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Journal of Endovascular Therapy : An... Oct 2022Ascending aorta and aortic arch diseases have an increasing interest among cardiovascular specialists regarding diagnosis and management. Innovations in endovascular... (Review)
Review
BACKGROUND
Ascending aorta and aortic arch diseases have an increasing interest among cardiovascular specialists regarding diagnosis and management. Innovations in endovascular surgery and evolution of open surgery have extended the indications for treatment in patients previously considered unfit for surgery. The aim of this systematic review of the literature was to present and analyze current cardiovascular guidelines for overlap and differences in their recommendations regarding ascending aorta and aortic arch diseases and the assessment of evidence.
METHODS
The English medical literature was searched using the MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials databases from January 2009 to December 2020. Recommendations on selected topics were analyzed, including issues from definitions and diagnosis (imaging and biomarkers) and indications for treatment to management, including surgical techniques, of the most important ascending aorta and aortic arch diseases.
RESULTS
The initial search identified 2414 articles. After exclusion of duplicate or inappropriate articles, the final analysis included 5 articles from multidisciplinary, cardiovascular societies published between 2010 and 2019. The definition of non-A-non-B aortic dissection is lacking from most of the guidelines. There is a disagreement regarding the class of recommendation and level of evidence for the diameter of ascending aorta as an indication. The indication for treatment of aortic disease may be individualized in specific cases while the growth rate may also affect the decision making. The role of endovascular techniques has not been established in current guidelines except by 1 society. Supportive evidence level in the management of aortic arch diseases remains limited.
CONCLUSION
In current recommendations of cardiovascular societies, the ascending aorta and aortic arch remain a domain of open surgery despite the introduction of endovascular techniques. Recommendations of the included societies are mostly based on expert opinion, and the role of endovascular techniques has been highlighted only from 1 society. The chronological heterogeneity apparent among guidelines and the inconsistency in evidence level should be also acknowledged. More data are needed to develop more solid recommendations for the ascending aorta and aortic arch diseases.
Topics: Aorta; Aorta, Thoracic; Aortic Aneurysm, Thoracic; Aortic Diseases; Blood Vessel Prosthesis Implantation; Endovascular Procedures; Humans; Treatment Outcome
PubMed: 34873944
DOI: 10.1177/15266028211061271 -
Seminars in Thoracic and Cardiovascular... 2021Aortic arch pathologies have been a surgical challenge, involving cerebral, visceral and myocardial protection. Innovative techniques including total arch replacement...
Aortic arch pathologies have been a surgical challenge, involving cerebral, visceral and myocardial protection. Innovative techniques including total arch replacement and frozen elephant trunk had evolved over last decades with promising mid-term outcomes. We evaluate our mid-term outcomes on total arch replacement with frozen elephant trunk and the role of timely second staged interventions. Between August 2014 and April 2020, 41 patients with aortic arch pathologies underwent total arch replacement with frozen elephant trunk with Thoraflex-Hybrid-Plexus device (Vascutek, Inchinnan, Scotland). Patients' perioperative, clinical and radiological outcomes were reviewed. Post discharge survival (n = 37) at 3 year was 100%. Overall survival of 85.3% over a median follow up of 3.3 years, inpatient mortality of 9.8%. Distribution of aortic pathologies with acute type A dissection or intramural hematoma (n = 15, 36.6%), thoracic aortic aneurysm, including arch and descending aortic aneurysm (n = 9, 22%) and chronic aortic dissection including chronic type A and type B dissections (n = 13, 31.7%). Mean operative, circulatory arrest, and antegrade cerebral perfusion time were 417 ± 121 minutes, 89 ± 28 minutes, and 154 ± 43 minutes, respectively. Second stage procedures were performed in 32% and distal stent graft induced new entry was observed in 19% of patients. We reported an Asian series of Thoraflex with outstanding midterm clinical outcomes, given descending aortic pathologies were tackled with a timely second stage interventions. The observation of aortic remodeling and distal stent graft induced new entry requires further investigations.
Topics: Aftercare; Aorta, Thoracic; Aortic Aneurysm, Thoracic; Blood Vessel Prosthesis; Blood Vessel Prosthesis Implantation; Humans; Patient Discharge; Retrospective Studies; Stents; Treatment Outcome
PubMed: 33181309
DOI: 10.1053/j.semtcvs.2020.11.016 -
European Journal of Cardio-thoracic... Jun 2021
Topics: Aorta, Thoracic; Aortic Aneurysm, Thoracic; Blood Vessel Prosthesis Implantation; Goals; Humans
PubMed: 33582754
DOI: 10.1093/ejcts/ezab075 -
Seminars in Vascular Surgery Jun 2023Thoracic aortic emergencies involving the aortic arch are potentially fatal conditions that require the entire surgical repertoire of conventional surgery, such as... (Review)
Review
Thoracic aortic emergencies involving the aortic arch are potentially fatal conditions that require the entire surgical repertoire of conventional surgery, such as complete aortic arch replacement using the frozen-elephant-trunk technique, through hybrid procedures, to full surgical endovascular options with conventional or delivered/fenestrated stent-grafts. An interdisciplinary aortic team should choose the optimal treatment of the pathologies of the aortic arch, considering the morphology of the entire aorta, from the root to beyond the bifurcation, as well as the clinical comorbidities. The treatment goal is a complication-free postoperative result and lasting freedom from aortic reinterventions. Irrespective of the selected therapy method, patients should then be connected to a specialized aortic outpatient clinic. The aim of this review was to provide an overview of pathophysiology and current treatment options in emergencies of the thoracic aorta, also involving the aortic arch. We wanted to summarize the preoperative considerations, intraoperative settings, and strategies, as well the postoperative follow-up.
Topics: Humans; Aorta, Thoracic; Blood Vessel Prosthesis; Emergencies; Blood Vessel Prosthesis Implantation; Aorta; Aortic Aneurysm, Thoracic; Treatment Outcome; Retrospective Studies; Stents
PubMed: 37330229
DOI: 10.1053/j.semvascsurg.2023.04.016 -
The Journal of Thoracic and... Dec 2022
Topics: Humans; Blood Vessel Prosthesis Implantation; Aorta, Thoracic; Aortic Aneurysm, Thoracic; Aortic Dissection; Blood Vessel Prosthesis; Treatment Outcome; Stents
PubMed: 34023158
DOI: 10.1016/j.jtcvs.2021.04.028 -
Asian Cardiovascular & Thoracic Annals Jul 2022Open total arch replacement is one of the most challenging procedures in cardiothoracic surgery and is the gold standard treatment for aortic arch pathology. Total arch...
BACKGROUND
Open total arch replacement is one of the most challenging procedures in cardiothoracic surgery and is the gold standard treatment for aortic arch pathology. Total arch replacement is associated with high rates of mortality and neurological morbidity. Using 14 years of data, we studied postoperative, in-hospital mortality, major complications, and examined associated risk factors.
MATERIALS AND METHOD
Medical records of patients who underwent open, total arch replacement surgery at Siriraj Hospital from 2006 to December 2019 were reviewed. Demographic data, clinical factors, preoperative status, intraoperative data, and postoperative data were analyzed.
RESULT
A total of 330 patients were included and 36 (10.9%) died in the hospital. More than one concomitant operation (odds ratio (OR) 5.16, < 0.001) and emergency operation (OR 3.45, = 0.003) were risk factors for in-hospital mortality. Major postoperative morbidity occurred in 124 (37.7%) patients (124 of 329). Emergency operation (OR 2.88, <0.001), preoperative creatinine clearance < 60 ml/ min/ 1.73 m (OR 2.04, = 0.004), and aortic cross-clamp time > 180 min (OR 1.75, = 0.022) were risk factors for major postsurgical complications.
CONCLUSION
In-hospital mortality after total arch replacement was 10.9% compared to international reports. Emergency operation was a major risk factor for both mortality and major complications. More than one concomitant operation, especially coronary artery bypass graft, more than doubled the risk of major complications.
Topics: Aorta, Thoracic; Aortic Aneurysm, Thoracic; Blood Vessel Prosthesis Implantation; Coronary Artery Bypass; Hospital Mortality; Humans; Postoperative Complications; Retrospective Studies; Treatment Outcome
PubMed: 35068185
DOI: 10.1177/02184923211072488 -
The Journal of Cardiovascular Surgery Jun 2022
Topics: Aortic Dissection; Aorta, Thoracic; Aortic Aneurysm, Thoracic; Humans; Treatment Outcome
PubMed: 35343662
DOI: 10.23736/S0021-9509.22.12332-3 -
QJM : Monthly Journal of the... May 2023
Topics: Humans; Aorta, Thoracic; Aortic Coarctation
PubMed: 36562573
DOI: 10.1093/qjmed/hcac281 -
The Annals of Thoracic Surgery Jun 2022Reconstruction of a right aortic arch is rarely required in the newborn period and has rarely been reported.
BACKGROUND
Reconstruction of a right aortic arch is rarely required in the newborn period and has rarely been reported.
METHODS
All patients who underwent a right aortic arch repair in the neonatal period from a single institution were retrospectively reviewed. The primary outcome measures included survival, complications, and reintervention.
RESULTS
Between 1984 and 2020, 15 patients were identified. Nine patients (60%) presented with an interrupted aortic arch, 5 with a hypoplastic arch (33%), and 1 with anomalous origin of the brachiocephalic vessels (7%). All patients had associated complex congenital heart disease. Median age at surgery was 6 days (range, 2-29 days); median weight was 3.11 kg (range, 2.5-4.18 kg). Genetic syndromes were prevalent and 77% of interrupted aortic arch patients had DiGeorge syndrome. Surgical techniques included end-to-side (27%), end-to-end (27%), or side-to-side anastomosis (13%) and placement of an interposition graft (7%); 65% required patch augmentation. Median intensive care unit and total hospital length of stay were 20 days (range, 7-92 days) and 28 days (range, 10-240 days), respectively. At a median follow-up of 3.97 years (range, 0.19-36 years), 13 of 15 patients were alive (87%). We found vocal cord paralysis in 27%, hemidiaphragm paralysis in 13%, and considerable airway compression in 27%. Overall, 27% patients required reintervention on the aortic arch: 2 surgical and 2 percutaneous balloon dilation.
CONCLUSIONS
Right aortic arch reconstruction in the newborn period is rare and associated with complex lesions with an acceptable reintervention rate.
Topics: Aorta, Thoracic; Aortic Arch Syndromes; Aortic Coarctation; Humans; Infant; Infant, Newborn; Retrospective Studies; Treatment Outcome
PubMed: 33864758
DOI: 10.1016/j.athoracsur.2021.04.005 -
Annals of Vascular Surgery Aug 2023The gold standard for aneurysmal repair of the ascending aorta and the aortic arch has been open surgery with an established track record of good results in suitable... (Review)
Review
The gold standard for aneurysmal repair of the ascending aorta and the aortic arch has been open surgery with an established track record of good results in suitable patients. In recent years, with innovations in the endovascular field alternative endovascular solutions for pathologies of the aortic arch and ascending aorta became available. At first reserved only for highly selected patients unfit for open surgery, endovascular aortic arch repair is now being offered to patients with suitable anatomy in high-volume referral centers after discussion in an interdisciplinary team. The present scoping review aims at providing an overview on indications, available devices, technical aspects, and feasibility studies of endovascular arch repair both in elective and emergent situations, including also experiences and considerations from our center.
Topics: Humans; Aorta, Thoracic; Aortic Aneurysm, Thoracic; Blood Vessel Prosthesis Implantation; Endovascular Procedures; Treatment Outcome; Stents; Blood Vessel Prosthesis
PubMed: 37328096
DOI: 10.1016/j.avsg.2023.06.004