ABSTRACT
BACKGROUND: Guidelines supporting the decision to replace the aorta in patients with chronic asymptomatic proximal aortic disease are limited by lack of data on operative risks and long-term effectiveness in relation to aortic size. Therefore, we assessed and compared outcomes of patients undergoing elective isolated proximal aortic replacement for this disease vs replacement during multicomponent operations. METHODS: From January 2006 to January 2011, 1,889 patients underwent proximal aortic replacement (isolated, 212; multicomponent, 1,677) for chronic asymptomatic ascending and arch pathology. Mean age was 60 ± 14 years, and maximum proximal aortic diameter was 52 ± 10 mm (isolated) and 49 ± 10 mm (multicomponent; p = 0.0004). Propensity matching using 64 preoperative variables yielded 197 well-matched patient pairs. RESULTS: Patients were more likely to undergo isolated replacement if they had prior cardiac operations and a larger middescending aortic diameter (p < 0.0001). Multicomponent operations were more common among those with connective tissue disorder or porcelain aorta. Among propensity-matched patients, in-hospital mortality was 1 of 197 (0.5%) in the isolated group vs 8 of 197 (4.1%) in the multicomponent group. Occurrence of stroke, renal failure, and prolonged ventilation were similar. Median postoperative stay was 7.9 vs 8.1 days (p = 0.07). At 30 days, 1 year, and 4 years, survival was 97%, 93%, and 87%, and freedom from reintervention was 98%, 90%, and 89%, respectively, similar between groups. CONCLUSIONS: Elective ascending aortic replacement is safe and effective. Ascending aneurysms should be treated aggressively even when encountered in patients undergoing a multicomponent operation. An aggressive approach to replacement of the ascending aorta may be warranted given the increased risk of stroke during a subsequent reoperation.
Subject(s)
Aortic Aneurysm, Thoracic/surgery , Blood Vessel Prosthesis Implantation/mortality , Cause of Death , Elective Surgical Procedures/methods , Hospital Mortality , Stroke/mortality , Age Factors , Aged , Aortic Dissection/diagnostic imaging , Aortic Dissection/surgery , Aortic Aneurysm, Thoracic/diagnostic imaging , Aortic Aneurysm, Thoracic/mortality , Blood Vessel Prosthesis Implantation/methods , Case-Control Studies , Elective Surgical Procedures/mortality , Female , Humans , Male , Middle Aged , Propensity Score , Retrospective Studies , Risk Assessment , Sex Factors , Stroke/etiology , Stroke/physiopathology , Survival AnalysisABSTRACT
OBJECTIVE: Persistent retrograde false lumen perfusion is a common mode of failure after thoracic endovascular aortic repair (TEVAR) for chronic dissection. Objectives were to describe a novel endovascular approach for false lumen occlusion and assess outcomes. METHODS: From 2009 to 2013, 21 patients (mean age, 64 ± 11 years) with chronic thoracoabdominal dissection underwent adjunctive false lumen embolization using covered stent devices for persistent retrograde perfusion. Eight patients had type B dissection, 13 had residual dissection after prior type A repair, and all were deemed high risk for open operation. False lumen embolization in 17 patients was an adjunct at the initial TEVAR or extension, including two as elephant trunk completion. In the other four, this was done as an isolated procedure, and three had previously undergone TEVAR sparing the celiac artery. Covered stent devices included iliac plugs in 18, nitinol embolization plugs in two, and occluded stent graft in one. More than one device was used in 15 patients. RESULTS: There was one hospital death due to left subclavian artery aneurysm rupture but no patient had stroke, paraplegia, myocardial infarction, or renal failure. Mean follow-up was 25 ± 19 months. During surveillance computed tomography imaging, false lumen thrombosis was noted in all patients, but four required further embolization because the thrombosis was incomplete. Mean maximum aortic diameter decreased from 64 ± 14 to 59 ± 15 mm. There was one late death from intracranial hemorrhage and no aortic ruptures. CONCLUSIONS: Adjunctive false lumen embolization with a covered stent device promotes thrombosis and remodeling after stent grafting the true lumen for chronic dissection. Further study of this strategy is warranted.
Subject(s)
Aortic Aneurysm, Thoracic/therapy , Aortic Dissection/therapy , Embolization, Therapeutic , Endovascular Procedures/instrumentation , Stents , Aged , Alloys , Aortic Dissection/diagnosis , Aortic Dissection/physiopathology , Aortic Aneurysm, Thoracic/diagnosis , Aortic Aneurysm, Thoracic/physiopathology , Aortography/methods , Chronic Disease , Embolization, Therapeutic/adverse effects , Endovascular Procedures/adverse effects , Female , Humans , Male , Middle Aged , Prosthesis Design , Thrombosis , Time Factors , Tomography, X-Ray Computed , Treatment Outcome , Vascular RemodelingABSTRACT
Thoracic endovascular aortic repair (TEVAR) is effective in treating acute complicated dissection, but in the chronic state it is frequently complicated by persistent retrograde false lumen perfusion that results in treatment failure. We describe a novel endovascular technique and present an illustrative case of a patient with chronic dissection for which covered stent devices were used as an adjunct to TEVAR to occlude the distal thoracic false lumen and interrupt retrograde perfusion. The case demonstrates that this strategy promotes remodeling when used in addition to stent grafting the true lumen for chronic dissection.
