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Frontiers in Cardiovascular Medicine 2022Acute type A aortic dissections (ATAAD) pose a challenge to surgeons due to high mortality, and decision making regarding the appropriate procedure is controversial....
BACKGROUND
Acute type A aortic dissections (ATAAD) pose a challenge to surgeons due to high mortality, and decision making regarding the appropriate procedure is controversial. This study compared the outcomes of hemiarch and total arch replacement for ATAAD.
METHODS
The PubMed, Web of Science, Embase and Cochrane databases were searched for comparative studies on hemiarch versus total arch replacement that were published before May 1, 2022.
RESULTS
We included 23 observational studies with a total of 4,576 patients. Combined data analysis showed that early mortality (RR = 0.82; 95% CI: 0.70-0.97; = 0.02), incidence of postoperative permanent neurological dysfunction (RR = 0.72; 95%CI:0.54∼0.94; = 0.02), and incidence of renal failure and dialysis (RR = 0.82; 95%CI:0.71∼0.96; = 0.01) were all lower for hemiarch than for total arch replacement. However, hemiarch replacement had a higher rate of late mortality (RR = 1.37; 95%CI:1.10∼1.71; = 0.005). There were no statistically significant differences between the two groups in terms of re-operation for bleeding, aortic re-operation, or postoperative pneumonia.
CONCLUSION
In this study, hemiarch replacement had better early outcomes but a higher late mortality rate than total arch replacement. Decisions regarding the extent of arch repair should be made according to location and extent of ATAAD and the experience of surgeons to ensure the most favorable prognosis.
SYSTEMATIC REVIEW REGISTRATION
[INPLASY.COM], identifier [INPLASY202250088].
PubMed: 36237909
DOI: 10.3389/fcvm.2022.988619 -
Journal of Vascular Surgery May 2024Despite open surgical repair (OSR) of abdominal aortic aneurysms being considered as a durable solution, disease progression and para-anastomotic aneurysms may require... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
Despite open surgical repair (OSR) of abdominal aortic aneurysms being considered as a durable solution, disease progression and para-anastomotic aneurysms may require further repair, and fenestrated and branched endovascular aneurysm repair (F/BEVAR) may be applied to address these pathologies. The aim of this systematic review was to assess technical success, mortality, and morbidity (acute kidney injury, spinal cord ischemia) at 30 days, and mortality and reintervention rates during the available follow-up, in patients managed with F/BEVAR after previous OSR.
METHODS
The PRISMA statement was followed, and the study was pre-registered to the PROSPERO (CRD42022363214). The English literature was searched, via Ovid, using MEDLINE, EMBASE, and CENTRAL databases, through November 30, 2022. Observational studies and case series with ≥5 patients (2000-2022), reporting on F/BEVAR outcomes after OSR, were considered eligible. The Newcastle-Ottawa Scale and GRADE were used to assess the risk of bias and quality of evidence. The primary outcome was technical success, mortality, and morbidity at 30 days. Data on the outcomes of interest were synthesized using proportional meta-analysis.
RESULTS
The initial search yielded 1694 articles. Eight retrospective studies (476 patients) were considered eligible. In 78.3% of cases, disease progression set the indication for reintervention. Technical success was estimated at 96% (95% confidence interval [CI], 89%-98%; I = 0%; 95% prediction interval [PI], 79%-99%). Thirty-day mortality was 2% (95% CI, 1%-9%; I = 0%; 95% PI, 0%-28%). The estimated spinal cord ischemia and acute kidney injury rates were 3% (95% CI, 1%-9%; I = 0%; 95% PI, 0%-30%) and 6% (95% CI, 2%-15%; I = 0%; 95% PI, 1%-40%), respectively. During follow-up, overall mortality was 5% (95% CI, 2%-12%; I = 34%; 95% PI, 0%-45%) and aorta-related mortality was 1% (95% CI, 0%-2%; I = 0%; 95% PI, 0%-3%). The rate of reinterventions was 16% (95% CI, 9%-26%; I = 22%; 95% PI, 3%-50%).
CONCLUSIONS
According to the available literature, F/BEVAR after OSR may be performed with high technical success and low mortality and morbidity during the perioperative period. Follow-up aortic-related mortality was 1%, whereas the reintervention rates were within the standard range following F/BEVAR.
Topics: Humans; Aortic Aneurysm, Abdominal; Retrospective Studies; Blood Vessel Prosthesis Implantation; Risk Factors; Treatment Outcome; Endovascular Procedures; Aortic Aneurysm; Acute Kidney Injury; Disease Progression; Spinal Cord Ischemia; Aortic Aneurysm, Thoracic
PubMed: 37757916
DOI: 10.1016/j.jvs.2023.09.026 -
Diagnostics (Basel, Switzerland) Nov 2022This work aims to review recent literature on penetrating aortic ulcers (PAUs) and intramural hematomas (IMHs), in order to identify clinical and imaging factors... (Review)
Review
BACKGROUND
This work aims to review recent literature on penetrating aortic ulcers (PAUs) and intramural hematomas (IMHs), in order to identify clinical and imaging factors connected to aortic-related adverse events (AAE).
METHODS
We performed a systematic review according to the Preferred Reporting Items for Systematic review and Metanalyses (PRISMA) guidelines. An electronic search was conducted on Medline and Embase databases. We included articles reporting on PAUs and/or IMHs localized in the descending thoracic and/or abdominal aorta and analyzing clinical and/or radiological markers of AAE.
RESULTS
Of 964 records identified through database searching, 17 were incorporated in the present review, including 193 and 1298 patients with type B PAUs and IMHs, respectively. The 30-days aortic-related mortality (ARM) was 4.3% and 3.9% for PAUs and IMHs. A total of 21% of patients with IMHs underwent intervention during the follow-up period, and 32% experienced an AAE. PAU markers of AAE were minimum depth (ranging from 9.5 to 15 mm) and diameter (≥12.5 mm). Maximum aortic diameter (MAD) cut-off values ranging from 38 to 44.75 mm were related to AAE for IMHs, together with ulcer-like projection (ULP) of the aortic wall.
CONCLUSIONS
Despite data heterogeneity in the literature, this PAU- and IMH-focused review has highlighted the imaging and clinical markers of disease progression, thus identifying patients that could benefit from an early intervention in order to reduce the AAE rate.
PubMed: 36359569
DOI: 10.3390/diagnostics12112727 -
Journal of Cardiac Surgery Jun 2021The frozen elephant trunk (FET) procedure became a popular entity for utilization in aortic arch aneurysm disease. However, its proper mortality and morbidities as well... (Meta-Analysis)
Meta-Analysis
BACKGROUND AND AIM OF THE STUDY
The frozen elephant trunk (FET) procedure became a popular entity for utilization in aortic arch aneurysm disease. However, its proper mortality and morbidities as well as the predictors of outcomes are poorly identified. This systematic review and meta-analysis explore FET outcomes and its predictors with a focus on zone aortic proximalization.
METHODS
We searched PubMed/MEDLINE, EMBASE, and Scopus databases from their beginning to June 2020 to find studies reporting the outcomes of the FET procedure for the total arch replacement (TAR).
RESULTS
A total of 64 studies including 7967 patients were evaluated. The pooled estimates of cerebrovascular accidents, paraplegia, renal failure, and in-hospital mortality were 7.104 (95% confidence interval [CI], 5.691-8.661; I = 78.53%), 3.465 (95% CI, 2.852-4.136; I = 15.96), 14.969 (95% CI, 11.361-18.977; I = 91.26%), and 8.933 (95% CI, 7.128-10.919; I = 78.51%), respectively. Stratification by the geographical locations and by the aortic pathologies led to lower heterogeneity, but not for renal failure. The distal anastomosis in Zone 2 was associated with a lower rate of renal failure compared with Zone 3 (odds ratio, 0.54; 95% CI, 0.36-0.81; p = .003; I = 0%).
CONCLUSIONS
The FET procedure for TAR can be performed with acceptable mortality and morbidities among patients with complex aortic pathologies. Moreover, the distal anastomosis in Zone 2 was associated with lower renal failure compared to Zone 3.
Topics: Aortic Dissection; Aorta, Thoracic; Aortic Aneurysm; Aortic Aneurysm, Thoracic; Blood Vessel Prosthesis Implantation; Humans; Retrospective Studies
PubMed: 33665866
DOI: 10.1111/jocs.15452 -
Journal of Vascular Surgery Apr 2020The purpose of the study was to provide a systematic review of the literature reporting the contemporary early outcomes after endovascular and open repair of... (Meta-Analysis)
Meta-Analysis
OBJECTIVE
The purpose of the study was to provide a systematic review of the literature reporting the contemporary early outcomes after endovascular and open repair of thoracoabdominal aortic aneurysms (TAAAs).
METHODS
MEDLINE and Embase were searched for studies from January 2006 to March 2018 that reported either endovascular (using branched or fenestrated endografts) or open repair of TAAA in at least 10 patients. Outcomes of interest included perioperative mortality, spinal cord injury (SCI), renal failure requiring dialysis, and stroke. Pooled proportions were determined using a random-effects model.
RESULTS
The analysis included 71 studies, of which 24 and 47 reported outcomes after endovascular and open TAAA repair, respectively. Endovascular cohort patients were older and had higher rates of coronary artery disease, chronic obstructive pulmonary disease, and diabetes. Endovascular repair was associated with higher rates of SCI (13.5%; 95% confidence interval [CI], 10.5%-16.7%) compared with open repair (7.4%; 95% CI, 6.2%-8.7%; P < .01) but similar rates of permanent paralysis (5.2% [95% CI, 3.8%-6.7%] vs 4.4% [95% CI, 3.3%-5.6%]; P = .39), lower rates of postoperative dialysis (6.4% [95% CI, 3.2%-9.5%] vs 12.0% [95% CI, 8.2%-16.3%]; P = .03) but similar rates of being discharged on permanent dialysis (3.7% [95% CI, 2.0%-5.9%] vs 3.8% [95% CI, 2.9%-5.3%]; P = .93), a trend to lower stroke (2.7% [95% CI, 1.9%-3.6%] vs 3.9% [95% CI, 3.0%-4.9%]; P = .06), and similar perioperative mortality (7.4% [95% CI, 5.9%-9.1%] vs 8.9% [95% CI, 7.2%-10.9%]; P = .21).
CONCLUSIONS
This systematic review summarizes the contemporary literature results of endovascular and open TAAA repair. Endovascular repair studies included patients with more comorbidities and were associated with higher rates of SCI but similar rates of permanent paraplegia, whereas open repair studies had higher rates of postoperative dialysis but similar rates of being discharged on permanent dialysis. Perioperative mortality rates were similar. Universally adopted reporting standards for patient characteristics, outcomes, and the conduct of contemporary comparative studies will allow better assessment and comparisons of the risks associated with the two surgical treatment options for TAAA.
Topics: Aortic Aneurysm, Thoracic; Blood Vessel Prosthesis; Endovascular Procedures; Humans; Vascular Grafting
PubMed: 31690525
DOI: 10.1016/j.jvs.2019.06.216 -
Journal of Cardiac Surgery Jan 2021To compare clinical outcomes of reimplantation versus remodeling in patients undergoing valve-sparing aortic root replacement (VSRR) surgery. (Meta-Analysis)
Meta-Analysis
OBJECTIVE
To compare clinical outcomes of reimplantation versus remodeling in patients undergoing valve-sparing aortic root replacement (VSRR) surgery.
METHOD
Electronic database search at PubMed, Scopus, Embase, Ovid, and Google scholar was performed from inception to January 2020. Primary outcomes were aortic valve (AV) reintervention and postoperative grade of aortic insufficiency (AI) while secondary outcomes were 30-day mortality, reoperation for bleeding, and operative times.
RESULTS
A total of 21 articles met the inclusion criteria. A total of 1283 patients had reimplantation while 1150 had remodeling. No difference in preoperative demographics was noted except reimplantation patients were younger (48 ± 16 vs. 56 ± 15 years; p < .00001). The cardiopulmonary bypass and aortic cross-clamp times were shorter in the remodeling cohort (168 ± 38 vs. 150 ± 37 min; p = .0001 and 133 ± 31 vs. 112 ± 30 min; p = .0002, respectively). No difference in concomitant total arch surgery (14% in reimplantation vs. 15% in remodeling; p = .53). Postoperatively, there were similar stroke rates (3% in both cohorts; p = .54), rates of reoperation for bleeding (9% in reimplantation vs. 12% in remodeling; p = .88), and 30-day mortality (3% in reimplantation vs. 4% in remodeling; p = .96). No difference in early AV reintervention (1% in reimplantation vs. 2% in remodeling; p = .07), and late AV reintervention (4% in reimplantation vs. 7% in remodeling; p = .07). The AI of +2 grade was significantly lower in the reimplantation cohort (5% vs. 8%; p = .01).
CONCLUSION
Our study shows comparable clinical outcomes between both techniques. The practice of each technique is largely center and surgeon dependent. Larger sample size cohorts with minimal confounding factors are required to confirm the above findings.
Topics: Aorta; Aortic Valve; Aortic Valve Insufficiency; Heart Valve Prosthesis Implantation; Humans; Reoperation; Replantation; Retrospective Studies; Treatment Outcome
PubMed: 33085112
DOI: 10.1111/jocs.15132 -
Expert Review of Cardiovascular Therapy Feb 2023Women with Turner syndrome (TS) have an increased risk of aortic disease, reducing life-expectancy. This study aimed to systematically review the prevalence of thoracic... (Meta-Analysis)
Meta-Analysis
OBJECTIVES
Women with Turner syndrome (TS) have an increased risk of aortic disease, reducing life-expectancy. This study aimed to systematically review the prevalence of thoracic aortic dilatation, aortic dimensions and growth, and the incidence of aortic dissection.
METHODS
A systematic literature search was conducted up to July 2022. Observational studies with an adult TS population were included, and studies including children aged <15 years old or specific TS populations were excluded.
RESULTS
In total 21 studies were included. The pooled prevalence of ascending aortic dilatation was 23% (95% CI 19-26) at a mean pooled age of 29 years (95% CI 26-32), while the incidence of aortic dissection was 164 per 100.000 patient-years (95% CI 95-284). Three reporting studies showed aortic growth over time to be limited. Risk factors for aortic dilation or dissection were older age, bicuspid aortic valve, aortic coarctation, and hypertension.
CONCLUSION
In adult TS women, ascending aortic dilatation is common and the hazard of aortic dissection increased compared to the general population, whereas aortic growth is limited. Conventional risk markers do not explain all aortic dissection cases; therefore, new imaging parameters and blood biomarkers are needed to improve prediction, allowing for patient-tailored follow-up and surgical decision-making.
Topics: Adult; Child; Humans; Female; Adolescent; Turner Syndrome; Prevalence; Dilatation; Aortic Diseases; Aortic Dissection; Aortic Valve
PubMed: 36688313
DOI: 10.1080/14779072.2023.2172403 -
Annals of Vascular Surgery Oct 2022Thoracic Endovascular Aortic Repair has been widely performed to treat various thoracic aortic pathologies. However, stent-graft placement in the thoracic aorta may... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Thoracic Endovascular Aortic Repair has been widely performed to treat various thoracic aortic pathologies. However, stent-graft placement in the thoracic aorta may result in left subclavian artery coverage, potentially leading to ischemic complications. The role of the left subclavian artery revascularization procedure to prevent ischemic complications remains controversial. Therefore, we conducted a systematic review and meta-analysis to identify ischemic outcomes in patients who underwent thoracic Endovascular Aortic Repair with or without left subclavian artery revascularization.
METHODS
A systematic search through electronic databases, including PubMed, Ovid Medline, and Cochrane, was conducted to identify relevant studies. The outcome parameters were left arm ischemia, stroke, and spinal cord ischemia. Risk ratio (RR) and Confidence Interval (CI) of 95% were measured and reported.
RESULTS
A total of 11,386 patients were identified from 22 studies. Patients who underwent left subclavian artery revascularization had lower risk of left arm ischemia (RR 0.25, 95% CI 0.09-0.68; P = 0.0006; I = 71%), lower risk of stroke (RR 0.52, 95% CI 0.30-0.88; P = 0.02; I = 70%), and lower risk of spinal cord ischemia (odds ratio OR 0.72, 95% CI 0.55-0.95; P = 0.02; I = 0%) between the 2 groups.
CONCLUSIONS
Revascularization procedure in patients with left subclavian artery coverage during thoracic Endovascular Aortic Repair is associated with a lower risk of left arm ischemia, stroke, and spinal cord ischemia. Left subclavian artery revascularization should be performed in anatomically high-risk patients. High-quality studies are needed to validate the outcomes.
Topics: Humans; Subclavian Artery; Aorta, Thoracic; Blood Vessel Prosthesis Implantation; Aortic Diseases; Treatment Outcome; Spinal Cord Ischemia; Endovascular Procedures; Ischemia; Stroke; Aortic Aneurysm, Thoracic; Risk Factors; Retrospective Studies
PubMed: 35577271
DOI: 10.1016/j.avsg.2022.04.037 -
The Cochrane Database of Systematic... Dec 2021Type B aortic dissection can lead to serious and life-threatening complications such as aortic rupture, stroke, renal failure, and paraplegia, all of which require... (Review)
Review
BACKGROUND
Type B aortic dissection can lead to serious and life-threatening complications such as aortic rupture, stroke, renal failure, and paraplegia, all of which require intervention. Traditionally, these complications have been treated with open surgery. Recently however, endovascular repair has been proposed as an alternative.
OBJECTIVES
To assess the effectiveness and safety of thoracic aortic endovascular repair versus open surgical repair for treatment of complicated chronic Type B aortic dissection (CBAD).
SEARCH METHODS
The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, and AMED databases, as well as the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers, to 2 August 2021. We searched references of relevant articles retrieved through the electronic search for additional citations.
SELECTION CRITERIA
We considered all randomised controlled trials (RCTs) and controlled clinical trials (CCTs) assessing the effects of thoracic aortic endovascular repair (TEVAR) versus open surgical repair (OSR) for treatment of complicated chronic Type B aortic dissection (CBAD). Outcomes of interest were mortality (all-cause, dissection-related), neurological sequelae (stroke, spinal cord ischaemia/paresis-paralysis, vertebral insufficiency), morphological outcomes (false lumen thrombosis, progression of dissection, aortic diameters), acute renal failure, ischaemic symptoms (visceral ischaemia, limb ischaemia), re-intervention, and health-related quality of life.
DATA COLLECTION AND ANALYSIS
Two review authors independently screened all titles and abstracts identified by the searches to identify those that met the inclusion criteria. From title and abstract screening, we did not identify any trials (RCTs or CCTs) that required full-text assessment. We planned to undertake data collection and analysis in accordance with recommendations described in the Cochrane Handbook for Systematic Reviews of Interventions. We planned to assess the certainty of evidence using GRADE.
MAIN RESULTS
We did not identify any trials (RCTs or CCTs) that met the inclusion criteria for this review.
AUTHORS' CONCLUSIONS
Due to lack of RCTs or CCTs investigating the effectiveness and safety of TEVAR compared to OSR for patients with complicated CBAD, we are unable to provide any evidence to inform decision-making on the optimal intervention for these patients. High-quality RCTs or CCTs addressing this objective are necessary. However, conducting such studies will be challenging for this life-threatening disease.
Topics: Aortic Dissection; Aorta, Thoracic; Humans; Ischemia
PubMed: 34905228
DOI: 10.1002/14651858.CD012992.pub2 -
Frontiers in Cardiovascular Medicine 2022Current management of isolated CoA, localized narrowing of the aortic arch in the absence of other congenital heart disease, is a success story with improved prenatal...
Current management of isolated CoA, localized narrowing of the aortic arch in the absence of other congenital heart disease, is a success story with improved prenatal diagnosis, high survival and improved understanding of long-term complication. Isolated CoA has heterogenous presentations, complex etiologic mechanisms, and progressive pathophysiologic changes that influence outcome. End-to-end or extended end-to-end anastomosis are the favored surgical approaches for isolated CoA in infants and transcatheter intervention is favored for children and adults. Primary stent placement is the procedure of choice in larger children and adults. Most adults with treated isolated CoA thrive, have normal daily activities, and undergo successful childbirth. Fetal echocardiography is the cornerstone of prenatal counseling and genetic testing is recommended. Advanced 3D imaging identifies aortic complications and myocardial dysfunction and guides individualized therapies including re-intervention. Adult CHD program enrollment is recommended. Longer follow-up data are needed to determine the frequency and severity of aneurysm formation, myocardial dysfunction, and whether childhood lifestyle modifications reduce late-onset complications.
PubMed: 35694677
DOI: 10.3389/fcvm.2022.817866