Analysis of risk factors for retrograde type A dissection associated with thoracic endovascular aortic repair / 中华放射学杂志

Objective:To investigate the risk factors for retrograde type A dissection (RTAD) associated with thoracic endovascular aortic repair (TEVAR) which provided the basis for clinical risk stratification and treatment decision.Methods:The clinical data of 1 688 patients with thoracic aortic disease who underwent TEVAR in our center from January 2004 to December 2019 were retrospectively analyzed. The pathological classification included aortic dissection (1 592 cases) and other thoracic aortic diseases (96 cases). Univariate analysis and categorical multiple logistic regression analysis were used to explore the risk factors for the development of RTAD during or after TEVAR.Results:A total of 18 cases of RTAD were found, with an overall incidence of 1.1% (18/1 688), all of which occurred in aortic dissection group. After adjusting for confounding factors, multivariate logistic regression analysis showed that the incidence of RTAD was significantly decreased(OR=0.27,95%CI 0.07-0.96, P=0.043) when the oversize of stentgraft was 11%-20%, the oversize of stentgraft was ≤10% as the control group, and the difference was statistically significant( P<0.05). The ascending aorta diameter was <40 mm as the control group, and there was no significant difference in the incidence of RTAD between the ≥40 mm group and the control group(OR=2.71,95%CI 0.94-7.84, P=0.065). Conclusions:Aortic dissection is more likely to develop RTAD than other thoracic aortic diseases. A proper stentgraft oversizing ratio could reduce the probability of RTAD. That is to say that a too low stentgraft oversizing ratio is not recommended.

Surgical treatment of retrograde type A aortic dissection after thoracic endovascular aortic repair for Stanford type B aortic dissection / 中国胸心血管外科临床杂志

@#Objective     To analyze the etiologies, surgical treatment and outcomes of retrograde type A aortic dissection (RTAD) after thoracic endovascular aortic repair (TEVAR) for Stanford type B aortic dissection. Methods     The clinical data of patients with RTAD after TEVAR for Stanford type B aortic dissection receiving operations in Changhai Hospital from March 2014 to August 2018 were analyzed. All patients were followed-up by clinic interview or telephone. Results     A total of 16 patients were enrolled, including 13 males and 3 females with a mean age of 49.1±12.2 years. The main symptoms of RTAD were chest pain in 12 patients, headache in 1 patient, conscious disturbance in 1 patient, and asymptomatic in 2 patients. All the 16 patients received total arch replacement with the frozen elephant trunk technique. Bentall procedure was used in 2 patients, aortic root plasticity in 10 patients and aortic valve replacement in 1 patient. The primary tear in 10 patients was located in the area which were anchored by bare mental stent, and in the other 6 patients it was located in the anterior part of ascending aorta. The mean cardiopulmonary bypass time was 152.2±29.4 min, aortic cross-clamping time was 93.6±27.8 min and selective cerebral perfusion time was 29.8±8.3 min. There was no death in hospital or within postoperative 30 days. The follow-up period was 32-85 (57.4±18.3) months. No death occurred during the follow-up period. One patient underwent TEVAR again 3 years after this operation and had an uneventful survival. Conclusion     Total arch replacement with the frozen elephant trunk technique is a suitable strategy for the management of RTAD after TEVAR for Stanford type B aortic dissection.

A Case of Aortoesophageal Fistula in Advanced Esophageal Cancer Treated with SB-Tube and TEVAR / 日本心臓血管外科学会雑誌

The patient is a 71-year-old man. After receiving chemoradiotherapy (CRTx) for an unresectable esophageal cancer, he developed sudden hematemesis during a follow-up examination. Subsequent imaging via contrast-enhanced computed tomography (CT) showed leakage of the contrast medium from the descending aorta into the esophagus. Consequently, an aortoesophageal fistula (AEF) was diagnosed and an emergency thoracic endovascular aortic stent graft repair (TEVAR) was scheduled. However, during the preparation for surgery, the patient vomited a large amount of blood and went into cardiopulmonary arrest. Following the administration of cardiopulmonary resuscitation, a Sengstaken-Blakemore tube (SB-tube) was inserted intranasally to control bleeding and TEVAR was performed to save his life. Although a gastrostomy was necessary after the surgery, the patient was transferred from the hospital on the 32nd day without any complications. Nonetheless, his general condition deteriorated as the cancer progressed and he died on the 103rd postoperative day. It is generally reported that the risk for esophageal perforation is 10-20% in CRTx for unresectable esophageal cancer. Although issues regarding the long-term prognosis of patients treated with TEVAR have been highlighted in recent years, there have also been reports of life-saving cases following its use; in this case, the patient was discharged home after SB-tube insertion and TEVAR with prompt treatment, resulting in his life being prolonged for an estimated 3 months.

Surgical Strategy for Protecting Major Branch Arteries during Thoracic Endovascular Aortic Repair for Shaggy Descending Aortic Aneurysms / 日本心臓血管外科学会雑誌

Surgery for a shaggy aortic aneurysm requires a meticulous strategy to prevent embolic complications since the complications are associated with longer length of hospital stay and higher mortality. However, until now, there are no established treatment options to prevent embolic complications. We report a case of a 75-year-old man with a descending aortic aneurysm and a shaggy aorta who underwent thoracic endovascular aortic repair (TEVAR) with major branch artery protection. During the procedure, we placed balloon catheters in the left subclavian and left common iliac arteries, a filter device in the superior mesenteric artery, and a sheath at the ostium of the right common iliac artery. The patient did not develop embolic or other complications and was discharged on the eighth postoperative day. Our strategy of using the balloon occlusion technique and filter placement at the major vessels effectively prevented embolic complications during TEVAR for a shaggy aorta.

Thoracic Endovascular Aortic Repair for Chronic Aortic Dissection with an Isolated Left Vertebral Artery / 日本心臓血管外科学会雑誌

Thoracic endovascular aortic repair (TEVAR) is valuable in the treatment of type B aortic dissection. An isolated left vertebral artery (ILVA) is a common anomaly of the aortic arch. The ILVA is covered during TEVAR in specific cases; however, whether the ILVA should be reconstructed in all cases remains controversial. We report a case of TEVAR performed for chronic aortic dissection in a patient with an ILVA. A 57-year-old woman with an ILVA had a type B acute aortic dissection one year prior to presentation and underwent TEVAR owing to dilation of an ulcer-like projection. We performed ILVA-left common carotid artery (LCCA) anastomosis and LCCA-left axillary artery bypass prior to TEVAR using our usual procedure. The postoperative course was favorable without any major complication. ILVA reconstruction may reduce the incidence of postoperative stroke and spinal cord injury. Usually, an ILVA is easily accessible through the supraclavicular approach, and the anatomical position of the vessel facilitates ILVA-LCCA anastomosis. ILVA reconstruction requires additional features and further consideration.

Successful Use of a Stent-Graft for Treating a Pseudoaneurysm Located at the Anastomosis of the Ascending Aorta and the Great Saphenous Vein / 日本心臓血管外科学会雑誌

Takayasu Arteritis causes annuloaortic ectasia and coronary ostial stenosis, which may necessitate open heart surgery. However, pseudoaneurysms are sometimes observed postoperatively, making subsequent treatment difficult. We report thoracic endovascular aortic repair of a pseudoaneurysm of the ascending aorta with an anastomosis of the great saphenous vein in a 61-year-old female with a history of multiple open-heart procedures. Thirty years earlier, she underwent aortic valve replacement and coronary artery bypass surgery for aortic regurgitation, and right coronary ostial stenosis. Eleven years after surgery, an ascending aortic aneurysm was found and Bentall's surgery was performed. Multiple open thoracotomies were subsequently performed. Postoperatively, a pseudoaneurysm was found at the anastomosis between the ascending aorta and the great saphenous vein. The patient was transferred to the emergency room owing to hemoptysis and was diagnosed with a ruptured pseudoaneurysm at the anastomosis of the ascending aorta and the great saphenous vein. By inserting a stent graft into the ascending aorta, we avoided further complications and her prognosis was good. She was discharged on postoperative day 18 and did not experience any end leak for a year. Thoracic endovascular aortic repair in the ascending aorta is a minimally invasive procedure that may be useful for high-risk patients.

Long-term outcomes after endovascular aortic treatment in patients with thoracic aortic diseases / Resultados a longo prazo após tratamento endovascular da aorta em pacientes com doenças da aorta torácica

Abstract Background Endovascular treatments for thoracic aortic diseases have been adopted rapidly, and long-term studies are relevant for durability evaluation. Objective To evaluate the long-term results of a prospective observational study of endovascular treatment in patients with thoracic aortic diseases who underwent percutaneous implantation of self-expandable endoprostheses. Methods Procedural success was defined as the absence of endoleak into the aneurysm or dissection-induced false lumen, no migration, and no conversion to open surgery. Intraoperative, postoperative, and late postoperative outcomes were evaluated in terms of complications, mortality, and evolution of the endoprosthesis over a follow-up of up to 179 months (median: 46 months). Results A total of 150 endoprostheses were implanted in 112 patients. Primary success was observed in 100 (82.14%) patients. Immediate mortality occurred in 7 patients (6.25%). Late mortality occurred in 31 patients (27.68%), 10 (8.93%) of whom died from cardiovascular causes, 12 (10.71%) from non-cardiovascular causes, and 2 (1.78%) from natural causes, while 7 (6.25%) had no diagnosis for cause of death. Types I, II, and IV endoleaks occurred during hospitalization in 4 (3.57%), 5 (4.46%), and 3 (2.68%) patients, respectively. Late types I and IV endoleaks occurred in 5 (4.46%) and 3 (2.68%) patients respectively. Twenty-two patients (19.64%) had clinical complications in the immediate postoperative period. Actuarial survival free from death from cardiovascular causes was 79.3% (95% confidence interval, 67.0-91.7%) at 132 months. Conclusions The low levels of intraoperative and postoperative complications demonstrate that endovascular treatment is safe and effective. The high rate of late survival for these critically ill patients indicates that the endovascular technique is beneficial for treatment of thoracic aortic diseases in terms of long-term outcomes.

Resumo Contexto Os tratamentos endovasculares para doenças da aorta torácica têm sido adotados rapidamente e estudos de longo prazo são relevantes para avaliação de durabilidade. Objetivo Avaliar através de estudo observacional e prospectivo, os resultados a longo prazo do tratamento endovascular em pacientes com doenças da aorta torácica submetidos a implante percutâneo de endoprótese autoexpansível. Métodos O sucesso do procedimento foi definido como ausência de vazamento interno para o aneurisma ou falso lúmen induzido por dissecção, ausência de migração e sem necessidade de conversão para cirurgia aberta. Os resultados intraoperatórios, pós-operatórios e tardios foram avaliados quanto a complicações, mortalidade e evolução da endoprótese em um seguimento de até 179 meses (mediana de 46 meses). Resultados Um total de 150 endopróteses foram implantadas em 112 pacientes. Sucesso primário foi observado em 100 (82,14%) pacientes. Mortalidade imediata ocorreu em sete pacientes (6,25%). A mortalidade tardia ocorreu em 31 pacientes (27,68%), dos quais 10 (8,93%) morreram por causas cardiovasculares; 12 (10,71%), por causas não cardiovasculares; dois (1,78%), por causas naturais e sete (6,25%) não tiveram a causa da morte diagnosticada. Vazamentos tipo I, II e IV ocorreram durante a internação em quatro (3,57%), cinco (4,46%) e três (2,68%) pacientes, respectivamente. Vazamentos tardios tipo I e IV ocorreram em cinco (4,46%) e três (2,68%) pacientes, respectivamente. Complicações clínicas no pós-operatório imediato foram observadas em 19,64% dos pacientes. A sobrevida atuarial por causas cardiovasculares foi de 79,3% em 132 meses. Conclusões Os baixos índices de complicações intra e pós-operatórias demonstram que o tratamento endovascular é seguro e eficaz. A alta taxa de sobrevida em 132 meses em pacientes críticos indica que a técnica é benéfica para o tratamento de doenças da aorta torácica em resultados a longo prazo.

Current state and progress of left subclavian artery revascularization in thoracic endovascular aortic repair / 国际外科学杂志

Thoracic endovascular aortic repair has served as the predominant treatment approach for patients with thoracic aortic diseases. In order to ensure the successful release of the stent as well as a good proximal anchoring effect, it is necessary to preserve or reconstruct the left subclavian supply as much as possible. With the advance of various endovascular assistive technologies, different left subclavian artery revascularization techniques have gained widespread acceptance. So far, techniques include carotid-subclavian bypass or transposition, chimney grafts, fenestrations, branched aortic devices can reconstruct the left subclavian artery and other branch vessels on the arch. This article reviewed the present situation of left subclavian artery reconstruction and the selection of surgical methods of thoracic endovascular aortic repair.

Short-term outcome of ascending aorta replacement combined with total aortic arch fenestration technique for acute type A aortic dissection / 中国胸心血管外科临床杂志

@#Objective    To report our clinical experience and outcomes of thoracic endovascular aortic repair (TEVAR) for acute Stanford type A dissection using ascending aorta replacement combined with implantation of a fenestrated stent-graft of the entire aortic arch through a minimally invasive technique. Methods    From 2016 to 2020 in our hospital, 24 patients (17 males and 7 females, aged 45-72 years) with complicated Stanford type A aortic dissection, underwent replacement of the proximal ascending aorta with TEVAR. None of the patients with dissection involved the three branches of the superior arch, and all patients were replaced with artificial blood vessels of the ascending aorta under non-hypothermic cardiopulmonary bypass, preserving the arch and the three branches above the arch, and individualized stent graft fenestration. Results    Surgical technical success rate was 100.0%. There was no intraoperative complication or evidence of endo-leak in 1 month postoperatively. Hospital stay was 10±5 d. During postoperative follow-up, the stent was unobstructed without displacement, the preserved branch of the aortic arch was unobstructed, and the true lumen of the descending aorta was enlarged. Conclusion     This hybrid technique by using TEVAR with fenestrated treatment is a minimally invasive and effective method to treat high-risk patients with acute Stanford type A aortic dissection.

Minimally invasive hybrid surgery for Stanford B aortic dissection involving the aortic arch / 中华胸心血管外科杂志

Objective:To investigate the effect and safety of one-staged hybrid surgery in the treatment of complicated Stanford B aortic dissection.Methods:246 consecutive patients who underwent one-staged hybrid technique with complicated type B aortic dissection (cTBAD) between January 2014 and July 2020 were retrospectively reviewed. The perioperative mortality and morbidity of the hybrid technique was assessed and the early results of follow up were evaluated.Results:The mean age of patients was(57.1±11.2)years old, and 175 (71.1%) were male. There were 166 cases of left common carotid artery-left subclavian artery vessels bypass + TEVAR (A group), operation time(62±8)min, post-operated hospitalization(5.2±1.3)days; 62 cases of right common carotid artery-left common carotid artery vessels bypass+ left common carotid artery-left subclavian artery vessels bypass + TEVAR (B group), operation time(88±12)min, post-operated hospitalization(6.1±1.8)days; 18 cases of debranch + TEVAR, operation time(236±36)min, post-operated hospitalization(8.8±2.1)days. 246 patients underwent hybrid procedure successfully (The technique success rate was 100%). 1 patient(0.4%)with traumatic aortic dissection (with cerebral trauma) died after operation 7 days. The average follow-up period was 5 years(30.3±7.1)xmonths. 236 patients(96%) without endoleak, 10 patients(4%)with proximal endoleak, 5 patients with regular follow-up, 5 patients with surgical treatment during one year (3 patients with re-TEVAR; 2 patients with opening operation); 25 patients(10.2%)incision hematomas, all these patients settled with closely observing and conservative treatment, and all these patients without reintervention. The rate of second intervention was 2% (5/246) the patency of bridging vessel was 99.7% (343/344). There was no paraplegia and stroke during perioperative period.Conclusion:One-staged hybrid surgery has a good short-term and med-term efficacy and safety for complicated Stanford B aortic dissection.

The long-term outcomes of one-stage hybrid procedure for aortic arch pathologies / 中华胸心血管外科杂志

Objective:To analyze the long-term outcomes of hybrid arch repair(HAR) treating aortic arch pathologies.Methods:Between January 2009 and January 2018, 87 consecutive patients underwent HAR for aortic arch pathologies at Beijing Anzhen Hospital. 76 were males. 2 cases were in zone 0, 46 cases were in zone 1, and 39 cases were in zone 2. The zones of the aortic arch were defined following the Ishimaru classification.Results:Five(5.7%) operative death occurred. 13 patients(19.1%) died during the follow-up. The overall survival rate was 88.4%, 83.3%, 83.3%, 49.8% at 1, 3, 5, 10 year, respectively. Multivariate Cox proportional risk analysis showed that stroke( HR=20.626, 95% CI: 2.698-157.685, P=0.004) was an independent risk factor for short-term death. Stroke( HR=16.234, 95% CI: 4.103-64.229, P<0.001) and spinal cord infury( HR=11.060, 95% CI: 2.150-56.893, P=0.004) were independent risk factors for long-term death. Conclusion:In conclusion, HAR could be an alternative procedure for the patients that are not suitable for open repair under the premise of strict control of indications. In the future, the risk assessment system and uniform operational indications for HAR should be further established.

Hemodynamic Analysis of Redissection after Endovascular Repair for One Stanford Type B Aortic Dissection Case / 医用生物力学

Objective Based on hemodynamic analysis, to investigate the cause of distal re-entry tear in Stanford type B aortic dissection after thoracic endovascular aortic repair (TEVAR).Methods A patient with type B aortic dissection was reexamined regularly with computed tomography angiography (CTA) at 1st month, 6th month, 12th month and 24th month after TEVAR. Based on the CTA images in each period, three-dimensional (3D) aorta models were reconstructed to perform morphological analysis and hemodynamic simulation.Results Compared with the diameter at 1st month after TEVAR, the diameter of true lumen at 12 months after TEVAR increased by 1.8 times and the global distortion of aorta increased by 16.67%. At postoperative 1st, 6th and 12th month, the maximum blood velocities at the new entry tear in systole were 69.6%, 33.7% and 92.1% higher than the average ones at distal landing zone, and the maximum wall shear stresses (WSSs) were 2.52, 2.32 and 3.52 times of the average WSSs respectively. In addition, the maximum time-averaged WSS (TAWSS) at 1st, 6th and 12th month after TEVAR were 1.88, 2.53 and 3.62 times of the mean TAWSS respectively.ConclusionsThe morphology of the aorta remodeled after TEVAR, and a sudden change in the diameter of true lumen occurred at distal anchoring zone and continued to increase. As a result, the blood flow velocity in this area accelerated, and the intima was continuously exposed to high WSS, leading to the redissection.

Castor single-branch stent in treating Stanford type B aortic dissection with insufficient anchorage zone / 中华普通外科杂志

Objective:To evaluate Castor single-branch covered-stent in the treatment of Stanford B aortic dissection(TBAD)with insufficient anchorage zone.Methods:Clinical data of 25 TBAD patients (proximal healthy landing zone ≤15 mm) treated with Castor branched stent-graft at Weifang People's Hospital from Apr 2019 to Sep 2021 were analyzed retrospectively.The stent model was selected according to preoperative CTA examination and intraoperative angiography,the operation result and follow up data were reviewed.Results:The operation success rate was 100%,the mean operative time was (137.8±35.8)min, and the mean blood loss was (52.8±24.5)ml. There were 2 cases of internal leakage (IA) and it was disappeared after balloon dilation, Branched stent stenosis occurred in 2 cases and relieved by balloon dilatation. The mean follow-up time was 14.6 months, and the patency rate of branch stent was 100% during the follow-up period. The true lumen diameter of thoracic aorta was significantly expanded and the false lumen diameter was significantly reduced 3 months after surgery compared with that before surgery ( P<0.05). Conclusion:Castor stenting in the treatment of TBAD with insufficient proximal anchoring area is simple and feasible, with satisfactory short term clinical effect.

Analysis of imaging characteristics of blunt traumatic aortic dissection: an 8-year experience / 世界急诊医学杂志（英文）

@#BACKGROUND: Traumatic aortic dissection (TAD) has a low incidence but extremely high mortality. It always presents atypical clinical manifestations that are easily missed or misdiagnosed. This study mainly aims to describe the imaging characteristics and management of TAD patients. METHODS: A retrospective analysis of 27 blunt TAD patients was performed between 2013 and 2020. Demographic features, imaging characteristics, and management were analyzed. RESULTS: Twenty-seven patients with type B aortic dissection (age 56.04±16.07 years, 20 men) were included. Aortic intimal tears were mostly initiated from the aortic isthmus. The sizes of the proximal intimal tears in the greater curvature were larger than those in the lesser curvature (1.78±0.56 cm vs. 1.24±0.52 cm, P=0.031). Compared with those in the control group, the maximum diameters of the aortic arch, thoracic aorta, and abdominal aorta in the TAD patients were all significantly widened (all P<0.050). Multivariate logistic regression analysis showed that the maximum diameter of the thoracic aorta was an independent risk factor for TAD, with a predictive value with an area under the receiver operating characteristic curve (AUC) of 0.673. Finally, 26 patients successfully underwent delayed thoracic endovascular aortic repair (TEVAR), and the remaining one patient was treated conservatively. No progression of aortic dissection or death occurred during the six-month follow-up period. CONCLUSIONS: In blunt trauma, the aortic isthmus is the most common site of proximal intimal tears. An accurate diagnosis of TAD requires an overall consideration of medical history and imaging characteristics. Delayed TEVAR might be an effective therapeutic option for TAD.

Thoracic Endovascular Aortic Repair Following Axillo-Femoral Bypass in a Patient with Stanford B Acute Aortic Dissection Accompanied by Renal Ischemia / 日本心臓血管外科学会雑誌

A 71-year-old male was admitted to our institution because of right leg pain and paleness, accompanied by sudden chest-back pain. The right femoral artery was not palpable. The reticulated cyanosis appeared on the right leg. Contrast enhanced computed tomography (CT) revealed an acute type B aortic dissection (TBAD) extending from the descending thoracic aorta to the left common iliac artery and right external iliac artery. The intimal tear was located at thoraco-abdominal aorta. There was a severe stenosis of the true lumen at bilateral common iliac arteries because of the dynamic compression caused by the extended false lumen. Blood to the right leg was not supplied from the dissected iliac artery, the peripheral circulation was maintained by collateral flow. The patient was diagnosed acute TBAD complicated with lower limb ischemia. An emergent right axillary artery-bifemoral arteries bypass was carried out for malperfusion of lower extremities. The symptoms in the lower limbs disappeared immediately. The bilateral femoral arteries were well palpated. However, 4 days later, uncontrollable severe hypertension and anuria appeared suddenly. Contrast enhanced CT revealed the stenosis of true lumen at bilateral renal arteries and an exacerbation of stenosis of true lumen at abdominal aorta. Emergent thoracic endovascular aortic repair (TEVAR) for entry closure was performed to improve the renal function and prevent mesenteric ischemia. Postoperative contrast enhanced CT revealed the complete closure of the entry tear and dilatation of the true lumen at the descending and abdominal aorta. At the bilateral renal arteries, the blood flow improved. The renal function recovered and mesenteric ischemia did not occurred. In this report, we presented a case of acute TBAD complicated with lower limbs ischemia and late onset acute ischemic renal failure. We first performed the right axillary artery-bifemoral arteries bypass grafting, after that we had to perform TEVAR to close the entry tear. One-stage emergent TEVAR should be considered for acute TBAD with the dynamic compression at the level of abdominal aorta in future.

Retroperitoneal iliac conduits as an alternative access site for endovascular aortic repair: a tertiary care center experience / Condutos ilíacos retroperitoneais como local de acesso alternativo para reparo endovascular de aneurisma: experiência em centro de atenção terciária

Abstract Background Retroperitoneal open iliac conduits (ROIC) are used in patients with hostile iliac anatomy undergoing endovascular aortic repair (EVAR). Objectives We hereby report our experience of ROIC in patients subjected to EVAR. Methods This was a retrospective evaluation of 8 patients out of a total of 75 patients (11%) who underwent EVAR in the last 10 years. Pre-procedure computed tomography angiography was used to assess the dimensions of iliac and femoral arteries. Patients who had small arterial dimensions (i.e. smaller than the recommended access size for the aortic endograft device) were subjected to ROIC. Results The mean age of the 3 males and 5 females studied was 45.7 ± 15.2 years. The indication for ROIC was the small caliber ilio-femoral access site in 7 patients and atherosclerotic disease in 1 patient. All external grafts were anastomosed to the right common iliac artery except one which was anastomosed to the aortic bifurcation site because of a small common iliac artery. The procedural success rate was 100%. Local access site complications included infection (n=1), retroperitoneal hematoma (n=1), and need for blood transfusion (n=3). The median post-intervention hospital stay was 10 days. All patients had favorable long-term outcomes at a median follow-up of 18 months. Conclusions Female patients require ROIC during EVAR more frequently. Adjunctive use of iliac conduit for EVAR was associated with favorable perioperative and short-term outcomes.

Resumo Contexto Os condutos ilíacos abertos retroperitoneais são utilizados em pacientes submetidos a reparo endovascular de aneurisma (REVA) com anatomia ilíaca hostil. Objetivos Relatamos a nossa experiência com os condutos ilíacos em pacientes submetidos a REVA. Métodos Trata-se de uma avaliação retrospectiva de oito pacientes, de um total de 75 (11%), os quais foram submetidos a REVA nos últimos 10 anos. Foi realizada angiotomografia computadorizada antes do procedimento para avaliar as dimensões das artérias ilíaca e femoral. Os pacientes com dimensões arteriais menores, abaixo do tamanho de acesso recomendado para o dispositivo de endoprótese aórtica, foram submetidos a condutos ilíacos. Resultados A média de idade dos participantes foi de 45,7±15,2 anos, sendo três do sexo masculino e cinco do sexo feminino. As indicações para condutos ilíacos foram local de acesso ilíaco femoral de pequeno calibre, para sete pacientes, e doença aterosclerótica, para um paciente. Todas as próteses externas foram anastomosadas na artéria ilíaca comum direita, com exceção de uma, que foi anastomosada no local da bifurcação aórtica por apresentar artéria ilíaca comum menor. A taxa de sucesso do procedimento foi de 100%. As complicações no local de acesso incluíram infecção (n = 1), hematoma retroperitoneal (n = 1) e necessidade de transfusão de sangue (n = 3). O tempo mediano de internação hospitalar pós-intervenção foi de 10 dias. Todos os pacientes apresentaram desfechos de longo prazo favoráveis no seguimento mediano de 18 meses. Conclusões As pacientes do sexo feminino necessitaram de condutos ilíacos durante REVA com maior frequência. O uso adjuvante de condutos ilíacos com REVA foi associado a desfechos perioperatórios e de curto prazo favoráveis.

Early and late results of open surgical and endovascular treatment of infrarenal abdominal aortic aneurysms, selected according to surgical risk / Resultados precoces e tardios dos tratamentos aberto e endovascular de aneurismas da aorta abdominal infrarrenal, selecionados de acordo com o risco cirúrgico

Abstract Background Open surgical repair (OSR) and endovascular aneurysm repair (EVAR) surgery are alternative treatments for infrarenal abdominal aortic aneurysm (IRAAA). Objectives To compare OSR and EVAR for the treatment of IRAAA. Methods 119 patients with IRAAA were electively operated by the same surgeon between January 1, 2006 and December 31, 2015, following selection for OSR or EVAR according to surgical risk. Complications, reinterventions, failures, and early and late mortality were analyzed. Results 63 OSR and 56 EVAR patients were analyzed. They were similar in terms of age (70 years), gender (92% men), and average diameter of IRAAA (6.5 cm), but with different comorbidities, surgical risk, and anatomy. EVAR was better than OSR regarding time in the operating theatre (177.5 vs. 233.3 minutes), need for transfusion (25 vs. 73%), and length of stay in ICU (1.3 vs. 3.3 days) and hospital (8.1 vs. 11.1 days). OSR allowed more associated procedures to be conducted simultaneously (19.0 vs. 1.8%). There were no significant differences between the groups with respect to complications (25.4 vs. 25.1%), reinterventions (3.2 vs. 5.2%), or early mortality (1.6 vs. 0%). During follow-up, OSR was associated with fewer revisions (3.13 vs. 4.21), angio-CTs (0.22 vs. 3.23), complications (6.4 vs. 37.5%), reinterventions (3.2 vs. 23.2%), and failures (1.6 vs. 10.7%), and had better survival (78.2 vs. 63.2%). Conclusions Correct selection of patients achieves excellent results because it avoids OSR in patients at high risk and avoids EVAR in patients with high anatomical complexity, achieving similar results in the perioperative period, but better results for OSR over the course of follow-up.

Resumo Contexto A cirurgia aberta (CA) e o reparo endovascular de aneurisma (REVA) são tratamentos alternativos para o aneurisma da aorta abdominal infrarrenal (AAAIR). Objetivos Comparar CA e REVA no tratamento do AAAIR. Métodos Foram incluídos 119 pacientes com AAAIR, operados eletivamente pelo mesmo cirurgião entre 1 de janeiro de 2006 e 31 de dezembro de 2015, após seleção para CA ou REVA de acordo com o risco cirúrgico. Complicações, reintervenções, falhas e mortalidade precoce e tardia foram analisadas. Resultados Foram analisados 63 pacientes de CA e 56 de REVA, com semelhanças de idade (70 anos), sexo (92% homens) e diâmetro médio do AAAIR (6,5 cm), mas com diferentes comorbidades, riscos cirúrgicos e anatomias. O REVA foi melhor que a CA em relação ao tempo na sala de cirurgia (177,5 vs. 233,3 minutos), necessidade de transfusão (25 vs. 73%) e tempo de permanência na unidade de terapia intensiva (1,3 vs. 3,3 dias) e no hospital (8,1 vs. 11,1 dias). A CA permitiu que mais procedimentos associados fossem realizados simultaneamente (19,0 vs. 1,8%). Não houve diferenças significativas entre os grupos em relação a complicações (25,4 vs. 25,1%), reintervenções (3,2 vs. 5,2%) e mortalidade precoce (1,6 vs. 0%). Durante o acompanhamento, a CA apresentou menos revisões (3,13 vs. 4,21), angiotomografias (0,22 vs. 3,23), complicações (6,4 vs. 37,5%), reintervenções (3,2 vs. 23,2%) e falhas (1,6 vs. 10,7%), além de ter melhor sobrevida (78,2 vs. 63,2%). Conclusões A seleção correta dos pacientes proporciona excelentes resultados porque evita pacientes com alto risco para CA e com complexidade anatômica para REVA. Os resultados são semelhantes no período perioperatório, mas melhores para CA durante o acompanhamento.

Analysis of clinical characteristics and prognostic risk factors in patients with Stanford type B aortic dissection complicated with hypertension / 中华危重病急救医学

Objective:To investigate the clinical characteristics as well as short-term and long-term prognostic factors of patients with Stanford type B aortic dissection (TBAD) with hypertension.Methods:Patients with TBAD who received thoracic endovascular aortic repair (TEVAR) admitted to Xiangyang Central Hospital from January 2014 to December 2018 were enrolled. The baseline data of patients admitted to the hospital were collected through the case management system, including gender, age, underlying diseases (hypertension, diabetes, coronary heart disease), smoking history, drinking history, duration of pain, vital signs at admission [heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP)], laboratory results [white blood cell count (WBC), platelet count (PLT), neutrophil/lymphocyte ratio (NLR), serum creatinine (SCr), C-reactive protein (CRP), D-dimer, ascending aorta diameter], etc. The clinical characteristics of TBAD patients with hypertension were analyzed. Logistic regression model and Cox proportional risk model were used to analyze the impact of hypertension on the short-term and long-term all-cause deaths after TEVAR in TBAD patients.Results:Among 227 TBAD patients, 160 cases (70.5%) were complicated with hypertension, while 67 cases (29.5%) were not. The average age, the proportion of diabetes and coronary heart disease, and the level of SBP, DBP and SCr at admission of TBAD patients with hypertension were higher than those of TBAD without hypertension [age (years old): 53.1±11.9 vs. 42.8±14.1, combined with diabetes: 8.8% vs. 1.5%, combined with coronary heart disease: 6.3% vs. 0%, SBP (mmHg, 1 mmHg = 0.133 kPa): 147.9±18.1 vs. 136.9±15.2, DBP (mmHg): 93.9±11.9 vs. 89.1±13.8, SCr (μmol/L): 97.8±25.4 vs. 89.8±23.6, all P < 0.05]. The short-term mortality of TBAD with hypertension group was significantly higher than that of TBAD without hypertension group [6.3% (10/160) vs. 0% (0/67), χ2 = 4.386, P = 0.036]. 227 patients with TBAD were followed up for 3-66 months, with a median follow-up time of 25 months. There was no significant difference in long-term mortality between TBAD patients with and without hypertensive during discharge follow-up [13.1% (21/160) vs. 9.0% (6/67), χ2 = 0.784, P = 0.376]. Further multivariate Logistic regression analysis and Cox regression analysis did not indicate that hypertension was an independent risk factor for short-term and long-term death in TBAD patients [odds ratio ( OR) and 95% confidence interval (95% CI) were 13.477 (0.541-330.215), 1.012 (0.990-1.035), both P > 0.05]. Age and HR were independent risk factors for the short-term mortality of TBAD patients [ OR and 95% CI were 15.287 (1.051-226.415), 0.026 (0.002-0.840), both P < 0.05]. Age, PLT and D-dimer were independent risk factors for the long-term mortality of TBAD patients [ OR and 95% CI were 1.808 (1.205-2.711), 0.555 (0.333-0.924), 1.482 (1.035-2.122), respectively, all P < 0.05]. Conclusions:The TBAD patients with hypertension have older age, high rates of diabetes or coronary heart disease. However, hypertension is not an independent risk factor for short-term and long-term mortality in TBAD patients.

Endovascular repair of complex aortic arch lesion with application of recanalize left subclaivian artery in intracavitary / 中华胸心血管外科杂志

Objective:To investigate the effect of different ways of reconstruction of left subclavian artery (LSA) in the treatment of complex aortic arch lesions.Methods:The clinical data of 34 patients with complex thoracic aortic disease undergoing intracavitary LSA reconstruction in our center from January 2019 to February 2020 were retrospectively analyzed. The distance of proximal healthy landing zone of all patients, including 29 aortic dissections involving LSA, 3 penetrating aortic ulcer and 2 thoracic aortic aneurysms, was less than 15 mm. Among them, 16 cases were treated with chimney technique, 16 cases were implanted with single branched stent-graft, 2 cases were received with left common carotid artery and LSA in situ fenestration.Results:The operation success rate of all 34 patients was 100%. One case was changed from in situ fenestration to chimney stenting. Followed up for 1-12 months, there were no death, cerebral ischemia, paraplegia and other postoperative complications. CTA review showed that the main and branch stents were in good shape, the patency rate of LSA branch stents was 100% and no endoleak occurred at 1 and 3 months after operation. The muscle strength and arterial blood pressure of bilateral upper limbs of all patients were basically the same.Conclusion:There is no consensus for the treatment of complex aortic arch lesions, so we need to customize the personalized plan and select the appropriate LSA reconstruction method in order to reduce the incidence of complications.

Endovascular Aortic Repair for Type B Acute Aortic Dissection with Leg Malperfusion / 日本心臓血管外科学会雑誌

Leg malperfusion accompanied with type B acute aortic dissection (AAD) is reported to be an independent predictor for mortality. In such a case, though aortic replacement, extra anatomical arterial bypass or endovascular aortic repair (EVAR) can be selected, an appropriate treatment strategy has not been established yet. A 53-year-old woman was urgently hospitalized with sudden low back pain and right leg weakness, despite the right popliteal and anterior tibial arteries being palpable. Computed tomography (CT) revealed a type B AAD, and antihypertensive therapy was initiated. She complained of intermittent claudication during rehabilitation, and right leg ischemia with decreased ankle brachial pressure index (ABPI) was detected. The follow-up CT revealed the narrow true lumen of the right common iliac artery compressed by the thrombosed false lumen and the large entry of the aortic dissection in the terminal aorta. At the subacute phase of the aortic dissection, EVAR was performed. To expand the true lumen and exclude the entry, Y-shaped stent-grafts were implanted in the infra-renal aorta and the bilateral common iliac arteries. The postoperative course was uneventful. Postoperative ABPI returned to the normal range, and the intermittent claudication disappeared. In conclusion, EVAR should be considered in patients with type B AAD complicated with leg malperfusion.