Acute Thoracic Aortic Pathology Research Articles

Первый опыт эндоваскулярного лечения острого расслоения аорты типа в по Стенфорду

Despite a large body of knowledge about acute thoracic aortic pathology, most physicians do not feel confidentin diagnosing and treating patients with this group of diseases characterized by high mortality. The emergenceof modern high-tech diagnostic methods, such as MSCT angiography, contributed to the early detection of bothacute and latent course of aortic pathology, as well as clearly determine the further treatment tactics. Currently,endovascular techniques are preferred in the treatment of acute thoracic aortic syndrome. This article presentsa case of successful endovascular treatment of acute aortic syndrome in our Republic.

Emergency endovascular management of acute thoracic aortic pathology A safe and feasible option

Endovascular repair has revolutionised the emergency treatment of thoracic aortic disease. We report our 10 year experience using this treatment in emergency cases.A prospectively maintained vascular database was analysed. Patients’ medical records and CT images stored on the hospital PACS system were also reviewed. Statistical analysis was done using IBM SPSS V21.There were a total of 59 thoracic aortic stenting procedures of which 33 (60% males with a mean age of 58 yrs) were performed for emergency thoracic pathologies: traumatic transection (n = 10), ruptured aneurysm (n = 6), non-traumatic dissection (n = 8) and penetrating aortic ulcer (n = 9). All patients had self-expanding endografts implanted. Two patients required debranching procedures before the endovascular treatment.Thirty-day mortality was 12.1% (4/33). 70% of patients received a single device. There were 7 procedure related complications, 6 requiring re-intervention: thoracotomy and drainage in 2 patients, proximal graft extension in 2, open drainage of groin haematoma in 1 and open repair of a common femoral artery pseudo-aneurysm in one patient.In total 23 patients were transferred from 11 centres nationwide. There were no mortalities or other complications related to patient transfer from peripheral centres. Although acute thoracic aortic pathology is life threatening, appropriate blood pressure management and treatment of associated injuries can result in favourable outcomes. Endovascular repair is a safe and effective treatment option which enables patients to be treated with reduced morbidity and mortality. Transfer of patients with acute pathology to a tertiary centre can safely be performed.

Treatment of acute thoracic aortic syndromes using endovascular techniques.

Acute thoracic aortic syndrome (ATAS) is a novel term to define emergency aortic conditions with common clinical features and challenges. Traditional management of ATAS includes surgical replacement of the aorta and is correlated with high perioperative mortality and morbidity. We aimed to evaluate our experience and outcomes in patients presenting with ATAS, managed by endovascular techniques. This cohort consisted of 31 consecutive patients (24 males; mean age, 57.5±13.81 years; range, 19-84 years) with acute thoracic aortic pathologies who underwent endovascular repair between January 2011 and January 2015. The study was designed as a retrospective analysis of prospectively maintained data. Complicated acute type-B aortic dissection was the most common pathology (35.5%). All aortic stent-grafts (n=37) and dissection stents (n=9) were implanted with 100% procedural success. The overall in-hospital mortality was 9.7%. The mean follow-up duration of patients who were alive at 30 days was 25.9±11.49 months (3-53 months). So far, there have been no late deaths after 30 days. In the high-risk setting of ATAS, endovascular procedures come forward as novel therapeutic strategies with promising results. Endovascular repair of ATAS can be considered as a first-line treatment alternative under emergency conditions with encouraging results, particularly when conventional surgical repair cannot be implemented due to prohibitive comorbidities.

Homemade proximal scalloped stent graft for thoracic endovascular aortic repair of zone 2 acute aortic syndrome

ObjectiveThe aim of this study was to evaluate the outcomes of homemade proximal scalloped stent grafts for thoracic endovascular aortic repair of zone 2 acute aortic syndrome. MethodsBetween May 2015 and December 2015, 10 patients with unremitting symptoms or rupture secondary to an acute aortic syndrome involving zone 2 underwent urgent or emergency thoracic endovascular aortic repair. Among them, 8 were treated using homemade proximal scalloped stent grafts to preserve the patency of the left subclavian artery. Indications included traumatic transection (n = 3) and acute (n = 4) and subacute (n = 1) complicated type B aortic dissection. Follow-up computed tomography scans were performed at 1 week and 3 and 6 months. ResultsThe median duration for stent graft modification was 15 minutes (range, 14-17 minutes). The technical success rate was 100%; sealing was achieved in all cases with no type I endoleaks. All left subclavian arteries were patent, although 1 case was associated with a 50% stenosis. No deaths occurred as a consequence of the aortic repair, but 1 patient died of a traumatic renal hematoma on postoperative day 5. During a mean follow-up of 7.2 ± 2 months, there were no conversions to open surgical repair, aortic ruptures, paraplegia, retrograde dissection, or other aortic complications. ConclusionsThe use of the homemade proximal scalloped stent graft is both feasible and effective for left subclavian artery revascularization during thoracic endovascular aortic repair involving a spectrum of acute thoracic aortic pathology. This approach provides a rapid, reproducible method of scalloping the endograft. Durability concerns will need to be assessed in additional studies with long-term follow-up.

Transesophageal echocardiography evaluation of the thoracic aorta.

Transesophageal echocardiography (TEE) can be used to identify risk factors such as aortic atherosclerosis[2] before any sort of surgical manipulations involving aorta and its related structures. TEE has become an important noninvasive tool to diagnose acute thoracic aortic pathologies. TEE evaluation of endoleaks helps early detection and immediate corrective interventions. TEE is an invaluable imaging modality in the management of aortic pathology. TEE has to a large extent improved the patient outcomes.

Budget Impact of Percutaneous Endovascular Abdominal Aorta Aneurysm Repair (PEVAR) Compared to Standard Endovascular Repair in Canadian Hospitals

Budget Impact of Percutaneous Endovascular Abdominal Aorta Aneurysm Repair (PEVAR) Compared to Standard Endovascular Repair in Canadian Hospitals

In situ laser fenestration during emergent thoracic endovascular aortic repair is an effective method for left subclavian artery revascularization

Retrograde laser fenestration of the left subclavian artery (LSA) during emergent thoracic endovascular aortic repair (TEVAR) uses a relatively simple intraoperative method of endograft modification to revascularize aortic branches for a variety of acute thoracic aortic pathologies. This study presents our expanded experience and midterm outcomes of TEVAR with laser fenestration to revascularize the LSA as an alternative to debranching. Patients who underwent TEVAR with LSA revascularization by laser graft fenestration from September 2009 through August 2012 were retrospectively reviewed. TEVAR was performed with deployment of a Dacron (DuPont, Wilmington, Del) endograft over the LSA orifice. Laser catheter fenestration of the graft was performed through retrograde brachial access, followed by balloon-expandable covered stent deployment through the fenestration to traverse the endograft and LSA. Routine postoperative follow-up imaging with computed tomography angiography was performed to assess TEVAR and LSA fenestration patency, endoleak, and aneurysm/dissection exclusion. TEVAR with laser fenestration was successfully performed in 22 patients (12 men; mean age, 57 years) in an urgent or emergent setting secondary to unremitting symptoms or rupture. Twelve patients had large symptomatic thoracic aortic aneurysms (eight secondary to chronic dissection); four patients had acute symptomatic type B aortic dissection, and six patients had an intramural hematoma or penetrating aortic ulcer, or both. An average of two endografts (range, 1-4) were deployed. LSA-covered stents were 8 to 10 mm in diameter. Mean operative time was 154± 65 minutes. Average hospital length of stay was 12± 7 days. No major fenestration-related complications occurred. One patient developed postoperative paraplegia. One patient died in the postoperative period, for an in-hospital mortality rate of 4.5%. Two patients died of non-TEVAR-related causes at a mean follow-up of 10 months (range, 1-40 months). Follow-up computed tomography angiography imaging demonstrated a 100% primary patency for the LSA stents. One patient had an asymptomatic LSA stent stenosis. Type II endoleaks from the LSA in two patients required endovascular coil embolization. No fenestration-related type I or III endoleaks were noted. In situ retrograde laser fenestration is a feasible and effective option for LSA revascularization during TEVAR involving a spectrum of acute thoracic aortic pathology. Laser fenestration provides a rapid, reproducible method of fenestrating the endograft material. The high technical success, low fenestration-related morbidity, and excellent midterm patency support this technique of intraoperative endograft modification.

In Situ Laser Fenestration During Thoracic Endovascular Aortic Repair Is an Effective Method for Left Subclavian Artery Revascularization

We have previously described our early experience using retrograde laser fenestration to revascularize the left subclavian artery (LSA) during zone II thoracic endovascular aortic repair (TEVAR). This technique uses a relatively simple intraoperative method of endograft modification to revascularize aortic branches for a variety of acute thoracic aortic pathologies. The aim of this study is to present our expanded experience and midterm outcomes of TEVAR with laser fenestration to revascularize the LSA as an alternative to debranching. A retrospective review of the electronic medical records was conducted of all patients who underwent TEVAR with LSA revascularization via laser graft fenestration from September 2009 through August 2012. TEVAR was carried out with deployment of a Dacron endograft over the orifice of the LSA. Through retrograde brachial access, a 0.018-inch guidewire was placed at the ostium of the LSA, followed by laser catheter fenestration of the graft. Balloon-expandable covered stents were deployed through the fenestration to traverse the endograft and LSA; the endograft portion of the covered stent was flared. Routine postoperative follow-up imaging with computed tomography angiography was performed to assess for TEVAR and LSA fenestration patency, endoleak, and aneurysm/dissection exclusion. TEVAR with laser fenestration was successfully performed in 22 patients (12 men; mean age, 57 years; range, 37-83 years) in an urgent or emergency setting secondary to unremitting symptoms. Thirteen patients had large symptomatic thoracic aortic aneurysms (10 secondary to chronic dissection); four patients had acute symptomatic type B aortic dissection, and five patients had intramural hematoma or penetrating aortic ulcer. An average of two endografts (range, 1-4) were placed during TEVAR. LSA-covered stents ranged from 8 to 10 mm in diameter. Mean operative time for TEVAR with laser fenestration was 154 ± 65 minutes. The average hospital length of stay was 12 ± 7 days. There were no fenestration-related complications. One patient developed postoperative paraplegia, and one patient died of massive hemoptysis in the postoperative period, for an in-hospital mortality rate of 4.5%. At a mean follow-up of 8 months (range, 1-32 months), two patients had died (9%) of non–TEVAR-related causes. Follow up computed tomography angiography imaging demonstrated a 100% primary patency for the LSA stents. One patient had an asymptomatic LSA stent stenosis. Two patients had type II endoleaks from the LSA that required reintervention. Both were successfully managed with endovascular coil embolization. There were no fenestration-related type I or III endoleaks. In situ retrograde laser fenestration is a feasible and effective option for LSA revascularization during TEVAR involving a spectrum of acute thoracic aortic pathologies. Laser fenestration provides a rapid, reproducible method of fenestrating the endograft material. The high technical success, low fenestration-related morbidity, and excellent midterm patency support this technique of intraoperative endograft modification. Longer follow-up remains necessary to determine the durability of this technique.

Thoracic stent grafting – a feasible solution for acute throracic aortic pathology

Background: Endovascular repair of the thoracic aorta has shown to reduce morbidity and mortality when compared with open surgery. The aim of our study was to describe our experience with stent graft treatment for acute thoracic aortic pathology.

Endovascular Repair of Acute Traumatic Thoracic Aortic Transection With Laser-Assisted In-Situ Fenestration of a Stent-Graft Covering the Left Subclavian Artery

To report the use of in-situ laser-assisted endograft fenestration during thoracic endovascular aortic repair (TEVAR). A healthy 26-year-old man presented to the emergency department after sustaining blunt chest trauma. He was hemodynamically stable, although he subjectively complained of tearing chest pain and pleuritic chest wall pain. Radiography revealed a left clavicular fracture, multiple rib fractures, and a widened mediastinum. Imaging showed a partially contained acute aortic transection just distal to the takeoff of the left subclavian artery (LSA); the arch had a bovine configuration, with a shared origin of the right innominate and left common carotid arteries. Endovascular repair was elected, but to avoid sacrificing the LSA, TEVAR with in-situ graft fenestration was performed to reduce the risk of posterior circulation stroke, spinal cord ischemia, and subclavian steal syndrome. A Talent thoracic stent-graft was deployed, with the covered portion of the endograft extending just distal to the shared origin of the innominate and left carotid arteries. A laser catheter was advanced through the LSA to fenestrate the endograft; the fenestration was dilated and stented with an iCast stent, which was flared proximally and distally to effect a seal. At 6 weeks, imaging documented that the repair was patent and secure; the patient continues to do well at his most recent follow-up at 8 months. This technique may provide a means for extending thoracic endografting technology to a greater number of patients with acute thoracic aortic pathology.

Role of Interventional Repair in the Thoracic Aorta

Endovascular treatment of chronic aneurysmatic diseases of the descending thoracic aorta has demonstrated encouraging peri-interventional mortality and morbidity and is accepted as a preferred strategy in experienced centers. The emergence of endovascular strategies for acute thoracic aortic pathologies is an even more exciting new territory for nonsurgical interventions considering the sobering results of open surgery. Although it is apparent that patients at high risk for open surgery will benefit from endovascular strategies, the exact role of stent-graft placement remains to be defined, as the community awaits solid long-term data and as devices and techniques continue to improve. While some indications and scenarios, such as acute type B dissection with associated malperfusion syndrome or imminent aortic rupture, have been shown to benefit from stent-graft treatment, others are less settled. The current paper discusses both the established and emerging indications, as well as technical and anatomical aspects of this fascinating therapeutic option.