-
Seminars in Vascular Surgery Jun 2023The most important descending thoracic aortic (DTA) pathologies are aneurysms, dissections, and traumatic injuries. In acute settings, these conditions can constitute a... (Review)
Review
The most important descending thoracic aortic (DTA) pathologies are aneurysms, dissections, and traumatic injuries. In acute settings, these conditions can constitute a significant risk of bleeding or ischemia of vital organs, resulting in a fatal outcome. Morbidity and mortality associated with aortic pathologies remain significant, despite improvements in medical therapy and endovascular techniques. In this narrative review, we present an overview of the transitions in the management of these pathologies and discuss current challenges and future perspectives. Diagnostic challenges include differentiating between thoracic aortic pathologies and cardiac diseases. Efforts have been made to identify a blood test that can rapidly differentiate these pathologies. Computed tomography is the cornerstone of diagnosing thoracic aortic emergencies. Our understanding of DTA pathologies has improved substantially due to the significant advancement in imaging modalities in the last 2 decades. On the basis of this understanding, the treatment of these pathologies has been revolutionized. Unfortunately, robust evidence from prospective and randomized studies is still lacking for the management of most DTA diseases. Medical management plays a crucial role in achieving early stability during these life-threatening emergencies. This includes intensive care monitoring, heart rate and blood pressure control, and considering permissive hypotension for patients presenting with ruptured aneurysms. Over the years, surgical management of DTA pathologies changed from open repair to endovascular repair with dedicated stent-grafts. Techniques in both spectrums have improved substantially.
Topics: Humans; Blood Vessel Prosthesis; Aortic Aneurysm, Thoracic; Blood Vessel Prosthesis Implantation; Stents; Emergencies; Prospective Studies; Endovascular Procedures; Treatment Outcome; Aorta, Thoracic
PubMed: 37330228
DOI: 10.1053/j.semvascsurg.2023.04.009 -
Heart, Lung & Circulation Sep 2020Circulatory arrest has been identified as an independent risk factor related to postoperative mortality in patients with Stanford type A aortic dissection. This study...
BACKGROUND
Circulatory arrest has been identified as an independent risk factor related to postoperative mortality in patients with Stanford type A aortic dissection. This study described a modified technique for distal aortic arch occlusion that markedly shortened the circulatory arrest time. The early results are encouraging.
METHODS
From May 2016 to September 2018, 51 patients with Stanford type A aortic dissection underwent the modified procedure for aortic arch replacement. All operations were performed via transitory circulatory arrest by clamping the distal aorta between the left common carotid artery and the left subclavian artery. The in-hospital and follow-up data of the treated patients were investigated.
RESULTS
Successful repair of the involved vasculature was achieved in all patients. One (1) patient died due to postoperative aspiration and infection, and three patients required continuous renal replacement therapy due to poor preoperative renal function. The remaining patients were successfully discharged. The median average circulatory arrest time was 5.0 (3.0-6.0) minutes. No cases of tracheotomy, delayed closure, secondary thoracotomy, or other complications occurred. During the follow-up period of 2.4-18.6 months, the implanted grafts and stented elephant trunks were all fully open and not kinked.
CONCLUSIONS
A modified distal aortic arch occlusion can considerably shorten the duration of circulatory arrest. Current experience suggests that this approach can serve as a feasible alternative for patients during aortic arch replacement because of its simplicity and satisfactory clinical effects.
Topics: Aged; Aortic Dissection; Aorta, Thoracic; Aortic Aneurysm, Thoracic; Computed Tomography Angiography; Female; Follow-Up Studies; Humans; Male; Middle Aged; Retrospective Studies; Vascular Surgical Procedures
PubMed: 32430219
DOI: 10.1016/j.hlc.2020.03.016 -
Surgical and Radiologic Anatomy : SRA May 2022To estimate the prevalence of the left-sided aortic arch (LSAA) variants, and the effect of possible moderators on variants' detection. (Meta-Analysis)
Meta-Analysis Review
PURPOSE
To estimate the prevalence of the left-sided aortic arch (LSAA) variants, and the effect of possible moderators on variants' detection.
METHODS
A systematic online literature search was conducted. The pooled prevalence with 95% confidence intervals was estimated for the typical and atypical branching patterns to compare the overall proportions of different variants. Meta-regression analyses were performed to investigate the effect of the subjects' gender and geographical region, and the multidetector computed tomography (MDCT) scanner's technology on the estimated prevalence.
RESULTS
In total, 18,075 cases from 23 imaging studies were included and 33 different LSAA variants were detected. The estimated heterogeneity was statistically significant. Based on the estimated prevalence, approximately 77% of the population is expected to have the typical branching anatomy with sequence brachiocephalic trunk-left common carotid artery-left subclavian artery, and 23% variant branching patterns. Approximately 71%, 23%, 2%, and 0.1% of the atypical populations are expected to have two, four, three, and five emerging branches, respectively. The meta-regression analyses showed that the number of detector rows of the MDCT scanner, and the subjects' geographical region are statistically significant moderators of the estimated prevalence.
CONCLUSION
The current findings indicate that the prevalence of the LSAA variant branching anatomy is significantly affected by the subjects' geographical region and the MDCT scanner's technological improvement, with the advanced scanners to facilitate the detection of the aortic arch variants. However, due to the heterogeneity among studies, further research is required.
Topics: Aorta, Thoracic; Brachiocephalic Trunk; Carotid Artery, Common; Humans; Prevalence; Subclavian Artery
PubMed: 35486163
DOI: 10.1007/s00276-022-02945-4 -
Journal of Cardiothoracic and Vascular... Apr 2021Despite advances in cardiac surgery and anesthesia, the rates of brain injury remain high in aortic arch surgery requiring circulatory arrest. The mechanisms of brain... (Review)
Review
Despite advances in cardiac surgery and anesthesia, the rates of brain injury remain high in aortic arch surgery requiring circulatory arrest. The mechanisms of brain injury, including permanent and temporary neurologic dysfunction, are multifactorial, but intraoperative brain ischemia is likely a major contributor. Maintaining optimal cerebral perfusion during cardiopulmonary bypass and circulatory arrest is the key component of intraoperative management for aortic arch surgery. Various brain monitoring modalities provide different information to improve cerebral protection. Electroencephalography gives crucial data to ensure minimal cerebral metabolism during deep hypothermic circulatory arrest, transcranial Doppler directly measures cerebral arterial blood flow, and near-infrared spectroscopy monitors regional cerebral oxygen saturation. Various brain protection techniques, including hypothermia, cerebral perfusion, pharmacologic protection, and blood gas management, have been used during interruption of systemic circulation, but the optimal strategy remains elusive. Although deep hypothermic circulatory arrest and retrograde cerebral perfusion have their merits, there have been increasing reports about the use of antegrade cerebral perfusion, obviating the need for deep hypothermia. With controversy and variability of surgical practices, moderate hypothermia, when combined with unilateral antegrade cerebral perfusion, is considered safe for brain protection in aortic arch surgery performed with circulatory arrest. The neurologic outcomes of brain protection in aortic arch surgery largely depend on the following three major components: cerebral temperature, circulatory arrest time, and cerebral perfusion during circulatory arrest. The optimal brain protection strategy should be individualized based on comprehensive monitoring and stems from well-executed techniques that balance the major components contributing to brain injury.
Topics: Aorta, Thoracic; Brain; Cerebrovascular Circulation; Circulatory Arrest, Deep Hypothermia Induced; Humans; Hypothermia, Induced; Perfusion; Treatment Outcome
PubMed: 33309497
DOI: 10.1053/j.jvca.2020.11.035 -
Journal of Cardiac Surgery Nov 2022We reviewed our center's experience with neonatal and infant hypoplastic aortic arch, unassociated with intracardiac malformations, and investigated changes in prenatal... (Review)
Review
OBJECTIVE
We reviewed our center's experience with neonatal and infant hypoplastic aortic arch, unassociated with intracardiac malformations, and investigated changes in prenatal detection rates over time for those requiring therapeutic procedures.
METHODS
We identified all prenatal diagnoses of hypoplastic aortic arch with situs solitus, unassociated with intracardiac malformations, made in Nevada between May 2017 and April 2022. In addition, we identified all those 0-180 days old, with prenatal care, that underwent a surgical or interventional cardiac catheterization aortic arch procedure, whether prenatally or postnatally diagnosed. We excluded those with ventricular septal defects, functionally univentricular hearts, interrupted aortic arches, or any associated malformation requiring an additional surgical or interventional procedure ≤6 months old. Additionally, we calculated prenatal detection rates for those undergoing a surgical or interventional catheterization procedure for each of the 5 years.
RESULTS
We identified 107 patients prenatally and postnatally. Of the 107 patients, 56 (34 prenatally diagnosed and 22 postnatally diagnosed) underwent an aortic arch procedure, and 51 additionally prenatally diagnosed, live-born infants did not undergo a procedure. Of the 56 procedures, 2 were by interventional catheterization, and 54 underwent a surgical repair. Prenatal detection for those undergoing a procedure statistically significantly increased over the 5 years from 38% to 82%, rho = 0.95 (p = .04).
CONCLUSIONS
Currently in Nevada, our prenatal detection rate is >80% in the general population for those between 0 and 6 months old who require a therapeutic procedure for aortic arch obstruction without intracardiac malformations.
Topics: Aorta, Thoracic; Aortic Coarctation; Female; Heart Defects, Congenital; Humans; Infant; Infant, Newborn; Nevada; Pregnancy; Prenatal Diagnosis; Retrospective Studies
PubMed: 36047366
DOI: 10.1111/jocs.16834 -
The Annals of Thoracic Surgery Jul 2019Vascular rings with a Kommerell diverticulum (KD) most commonly occur in patients with a right aortic arch. We report on a less commonly seen subset of vascular ring...
BACKGROUND
Vascular rings with a Kommerell diverticulum (KD) most commonly occur in patients with a right aortic arch. We report on a less commonly seen subset of vascular ring patients-those with a double aortic arch and a KD.
METHODS
Between 2002 and 2017, 66 patients underwent an operation for a double aortic arch. Ten of those patients also had excision of a KD. We performed a retrospective medical record review of these patients to characterize their demographics and outcomes.
RESULTS
All 10 patients (7 male, 3 female) had a double aortic arch that was right dominant and also had a KD. The patients were a mean age of 4.9 ± 4.3 years (range, 6 months to 29 years), and median age was 4 years. All patients had preoperative computed tomographic angiography or magnetic resonance imaging and mean compression of the distal trachea of 63% ± 12% (range, 40% to 80%). The distal left arch was atretic in all patients. All patients underwent division of their left aortic arch, division of the ligamentum, and resection of the KD. The left subclavian artery was transferred to the left carotid artery in 2 patients. The mean size of the diverticulum was 9 × 10 mm. There were no major postoperative complications or readmissions. The postoperative length of stay was 3.1 ± 0.8 days. Five of the patients reported no related persisting symptoms. The remaining 5 patients reported substantial symptomatic relief with only minor respiratory symptoms.
CONCLUSIONS
Vascular ring patients with a double aortic arch can also have a KD. In addition to dividing the smaller aortic arch and the ligamentum, we recommend excision of the KD.
Topics: Adult; Aorta, Thoracic; Aortic Diseases; Carotid Arteries; Child; Child, Preschool; Computed Tomography Angiography; Diverticulum; Female; Humans; Imaging, Three-Dimensional; Infant; Male; Postoperative Complications; Retrospective Studies; Subclavian Artery; Vascular Malformations
PubMed: 30849335
DOI: 10.1016/j.athoracsur.2019.01.062 -
Anatomia, Histologia, Embryologia May 2022Anomalies in the subclavian and common carotid arteries can be of interest in cases of cranial mediastinal surgeries, as well as to diagnose the cause of oesophageal...
Anomalies in the subclavian and common carotid arteries can be of interest in cases of cranial mediastinal surgeries, as well as to diagnose the cause of oesophageal constrictions leading to clinical signs of dysphagia (dysphagia lusoria). The development and regression of the aortic arches are of key importance in understanding the origin of these type of vascular anomalies. This report describes the congenital anomalous aortic origin of the common carotid and the subclavian arteries in a 14-year-old dog and the plausible developmental pattern failure. Academic dissection revealed a common bicarotid trunk and bisubclavian trunk arising from the most cranial aspect of the aortic arch. Despite the abnormal origin, these vessels displayed a predominantly standard anatomical course. All the anticipated branches were identified and described. Cardiac abnormalities were also noted including right atrial dilation, coronary sinus enlargement, right and left valvular endocardiosis, a patent foramen ovale and marked concentric left ventricular hypertrophy with compensatory left atrial dilation. Additionally, the right recurrent laryngeal nerve demonstrated an aberrant course consistent with a 'non-recurrent laryngeal nerve' (non-RLN). Awareness of the anatomical variations of the aortic arch is important for surgical interventions of the cranial mediastinum as well as radiological interpretation. Although infrequent, the variants similar to the one described here have been reported in different species.
Topics: Animals; Aorta, Thoracic; Carotid Artery, Common; Deglutition Disorders; Dog Diseases; Dogs; Heart Defects, Congenital; Subclavian Artery
PubMed: 35170797
DOI: 10.1111/ahe.12788 -
Clinical Gastroenterology and... Jun 2021
Topics: Aorta, Thoracic; Humans; Vascular Ring
PubMed: 32289546
DOI: 10.1016/j.cgh.2020.04.015 -
Future Cardiology Oct 2021The frozen elephant trunk technique has revolutionized aortic arch repair to enable more extensive arch and descending thoracic aortic treatment in a single setting. We... (Review)
Review
The frozen elephant trunk technique has revolutionized aortic arch repair to enable more extensive arch and descending thoracic aortic treatment in a single setting. We review the current evidence supporting the use of the Thoraflex Hybrid (Terumo Aortic, FL, USA) device and discuss advantages, pitfalls and future design considerations.
Topics: Aorta, Thoracic; Aortic Aneurysm, Thoracic; Blood Vessel Prosthesis; Blood Vessel Prosthesis Implantation; Endovascular Procedures; Humans; Retrospective Studies; Treatment Outcome
PubMed: 33544641
DOI: 10.2217/fca-2020-0152 -
Journal of Clinical Ultrasound : JCU May 2020"Bovine aortic arch" is the second most common variant of aortic arch branching, in which only two branches originate directly from the aorta. The prevalence of this...
OBJECTIVE
"Bovine aortic arch" is the second most common variant of aortic arch branching, in which only two branches originate directly from the aorta. The prevalence of this condition has been reported in different studies to be around 6% in human fetuses and 11-27% in the adult population. In this study, we describe the prevalence of bovine aortic arch in fetuses, and assess the prevalence of concomitant fetal anomalies.
METHODS
A retrospective analysis of 417 fetuses between 15-40 weeks of gestation. Data regarding branching of the fetal aortic arch and other fetal anomalies were collected by fetal echocardiography and/or fetal ultrasonography.
RESULTS
A bovine arch was found in 20/413 fetuses (4.8%, 95CI 3.1-7.3%), of whom 14/310 (4.5%) had no fetal anomalies, and 6/77 (7.8%) exhibited minor changes (P = .241). None of the 26 fetuses with major anomalies had a bovine arch.
CONCLUSION
Fetuses in this study had a lower prevalence of bovine aortic arch than that previously reported in adults, most probably due to differences in the population examined. This study was underpowered to determine that bovine arch is a common anatomic variant, and is not associated with fetal anomalies.
Topics: Adult; Animals; Aorta, Thoracic; Cardiovascular Abnormalities; Cattle; Echocardiography; Female; Fetus; Gestational Age; Humans; Male; Pregnancy; Prevalence; Retrospective Studies; Ultrasonography, Prenatal
PubMed: 31777971
DOI: 10.1002/jcu.22800