Case Report and Review of Literature: Late Retrograde Type A Aortic Dissection With Rupture after Repair of Type B Aortic Dissection with a GORE TAG Endovascular Prosthesis.
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SUBMITTER: Manetta F
PROVIDER: S-EPMC4082457 | biostudies-other | 2014 Jun
REPOSITORIES: biostudies-other
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Project description:BACKGROUND:Retrograde type A aortic dissection (RTAD) is a rare but life-threatening complication after thoracic endovascular aortic repair (TEVAR) for type B aortic dissection (TBAD). A graft inversion technique was applied to distal anastomosis in total arch replacement for this complicated dissection. We reviewed our results of the processing for this serious complication. The aim is to evaluate the feasibility of this technology. METHODS:From January 2013 to December 2017, 20 patients (80% male, mean age 50.9?±?9.5?years) with retrograde type A aortic dissection after thoracic endovascular aortic repair for type B aortic dissection were scheduled for surgical treatment at our center. All patients underwent an ascending aorta and total aortic arch replacement procedure. The 20 patients were divided into two groups, 1 group involved 9 patients underwent surgery using stepwise technique; the graft inversion technique was performed in the other group containing the remaining 11 patients. The postoperative variables, including cardiopulmonary bypass time, the circulatory arrest time, the aortic cross clamp time, were analyzed. Meanwhile we also analyzed the postoperative mortality and complications to evaluate the early and mid-term outcomes of surgical treatment for RTAD after TEVAR. RESULTS:In-hospital mortality was 10% (2 of 20 patients). No patient developed postoperative paraplegia, renal failure, stroke, or distal anastomotic bleeding. Two patients developed renal insufficiency, one developed neurologic insufficiency, and one developed pulmonary infection, all of which were managed accordingly. Cardiopulmonary bypass (CPB) time, and circulatory arrest time were significantly shorter in the graft inversion group than in the stepwise group (165.8?±?37.9?min versus 206.1?±?46.8?min, p<0.05; 34.5?±?5.6?min versus 42.4?±?9.5?min, p<0.05, respectively). The 18 survivors had a mean follow-up of 25.8?±?18.2?months, and all patients remained alive and well. CONCLUSION:Graft inversion can enable a secure distal anastomosis under good surgical exposure, resulting in reduced durations of CPB, and circulatory arrest for RTAD after TEVAR. Surgical treatment could be a safe alternative for treatment of this patients.
| S-EPMC6360802 | biostudies-other
Project description:The aim of this study was to evaluate all-cause mortality and aortic reoperations after surgery for Stanford type A aortic dissection (TAAD). We evaluated the late outcome of patients who underwent surgery for acute TAAD from January 2005 to December 2017 at the Helsinki University Hospital, Finland. We studied 309 patients (DeBakey type I TAAD: 89.3%) who underwent repair of TAAD. Aortic root repair was performed in 94 patients (30.4%), hemiarch repair in 264 patients (85.4%) and partial/total aortic arch repair in 32 patients (10.4%). Hospital mortality was 13.6%. At 10 years, all-cause mortality was 34.9%, and the cumulative incidence of aortic reoperation or late aortic-related death was 15.6%, of any aortic reoperation 14.6%, reoperation on the aortic root 6.6%, on the aortic arch, descending thoracic and/or abdominal aorta 8.7%, on the descending thoracic and/or abdominal aorta 6.4%, and on the abdominal aorta 3.8%. At 10 years, cumulative incidence of reoperation on the distal aorta was higher in patients with a diameter of the descending thoracic aorta ≥35 mm at primary surgery (cumulative incidence in the overall series: 13.2% vs. 4.0%, SHR 3.993, 95%CI 1.316-12.120; DeBakey type I aortic dissection: 13.6% vs. 4.5%, SHR 3.610, 95%CI 1.193-10.913; patients with dissected descending thoracic aorta: 15.8% vs. 5.9%, SHR 3.211, 95%CI 1.067-9.664). In conclusion, surgical repair of TAAD limited to the aortic segments involved by the intimal tear was associated with favorable survival and a low rate of aortic reoperations. However, patients with enlarged descending thoracic aorta at primary surgery had higher risk of late reoperation. Half of the distal aortic reinterventions were performed on the abdominal aorta.
| S-EPMC7563246 | biostudies-literature
Project description:Endovascular abdominal aortic aneurysm (AAA) repair has been widely used for the treatment of AAA as a safe and efficient method, but endoleaks causing persistent expansion of aneurysm sac may cause aneurysmal rupture and death. Type 3 endoleak is rare but a predominant cause of late rupture. Type 3b endoleak can be misdiagnosed as type 2 endoleak, which is more frequent. Here we report two cases of type 3b endoleak mimicking type 2 endoleak, which were successfully treated by open surgery of partial explantation of the stent-graft and endoaneurysmal interposition graft replacement.
| S-EPMC5493191 | biostudies-other
Project description:ObjectiveThe study objective was to evaluate the management of malperfusion in acute type B aortic dissection with endovascular fenestration/stenting.MethodsFrom 1996 to 2018, 182 patients with an acute type B aortic dissection underwent fenestration/stenting for suspected malperfusion based on imaging, clinical manifestations, and laboratory findings. Data were obtained from medical record review and the National Death Index database.ResultsThe median age of patients was 55 years. Signs of malperfusion included abdominal pain (61%), lower-extremity weakness (27%), nonpalpable lower-extremity pulses (24%), and abnormal lactate, creatinine, liver enzymes, and creatine kinase levels. Confirmed hemodynamically significant malperfusion affected the spinal cord (2.7%), celiac (24%), superior mesenteric (40%), renal (51%), and iliofemoral (43%) arterial distributions. Of the 182 patients, 99 (54%) underwent aortic fenestration/stenting, 108 (59%) had 1 or multi-branch vessel fenestration/stenting, 5 (2.7%) had concomitant thoracic endovascular aortic repair, 17 (9.3%) had additional thrombolysis or thromboembolectomy, and 48 (26%) received no intervention. After fenestration/stenting, 24 patients (13%) required additional procedures for necrotic bowel or limb and 9 patients (4.9%) had subsequent aortic repair (thoracic endovascular aortic repair, open repair) before discharge. The new-onset paraplegia was 0%. The in-hospital mortality was 7.7% over 20+ years and 0% in the last 8 years. The 5- and 10-year survivals were 72% and 49%, respectively. The significant risk factors for late mortality were age and acute paralysis (hazard ratio, 3.5; both P < .0001). Given death as a competing factor, the 5- and 10-year cumulative incidence of reintervention was 21% and 31% for distal aortic pathology, respectively.ConclusionsPatients with acute type B aortic dissection with malperfusion can be managed with endovascular fenestration/stenting with excellent short- and long-term outcomes. This approach is particularly helpful to patients with static malperfusion of aortic branch vessels.
| S-EPMC7103520 | biostudies-literature
Project description:A 69-year-old woman with a history of graft replacement for abdominal aortic aneurysm developed a complicated type B aortic dissection that resulted in renal malperfusion after thoracic endovascular aortic repair (TEVAR). The primary entry tear was formed at the aortic arch and the false lumen (FL) continued to the abdominal aorta. The distal end of the FL formed a pouch-like blind alley above the suture line of the bifurcated abdominal graft. The true lumen (TL) was compressed and caused severe limb ischemia. The right renal artery (rRA) originated from the FL. The patient had initially undergone emergent axillofemoral bypass for limb malperfusion. Three weeks later, restenosis of the TL caused visceral malperfusion, and a huge thrombus formed in the FL pouch. TEVAR expanded the TL and restored visceral vascularization. However, the expanded TL compressed the thrombus in the blind alley to the rRA orifice and caused right renal malperfusion. The history of abdominal graft replacement may have increased the risk of a thrombotic event after TEVAR. Primary TEVAR may have helped prevent thrombus formation in the FL pouch. <Learning objective: This case report describes visceral arterial embolism induced by endovascular aortic repair (TEVAR) for type B aortic dissection in a patient with prior abdominal aortic grafting. A huge thrombus formed in the blind pouch of the false lumen (FL) above the graft suture line. TEVAR expanded the true lumen and the FL thrombus occluded a visceral artery with FL origin. Post-graft replacement has a risk of thrombus formation in the FL pouch and thrombus compression in visceral arteries.>.
| S-EPMC6149603 | biostudies-literature
Project description:Aortic dissection (AD) is a life-threatening vascular disease with limited treatment strategies. Here, we show that loss of the GWAS-identified SH2B3 gene, encoding lymphocyte adaptor protein LNK, markedly increases susceptibility to acute AD and rupture in response to angiotensin (Ang) II infusion. As early as day 3 following Ang II infusion, prior to the development of AD, Lnk-/- aortas display altered mechanical properties, increased elastin breaks, collagen thinning, enhanced neutrophil accumulation, and increased MMP-9 activity compared with WT mice. Adoptive transfer of Lnk-/- leukocytes into Rag1-/- mice induces AD and rupture in response to Ang II, demonstrating that LNK deficiency in hematopoietic cells plays a key role in this disease. Interestingly, treatment with doxycycline prevents the early accumulation of aortic neutrophils and significantly reduces the incidence of AD and rupture. PrediXcan analysis in a biobank of more than 23,000 individuals reveals that decreased expression of SH2B3 is significantly associated with increased frequency of AD-related phenotypes (odds ratio 0.81). Thus, we identified a role for LNK in the pathology of AD in experimental animals and humans and describe a new model that can be used to inform both inherited and acquired forms of this disease.
| S-EPMC6237478 | biostudies-literature
Project description:ObjectiveThoracic endovascular aortic repair (TEVAR) is recommended for type B aortic dissection and recently has even been used in selected cases of proximal (Stanford type A) aortic dissections in scenarios of prohibitive surgical risk. However, mechanical interactions between the native aorta and stent-graft are poorly understood, as some cases ended in failure. The aim of this study is to explore and better understand biomechanical changes after TEVAR and predict the result via virtual stenting.MethodsA case of type A aortic dissection was considered inoperable and selected for TEVAR. The procedure failed due to stent-graft migration even with precise deployment. A novel patient-specific virtual stent-graft deployment model based on finite element method was employed to analyze TEVAR-induced changes under such conditions. Two landing positions were simulated to investigate the reason for stent-graft migration immediately after TEVAR and explore options for optimization.ResultsSimulation of the actual procedure revealed that the proximal bare metal stent pushed the lamella into the false lumen and led to further stent-graft migration during the launch phase. An alternative landing position has reduced the local deformation of the dissection lamella and avoided stent-graft migration. Higher maximum principal stress (>20 KPa) was found on the lamella with deployment at the actual position, while the alternative strategy would have reduced the stress to <5 KPa.ConclusionsVirtual stent-graft deployment simulation based on finite element model could be helpful to both predict outcomes of TEVAR and better plan future endovascular procedures.
| S-EPMC8307501 | biostudies-literature
Project description:BACKGROUND:Clinical and imaging surveillance practices following endovascular aneurysm repair (EVAR) for intact abdominal aortic aneurysm (AAA) vary considerably and compliance with recommended lifelong surveillance is poor. The aim of this study was to develop a dynamic prognostic model to enable stratification of patients at risk of future secondary aortic rupture or the need for intervention to prevent rupture (rupture-preventing reintervention) to enable the development of personalized surveillance intervals. METHODS:Baseline data and repeat measurements of postoperative aneurysm sac diameter from the EVAR-1 and EVAR-2 trials were used to develop the model, with external validation in a cohort from a single-centre vascular database. Longitudinal mixed-effects models were fitted to trajectories of sac diameter, and model-predicted sac diameter and rate of growth were used in prognostic Cox proportional hazards models. RESULTS:Some 785 patients from the EVAR trials were included, of whom 155 (19·7 per cent) experienced at least one rupture or required a rupture-preventing reintervention during follow-up. An increased risk was associated with preoperative AAA size, rate of sac growth and the number of previously detected complications. A prognostic model using predicted sac growth alone had good discrimination at 2?years (C-index 0·68), 3?years (C-index 0·72) and 5?years (C-index 0·75) after operation and had excellent external validation (C-index 0·76-0·79). More than 5?years after operation, growth rates above 1?mm/year had a sensitivity of over 80 per cent and specificity over 50 per cent in identifying events occurring within 2?years. CONCLUSION:Secondary sac growth is an important predictor of rupture or rupture-preventing reintervention to enable the development of personalized surveillance intervals. A dynamic prognostic model has the potential to tailor surveillance by identifying a large proportion of patients who may require less intensive follow-up.
| S-EPMC6175165 | biostudies-literature
Project description:BackgroundThoracic endovascular aortic repair (TEVAR) has been chosen as a less invasive alternative for type B aortic dissections (TBADs). However, the therapeutic effect of TEVAR has been challenged by postoperative adverse events, which were induced by inflammatory response. Glucocorticoids have been widely used because of the powerful and effective anti-inflammatory properties. Nevertheless, the prognostic effect of glucocorticoids after TBAD patients underwent TEVAR remains unclear. The objective of this study was to assess the potential effect of postoperative glucocorticoids on the prognosis of TEVAR for TBADs.MethodsA total of 92 chronic TBADs patients underwent TEVAR with epidural anesthesia between June 2012 and June 2014 was retrospectively reviewed. The patients were stratified into dexamethasone (DXM) and non-dexamethasone group (N-DXM). The indications for TEVAR were as following: malperfusion (n = 28); contained or impending rupture (n = 17); persistent intractable chest/back pain (n = 32); refractory hypertension (n = 15).ResultsNo 30-day mortality and incision infection occurred in each group. The postoperative pain score on the second day was significantly higher in N-DXM group (3.60 ± 0.21 versus 4.83 ± 0.32, P = 0.001). The differences of white blood cell, body temperature and heart rate were pronounced in both groups judged by the peak values (13.01 ± 0.58 × 10(9)/L versus 10.04 ± 0.61 × 10(9)/L, 37.67 ± 0.08 °C versus 37.92 ± 0.09 °C and 89.06 ± 1.21 bpm versus 95.95 ± 1.70 bpm, P = 0.002, 0.04 and 0.001, respectively). The white blood cells in DXM group significantly increased on the second and third postoperative day (P = 0.009 and 0.023), while the body temperature and heart rate showed an apparent decline on the second (P = 0.001 and 0.028), third (P = 0.007 and 0.005) and fourth postoperative days (P = 0.024 and 0.018). However, the changes of false lumen volumes and the endoleak incidence at 3-month follow-up were comparable in the two groups. No significant difference of post-implantation syndrome was observed either.ConclusionsAlthough postoperative prophylactic glucocorticoids administration was unable to influence mortality, incision infection or the change of false lumen volumes, it enabled to enhance the recovery of vital signs and alleviate the postoperative pain. A prospective, randomized controlled trial has been registered (NCT02523300), which will be warranted before prophylactic administration of glucocorticoids after TEVAR procedure could be recommended in the clinical work.
| S-EPMC4807598 | biostudies-literature
Project description:ObjectiveAcute aortic dissection is a life-threatening condition. Thoracic endovascular aortic repair (TEVAR), together with optimized medical treatment, is currently the first line treatment for acute Stanford type B aortic dissection. TEVAR can close the entry tear and reduce mortality. Aortic remodeling after TEVAR can directly affect the patient's long-term prognosis. The factors that influence aortic remodeling have, however, received insufficient clinical attention and remain unclear. It is very important to identify these factors.MethodsA total of 100 patients were continuously enrolled from 2011 to 2018 in 2 centers. Relevant data, including time from hospital admission to surgery, medicine use and aortic computed tomography angiography images obtained before and 6 months after surgery were collected. Patients were divided into favorable and adverse aortic remodeling groups, according to the degree of aortic remodeling. Analysis of variance and the chi-square test were performed using SPSS software to compare differences between groups and to determine the factors that influence postoperative aortic remodeling.ResultsThe proportion of single-stent implantations was higher in the favorable remodeling group than in the adverse remodeling group (79.5% vs. 53.8% in distal end of stent-graft level and 81.3% vs. 56.4% in diaphragm level, respectively, p < 0.05). The earlier the TEVAR procedure was performed, the better the aortic remodeling (3.4 days vs. 4.8 days in distal stent graft levels, and 3.6 days vs. 4.9 days in diaphragm level, respectively, p < 0.05), the presence of residual distal entry tears in the abdominal aorta also improved aortic remodeling after TEVAR (85.7% vs. 55.1% in the celiac trunk level, and 92.0% vs. 48.9% in the right renal artery level, respectively, p < 0.05).ConclusionSingle stent-graft implantation and early surgery were associated with favorable aortic remodeling. Distal entry tears were also conducive to aortic remodeling after surgery for aortic dissection.
| S-EPMC8262045 | biostudies-literature