-
Frontiers in Cardiovascular Medicine 2021Bicuspid aortic valve (BAV) disease presents a unique management challenge both pre- and post-operatively. 4D flow MRI offers multiple tools for the assessment of the... (Review)
Review
Bicuspid aortic valve (BAV) disease presents a unique management challenge both pre- and post-operatively. 4D flow MRI offers multiple tools for the assessment of the thoracic aorta in aortic valve disease. In particular, its assessment of flow patterns and wall shear stress have led to new understandings around the mechanisms of aneurysm development in BAV disease. Novel parameters have now been developed that have the potential to predict pathological aortic dilatation and may help to risk stratify BAV patients in future. This systematic review analyses the current 4D flow MRI literature after aortic valve and/or ascending aortic replacement in bicuspid aortic valve disease. 4D flow MRI has also identified distinct challenges posed by this cohort at the time of valve replacement compared to standard management of tri-leaflet disorders, and may help tailor the type and timing of replacement. Eccentric pathological flow patterns seen after bioprosthetic valve implantation, but not with mechanical prostheses, might be an important future consideration in intervention planning. 4D flow MRI also has promising potential in supporting the development of artificial valve prostheses and aortic conduits with more physiological flow patterns.
PubMed: 33842561
DOI: 10.3389/fcvm.2021.629227 -
Medical Science Monitor : International... Mar 2021Kommerell diverticulum (KD) combined with right-sided aortic arch (RAA) and aberrant left subclavian artery (ALSA) are rare and limited to a few case reports and small...
Kommerell diverticulum (KD) combined with right-sided aortic arch (RAA) and aberrant left subclavian artery (ALSA) are rare and limited to a few case reports and small series. Thoracic endovascular aortic repair (TEVAR), which is mini-invasive, is widely utilized in complicated aortic disease. We performed a systematic review of the literature to identify all patients who underwent endovascular repair for KD in terms of technical feasibility and procedural outcomes. Published and accepted studies only in English as well as article reference lists were searched and extracted to assess case series reporting solely TEVAR in KD patients. There were 28 patients with KD/RAA identified from 19 studies. All of them underwent endovascular technique for KD exclusion and the median age was 69 years (range 39-83 years). Hypertension (n=17) was the most common comorbidity in this cohort, followed by diabetes mellitus (n=3), hyperlipidemia (n=3), and smoking (n=3). The presenting symptoms were dysphagia (n=8, 29%), intermittent back pain (n=4, 14%), and acute aortic dissection (n=6, 21%), while asymptomatic was found in 9 patients (n=9, 32%). A technical success rate of 100% was reported associated with various managements of ALSA, proximal embolization (n=19, 68%), in-situ revascularization (n=3, 11%), and left carotid-subclavian bypass (n=3, 11%). All patients survived without severe complications and were discharged home within less than 14 days. The mean follow-up time was 9.3 months, patency was found in all patients, thrombosis and distinct shrinkage of KD aneurysm as indicated by CT-scans were noted (n=20, 71%), and type II endoleak was found in only 4 patients (n=4, 14%). TEVAR appears to be safe and offers favorable results, but it still needs substantial evidence to support routine use in KD. TEVAR is an alternative to open repair in selected cases, but it needs further investigation in a large cohort.
Topics: Adult; Aged; Aged, 80 and over; Aortic Dissection; Aorta, Thoracic; Aortic Diseases; Blood Vessel Prosthesis; Blood Vessel Prosthesis Implantation; Diverticulum; Embolization, Therapeutic; Endovascular Procedures; Female; Humans; Male; Middle Aged; Retrospective Studies; Stents; Treatment Outcome
PubMed: 33755659
DOI: 10.12659/MSM.930031 -
BMJ Open Mar 2021To review comparisons of the effectiveness of endovascular stent grafting (ESG) against open surgical repair (OSR) for treatment of chronic arch or descending thoracic... (Meta-Analysis)
Meta-Analysis
OBJECTIVE
To review comparisons of the effectiveness of endovascular stent grafting (ESG) against open surgical repair (OSR) for treatment of chronic arch or descending thoracic aortic aneurysms (TAA).
DESIGN
Systematic review and meta-analysis DATA SOURCES: MEDLINE, EMBASE, CENTRAL, WHO International Clinical Trials Routine data collection, current controlled trials, clinical trials and the NIHR portfolio were searched from January 1994 to March 2020.
ELIGIBILITY CRITERIA FOR SELECTIVE STUDIES
All identified studies that compared ESG and OSR, including randomised controlled trials (RCTs), quasi-randomised and non-RCTs, comparative cohort studies and case-control studies matched on main outcomes were sought. Participants had to receive elective treatments for arch/descending (TAA). Studies were excluded where other thoracic aortic conditions (eg, rupture or dissection) were reported, unless results for patients receiving elective treatment for arch/descending TAA reported separately.
DATA EXTRACTION AND SYNTHESIS
Data were extracted by one reviewer and checked by another. Risk of Bias was assessed using the ROBINS-I tool. Meta-analysis was conducted using random effects. Where meta-analysis not appropriate, results were reported narratively.
RESULTS
Five comparative cohort studies met inclusion criteria, reporting 3955 ESG and 21 197 OSR patients. Meta-analysis of unadjusted short-term (30 day) all-cause mortality favoured ESG (OR 0.75; 95% CI 0.55 to 1.03)). Heterogeneity identified between larger and smaller studies. Sensitivity analysis of four studies including only descending TAA showed no statistical significance (OR 0.73, 95% CI 0.45 to 1.18)), moderate heterogeneity. Meta-analysis of adjusted short-term all-cause mortality favoured ESG (OR 0.71, 95% CI 0.51 to 0.98)), no heterogeneity. Longer-term (beyond 30 days) survival from all-cause mortality favoured OSR in larger studies and ESG in smaller studies. Freedom from reintervention in the longer-term favoured OSR. Studies reporting short-term non-fatal complications suggest fewer events following ESG.
CONCLUSIONS
There is limited and increasingly dated evidence on the comparison of ESG and OSR for treatment of arch/descending TAA.
PROSPERO REGISTRATION NUMBER
CRD42017054565.
Topics: Aortic Aneurysm, Abdominal; Aortic Aneurysm, Thoracic; Elective Surgical Procedures; Endovascular Procedures; Humans; Stents; Treatment Outcome
PubMed: 33664076
DOI: 10.1136/bmjopen-2020-043323 -
Journal of Vascular Surgery Nov 2021The aim of the present study was to demonstrate the clinical outcomes of intentional coverage of the celiac artery (CA) during thoracic endovascular aneurysm repair... (Meta-Analysis)
Meta-Analysis
OBJECTIVE
The aim of the present study was to demonstrate the clinical outcomes of intentional coverage of the celiac artery (CA) during thoracic endovascular aneurysm repair (TEVAR).
METHODS
The MEDLINE, EMBASE, and Cochrane Library databases were searched for studies reporting coverage of CA during TEVAR. The methodologic quality of the included studies was assessed using the Moga score and Newcastle-Ottawa scale. A random effects model was used to pool the estimates. A meta-analysis was performed with investigation of the following outcomes: visceral ischemia, spinal cord ischemia (SCI), stroke, endoleak, reintervention, 30-day mortality, and 1-year mortality.
RESULTS
A total of 10 studies with 171 patients were included. The summary estimate rate of visceral ischemia events was 4.2% (95% confidence interval [CI], 0.9-8.9%; I = 4.1%). The incidence of stroke and SCI was 0.2% (95% CI, 0%-3.4%; I = 0%) and 3% (95% CI, 0.3%-7.4%; I = 6.1%). The rate of endoleak during the follow-up period was 24.1% (95% CI, 14.3%-35.1%; I = 20.0%). The reintervention rate was 13.6% (95% CI, 4.4%-25.7%; I = 66.0%). The 30-day and 1-year mortality were 2.9% (95% CI, 0.3%-7.2%; I = 6.2%) and 15.2% (95% CI, 7.8%-23.9%; I = 0%).
CONCLUSIONS
Among the patients with complex thoracic aortic pathologies deemed at high risk for open reconstruction, TEVAR with intentional coverage of the CA is a safe and feasible option to extend the distal sealing zone with acceptable rates of visceral ischemia, SCI, type II endoleak from the CA, and 30-day mortality.
Topics: Aged; Aorta, Thoracic; Aortic Diseases; Blood Vessel Prosthesis; Blood Vessel Prosthesis Implantation; Celiac Artery; Endovascular Procedures; Female; Humans; Male; Middle Aged; Postoperative Complications; Risk Assessment; Risk Factors; Time Factors; Treatment Outcome
PubMed: 33592296
DOI: 10.1016/j.jvs.2021.01.053 -
European Journal of Vascular and... Apr 2021Physician modified stent grafts (PMSGs) present satisfactory results in selected cases of complex aortic pathologies. However, the technique lacks standardisation and...
OBJECTIVE
Physician modified stent grafts (PMSGs) present satisfactory results in selected cases of complex aortic pathologies. However, the technique lacks standardisation and depends on the surgeon and aortic segment. The aim of this article is to review comprehensively the technical details and clinical results of PMSGs related to patients with pathology in all aortic locations.
METHODS
A MEDLINE search (last search 20 April 2020) identified 20 relevant papers in the English language published over the last 20 years evaluating clinical outcomes after a PMSG and specifying the technical details to design it.
RESULTS
Seven hundred and eleven patients were included in the analyses, with 59% being operated on as an emergency. Ninety-two per cent of abdominal aortic segment PMSGs (A-PMSGs) were performed either as an emergency or before 2012. The main indications were available in 670 cases; 435 were degenerative aneurysms (64.9%) and 171 were aortic dissections (25.5%). Most of the endografts used were composed of polyethylene terephthalate, except for the Ankura (expanded polytetrafluoroethylene [Lifetech Scientific, Shenzhen, China]; n = 50, 7.5%). The Valiant (Medtronic, Minneapolis, MN, USA) represented 65% (n = 169) of aortic arch PMSGs (aa-PMSGs) and the Zenith platform (Cook Medical, Bloomington, IN, USA) 51% (n = 139) of A-PMSGs. A snare was used to reinforce the fenestration in 458 PMSGs (66%) and a cautery device cut the fenestration in 484 (75%) PMSGs. No bridging stent was used in 47 (7.0%) PMSGs (these aa-PMSGs had large fenestrations). Technical success ranged from 87.5% to 100% and 30 day mortality from 0% to 8%. Primary branch patency ranged from 96.3% to 100% at 12 month follow up. Zero to 14% of patients experienced type 3 or type 1 endoleak at 14.8 month follow up.
CONCLUSION
PMSG is a useful technique, particularly when validated treatments are not available. However, it is a non-standardised technique and the long term consequences of modifications remain unknown.
Topics: Aged; Aorta; Aortic Diseases; Blood Vessel Prosthesis; Blood Vessel Prosthesis Implantation; Endoleak; Endovascular Procedures; Female; Humans; Male; Middle Aged; Prosthesis Design; Risk Factors; Stents; Time Factors; Treatment Outcome; Vascular Patency
PubMed: 33589325
DOI: 10.1016/j.ejvs.2021.01.019 -
Journal of Cardiac Surgery Jan 2021Up to 10% of acute type A aortic dissection (TAAD) patients are deemed unfit for open surgical repair, exposing these patients to high mortality rates. In recent years,...
PURPOSE
Up to 10% of acute type A aortic dissection (TAAD) patients are deemed unfit for open surgical repair, exposing these patients to high mortality rates. In recent years, thoracic endovascular aortic repair has proven to be a promising alternative treatment modality in specific cases. This study presents a comprehensive overview of the current state of catheter-based interventions in the setting of primary TAAD.
METHODS
A literature search was conducted, using MEDLINE and PubMed databases according to PRISMA guidelines, updated until January 2020. Articles were selected if they reported on the endovascular repair of DeBakey Type I and II aortic dissections. The exclusion criteria were retrograde type A dissection, hybrid procedures, and combined outcome reporting of mixed aortic pathologies (e.g., pseudoaneurysm and intramural hematoma).
RESULTS
A total of 31 articles, out of which 19 were case reports and 12 case series, describing a total of 92 patients, were included. The median follow-up was 6 months for case reports and the average follow-up was 14 months for case series. Overall technical success was 95.6% and 30-day mortality of 9%. Stroke and early endoleak rates were 6% and 18%, respectively. Reintervention was required in 14 patients (15%).
CONCLUSION
This review not only demonstrates that endovascular repair in the setting of isolated TAAD is feasible with acceptable outcomes at short-term follow-up, but also underlines a lack of mid-late outcomes and reporting consistency. Studies with longer follow-up and careful consideration of patient selection are required before endovascular interventions can be widely introduced.
Topics: Aortic Aneurysm, Thoracic; Blood Vessel Prosthesis Implantation; Dissection; Endovascular Procedures; Humans; Retrospective Studies; Risk Factors; Stents; Treatment Outcome
PubMed: 33169411
DOI: 10.1111/jocs.15192 -
Journal of the American Heart... Nov 2020Background The prevalence of thoracic aortic aneurysms (TAA) in patients with known abdominal aortic aneurysms (AAA) is not well known and understudied. Our aim was to... (Meta-Analysis)
Meta-Analysis
Background The prevalence of thoracic aortic aneurysms (TAA) in patients with known abdominal aortic aneurysms (AAA) is not well known and understudied. Our aim was to conduct a systematic review and meta-analysis of the overall prevalence of synchronous and metachronous TAA (SM-TAA) in patients with a known AAA and to understand the characteristics of this sub-population. Methods and Results We searched MEDLINE, EMBASE, and CENTRAL (Cochrane Central Register of Controlled Trials) from inception to November 2019 for all population-based studies reporting on the prevalence of SM-TAAs in a cohort of patients with AAA. Article screening and data extraction were performed by 2 authors and data were pooled using a random-effects model of proportions using Freeman-Tukey double arcsine transformation. The main outcome was the prevalence of SM-TAAs in patients with AAAs. Secondary outcomes were the prevalence of synchronous TAAs, metachronous TAAs, prevalence of TAAs in patients with AAA according to the anatomic location (ascending, arch, and descending) and the differences in prevalence of these aneurysms according to sex and risk factors. Six studies were included. The pooled-prevalence of SM-TAA in AAA patients was 19.2% (95% CI, 12.3-27.3). Results revealed that 15.2% (95% CI, 7.1-25.6) of men and 30.7% (95% CI, 25.2-36.5) of women with AAA had an SM-TAA. Women with AAA had a 2-fold increased risk of having an SM-TAA than men (relative risk [RRs], 2.16; 95% CI, 1.32-3.55). Diabetes mellitus was associated with a 43% decreased risk of having SM-TAA (RRs, 0.57; 95% CI, 0.41-0.80). Conclusions Since a fifth of AAA patients will have an SM-TAA, routine screening of SM-TAA and their clinical impact should be more thoroughly studied in patients with known AAA.
Topics: Aortic Aneurysm, Abdominal; Aortic Aneurysm, Thoracic; Humans; Prevalence
PubMed: 33103575
DOI: 10.1161/JAHA.120.017468 -
Diagnostics (Basel, Switzerland) Oct 2020Right aortic arch presents a reported incidence of 0.1% of the general population; the aim of our study was to evaluate the risk of associated intracardiac (ICA),... (Review)
Review
Right aortic arch presents a reported incidence of 0.1% of the general population; the aim of our study was to evaluate the risk of associated intracardiac (ICA), extracardiac (ECA), or chromosomal abnormalities in fetuses with right aortic arch (RAA) and concomitant right ductal arch (RDA). A systematic review of the literature selected 18 studies including 60 cases of RAA/RDA. A meta-analysis with a random effect model calculated for each outcome the pooled crude proportion of associated abnormal outcomes in cases of RAA/RDA and the pooled proportions and odds ratios in RAA with LDA or RDA. Quality assessment of the included studies was achieved using the NIH quality assessment tool for case series studies. RAA/RDA presents risk of associated conotruncal CHDs of about 30% and risk of 22q11 microdeletion in the region of 1%. Two-thirds of 22q11 microdeletions had concomitant thymic hypoplasia and no other chromosomal defects were described. Risks for ICA, ECA, 22q11 microdeletion, and aberrant left subclavian artery are not substantially different in RAA with right or left arterial duct. RAA increases the risk of associated cardiac defects regardless of laterality of the ductal arch. In isolated RDA/RAA cases, absolute risks of extracardiac associated problems or surgery are rather low, we would therefore recommend reassurance, particularly when the thymus and karyotype are normal.
PubMed: 33076538
DOI: 10.3390/diagnostics10100831 -
Journal of the American Heart... Oct 2020Background Moderate hypothermic circulatory arrest (MHCA) has been widely used in aortic arch surgery. However, the renal function after MHCA remains controversial. We... (Meta-Analysis)
Meta-Analysis
Effect of Deep Hypothermic Circulatory Arrest Versus Moderate Hypothermic Circulatory Arrest in Aortic Arch Surgery on Postoperative Renal Function: A Systematic Review and Meta-Analysis.
Background Moderate hypothermic circulatory arrest (MHCA) has been widely used in aortic arch surgery. However, the renal function after MHCA remains controversial. We performed a systematic review and meta-analysis direct comparison of the postoperative renal function of MHCA versus deep hypothermic circulatory arrest (DHCA) in aortic arch surgery. Methods and Results We searched PubMed, Embase, and the Cochrane Library for postoperative renal function after aortic arch surgery with using MHCA and DHCA, published from inception to January 31, 2020. The primary outcome was renal failure. Secondary outcomes were the need for renal therapy and other major postoperative outcomes. The random-effects model was used for all comparisons to pool the estimates. A total of 14 observational studies with 4142 patients were included. Compared with DHCA, MHCA significantly reduced the incidence of renal failure (odds ratio [OR], 0.76; 95% CI, 0.61-0.94; =0.011; I=0.0%) and the need of renal replacement (OR, 0.68; 95% CI, 0.48-0.97; =0.034; I=0.0%). Subgroup analysis showed that when the hypothermic circulatory arrest time was <30 minutes, the incidence of renal failure in MHCA group was significantly lower than that in DHCA group (OR, 0.73; 95% CI, 0.54-0.99; =0.040; I=1.1%), whereas an insignificant difference between 2 groups when hypothermic circulatory arrest time was >30 minutes (OR, 0.76; 95% CI, 0.51-1.13; =0.169; I=17.3%). Conclusions MHCA compared with DHCA reduces the incidence of renal failure and the need for renal replacement. Registration URL: https://www.crd.york.ac.uk/prospero; Unique identifier: CRD42020169348.
Topics: Aorta, Thoracic; Circulatory Arrest, Deep Hypothermia Induced; Humans; Hypothermia, Induced; Postoperative Complications; Renal Insufficiency; Risk Assessment; Vascular Surgical Procedures
PubMed: 32990132
DOI: 10.1161/JAHA.120.017939 -
The Journal of Cardiovascular Surgery Dec 2020Thoracic endovascular aortic repair (TEVAR) for treatment of blunt traumatic aortic injuries (BTAIs) is nowadays the gold standard technique in adult patients, replacing...
INTRODUCTION
Thoracic endovascular aortic repair (TEVAR) for treatment of blunt traumatic aortic injuries (BTAIs) is nowadays the gold standard technique in adult patients, replacing gradually the use of open repair (OR). Although randomized controlled trials will never be performed comparing TEVAR to OR for BTAIs management, trauma and vascular societies guidelines today primarily recommend the former for BTAI patients with a suitable anatomy. The aim of this review was to describe past and recent data published in literature regarding pros and cons of TEVAR treatment in BTAI, and to analyze some debated issues and future perspectives.
EVIDENCE ACQUISITION
Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and Scale for the Assessment of Narrative Review Articles (SANRA) were used to obtain and describe selected articles on TEVAR in BTAI.
EVIDENCE SYNTHESIS
Young (<50 years) men were the most operated population. The use of TEVAR increased over the years, with a progressive reduction in mortality and overall postoperative complication rates when compared with OR. Lack of information remains about the percentage of urgent cases.
CONCLUSIONS
TEVAR is considered nowadays the treatment of choice in BTAI patients. In case of aortic rupture (grade IV) the treatment is mandatory, while intimal tear (grade I) and intramural hematoma (grade II) can be safely managed with no operative management (NOM). Debate is still ongoing on grade III (pseudoaneurysms). Unfortunately, several aspects remain not yet clarified, including disease classification, type and grade to treat, timing (urgent versus elective), priority of vascular injuries in polytrauma patients, and TEVAR use in pediatrics and young patients.
Topics: Adult; Aorta, Thoracic; Blood Vessel Prosthesis Implantation; Endovascular Procedures; Female; Humans; Male; Middle Aged; Postoperative Complications; Risk Assessment; Risk Factors; Treatment Outcome; Vascular System Injuries; Wounds, Nonpenetrating
PubMed: 32964899
DOI: 10.23736/S0021-9509.20.11580-5