stroke and death among patients undergoing inner branched TEVAR. It is strongly necessary to perform a rigorous risk assessment of aortic plaque embolism and coronary artery disease when the surgical plan of the inner branched TEVAR is determined.
CLINICAL IMPACT
Treatment arch pathologies with inner branched TEVAR provides acceptable early stroke rate and mortality. Aortic pathology mainly influenced the early stroke rate, and early recognizing high-risk patients for aortic plaque embolism is of supreme importance for reducing the early stroke rate. In addition, the history of coronary artery disease was strongly associated with early mortality, and attention should be paid to the coronary artery assessment and perioperative management of these patients.
PubMed: 37476985
DOI: 10.1177/15266028231187715 -
Journal of Vascular Surgery Oct 2022Best medical therapy (BMT) should be recommended for treating uncomplicated Stanford type B aortic dissection (uSTBAD), whereas thoracic aortic endovascular repair... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
Best medical therapy (BMT) should be recommended for treating uncomplicated Stanford type B aortic dissection (uSTBAD), whereas thoracic aortic endovascular repair (TEVAR) has been controversial for uSTBAD.
METHODS
In this paper, a meta-analysis was conducted on all available randomized controlled trials and observational studies that evaluated the relative benefits and harms of TEVAR and BMT for the management of patients suffering from uSTBAD. Primary endpoints consisted of early adverse events, long-term adverse events, and aortic remodeling. In addition, risk differences (RDs) or odds ratios (ORs) with 95% confidence intervals (CIs) were estimated. The random-effects model or the fixed-effects model was used in accordance with the 50% heterogeneity threshold.
RESULTS
Seven observational studies and two randomized controlled studies from 11 articles that contained 15,066 patients with uSTBAD (1518 TEVARs) met the inclusion criteria. For early outcomes, no significant differences were found between the TEVAR group and the BMT group in aortic rupture, retrograde dissection, paraplegia/paraparesis, reintervention, aorta-related death, and all-cause death. In the long run, the TEVAR group was found to have a significantly lower incidence of adverse events, which included aortic rupture (OR, 0.26; 95% CI, 0.16-0.42; P < .05; heterogeneity: P = .90, I = 0%), reintervention (OR, 0.45; 95% CI, 0.26-0.75; P < .05; heterogeneity: P = .17, I = 41%), aorta-related death (OR, 0.27; 95% CI, 0.18-0.42; P < .05; heterogeneity: P = .61, I = 0%), and all-cause death (OR, 0.52; 95% CI, 0.42-0.66; P < .05; heterogeneity: P = .05, I = 53%) as compared with the BMT group. Moreover, in compared with BMT, TEVAR was found to significantly contribute to the complete thrombosis of thoracic false lumen (OR, 55.34; 95% CI, 34.32-89.21; P < .05; heterogeneity: P = .97, I = 0%), and aortic regression (true lumen expansion and false lumen shrinkage).
CONCLUSIONS
Although early endovascular repair of uSTBAD does not outperform BMT, its implementation is found to be necessary to facilitate the long-term prognosis. Accordingly, if early TEVAR is to be deferred, close follow-up is critical to allow for timely reintervention.
Topics: Aortic Dissection; Aortic Aneurysm, Thoracic; Aortic Rupture; Blood Vessel Prosthesis Implantation; Endovascular Procedures; Humans; Observational Studies as Topic; Retrospective Studies; Treatment Outcome
PubMed: 35390485
DOI: 10.1016/j.jvs.2022.03.876 -
World Journal For Pediatric &... Sep 2020Pediatric aortic root dilatation is a life-threatening condition that lacks guidelines for surgical management. We aimed to analyze the data on aortic valve...
BACKGROUND
Pediatric aortic root dilatation is a life-threatening condition that lacks guidelines for surgical management. We aimed to analyze the data on aortic valve interventions during root surgery to guide decision-making.
METHODS
A search was performed of MEDLINE, Embase, CENTRAL, ClinicalTrials.gov, and WHO ICTRP. Citations were screened in duplicate and independently to identify randomized controlled trials, cohorts, and case series involving populations aged 0 to 18 years, who received valve-sparing and valve-replacing aortic root surgeries between 1999 and 2019. Outcomes considered included mortality (perioperative, one year, five year), reintervention rates.
RESULTS
After duplicate removal, 689 citations were screened through abstract and full text review, identifying five eligible studies. All five were observational studies evaluating valve-sparing procedures. There were 81 patients with a mean study age range of 9.9 to 13.9 years. Both reimplantation (74%) and remodeling (26%) subtypes were done. Range of mean duration of follow-up was 1.2 to 4.4 years. There was no mortality reported until the one-year follow-up period. The long-term mortality rate was calculated as 0.02 per patient-year (95% CI: 0.01-0.05). The long-term reintervention rate was 0.08 per patient-year (95% CI: 0.05-0.13).
CONCLUSIONS
There is limited experience on aortic valve intervention during aortic root surgery in children. Single-arm studies on valve-sparing surgeries show excellent survival up to one year. Mortality and reintervention rates increase in the longer term. The small sample size and lack of controlled studies do not allow for direct comparisons between procedure types.
Topics: Aorta, Thoracic; Aortic Valve; Child, Preschool; Heart Valve Diseases; Heart Valve Prosthesis Implantation; Humans; Replantation
PubMed: 32853070
DOI: 10.1177/2150135120926979 -
Monaldi Archives For Chest Disease =... Sep 2023CHARGE syndrome (CS) is a rare genetic disease that affects many areas of the body. The aim of the present systematic review was to evaluate the prevalence and types of...
CHARGE syndrome (CS) is a rare genetic disease that affects many areas of the body. The aim of the present systematic review was to evaluate the prevalence and types of congenital heart diseases (CHDs) in CS and their impact on clinical outcome. A systematic review from 1981 to September 2022 was conducted. Clinical studies that reported the association between CS and CHDs were identified, including a case report of a rare congenital anomaly of the aortic arch (AA) with persistent fifth aortic arch (PFAA). Demographic, clinical and outcome data were extracted and analyzed. Sixty-eight studies (44 case reports and 24 case series; n=943 CS patients) were included. The prevalence of CHDs was 76.6%, patent ductus arteriosus (PDA) 26%, ventricular (VSD) 21%, atrial septal defects (ASD) 18%, tetralogy of Fallot 11%, aortic abnormalities 24%. PFAA has not been previously reported in CS. Cardiac surgery was performed in more than half of CS patients (150/242, 62%). In-hospital mortality rate was about 9.5% (n=86/900) in case series studies and 12% (n=5/43) in case reports, including cardiovascular (CV) and non-CV causes. CHDs and feeding disorders associated with CS may have a substantial impact on prognosis. CHDs were usually associated with CS and represent important causes of morbidity and mortality. PFAA, although rare, may also be present. The prognosis is highly dependent on the presence of cardiac and non-cardiac developmental abnormalities. Further studies are needed to better identify the main causes of the long-term outcome of CS patients.
PubMed: 37675914
DOI: 10.4081/monaldi.2023.2661 -
Archives of Cardiovascular Diseases Dec 2023Leaflet thrombosis and reduced leaflet motion have become a concern with the expanding use of transcatheter aortic valve replacement in lower-risk patients. (Meta-Analysis)
Meta-Analysis
BACKGROUND
Leaflet thrombosis and reduced leaflet motion have become a concern with the expanding use of transcatheter aortic valve replacement in lower-risk patients.
AIMS
To assess the proportions, predictors and clinical impact of leaflet thrombosis and reduced leaflet motion after transcatheter aortic valve replacement.
METHODS
We performed a meta-analysis of studies assessing the proportions of and/or clinical outcomes according to the presence of leaflet thrombosis after transcatheter aortic valve replacement identified with computed tomography and/or echocardiography.
RESULTS
Fifty-three studies, representing 25,258 patients undergoing transcatheter aortic valve replacement, were considered. The proportion of leaflet thrombosis was 5.2% overall, and was higher in computed tomography versus echocardiography (16.4% vs. 1.1%, respectively); reduced leaflet motion was identified in 11% of patients with four-dimensional computed tomography. Intra-annular bioprostheses were associated with a higher proportion of leaflet thrombosis, whereas chronic oral anticoagulation was protective for leaflet thrombosis in both computed tomography and echocardiographic studies (9.7% vs. 17.5%; relative risk [RR]: 0.51, 95% confidence interval [95% CI]: 0.37-0.71 and 0.9% vs. 2.7%; RR: 0.22, 95% CI: 0.06-0.79, respectively) and for reduced leaflet motion (2.5% vs. 12.4%; RR: 0.32, 95% CI: 0.13-0.76). Leaflet thrombosis was not associated with an increased risk of death, but with a higher risk of stroke in computed tomography studies (2.8% vs. 2.4%; RR: 1.63, 95% CI: 1.05-2.55), a difference more pronounced when considering reduced leaflet motion (3.5% vs. 1.7%; RR: 2.39, 95% CI: 0.63-8.34).
CONCLUSIONS
The proportion of leaflet thrombosis is highly variable according to the screening approach, the type of valve and the use of oral anticoagulation. The occurrence of cerebral events is increased when leaflet thrombosis and/or reduced leaflet motion are diagnosed, but leaflet thrombosis has no impact on survival.
Topics: Humans; Transcatheter Aortic Valve Replacement; Aortic Valve; Heart Valve Prosthesis; Thrombosis; Anticoagulants; Aortic Valve Stenosis; Treatment Outcome
PubMed: 37968182
DOI: 10.1016/j.acvd.2023.10.003 -
The Cochrane Database of Systematic... Apr 2023Aortic aneurysms occur when the aorta, the body's largest artery, grows in size, and can occur in the thoracic or abdominal aorta. The approaches to repair aortic... (Review)
Review
BACKGROUND
Aortic aneurysms occur when the aorta, the body's largest artery, grows in size, and can occur in the thoracic or abdominal aorta. The approaches to repair aortic aneurysms include directly exposing the aorta and replacing the diseased segment via open repair, or endovascular repair. Endovascular repair uses fluoroscopic-guidance to access the aorta and deliver a device to exclude the aneurysmal aortic segment without requiring a large surgical incision. Endovascular repair can be performed under a general anesthetic, during which the unconscious patient is paralyzed and reliant on an anesthetic machine to maintain the airway and provide oxygen to the lungs, or a loco-regional anesethetic, for which medications are administered to provide the person with sufficient sedation and pain control without requiring a general anesthetic. While people undergoing general anesthesia are more likely to remain still during surgery and have a well-controlled airway in the event of unanticipated complications, loco-regional anesthesia is associated with fewer postoperative complications in some studies. It remains unclear which anesthetic technique is associated with better outcomes following the endovascular repair of aortic aneurysms.
OBJECTIVES
To evaluate the benefits and harms of general anesthesia compared to loco-regional anesthesia for endovascular aortic aneurysm repair.
SEARCH METHODS
We used standard, extensive Cochrane search methods. The latest search was 11 March 2022.
SELECTION CRITERIA
We searched for all randomized controlled trials that assessed the effects of general anesthesia compared to loco-regional anesthesia for endovascular aortic aneurysm repairs.
DATA COLLECTION AND ANALYSIS
We used standard Cochrane methods. Our primary outcomes were: all-cause mortality, length of hospital stay, length of intensive care unit stay. Our secondary outcomes were: incidence of endoleaks, requirement for re-intervention, incidence of myocardial infarction, quality of life, incidence of respiratory complications, incidence of pulmonary embolism, incidence of deep vein thrombosis, and length of procedure. We planned to use GRADE methodology to assess the certainty of evidence for each outcome.
MAIN RESULTS
We found no studies, published or ongoing, that met our inclusion criteria.
AUTHORS' CONCLUSIONS
We did not identify any randomized controlled trials that compared general versus loco-regional anesthesia for endovascular aortic aneurysm repair. There is currently insufficient high-quality evidence to determine the benefits or harms of either anesthetic approach during endovascular aortic aneurysm repair. Well-designed prospective randomized trials with relevant clinical outcomes are needed to adequately address this.
Topics: Humans; Anesthesia, Conduction; Anesthesia, General; Anesthetics, General; Aortic Aneurysm, Abdominal; Endovascular Procedures; Prospective Studies; Quality of Life
PubMed: 37052421
DOI: 10.1002/14651858.CD013182.pub2 -
Journal of Clinical Medicine Mar 2023In situ laser-fenestrated thoracic aortic endovascular repair (FTEVAR) has emerged as a valuable alternative for aortic arch management. This review assessed the early... (Review)
Review
BACKGROUND
In situ laser-fenestrated thoracic aortic endovascular repair (FTEVAR) has emerged as a valuable alternative for aortic arch management. This review assessed the early and follow-up outcomes of in situ laser-FTEVAR in aortic arch pathologies.
METHODS
The PRISMA statement was followed. The English literature was searched, via Ovid, until 15 October 2022. Observational studies, published after 2000, reporting on early and follow-up outcomes for the in situ laser-FTEVAR were eligible. The Newcastle-Ottawa Scale was used to assess the risk of bias. Primary outcomes were the technical success, stroke, and mortality at 30-days, and the secondary were the mortality and reintervention during follow-up.
RESULTS
Six retrospective studies from 591 and 247 patients were included. Fifty-nine (23.9%) patients were managed for aortic arch aneurysms and 146 (59.1%) for dissections; 22.6% of them for type A. Technical success was at 98% (range 90-100%). Eight patients died (3.2%) and 11 cases presented any type of stroke (4.5%) during the 30-day follow-up. The mean follow-up was 15 months (1-40 months). Ten deaths were reported (4.2%); one was aortic-related (10%). Thirteen re-interventions (6.0%) were performed.
CONCLUSIONS
In situ laser-FTEVAR for aortic arch repair may be performed with high technical success and low 30-day and midterm follow-up mortality, stroke, and re-intervention rates when applied in well selected patients and performed by experienced teams.
PubMed: 37048580
DOI: 10.3390/jcm12072496 -
European Journal of Vascular and... Apr 2022Increased aortic stiffness (AoS) has been recognised as a risk factor in the development of cardiovascular disease. The aim of this systematic review and meta-analysis... (Meta-Analysis)
Meta-Analysis
OBJECTIVE
Increased aortic stiffness (AoS) has been recognised as a risk factor in the development of cardiovascular disease. The aim of this systematic review and meta-analysis was to assess the impact of aortic repair on AoS.
DATA SOURCES
PubMed, Scopus, and Web of Science were searched systematically for relevant studies evaluating the consequences of endovascular and open aortic repair on AoS.
REVIEW METHODS
The Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA-P) statement was followed to perform the research process. Papers containing data on AoS before and after both thoracic (TEVAR) and abdominal (EVAR) endovascular repair, as well as open surgical repair (OSR), were included for detailed evaluation. A fixed effects model was used to perform analysis. The Newcastle-Ottawa Scale was calculated for each included study.
RESULTS
The first article cluster comprised 367 papers. After removal of duplicates and the adoption of inclusion/exclusion criteria, 14 articles remained, 13 of which were selected for meta-analysis. Ten studies analysed EVAR and three analysed TEVAR. Five of the selected papers were case control studies, with OSR adopted in four of these as the EVAR comparator. Several graft types were used in the endovascular group. AoS increased after TEVAR and EVAR, in terms of pulse wave velocity (PWV), even though several spatial levels and measurement modalities were adopted. No differences were described after OSR, although no pooled data could be analysed.
CONCLUSION
EVAR and TEVAR both demonstrated a significant increase in AoS measurement (PWV). Although the heterogeneity and the low number of available studies limit the strength of the results, this review highlights the potential deleterious endograft role in the cardiovascular system although further studies are needed to achieve robust evidence. Further studies are needed to improve the mutual interaction between aorta and endograft, minimising their impact on the native aortic wall properties.
Topics: Aorta; Aortic Aneurysm, Abdominal; Blood Vessel Prosthesis Implantation; Endovascular Procedures; Humans; Pulse Wave Analysis; Risk Factors; Treatment Outcome; Vascular Stiffness
PubMed: 35283000
DOI: 10.1016/j.ejvs.2022.01.008