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BACKGROUND: The use of the cell saver is well-established in open aneurysm repair; however, its role in endovascular repair is yet to be determined. The aim of this study was to analyze the effects of cell saver usage in patients undergoing complex endovascular procedures. MATERIALS AND METHODS: Single-center retrospective cohort study, including consecutive patients undergoing fenestrated and/or branched repair for the treatment of thoracoabdominal and complex abdominal aortic aneurysms (CAAAs) between January 2019 and December 2022. The cell saver was a standard part of the intraoperative setup of these procedures, and its use was readily available. The primary endpoint was the percentage of patients, in which autologous blood collected was transfused (cell saver blood transfusion [CSBT]), alongside the useable amount obtained. Secondary endpoints included mean blood loss, postoperative hemoglobin levels, and 30-day mortality. RESULTS: A total of 170 patients (77.1% male, mean age 71.2 ± 9.2 years) were included, with a median blood loss of 700 mL (interquartile range [IQR] 400-1,200 mL). A total of 96 patients received some kind of blood transfusion (BT) (56.5%): 35 patients were (20.6%) allogenic BT, 31 patients were (18.2%) CSBT only, and 30 patients were (17.6%) a combination of both. In total, 61 patients (35.9% or 63.5% of all patients requiring BTs) received CSBT, with a median useable blood volume of 282 mL (IQR, 194.5-508 mL). Thirty-day mortality was similar in both groups. Although the CSBT group had lower intraoperative hemoglobin values (9.25 ± 1.55 vs. 10.36 ± 1.88 mg/dL; P < 0.001), both groups presented similar postoperative hemoglobin (Hb) levels. CONCLUSIONS: Blood loss during complex endovascular repair is not insignificant. In this cohort, over 50% of included patients required some kind of BT, 32.3% of which received exclusively CSBT, while 31.3% had supplementary CSBT alongside allogenic BT. This data showcases its potential role in these repairs, paving the way for its standardization in the intraoperative setup of these complex procedures.
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OBJECTIVE: To evaluate sex based differences in ascending aorta and arch anatomy in patients with underlying proximal aortic disease and to evaluate their impact on feasibility for total endovascular repair with custom made, branched arch devices. METHODS: This was a retrospective cross sectional review of all patients undergoing open and or total endovascular arch repair due to distal ascending aorta and or aortic arch pathologies in a single high volume aortic centre between 2012 and 2022. Anatomical ascending aorta and aortic arch parameters were analysed on a flow centreline on a dedicated 3D workstation. Sex related differences of the ascending aorta, aortic arch, and supra-aortic vessels were evaluated. Subsequently, four endovascular devices were assessed for feasibility: double and triple branched devices both for the Zenith (Cook Medical) and Relay (Terumo Aortic) platforms, first in accordance with the instructions for use and then considering the possibility of adjunctive cervical debranching. The primary endpoints were sex specific differences in aortic anatomy, while secondary endpoints included sex based feasibility of branched endograft devices. RESULTS: During the study period, 395 patients underwent total aortic arch repair, of whom 152 (51 female, 33.5%) had high quality computed tomography angiograms available and were included in the study. Female patients had a shorter proximal landing zone than males (22 mm vs. 47 mm; p < .001). Left subclavian artery dissection was more frequent in men (24.8% vs. 3.9%; p < .001). Other anatomical parameters showed a similar distribution between sexes. Female patients presented a lower feasibility for double branched devices (35.3% vs. 58.4%; p = .015) as well as a tendency for lower feasibility rates for triple branched devices (31.4% vs. 47.5%; p = .081). CONCLUSION: Although most ascending aortic and arch parameters showed similar trends in both sexes, the availability of a suitable proximal landing zone was lower in female patients. Consequently, female patients had lower feasibility rates for double arch branched endografts and, to lesser extent, for triple arch branched endografts.
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OBJECTIVE: This study aimed to evaluate the impact of target vessel anatomy and bridging stent geometry on target vessel instability in branched endovascular aortic repair (B-EVAR). METHODS: This retrospective, single centre cohort study included all consecutive B-EVARs performed between September 2018 and December 2022 for thoraco-abdominal aortic aneurysm (TAAA) or complex abdominal aortic aneurysm (CAAA). The primary endpoints were target vessel instability and related re-interventions at 12 months. Secondary endpoints were 30 day results, including target vessel instability and re-interventions. Target vessel instability analysis consisted of assessment of target vessel anatomy, including diameter, aortic trunk to branch angle, and tortuosity. Post-operative parameters included change of clock position/horizontal misalignment, bridging length (gap), sealing length, tortuosity, post-stenting angle, and oversizing ratio. RESULTS: A total of 69 patients (TAAA: n = 56, 81%; CAAA: n = 13, 19%) and 271 (133 visceral and 138 renal) target vessels were included. The cumulative incidence of target vessel instability was 4.8%, 6.4%, and 7.9% at one, two, and three years, respectively. In the renal target vessel group, vessel diameter ≤ 4 mm (hazard ratio [HR] 1.28, 95% confidence interval [CI] 1.116 - 2.54; p = .022) and a bridging length ≥ 25 mm (HR 1.320, 95% CI 1.066 - 1.636; p = .011) were associated with increased target vessel instability. In visceral vessels, a change in clock position/horizontal misalignment ≥ 70 minutes (HR 1.072, 95% CI 1.026 - 1.121; p = .002) showed a significant association with target vessel instability. CONCLUSION: Target vessel diameter, bridging length (gap), and horizontal misalignment seemed to be associated with adverse target vessel outcomes. This may be solved with more customised endograft solutions to reduce the negative impact of the latter parameter.
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OBJECTIVE: With an increasing life expectancy, more octogenarian patients are referred with complex aortic aneurysms (cAAA). The aim of this study was to evaluate short and mid-term outcomes following fenestrated aortic repair (FEVAR) in octogenarians. SUMMARY BACKGROUND DATA: Few studies looking at octogenarian-specific outcomes with diverging results. METHODS: Retrospective, multicentre cohort study including consecutive patients undergoing elective FEVAR for cAAAs or type IV thoracoabdominal aortic aneurysms between 2007-2022 in eight high-volume centres. Octogenarians vs. non-octogenarians were compared. The primary outcome was 30-day mortality. Secondary outcomes included 1, 2 and 5-year survival and reintervention rates. RESULTS: A total of 729 patients (median age of 74.8 years [IQR 69.2 - 79.14]) were included, 169 (23%) of which were octogenarians, with 316 (43.3%) patients undergoing juxta/pararenal aneurysm repair. Although octogenarians presented less complex but larger (61 mm vs. 58 mm) aneurysms, the number of fenestrations was similar across groups. No differences in in-hospital mortality (4.1 vs. 3.0%), MAE (16.6% vs 12.2%) or reintervention rates (11.2 vs. 10%) were found. Multivariable logistic regression of in-hospital mortality identified BMI (OR 0.66, 95% CI 0.51-0.95, P=0.003), chronic heart failure (OR 7.70, 95% CI 1.36-36.15, P=0.003) and GFR<45 ml/min/1.73 m2 (OR 5.25, 95% CI 1.20-22.86, P=0.027) as independent predictors. Median follow-up was 41 months. The 1, 2 and 5-year survival rates were 91.3%, 81.8% and 49.5% in octogenarians vs 90.6%, 86.5% and 68.8% in non-octogenarian patients (Log-rank: =0.001). Freedom from aortic-related death and freedom from reintervention at five-years were similar across groups (log-rank=0.94 and .76, respectively). Age>80 was not an independent predictor of 30-day or long-term mortality on multivariable and Cox regression analysis. CONCLUSIONS: Elective FEVAR in octogenarians appears to be safe, with similar outcomes as in younger patients. Future studies looking at improved patient selection methods to ensure long-term survival benefits in both octogenarians and younger patients are warranted.
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OBJECTIVE: The European Society for Vascular Surgery (ESVS) has developed clinical practice guidelines for the care of patients with aneurysms of the abdominal aorta and iliac arteries in succession to the 2011 and 2019 versions, with the aim of assisting physicians and patients in selecting the best management strategy. METHODS: The guideline is based on scientific evidence completed with expert opinion on the matter. By summarising and evaluating the best available evidence, recommendations for the evaluation and treatment of patients have been formulated. The recommendations are graded according to a modified European Society of Cardiology grading system, where the strength (class) of each recommendation is graded from I to III and the letters A to C mark the level of evidence. RESULTS: A total of 160 recommendations have been issued on the following topics: Service standards, including surgical volume and training; Epidemiology, diagnosis, and screening; Management of patients with small abdominal aortic aneurysm (AAA), including surveillance, cardiovascular risk reduction, and indication for repair; Elective AAA repair, including operative risk assessment, open and endovascular repair, and early complications; Ruptured and symptomatic AAA, including peri-operative management, such as permissive hypotension and use of aortic occlusion balloon, open and endovascular repair, and early complications, such as abdominal compartment syndrome and colonic ischaemia; Long term outcome and follow up after AAA repair, including graft infection, endoleaks and follow up routines; Management of complex AAA, including open and endovascular repair; Management of iliac artery aneurysm, including indication for repair and open and endovascular repair; and Miscellaneous aortic problems, including mycotic, inflammatory, and saccular aortic aneurysm. In addition, Shared decision making is being addressed, with supporting information for patients, and Unresolved issues are discussed. CONCLUSION: The ESVS Clinical Practice Guidelines provide the most comprehensive, up to date, and unbiased advice to clinicians and patients on the management of abdominal aorto-iliac artery aneurysms.
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BACKGROUND: While most European Regions perform well in global comparisons, large discrepancies within stroke epidemiological parameters exist across Europe. The objective of this analysis was to evaluate the stroke burden across European regions and countries in 2019 and its difference to 2010. METHODS: The GBD 2019 analytical tools were used to evaluate regional and country-specific estimates of incidence, prevalence, deaths, and disability-adjusted life years of stroke for the European Region as defined by the World Health Organization, with its 53 member countries (EU-53) and for European Union as defined in 2019, with its 28 member countries (EU-28), between 2010 and 2019. Results were analyzed at a regional, subregional, and country level. RESULTS: In EU-53, the absolute number of incident and prevalent strokes increased by 2% (uncertainty interval [UI], 0%-4%), from 1â 767â 280 to 1â 802â 559 new cases, and by 4% (UI, 3%-5%) between 2010 and 2019, respectively. In EU-28, the absolute number of prevalent strokes and stroke-related deaths increased by 4% (UI, 2%-5%) and by 6% (UI, 1%-10%), respectively. All-stroke age-standardized mortality rates, however, decreased by 18% (UI, -22% to -14%), from 82 to 67 per 100â 000 people in the EU-53, and by 15% (UI, -18% to -11%), from 49.3 to 42.0 per 100â 000 people in EU-28. Despite most countries presenting reductions in age-adjusted incidence, prevalence, mortality, and disability-adjusted life year rates, these rates remained 1.4×, 1.2×, 1.6×, and 1.7× higher in EU-53 in comparison to the EU-28. CONCLUSIONS: EU-53 showed a 2% increase in incident strokes, while they remained stable in EU-28. Age-standardized rates were consistently lower for all-stroke burden parameters in EU-28 in comparison to EU-53, and huge discrepancies in incidence, prevalence, mortality, and disability-adjusted life-year rates were observed between individual countries.
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Carga Global de Enfermedades , Accidente Cerebrovascular , Humanos , Europa (Continente)/epidemiología , Accidente Cerebrovascular/epidemiología , Incertidumbre , Organización Mundial de la SaludRESUMEN
OBJECTIVE: To evaluate the contemporary growth rate of small abdominal aortic aneurysms (AAAs) in view of recent epidemiological changes, such as decreasing smoking rates and establishment of population screening programmes. DATA SOURCES: MEDLINE, CENTRAL, PsycINFO, Web of Science Core Collection, and OpenGrey databases. REVIEW METHODS: Systematic review following the PRISMA guidelines. In October 2021, databases were queried for studies reporting on AAA growth rates published from 2015 onwards. The primary outcome was contemporary AAA growth rates in mm/year. Data were pooled in a random effects model meta-analysis, and heterogeneity was assessed through the I2 statistic. GRADE assessment of the findings was performed. The protocol was published in PROSPERO (CRD42022297404). RESULTS: Of 8 717 titles identified, 43 studies and 28 277 patients were included: 1 241 patients from randomised controlled trials (RCTs), 23 941 from clinical observational studies, and 3 095 from radiological or translational research studies. The mean AAA growth rate was 2.38 mm/year (95% CI 2.16 - 2.60 mm/year; GRADE = low), with meta-regression analysis adjusted for baseline diameter showing an increase of 0.08 mm/year (95% CI 0.024 - 0.137 mm/year; p = .005) for each millimetre of increased baseline diameter. When analysed by study type, the growth rate estimated from RCTs was 1.88 mm/year (95% CI 1.69 - 2.06 mm/year; GRADE = high), while it was 2.31 mm/year (95% CI 1.95 - 2.67 mm/year; GRADE = moderate) from clinical observational studies, and 2.85 mm/year (95% CI 2.44 - 3.26 mm/year; GRADE = low) from translational and radiology based studies (p < .001). Heterogeneity was high, and small study publication bias was present (p = .003), with 27 studies presenting a moderate to high risk of bias. The estimated growth rate from low risk studies was 2.09 mm/year (95% CI 1.87 - 2.32; GRADE = high). CONCLUSION: This study estimated a contemporaneous AAA growth rate of 2.38 mm/year, being unable to demonstrate any clinically meaningful AAA growth rate reduction concomitant with changed AAA epidemiology. This suggests that the RESCAN recommendations on small AAA surveillance are still valid. However, sub-analysis results from RCTs and high quality study data indicate potential lower AAA growth rates of 1.88 - 2.09 mm/year, findings that should be validated in a high quality prospective registry.
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Late aortic and graft-related complications after open aortic repair are not infrequent and a significant number of them are missed, diagnosed at a very late stage, or present as urgent complications such as aortic rupture or aorto-enteric fistula. Once a late complication is diagnosed and reintervention is necessary, both open and endovascular strategies are possible. Open reintervention is complex and usually associated with very high rates of morbidity and mortality. Endovascular techniques may offer several solutions for these cases, which may be tailored to the patient and specific complication. In this review, we aim to summarize current indications, options, and strategies for endovascular salvage after failed or complicated open surgical repair.
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OBJECTIVES: The aim of the study was to investigate the outcomes of branched endovascular arch repair (b-TEVAR) with a custom-made double- or triple-branched arch endograft in patients with distal anastomotic aneurysms after open repair of the ascending aorta or proximal arch replacement. METHODS: Retrospective analysis was conducted of all consecutive patients with anastomotic aneurysms after open surgical repair involving the ascending aorta and/or aortic arch treated with b-TEVAR. All patients were treated with a custom-made double or triple inner-branched arch endograft. Study end points were technical success, 30-day and follow-up mortality/morbidity and re-interventions. RESULTS: Between 2018 and 2022, 10 patients were treated with custom-made double- or triple-branched thoracic endovascular aortic repair due to anastomotic aneurysms after open ascending aorta and/or proximal aortic arch replacement. Eight patients received a triple and 2 a double arch-branched endograft. Eight cases were performed electively and 2 urgently for contained rupture. Technical success was achieved in 9 cases (90%). All elective patients survived. Two patients treated due to contained ruptures expired. Within 30 postoperative days, 1 transient ischaemic attack occurred. No early endograft-related re-interventions were necessary. The median follow-up was 20 months. One patient died 2 months after discharge due to sepsis caused by pneumonia. No further deaths or endograft-related re-interventions were observed. CONCLUSIONS: Endovascular aortic arch repair with double or triple inner-branched arch endograft for anastomotic aneurysms after open ascending and/or proximal arch replacement is technically feasible and a promising alternative in a patient cohort unfit for surgery.
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Aneurisma Falso , Aneurisma , Aneurisma de la Aorta Torácica , Implantación de Prótesis Vascular , Procedimientos Endovasculares , Humanos , Aorta Torácica/diagnóstico por imagen , Aorta Torácica/cirugía , Prótesis Vascular/efectos adversos , Aneurisma de la Aorta Torácica/cirugía , Aneurisma de la Aorta Torácica/etiología , Implantación de Prótesis Vascular/efectos adversos , Aneurisma Falso/etiología , Aneurisma Falso/cirugía , Estudios Retrospectivos , Resultado del Tratamiento , Procedimientos Endovasculares/efectos adversos , Stents , Aneurisma/etiología , Diseño de PrótesisRESUMEN
Objective: The optimal degree of proximal thoracic endograft oversizing when aiming for durable sealing in prosthetic grafts is unknown. The aim of the present study was to create an in vitro model for testing different oversized thoracic endografts in a reproducible and standardized manner and, subsequently, determine the optimal oversizing range when planning procedures with a proximal landing in prosthetic zones in the descending thoracic aorta or aortic arch. Methods: An in vitro model consisting of a fixed 24-mm polyethylene terephthalate (Dacron; DuPont) graft sutured proximally and distally to two specifically designed 40-mm rings, with four force sensing resistors attached at four equally distant positions and a USB camera attached proximally for photographic and video documentation was used for deployment of Zenith TX2 (Cook Medical Inc) dissection platform endografts with diameters between 24 and 36 mm. After deployment, ballooning with a 32-mm compliant balloon was performed to simulate real-life conditions. The assessment of oversizing included visual inspection, calculation of the valley areas created between the prosthetic wall and the stent graft fabric, distance between the stent graft peaks, the radial force exerted by the proximal sealing stent, and the pull-out force necessary for endograft extraction. Results: A total of 70 endografts were deployed with the oversizing ranging from 0% to 50%: 10 × 24 mm, 10 × 26 mm, 10 × 28 mm, 10 × 30 mm, 10 × 32 mm, 10 × 34 mm, and 10 × 36 mm. Two cases of infolding occurred with 50% oversizing. The valley areas increased from 8.79 ± 0.23 mm2 with 16.7% oversizing to 14.26 ± 0.45 mm2 with 50% oversizing (P < .001). A significant difference was found in the pull-out force required for endografts with <10% oversizing vs ≥10% oversizing (P < .001). The difference reached a plateau at â¼4 N with oversizing of >15%. The mean radial force of the proximal sealing stent was greater after remodeling with a compliant balloon (0.55 ± 0.02 N vs 0.60 ± 0.02 N after ballooning; P < .001). However, greater oversizing did not lead to an increase in the radial force exerted by the proximal sealing stent. Conclusions: The findings from the present study offer additional insight into the mechanics of oversized stent grafts in surgical grafts. In endografts with the Zenith stent design (TX2), oversizing of <16.7% resulted in reduced resistance to displacement forces, and oversizing of >50% was associated with major infolding in 20% of cases. Long-term in vitro and in vivo testing is required to understand how these mechanical properties affect the clinical outcomes of oversizing.
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PURPOSE: To describe the transaxillary branch-to-branch-to-branch carotid catheterization technique (tranaxillary 3BRA-CCE IT) for cannulation of all supra-aortic vessels using only 1 femoral and 1 axillary access during triple-branch arch repair. TECHNIQUE: After deployment of the triple-branch arch device, catheterization and bridging of the innominate artery (IA) should be performed through a right axillary access (cutdown or percutaneous). Then, the retrograde left subclavian (LSA) branch should be catheterized (if not preloaded) from a percutaneous femoral access, and a 12×90Fr sheath should be advanced to the outside of the endograft. Subsequently, catheterization of the left common carotid artery (LCCA) antegrade branch should be performed, followed by snaring of a wire in the ascending aorta which was inserted through the axillary access, creating a branch-to-branch-to-branch through-and-through guidewire. Over the axillary access, a 12×45Fr sheath should be inserted into the IA branch and looped in the ascending aorta using a push-and-pull technique so that it faces the LCCA branch, allowing for stable catheterization of the LCCA. The retrograde LSA branch should then be bridged following the standard fashion. CONCLUSIONS: This series of 5 patients demonstrates that triple-branch arch repair can be performed with the transaxillary 3BRA-CCE IT, allowing catheterization of the supra-aortic vessels without manipulation of the carotid arteries. CLINICAL IMPACT: The transaxillary 3BRA-CCE IT allows catheterization and bridging of all supra-aortic vessels in triple-branch arch repair through only 2 vascular access points, the femoral artery and the right axillary artery. This technique avoids carotid surgical cutdown and manipulation during these procedures, reducing the risk of access site complications, including bleeding and reintervention, reintubation, cranial nerve lesions, increased operating time, and so on, and has the potential to change the current vascular access standard used during triple-branch arch repair.
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OBJECTIVE: Pararenal abdominal aortic aneurysms (p-AAA) require complex endovascular aortic repair or open surgical repair with suprarenal clamping. Custom made devices (CMD), including fenestrated and branched endovascular aortic repair (F/B-EVAR) or off the shelf (OTS) multibranched devices, are available treatment options. The aim of this study was to determine the additional healthy aortic coverage using an OTS multibranched endograft vs. a CMD for the treatment of p-AAAs. METHODS: This was a retrospective single centre analysis of prospectively collected data. Consecutive patients with p-AAAs requiring a proximal landing zone above the coeliac artery (CA), planned and treated with CMDs (Zenith Fenestrated) between January 2017 and December 2021 were included in this study. Treatment with supracoeliac coverage using available OTS multibranched devices was simulated using available pre-operative images: T-Branch; E-nside; and TAMBE. Study endpoints included the need for additional proximal aortic coverage, and the number of the segmental arteries additionally covered proximally from the CA for OTS devices compared with CMDs. RESULTS: Eighty three patients with p-AAAs were treated with CMDs (all FEVAR), including juxtarenal AAAs (n = 46; 56%), suprarenal AAAs (n = 20; 24%), and short neck AAAs (n = 17; 20%). In this study, treatment with 249 (3 × 83) OTS endografts was simulated. When compared with CMDs, OTS devices required a mean of 74 ± 19 mm of additional proximal healthy aortic coverage from the CA (CMD: 33 ± 19 mm vs. OTS: 108 ± 6 mm; p ≤ .001), as well as an average sacrifice of 2.5 additional segmental arteries (CMD: 1.3 ± 0.8 vs. OTS: 3.8 ± 0.9; p ≤ .001). In 94% of patients, at least one of the available multibranched endografts could have been implanted in accordance with instructions for use. CONCLUSION: Despite not requiring customisation time, OTS endografts for the treatment of p-AAA lead to more extensive healthy aortic coverage, as well as an average sacrifice of 2.5 additional segmental arteries, compared with CMDs. When compared with OTS devices, CMDs appear to limit the extent of unnecessary aortic coverage and the theoretical subsequent risk of spinal cord ischaemia.
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Aneurisma de la Aorta Abdominal , Aneurisma de la Aorta Torácica , Implantación de Prótesis Vascular , Procedimientos Endovasculares , Humanos , Prótesis Vascular , Implantación de Prótesis Vascular/efectos adversos , Aneurisma de la Aorta Torácica/cirugía , Estudios Retrospectivos , Resultado del Tratamiento , Procedimientos Endovasculares/efectos adversos , Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Aneurisma de la Aorta Abdominal/cirugía , Diseño de PrótesisRESUMEN
OBJECTIVE: To report the mid-term outcomes of fenestrated-branched endovascular aneurysm repair (F-BEVAR) following a failed previous endovascular aneurysm repair (pEVAR) or previous open aneurysm repair (pOAR). METHODS: Data from consecutive patients who underwent F-BEVAR for pEVAR or pOAR from 2006 to 2021 from 17 European vascular centers were analyzed. Endpoints included technical success, major adverse events, 30-day mortality, and 5-year estimates of survival, target vessel primary patency, freedom from reinterventions, type I/III endoleaks, and sac growth >5 mm. BACKGROUND: Treatment of a failed previous abdominal aortic aneurysm repair is a complex undertaking. F-BEVAR is becoming an increasingly attractive option, although comparative data are limited regarding associated risk factors, indications for treatment, and various outcomes. RESULTS: There were 526 patients included, 268 pOAR and 258 pEVAR. The median time from previous repair to F-BEVAR was 7 (interquartile range, 4-12) years, 5 (3-8) for pEVAR, and 10 (6-14) for pOAR, P <0.001. Predominant indication for treatment was type Ia endoleak for pEVAR and progression of the disease for pOAR. Technical success was 92.8%, pOAR (92.2%), and pEVAR (93.4%), P =0.58. The 30-day mortality was 6.5% overall, 6.7% for pOAR, and 6.2% for pEVAR, P =0.81. There were 1853 treated target vessels with 5-year estimates of primary patency of 94.4%, pEVAR (95.2%), and pOAR (94.4%), P =0.03. Five-year estimates for freedom from type I/III endoleaks were similar between groups; freedom from reintervention was lower for pEVAR (38.3%) than for pOAR (56.0%), P =0.004. The most common indication for reinterventions was for type I/III endoleaks (37.5%). CONCLUSIONS: Repair of a failed pEVAR or pOARis safe and feasible with comparable technical success and survival rates. While successful treatment can be achieved, significant rates of reintervention should be anticipated, particularly for issues related to instability of target vessels/bridging stents.
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Aneurisma de la Aorta Abdominal , Implantación de Prótesis Vascular , Procedimientos Endovasculares , Humanos , Prótesis Vascular , Aneurisma de la Aorta Abdominal/cirugía , Implantación de Prótesis Vascular/efectos adversos , Reparación Endovascular de Aneurismas , Endofuga/epidemiología , Endofuga/cirugía , Resultado del Tratamiento , Procedimientos Endovasculares/efectos adversos , Factores de Tiempo , Factores de Riesgo , Sistema de Registros , Estudios Retrospectivos , Diseño de PrótesisRESUMEN
BACKGROUND: The aim of this study was to analyse the influence of true, false, and combined lumen perfusion of renal arteries on mid- and long-term kidney volume in patients with type B aortic dissection (TBAD). METHODS: Retrospective analysis of patients diagnosed with a TBAD between 2008 and 2015 in a single high-volume European center. The origin of the renal arteries was evaluated on a dedicated 3D workstation (TeraRecon Inc., San Mateo, CA, USA) and coded as either arising from the true lumen (TL), false lumen (FL) or from a combination of both (CL). Additional evaluated anatomical parameters were renal volume, length, width, and depth of the kidneys. Measurements were recorded at the time of diagnosis (T0) and at 1-month (T1), 6-months (T2), 18-months (T3) and 36-month of follow-up time (T4). RESULTS: A total of 131 renal arteries and kidneys were evaluated in 69 patients. Mean age was 64±13 years and 77% were male. The absolute number and percentage of assessed renal arteries/kidneys was 131 (100%) at T0, 89 (68%) at T1, 73 (56%) at T2, 57 (44%) at T3 and 43 (44%) at T4. At the time of diagnosis, 71.6% renal arteries originated from the TL, 19.1% from the FL and 9.2% from a CL. TEVAR was performed in 92.7% patients and nine patients had additional renal artery stenting. At T0 the mean renal volume was 212.1±70.9cm3, 178±61.2 in women versus 222.2±70.6 in men (P=0.002). Forty-three percent of the patients had a renal volume reduction ≥15% from T0 to their last available CTA. Mixed model analysis showed a significant overall renal volume reduction of 13.7cm3 from T0 to T4 (P<0.05). No significant differences in renal-volume reduction were observed depending on origin of the renal artery, though an estimated reduction of renal volume from T0 to T4 of 40.8 cm3 was seen when the kidneys were perfused by a CL, while TL perfusion only caused a reduction of 15.6 cm3 and no relevant volume change over time was observed when the renal artery originated from FL. Alongside a renal volume reduction, mixed model analysis also showed a significant serum-creatinine increase, from 0.8618mg/at T0 to 1.38±0.56 mg/dL at T4 (P<0.001), as well as a significant glomerular filtration rate reduction over time, from > 60mL/min at T0 to 49±13 mL/min at T4 (P<0.001). A negative correlation was observed between creatinine values and renal volume change, while a positive correlation was observed between GFR and renal volume change (P<0.001). CONCLUSIONS: There is a significant mid-term renal-volume reduction in patients with TBAD, independent of the origin of the renal arteries. Albeit not statistically significant, combined renal artery perfusion may lead to a greater volume reduction, potentially secondary to a relevant dynamic compression by the dissection membrane. Further multicentre studies are warranted to determine the effect on long-term renal function and on possible preventive strategies.
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Aneurisma de la Aorta Torácica , Disección Aórtica , Implantación de Prótesis Vascular , Procedimientos Endovasculares , Anciano , Disección Aórtica/complicaciones , Disección Aórtica/diagnóstico por imagen , Disección Aórtica/cirugía , Aneurisma de la Aorta Torácica/complicaciones , Aneurisma de la Aorta Torácica/diagnóstico por imagen , Aneurisma de la Aorta Torácica/cirugía , Implantación de Prótesis Vascular/efectos adversos , Creatinina , Procedimientos Endovasculares/efectos adversos , Femenino , Humanos , Riñón/fisiología , Masculino , Persona de Mediana Edad , Perfusión , Estudios Retrospectivos , Factores de Tiempo , Resultado del TratamientoRESUMEN
OBJECTIVE: The Munich Valsalva Implantation Technique (MuVIT) is a non-invasive alternative which uses a modified Valsalva manoeuvre to reduce cardiac output (CO). The aim of this study was to evaluate the technical success and safety of MuVIT in standard and complex endovascular thoracic aneurysm repair (TEVAR). METHODS: This was a retrospective single centre cohort study. Patients were included who underwent CO reduction with MuVIT between March 2020 and February 2021 for standard and fenestrated/branched TEVAR (fbTEVAR). The target systolic blood pressure (SBP) reduction was used as an indicator of CO reduction. The aim of the SBP reduction was 50% in patients undergoing proximal sealing in Ishimaru zones 0-1 (Group 1), and 30% in patients with sealing in Ishimaru zones 2-3 (Group 2). Efficacy outcomes included MuVIT technical success and procedural technical success. Safety outcomes included MuVIT and procedural related complications in the first 30 days. RESULTS: During the study period 52 cases were screened for MuVIT. Of these, 40 patients (77%) underwent procedures that were performed under MuVIT. Exclusion reasons were local anaesthesia (n = 9); pulmonary contraindications (n = 2), and poor heart pump function (n = 1). Fifteen patients (37.5%) underwent bTEVAR, three patients (7.5%) fTEVAR, and 22 patients (55%) standard TEVAR. Twenty nine (72.5%) procedures were elective, seven (17.5%) were urgent, and four (10%) were as an emergency. Successful proximal endograft deployment under MuVIT was 100%. The target SBP reduction was achieved in 95% (Group 1: 89.5%, Group 2: 100%), with an overall mean reduction of 46% (Group 1: 55%, Group 2: 40%). The 30 day mortality was 7.5%, and was not MuVIT related. Two patients with COPD Gold III/IV developed respiratory complications. CONCLUSION: MuVIT is a safe and effective manoeuvre for CO reduction during aortic arch TEVAR. However, careful patient selection is required and potential adverse effects on patients with severe COPD needs further evaluation.
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Aneurisma de la Aorta Torácica , Disección Aórtica , Implantación de Prótesis Vascular , Procedimientos Endovasculares , Enfermedad Pulmonar Obstructiva Crónica , Disección Aórtica/cirugía , Aorta Torácica/diagnóstico por imagen , Aorta Torácica/cirugía , Aneurisma de la Aorta Torácica/diagnóstico por imagen , Aneurisma de la Aorta Torácica/etiología , Aneurisma de la Aorta Torácica/cirugía , Prótesis Vascular , Implantación de Prótesis Vascular/métodos , Gasto Cardíaco , Estudios de Cohortes , Procedimientos Endovasculares/métodos , Humanos , Diseño de Prótesis , Enfermedad Pulmonar Obstructiva Crónica/etiología , Enfermedad Pulmonar Obstructiva Crónica/cirugía , Estudios Retrospectivos , Factores de Tiempo , Resultado del TratamientoRESUMEN
OBJECTIVES: The aim of this study was to determine the proportion of patients undergoing open arch repair who would be anatomically suitable for multi-branched endovascular arch repair. METHODS: This study was a single-centre review of patients undergoing open arch repair between 2000 and 2020. Anatomical feasibility was determined by comparing arch measurements to the anatomical criteria of the Zenith® double and triple inner branched-arch endografts (Cook Medical) and the Relay® double arch branched device (Terumo-Aortic). RESULTS: Ninety (90) patients were included in this study, with 43/90 presenting degenerative aneurysm. The distance between the sinotubular junction and the brachiocephalic trunk measured 114 ± 30 mm on the outer curvature, and the maximum diameter of the proximal landing zone (PLZ) was 41 ± 11mm. A total of 42/90 patients (47%) were anatomically suitable for at least 1 stent graft and 29/90 patients (32%) were eligible for a triple-branched endograft. The most important determinant factors of anatomical suitability were the PLZ diameter (Cramer's V = 0.743, P < 0.001) and length (Cramer's V = 0.777, P < 0.001). CONCLUSIONS: This study shows that the proportion of patients who may be anatomically suitable for branched-arch repair remains limited. The PLZ dimensions tend to be the most important anatomical limitations and should receive more emphasis in the development of branched-arch devices.