Baris Ata Ozdemir

Retrograde aortic dissection after thoracic endovascular aortic repair.

Objective:To provide data regarding the etiology and timing of retrograde type A aortic dissection (RTAD) after thoracic endovascular aortic repair (TEVAR). Methods:Details of patients who had RTAD after TEVAR were obtained from the MOTHER Registry supplemented by data from a systematic review of the literature. Univariate analysis and binary logistic regression analysis of patient or technical factors was performed. Results:In MOTHER, RTAD developed in 16 of the 1010 patients (1.6%). Binary logistic regression demonstrated that an indication of TEVAR for aortic dissection (acute P = 0.000212; chronic P = 0.006) and device oversizing (OR 1.14 per 1% increase in oversizing above 9%, P < 0.0001) were significantly more frequent in patients with RTAD. Data from the systematic review was pooled with MOTHER data and demonstrated that RTAD occurred in 1.7% (168/9894). Most of RTAD occurred in the immediate postoperative (58%) period and was associated with a high mortality rate (33.6%). The odds ratio of RTAD for an acute aortic dissection was 10.0 (CI: 4.7–21.9) and 3.4 (CI: 1.3–8.8) for chronic aortic dissection. The incidence of RTAD was not significantly different for endografts with proximal bare stent (2.8%) or nonbare stent (1.9%) (P = 0.1298). Conclusions:Although RTAD after TEVAR is an uncommon complication, it has a high mortality rate. RTAD is significantly more frequent in patients treated for acute and chronic type B dissection, and when the endograft is significantly oversized. The proximal endograft configuration was not associated with any difference in the incidence of RTAD.

Research Activity and the Association with Mortality

Introduction The aims of this study were to describe the key features of acute NHS Trusts with different levels of research activity and to investigate associations between research activity and clinical outcomes. Methods National Institute for Health Research (NIHR) Comprehensive Clinical Research Network (CCRN) funding and number of patients recruited to NIHR Clinical Research Network (CRN) portfolio studies for each NHS Trusts were used as markers of research activity. Patient-level data for adult non-elective admissions were extracted from the English Hospital Episode Statistics (2005-10). Risk-adjusted mortality associations between Trust structures, research activity and, clinical outcomes were investigated. Results Low mortality Trusts received greater levels of funding and recruited more patients adjusted for size of Trust (n = 35, 2,349 £/bed [95% CI 1,855–2,843], 5.9 patients/bed [2.7–9.0]) than Trusts with expected (n = 63, 1,110 £/bed, [864–1,357] p<0.0001, 2.6 patients/bed [1.7–3.5] p<0.0169) or, high (n = 42, 930 £/bed [683–1,177] p = 0.0001, 1.8 patients/bed [1.4–2.1] p<0.0005) mortality rates. The most research active Trusts were those with more doctors, nurses, critical care beds, operating theatres and, made greater use of radiology. Multifactorial analysis demonstrated better survival in the top funding and patient recruitment tertiles (lowest vs. highest (odds ratio & 95% CI: funding 1.050 [1.033–1.068] p<0.0001, recruitment 1.069 [1.052–1.086] p<0.0001), middle vs. highest (funding 1.040 [1.024–1.055] p<0.0001, recruitment 1.085 [1.070–1.100] p<0.0001). Conclusions Research active Trusts appear to have key differences in composition than less research active Trusts. Research active Trusts had lower risk-adjusted mortality for acute admissions, which persisted after adjustment for staffing and other structural factors.

Thoracic endovascular aortic repair in management of aortoesophageal fistulas

OBJECTIVE To provide a systematic review of the outcomes of thoracic endovascular aortic repair (TEVAR) for aortoesophageal fistula (AEF) and to identify prognostic factors associated with poor outcomes. METHODS Literature searches of the Embase, Medline, and Cochrane databases identified relevant articles reporting results of TEVAR for AEF. The main outcome measure was the composite of aortic mortality, recurrence of the AEF, and stent graft explantation. The secondary outcome measure was aortic-related mortality. RESULTS Fifty-five articles were integrated after a literature search identified 72 patients treated by TEVAR for AEFs. The technical success rate of TEVAR was 87.3%. The overall 30-day mortality was 19.4%. Prolonged antibiotics (>4 weeks) were administered in 80% of patients. Concomitant or staged resection or repair of the esophagus was performed in 44.4% of patients. Stent graft explantation was performed within the first month after TEVAR as a planned treatment in 11.1%. After a mean follow-up of 7.4 months (range, 1-33 months), the all-cause mortality was 40.2%, and the aortic-related mortality was 33.3. Prolonged antibiotic treatment (P = .001) and repair of AEFs due to a foreign body (P = .038) were associated with a significant lower aortic mortality. On univariate analysis, TEVAR and concomitant or staged adjunctive procedures (resection, repair of the esophagus, or a planned stent graft explantation) were associated with a significantly lower incidence of aortic-related mortality (P = .0121). When entered into a binary logistic regression analysis, prolonged antibiotic treatment was the only factor associated with a significant lower incidence of the endpoint (P = .003). CONCLUSIONS Late infection or recurrence of the AEF and associated mortality rates are high when TEVAR is used as a sole therapeutic strategy. Prolonged antibiotic treatment has a strong negative association with mortality. A strategy of a temporizing endovascular procedure to stabilize the patient in extremis, and upon recovery, an open surgical esophageal repair with or without stent graft explantation is advocated.

Open Surgical Secondary Procedures after Thoracic Endovascular Aortic Repair

OBJECTIVES Improved outcomes of thoracic endovascular aortic repair (TEVAR) compared with open repair have changed the therapeutic paradigm of thoracic aortic lesions. As the number of TEVAR survivors has grown, reports of complications have similarly increased. Although secondary endovascular rescue measures are often undertaken, patients with serious complications are often converted, ultimately, to open repair. The aim of this study was to assess causes and midterm results of open surgical secondary procedures after thoracic endovascular aortic repair. METHODS A total of 236 patients underwent TEVAR. Fourteen of these patients required open repair because of six aortobronchial fistulas, four retrograde type A dissections, two aneurysm enlargement without endoleak, one thoracic stent-graft collapse, and one aortoesophageal fistula. Eight (57.1%) patients underwent surgical repair using cardiopulmonary bypass. Six stent-grafts were totally removed, and eight stent-grafts were left in situ. Four patients underwent supracoronary ascending aorta replacement, and one an extensive replacement of the aortic arch through sternotomy. Three patients had descending aortic replacement through left thoracotomy combined with a total esophagectomy in one case. One patient was treated by ligation of the aortic arch, ascending to supraceliac abdominal aorta bypass and stent-graft explantation. One patient was treated by exclusion bypass of the descending thoracic aorta. Pulmonary resection and large pleural or intercostal muscle flap interposition to wrap the stent-graft left in situ was done in four cases of aortobronchial fistula. RESULTS All patients survived the surgical procedure. Ten patients (71%) had an uneventful postoperative course. There were two in-hospital deaths (14.3%). Both died from multi-organ failure in the early postoperative course after surgical repair of a stent-graft infection and an aortoesophageal fistula. One patient suffered a definitive paraplegia and a secondary aortoesophageal fistula requiring reoperation for esophageal repair. One patient, treated by pulmonary resection and flap interposition to wrap the stent-graft, underwent stent-graft explantation and in situ descending aortic replacement because of stent-graft reinfection. Actuarial survival was 87.7% after a mean follow-up of 26.3 months (range 9-72 months). CONCLUSIONS Complications or prevention of complications after TEVAR either due to device failure or adverse events may require conversion to open repair or additional open surgical procedure. Open repair can be performed by a team experienced in management of diseases of the thoracic aorta and a low mortality rate achieved despite the precarious preoperative conditions and complex aortic pathologies of patients.

Thoracic Endovascular Aortic Repair for Aortobronchial Fistula

The objective was to provide a systematic review of outcomes of thoracic endovascular aortic repair for aortobronchial fistula. A literature search identified 134 patients. The technical success rate was 93.2%. The overall 30-day mortality was 5.9%. After a mean follow-up of 17.4 months, the aortic-related mortality was 14.3%. Recurrence of the aortobronchial fistula was observed in 11.1% of the patients. Thoracic endovascular aortic repair of aortobronchial fistulas appears to be a viable alternative with excellent short-term results. Strict follow-up and aggressive adjunctive measures are needed to treat ongoing infection to prevent late related mortality.

Factors favoring retrograde aortic dissection after endovascular aortic arch repair

OBJECTIVE To assess factors predisposing patients to retrograde type A aortic dissection (RTAD) who have undergone hybrid aortic arch repair. METHODS From 2001 to 2013, 32 patients underwent hybrid aortic arch repair in our department: 19 in zone 1 and 13 in zone 0. Among these patients, 6 experienced RTAD (18.7%): 3 in zone 0 (23%), 3 in zone 1 (15.8%). Preoperative computed tomography scans of these 32 patients were evaluated. A morphologic assessment of the aortic arch, ascending aorta, and aortic root was performed. Other potential risk factors were investigated. Binary logistic regression was performed to test for possible associations with RTAD. RESULTS Five patients were successfully converted to open repair. Patients who had RTAD were similar to those who did not, across pertinent variables, including age, type of device, diameter of the ascending aorta, and presence of a bicuspid aortic valve (all P > .1). Incidence of RTAD was observed to be higher among women (P = .034), patients with stent-graft oversizing ≥10% (P = .018), and patients treated with a stent-graft of diameter >42 mm (P = .01). Aortic morphology analysis showed that an indexed aortic diameter of ≥20 mm/m(2) (P = .003); aortic root morphology, specifically loss of the sinotubular junction (P = .004); and presence of an aortic arch malformation (P = .03) were correlated with risk of RTAD. Two patients in the zone-0 group with severe angulation (>120°) between the ascending and the transverse aorta suffered RTAD. CONCLUSIONS The occurrence of RTAD after hybrid aortic arch repair is common. To prevent this complication, preoperative screening of the aortic arch, ascending aorta, and aortic root morphology is critical.

Systematic review of outcomes of combined proximal stent-grafting with distal bare stenting for management of aortic dissection

OBJECTIVE Available data on outcomes of combined proximal stent-grafting with distal bare stenting for management of aortic dissection are limited. The objective of this study was to provide a systematic review of outcomes of this approach. METHODS Studies involving combined proximal stent-grafting with distal bare stenting for management of aortic dissection were systematically searched and reviewed through MEDLINE databases. RESULTS A TOTAL OF FOUR STUDIES WERE INCLUDED: 108 patients treated for management of acute (n=54) and chronic (n=54) aortic dissection. The technical success rate was 95.3% (range, 84-100%). The 30-day mortality rate was 2.7% (range from 0% to 5%). The morbidity rate occurring within 30 days was 51.8% (range from 0% to 65%) and included stroke (2.7%), paraplegia (2.7%), retrograde dissection (1.8%), renal failure (14.8%), severe cardiopulmonary complications (5.5%) and bowel ischemia (0.9%). The incidence of type I endoleak was 9.2% (10/108). During follow-up, 5 (4.6%) deaths were related to aortic rupture or aortic repair. Mean re-intervention rate was 12.9%. Two cases (1.9%) of delayed retrograde type A dissection and one case of aortobronchial fistula (0.9%) were reported. The most common delayed complication was thoracic stent-graft migration (4.7%). The rate of device failure was 9.2%. Favorable aortic remodeling was observed: studies reporting midterm follow-up of the true lumen demonstrated a high rate of both false lumen regression and true lumen expansion. At 12 months, complete false lumen thrombosis was observed at the thoracic level in 70.4% and at the abdominal level in 13.5% of patients. CONCLUSIONS Combined proximal stent-grafting with distal bare stenting appears to be a feasible approach for the management of Type B aortic dissection. Although this approach clearly improved true lumen perfusion and diameter, it failed to completely suppress false lumen patency. However, it should be acknowledged that contemporary data on this approach is limited to small studies with variable results.

Infrainguinal angioplasty with drug-eluting stents and balloons

OBJECTIVE The objective of this study was to provide a systematic review and meta-analysis of outcomes of infrainguinal angioplasty with drug-eluting stent (DES) or balloon (DEB). METHODS The EMBASE, MEDLINE, and Cochrane databases and the Current Controlled Trials register were systematically interrogated for articles reporting results of infrainguinal angioplasty with DESs or DEBs. Clinical and angiographic end points were included. RESULTS The review included 26 studies that reported on 2407 limbs; 11 were prospective randomized controlled trials. Infrapopliteal angioplasty with DEB was reported in 109 limbs (claudication, 19; critical limb ischemia [CLI], 90) (limb salvage in CLI, 95.6%; target lesion revascularization [TLR], 17.3%; mortality, 16%; mean follow-up, 12.3 months). Infrapopliteal angioplasty with DES was reported in 882 limbs (claudication, 160; CLI, 590; unclear severity, 132) (limb salvage in CLI, 97.4%, TLR, 10.8%; mortality, 17%; mean follow-up, 22.9 months). Femoropopliteal angioplasty with DES was reported in 1174 limbs (claudication, 301; CLI, 58; unclear severity, 815) (limb salvage in CLI, 89.6%; TLR, 17.3%; mortality, 3%; mean follow-up, 10.6 months). Femoropopliteal angioplasty with DEB was reported in 242 limbs (claudication, 182; CLI, 12; unclear severity, 48) (TLR, 10.6%; mortality, 2%; mean follow-up, 11 months). Meta-analysis of studies comparing DEB with standard balloon angioplasty demonstrated a result in favor of DEBs for preventing binary primary restenosis (odds ratio [OR], 0.27; P = .005) and TLR (OR, 0.17; P = .001). The meta-analysis comparing DESs with bare-metal stents demonstrated a result in favor of DES with regard to preventing TLR (OR, 0.15; P = .001) and binary primary restenosis (OR, 0.23; P = .001). Drug-eluting technology did not prevent more deaths or amputations. CONCLUSIONS Early angiographic data suggest that drug-eluting devices prevent restenosis in the short term, but there is as yet no evidence of an increase in limb salvage rates or a reduction in mortality. Further large randomized controlled trials with a focus on clinical outcomes and longer follow-up are needed.

Physician-Modified Thoracic Stent-Grafts for the Treatment of Aortic Arch Lesions:

Purpose: To evaluate outcomes of physician-modified thoracic stent-grafts for the treatment of aortic arch aneurysms. Methods: A retrospective dual-center analysis was performed involving 36 patients (mean age 74.7±9 years, range 58–91; 27 men) with an aortic arch lesion who were treated between November 2013 and June 2016 using physician-modified thoracic stent-grafts. Half of the patients had a degenerative aneurysm; the remainder had type B dissection (n=9), traumatic transection (n=3), type Ia endoleak after previous endografting (n=5), or aortoesophageal fistula (n=1). All patients were considered to be at high surgical risk. Patients were treated using an aortic arch stent-graft with a single fenestration (n=24) or a proximal scallop (n=12); zone 0 was involved in 16 patients, zone 1 in 9, and zone 2 in 11. The modified thoracic stent-graft was deployed after supra-aortic branch revascularization in 24 (67%) patients. Results: Mean time required for stent-graft modifications was 18 minutes (range 14–21). Technical success was obtained in all cases with no type I endoleak. One (3%) patient had a stroke without permanent sequelae. The 30-day mortality was 6%. During a mean follow-up of 11.4±6 months (range 2–36), there were no conversions to open repair. The overall mortality was 14%; aorta-related mortality was 6%. Conclusion: Our experience suggests that physician-modified thoracic stent-grafts are feasible for aortic arch lesions and provide encouraging results in the short term. Durability concerns will need to be assessed.

Hybrid Aortic Repair of Dissecting Aortic Arch Aneurysm after Surgical Treatment of Acute Type A Dissection.

BACKGROUND The aim of this study was to evaluate the short-term and midterm results of hybrid repair of dissecting aortic arch aneurysms subsequent to surgical treatment of acute type A dissections. METHODS Between 2003 and 2014, 7 consecutive patients, previously operated for acute type A dissection, underwent hybrid repair of their aortic arch for a dissecting aortic arch aneurysm (6 men, mean age 62 ± 11 years). Aneurysm formation requiring treatment in these aortic arches was observed from 2 to 20 years after the initial aortic dissection repair. A hybrid technique was used in all patients, with supra-aortic debranching through a redo sternotomy and either simultaneous (6 patients) or staged endovascular stent grafting (1 patient). Two patients were treated in an emergent setting (1 ruptured and 1 symptomatic aneurysm). Two patients required a more extensive aortic repair of either the thoracic aorta (n, 1) or of the thoracoabdominal aorta (n, 1). One patient underwent, saphenous vein bypass from the ascending aorta to the anterior descending coronary artery on full cardiopulmonary bypass. Follow-up computed tomography scans were performed at 1 week, 3, and 6 months, and annually thereafter. RESULTS Technical success was achieved in all the cases. One transient ischemic attack, 1 stroke, and 1 episode of transient spinal cord ischemia were observed. Thirty-day mortality was not observed. A type I endoleak at 6 months was successfully treated with deployment of a second stent graft. After a mean follow-up of 3.5 ± 3.1 years (range, 0.4-9.6 years), no aortic-related mortality was observed. No cases of stent-graft migration or secondary rupture were observed. CONCLUSIONS Our experience demonstrates the promising potential of endovascular repair of dissecting aortic arch aneurysms after surgical treatment of acute type A dissection. The potential to diminish the magnitude of the surgical procedure and the consequences of aortic arch exposure, and above all avoiding the need for circulatory arrest are promising and mandate further investigation to determine the efficacy and durability of this technique.