Beyond the Aortic Root: Staged Open and Endovascular Repair of Arch and Descending Aorta in Patients With Connective Tissue Disorders

Roselli, Eric E.; Idrees, Jay J.; Lowry, Ashley M.; Masabni, Khalil; Soltesz, Edward G.; Johnston, Douglas R.; Kalahasti, Vidyasagar; Blackstone, Eugene H.; Sabik, Joseph F.; Lytle, Bruce W.; Svensson, Lars

doi:10.1016/j.athoracsur.2015.08.011

Cited by 63 publications

(36 citation statements)

References 21 publications

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“…146,147 This hybrid technique is currently associated with acceptable in-hospital mortality (ranging from 0% to 27.7%) and 5-year survival (ranging from 68% to 96%) for acute aortic dissection with arch involvement. [148][149][150][151] Notably, these are pooled data from a review of small studies with limited follow-up data. Positive aortic remodeling, defined as postoperative partial or complete FL thromboses in the descending aorta, is reported in about 90% of the cases.…”

Section: Surgerymentioning

confidence: 99%

“…150 Finally, hybrid aortic repair has also been associated with promising outcomes for patients with connective tissue disorders (including Marfan, Ehlers-Danlos, and Loeys-Dietz syndromes). 151 However, these surgical interventions should be carried out in stages to reduce the risk of perioperative complications. Moreover, these patients require lifelong imaging surveillance due to the increased risk of aortic complications during follow-up.…”

Section: Surgerymentioning

confidence: 99%

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Update in the management of type B aortic dissection

et al. 2016

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Stanford type B aortic dissection (TBAD) is a life-threatening aortic disease. The initial management goal is to prevent aortic rupture, propagation of the dissection, and symptoms by reducing the heart rate and blood pressure. Uncomplicated TBAD patients require prompt medical management to prevent aortic dilatation or rupture during subsequent follow-up. Complicated TBAD patients require immediate invasive management to prevent death or injury caused by rupture or malperfusion. Recent developments in diagnosis and management have reduced mortality related to TBAD considerably. In particular, the introduction of thoracic stent-grafts has shifted the management from surgical to endovascular repair, contributing to a fourfold increase in early survival in complicated TBAD. Furthermore, endovascular repair is now considered in some uncomplicated TBAD patients in addition to optimal medical therapy. For more challenging aortic dissection patients with involvement of the aortic arch, hybrid approaches, combining open and endovascular repair, have had promising results. Regardless of the chosen management strategy, strict antihypertensive control should be administered to all TBAD patients in addition to close imaging surveillance. Future developments in stent-graft design, medical therapy, surgical and hybrid techniques, imaging, and genetic screening may improve the outcomes of TBAD patients even further. We present a comprehensive review of the recommended management strategy based on current evidence in the literature.

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Section: Surgerymentioning

confidence: 99%

Section: Surgerymentioning

confidence: 99%

Update in the management of type B aortic dissection

et al. 2016

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“…Indeed, as demonstrated by the results of the current study and others pertaining to complex aortic root and ascending aortic surgeries, the most appropriate option would be to offer this only at high-volume experienced centers that have demonstrated excellent surgical outcomes, after shared decision making. 10,[36][37][38][39][40][41] These findings need prospective validation, especially in patients with an isolated BAV aortopathy.…”

Section: Discussionmentioning

confidence: 99%

Aortic Cross-Sectional Area/Height Ratio and Outcomes in Patients With Bicuspid Aortic Valve and a Dilated Ascending Aorta

Masri

Kalahasti

Svensson

et al. 2017

Circ: Cardiovascular Imaging

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Background— In patients with bicuspid aortic valve and dilated proximal ascending aorta, we sought to assess (1) factors associated with increased longer-term cardiovascular mortality and (2) incremental prognostic use of indexing aortic root to patient height. Methods and Results— We studied 969 consecutive bicuspid aortic valve patients (50±13 years; 87% men) with proximal aorta ≥4 cm, who also had a gated contrast-enhanced thoracic computed tomography or magnetic resonance angiography. A ratio of ascending aortic area/height was calculated on tomography, and ≥10 cm 2 /m was considered abnormal, as previously reported. Society of Thoracic Surgeons score and cardiovascular death were recorded. Greater than or equal to III+ aortic regurgitation and severe aortic stenosis were seen in 37% and 10%, respectively. Society of Thoracic Surgeons score and right ventricular systolic pressure were 2±3 and 15±16 mm Hg, respectively. Abnormal ascending aortic area/height ratio was noted in 33%; 44% underwent ascending aortic surgery at 34 days. At 10.8 years (interquartile range, 9.6–12.3), 82 (9%) died (0.4% in-hospital postoperative mortality). On multivariable Cox survival analysis, ascending aortic area/height ratio (hazard ratio, 2; 95% confidence interval, 1.20–3.35) was associated with cardiovascular death, whereas aortic surgery (hazard ratio, 0.46; confidence interval, 0.26–0.80) was associated with improved survival (both P <0.01). Of the 405 patients with ascending aortic diameter of 4.5 to 5.5 cm, 64% had an abnormal ascending aortic area/height ratio, and 70% deaths occurred in patients with an abnormal ratio. Conclusions— In bicuspid aortic valve patients with dilated proximal ascending aorta, ascending aortic area/height ratio was independently associated with cardiovascular death.

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“…As a caveat, endovascular repair may be useful to treat patients with connective tissue disorders when the endograft can be landed in existing graft material [40]. For example, these techniques could be used for late complications of open repair (i.e., pseudoaneurysms or patch aneurysms) or progression of repair, and they may be potentially lifesaving as emergent bridge procedures, until the patient can be stabilized for later definitive open repair [41][42][43].…”

Section: Patients With Connective Tissue Disordersmentioning

confidence: 98%

Open aortic surgery after thoracic endovascular aortic repair

Coselli

Spiliotopoulos

Preventza

et al. 2016

Gen Thorac Cardiovasc Surg

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In the last decade, thoracic endovascular aortic aneurysm repair (TEVAR) has emerged as an appealing alternative to the traditional open aortic aneurysm repair. This is largely due to generally improved early outcomes associated with TEVAR, including lower perioperative mortality and morbidity. However, it is relatively common for patients who undergo TEVAR to need a secondary intervention. In select circumstances, these secondary interventions are performed as an open procedure. Although it is difficult to assess the rate of open repairs after TEVAR, the rates in large series of TEVAR cases (>300) have ranged from 0.4 to 7.9 %. Major complications of TEVAR that typically necessitates open distal aortic repair (i.e., repair of the descending thoracic or thoracoabdominal aorta) include endoleak (especially type I), aortic fistula, endograft infection, device collapse or migration, and continued expansion of the aneurysm sac. Conversion to open repair of the distal aorta may be either elective (as for many endoleaks) or emergent (as for rupture, retrograde complicated dissection, malperfusion, and endograft infection). In addition, in select patients (e.g., those with a chronic aortic dissection), unrepaired sections of the aorta may progressively dilate, resulting in the need for multiple distal aortic repairs. Open repairs after TEVAR can be broadly classified as full extraction, partial extraction, or full salvage of the stent-graft. Although full and partial stent-graft extraction imply failure of TEVAR, such failure is generally absent in cases where the stent-graft can be fully salvaged. We review the literature regarding open repair after TEVAR and highlight operative strategies.

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Beyond the Aortic Root: Staged Open and Endovascular Repair of Arch and Descending Aorta in Patients With Connective Tissue Disorders

Cited by 63 publications

References 21 publications

Update in the management of type B aortic dissection

Update in the management of type B aortic dissection

Aortic Cross-Sectional Area/Height Ratio and Outcomes in Patients With Bicuspid Aortic Valve and a Dilated Ascending Aorta

Open aortic surgery after thoracic endovascular aortic repair

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