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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 -
BMC Cardiovascular Disorders Mar 2023A paradoxical protective effect of diabetes on the development and progression of abdominal aortic aneurysms (AAA) has been known for years. This study aimed to... (Meta-Analysis)
Meta-Analysis
The association between diabetes and abdominal aortic aneurysms in men: results of two Danish screening studies, a systematic review, and a meta-analysis of population-based screening studies.
BACKGROUND
A paradoxical protective effect of diabetes on the development and progression of abdominal aortic aneurysms (AAA) has been known for years. This study aimed to investigate whether the protective role of diabetes on AAAs has evolved over the years.
METHODS
A cross-sectional study, a systematic review and meta-analysis. This study was based on two large, population-based, randomised screening trials of men aged 65-74; VIVA (2008-2011) and DANCAVAS (2014-2018), including measurement of the abdominal aorta by ultrasound or CT, respectively. Analyses were performed using multiple logistic regressions to estimate the odds ratios (ORs) for AAAs in men with diabetes compared to those not having diabetes. Moreover, a systematic review and meta-analysis of population-based screening studies of AAAs to visualise a potential change of the association between diabetes and AAAs. Studies reporting only on women or Asian populations were excluded.
RESULTS
In VIVA, the prevalence of AAA was 3.3%, crude OR for AAA in men with diabetes 1.04 (95% confidence interval, CI, 0.80-1.34), and adjusted OR 0.64 (CI 0.48-0.84). In DANCAVAS, the prevalence of AAA was 4.2%, crude OR 1.44 (CI 1.11-1.87), and adjusted OR 0.78 (CI 0.59-1.04). Twenty-three studies were identified for the meta-analysis (N = 224 766). The overall crude OR was 0.90 (CI 0.77-1.05) before 2000 and 1.16 (CI 1.03-1.30) after 1999. The overall adjusted OR was 0.63 (CI 0.59-0.69) before 2000 and 0.69 (CI 0.57-0.84) after 1999.
CONCLUSION
Both the crude and adjusted OR showed a statistically non-significant trend towards an increased risk of AAA by the presence of diabetes. If this represents an actual trend, it could be due to a change in the diabetes population.
TRIAL REGISTRATION
DANCAVAS: Current Controlled Trials: ISRCTN12157806. VIVA: ClinicalTrials.gov NCT00662480.
Topics: Male; Humans; Female; Cross-Sectional Studies; Diabetes Mellitus; Aortic Aneurysm, Abdominal; Ultrasonography; Denmark; Mass Screening; Risk Factors
PubMed: 36927295
DOI: 10.1186/s12872-023-03160-8 -
Frontiers in Cardiovascular Medicine 2023Thoracic endovascular aortic repair, initially intended for thoracic aortic disease treatment, has extended its application to the proximal zone of the aorta. However,...
BACKGROUND
Thoracic endovascular aortic repair, initially intended for thoracic aortic disease treatment, has extended its application to the proximal zone of the aorta. However, the safety and surgical outcomes of extending the proximal landing zone into the ascending aorta (zone 0) in selected cases remain unknown. Thus, we performed a systematic review and meta-analysis of zone 0 thoracic endovascular aortic repair (TEVAR) to obtain a deeper understanding of its safety, outcomes, and trends over time.
METHODS
A literature search was performed using PubMed, EMBASE, and Web of Science databases in accordance with the preferred reporting items for systematic reviews and meta-analyses guidelines, from January, 1997 to January, 2022. Only studies involving zone 0 TEVAR were included. The retrieved data from the eligible studies included basic study characteristics, 30-day/in-hospital mortality rate, indications, comorbidities, stent grafts, techniques, and complications. Summary effect measures of the primary outcomes were obtained by logarithmically pooling the data with an inverse variance-weighted fixed-effects model.
RESULTS
Fifty-three studies with 1,013 patients were eligible for analysis. The pooled 30-day/in-hospital mortality rate of zone 0 TEVAR was 7.49%. The rates of post-operative stroke, type Ia endoleak, retrograde type A aortic dissection, and spinal cord ischemia were 8.95, 9.01, 5.72, and 4.12%, respectively.
CONCLUSIONS
Although many novel stent grafts and techniques targeting zone 0 TEVAR are being investigated, a consensus on technique and device selection in zone 0 TEVAR is yet to be established in current practice. Furthermore, the post-operative stroke rate is relatively high, while other complication rates and perioperative death rate are comparable to those of TEVAR for other aortic zones.
PubMed: 36910538
DOI: 10.3389/fcvm.2023.1034354 -
European Journal of Vascular and... Jun 2023Type B aortic dissections (TBAD) have a high mortality rate and are challenging to both classify and manage. There is significant evidence supporting the use of early... (Review)
Review
OBJECTIVE
Type B aortic dissections (TBAD) have a high mortality rate and are challenging to both classify and manage. There is significant evidence supporting the use of early intervention in complicated TBAD with thoracic endovascular aortic repair (TEVAR). Currently, there is equipoise regarding the optimal timing for TEVAR in TBAD. This systematic review answers whether early TEVAR in the hyperacute or acute phase of the disease has improved aorta related events in the one year follow up period with no change in mortality rate when compared with TEVAR in the subacute or chronic phase.
DATA SOURCES
A systematic review and meta-analysis was performed with Preferred Reporting Items for Systematic Reviews and Meta-Analyses literature search guidelines for MEDLINE, Embase, and Cochrane Reviews until 12 April 2021. Inclusion and exclusion criteria targeting the review objective and high quality research were employed by separate authors.
REVIEW METHODS
These studies were then reviewed for suitability, risk of bias, and heterogeneity using the ROBINS-I tool. Results were extracted for the meta-analysis with RevMan using odds ratios with 95% confidence intervals with I used to assess heterogeneity.
RESULTS
Twenty articles were included. A meta-analysis showed no significant difference between acute phase TEVAR (excluding the hyperacute phase) and subacute or chronic phase TEVAR for the all cause 30 day and one year mortality rates. Aorta related events in the 30 day post-operative period were unaffected by the timing of intervention but had significant improvement in aorta related events in the one year follow up favouring TEVAR in the acute phase compared with subacute or chronic phase. Risk of confounding was high but with low heterogeneity.
CONCLUSION
Without prospective randomised controlled studies, it is evident that there is improved aortic remodelling in long term follow up with intervention in the acute setting from three to 14 days after symptom onset. This suggests that TEVAR in the acute period of TBAD is both safe and beneficial, and can be considered for early stent grafting based on clinical, anatomical and patient factors.
PubMed: 36871923
DOI: 10.1016/j.ejvs.2023.02.080 -
Aorta (Stamford, Conn.) Feb 2023An aberrant right subclavian artery (ARSA) is the most common congenital variant of the aortic arch. Usually, this variation is largely asymptomatic, but sometimes it...
An aberrant right subclavian artery (ARSA) is the most common congenital variant of the aortic arch. Usually, this variation is largely asymptomatic, but sometimes it may be involved in aortic dissection (AD). Surgical management of this condition is challenging. The therapeutic options have been enriched in recent decades by establishing individualized endovascular or hybrid procedures. Whether these less invasive approaches bear advantages, and how they have changed the treatment of this rare pathology, is still unclear. Therefore, we conducted a systematic review. We performed a review of literature from the past 20 years (from January 2000 until February 2021) complying with the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. All reported patients treated for Type B AD in the presence of an ARSA were identified and classified into three groups according to the received therapy (open, hybrid, and total endovascular). Patient characteristics, as well as in-hospital mortality, and major and minor complications were determined and statistically analyzed. We identified 32 relevant publications comprising 85 patients. Open arch repair has been offered to younger patients, but significantly less often in symptomatic patients needing urgent repair. Therefore, the maximum aortic diameter was also significantly larger in the open repair group compared with that in the hybrid or total endovascular repair group. Regarding the endpoints, we did not find significant differences. The literature review revealed that open surgical therapies are preferred in patients presenting with chronic dissections and larger aortic diameters, most likely because they are unsuitable for endovascular aortic repair. Hybrid and total endovascular approaches are more often applied in emergency situations, where aortic diameters remain smaller. All therapies demonstrated good, early, and midterm outcomes. But, these therapies carry potential risks in the long term. Therefore, long-term follow-up data are urgently needed to validate that these therapies are sustainable.
PubMed: 36848908
DOI: 10.1055/s-0042-1757948 -
Aorta (Stamford, Conn.) Dec 2022In this systematic review, the available literature on the presentation and management of acute thoracic aortic dissections in Africa is examined. Though Africa has 17%...
In this systematic review, the available literature on the presentation and management of acute thoracic aortic dissections in Africa is examined. Though Africa has 17% of the world population, it accounts for approximately 1% of the available literature with much of our understanding coming from registries arising from the developed world, such as the International Registry of Acute Aortic Dissection. The literature from the African continent consists mainly of case reports, small case series, and few original studies. Case reports make an important contribution to our understanding of uncommon conditions but can skew our understanding of aortic dissections in this region by describing unusual presentations and management. In this review, we describe the available studies retrieved from large medical databases (Medline and Health Management Information Consortium) and motivate the need for national registries to provide a more accurate appreciation of the scope of the problem on this continent.
PubMed: 36539145
DOI: 10.1055/s-0042-1757797 -
Frontiers in Cardiovascular Medicine 2022Despite the rapid development of thoracic endovascular aortic repair (TEVAR), it is still a challenge to maintain the blood flow of the branch arteries above the aortic...
OBJECTIVE
Despite the rapid development of thoracic endovascular aortic repair (TEVAR), it is still a challenge to maintain the blood flow of the branch arteries above the aortic arch in Stanford type B aortic dissection involving the left subclavian artery (LSA). The Castor stent graft is an integrated, customized, single-branch stent that enables reconstruction of the LSA. The purpose of this systematic review and meta-analysis was to assess the efficacy of the Castor stent graft for type B aortic dissection.
MATERIALS AND METHODS
An extensive electronic literature search (PROSPERO registration number: CRD42022322146) was undertaken to identify all articles published up to August 2022 that described thoracic aortic repair with branch stents in the treatment of type B aortic dissection involving the LSA. The quality of the included studies was analyzed using the MINORS criteria. The primary outcome measures were the technical success rate, early mortality rate, endoleak rate, and 1-year survival rate. The secondary outcome measures were the stroke rate, left upper extremity ischemia rate, and target vessel patency rate.
RESULTS
Eleven studies involving 415 patients were eligible for this meta-analysis. The LSA was successfully preserved in all procedures. The technical success rate was 97.5% (95% CI: 0.953-0.991); the intraoperative endoleak rate was 0.1% (95% CI: 0.000-0.012); the intraoperative LSA patency rate was 99.52%; the intraoperative LSA stent deformation and stenosis rate was 0.15% (95% CI: 0.000-0.051); the early type I endoleak rate was 1.6% (95% CI: 0.003-0.035); the 30-day mortality rate was 0.96%; the early reintervention rate was 0.9% (95% CI: 0.000-0.040); and the perioperative stroke rate was 0% (95% CI: 0.000-0.005). The 1-year survival rate was 99.7% (95% CI: 0.976-1.000). The half-year LSA patency rate was 99.3%, the 1-year LSA patency rate was 97.58%, and the 2-year LSA patency rate was 95.23%. During the follow-up period, the leakage rate was 0.3% (95% CI: 0.000-0.017), the incidence of left upper extremity ischemia rate was 0.5% (95% CI: 0.000-0.035), and the deformation and stenosis rate of the LSA stent was 2.2% (95% CI: 0.06-0.046).
CONCLUSION
This meta-analysis shows that endovascular repair of type B aortic dissection using the Castor stent-graft may be technically feasible and effective. However, this conclusion needs to be interpreted with caution, as the quality of evidence for all outcomes is between low and very low.
SYSTEMATIC REVIEW REGISTRATION
[https://www.crd.york.ac.uk/prospero/], identifier [CRD42022322146].
PubMed: 36523362
DOI: 10.3389/fcvm.2022.1052094 -
Journal of Cardiac Surgery Dec 2022New temperature management concepts of moderate and mild hypothermic circulatory arrest during aortic arch surgery have gained weight over profound cooling. Comparisons... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVES
New temperature management concepts of moderate and mild hypothermic circulatory arrest during aortic arch surgery have gained weight over profound cooling. Comparisons of all temperature levels have rarely been performed. We performed direct and indirect comparisons of deep hypothermic circulatory arrest (DHCA) (≤20°C), moderate hypothermic circulatory arrest (MHCA) (20.1-25°C), and mild hypothermic circulatory arrest (mild HCA) (≥25.1°C) in a network meta-analysis.
METHODS
The literature was systematically searched for all papers published through February 2022 reporting on clinical outcomes after aortic arch surgery utilizing DHCA, MHCA and mild HCA. The primary outcome was operative mortality. The secondary outcomes were postoperative stroke and acute kidney failure (AKI).
RESULTS
A total of 34 studies were included, with a total of 12,370 patients. DHCA was associated with significantly higher postoperative incidence of stroke when compared with MHCA (odds ratio [OR], 1.46, 95% confidence interval [CI], 1.19-1.78) and mild HCA: (OR, 1.50, 95% CI, 1.14-1.98). Furthermore, DHCA and MHCA were associated with higher operative mortality when compared with mild HCA (OR 1.71, 95% CI, 1.23-2.39 and OR 1.50, 95% CI, 1.12-2.00, respectively). Separate analysis of randomized and propensity score matched studies showed sustained increased risk of stroke with DHCA in contrast to MHCA and mild HCA (OR, 1.61, 95% CI, 1.18-2.20, p value = .0029 and OR, 1.74, 95% CI, 1.09-2.77, p value = .019).
CONCLUSIONS
In the included studies, the moderate to mild hypothermia strategies were associated with decreased operative mortality and the risk of postoperative stroke. Large-scale prospective studies are warranted to further explore appropriate temperature management for the treatment of aortic arch pathologies.
Topics: Humans; Aorta, Thoracic; Aortic Aneurysm, Thoracic; Treatment Outcome; Temperature; Network Meta-Analysis; Retrospective Studies; Circulatory Arrest, Deep Hypothermia Induced; Stroke; Cerebrovascular Circulation; Perfusion
PubMed: 36378895
DOI: 10.1111/jocs.17206 -
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 -
Frontiers in Cardiovascular Medicine 2022Treatment of aortic arch aneurysms and dissections require highly complex surgical procedures with devastating complications and mortality rates. Currently, repair of...
Treatment of aortic arch aneurysms and dissections require highly complex surgical procedures with devastating complications and mortality rates. Currently, repair of the complete arch until the proximal descending thoracic aorta consists of a two-stage procedure, called elephant trunk (ET) technique, or a single stage a single-stage technique referred to as frozen elephant trunk (FET). There is conflicting evidence about the perioperative results of ET in comparison with FET. We carried out a meta-analysis to investigate possible differences in perioperative and early (up to 30 days) outcomes of ET vs. FET, particularly for mortality, spinal cord injury (SCI), stroke, and renal failure. We also performed a meta-regression to explore the effects of age and sex as possible cofactors. Twenty-one studies containing data from interventions conducted between 1997 and 2019 and published between 2008 and 2021 with 3153 patients (68.5% male) were included. ET was applied to 1,693 patients (53.7%) and FET to 1460 (46.3%). Overall mortality after ET was 250/1693 (14.8%) and after FET 116/1460 (7.9%). Relative risk (RR) and 95% confidence interval (CI) were 1.37 [1.04 to 1.81], = 0.027. There was no significant effect of age and sex. SCI occurrence after the second stage of ET was 45/1693 (2.7%) and after FET 70/1,460 patients (4.8%) RR 0.53 [0.35 to 0.81], = 0.004. Age and sex were not associated with the risk of SCI. No significant differences were observed between ET and FET in the incidence of stroke and renal failure. Our results indicate that ET is associated with higher early mortality but lower incidence of SCI compared to FET. When studies published in the last 5 years were analyzed, no significant differences in mortality or SCI were found between ET and FET. This difference is attributed to a decrease in mortality after ET, as the mortality after FET did not change significantly over time.
PubMed: 36337868
DOI: 10.3389/fcvm.2022.999314