Early and late results of descending thoracic and thoracoabdominal aortic aneurysm open repair with deep hypothermia and circulatory arrest

Fehrenbacher, John W.; Siderys, Harry; Terry, Colin; Kuhn, John E.; Corvera, Joel S.

doi:10.1016/j.jtcvs.2010.08.054

Cited by 73 publications

(58 citation statements)

References 42 publications

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“…These numbers are similar to the 3-year survival of 60% [4] and 9.8-year survival of 51% [14] reported by other large, tertiary referral centers. The long-term survival data are quite humbling, and it is evident from this and other studies, including modern series of open aortic repair from centers of excellence [15–18], that patients with descending thoracic and thoracoabdominal aortic disease represent a unique subgroup of patients at notable risk for late death, despite correction of their aortic pathology (Table 5). For comparison, survival rates after coronary artery bypass grafting are approximately 92% at 3 years and 84% at 6 years [19], which are substantially higher than that reported after endovascular or open descending and thoracoabdominal repair.…”

Section: Commentmentioning

confidence: 96%

Results of Thoracic Endovascular Aortic Repair 6 Years After United States Food and Drug Administration Approval

Shah¹,

Barfield²,

Andersen³

et al. 2012

The Annals of Thoracic Surgery

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Background Since United States Food and Drug Administration approval in 2005, the short-term safety and efficacy of thoracic endovascular aortic repair (TEVAR) have been established. However, longer-term follow-up data remain lacking. The objective of this study is to report 6-year outcomes of TEVAR in clinical practice. Methods A prospective cohort review was performed of all patients undergoing TEVAR at a single referral institution between March 2005 and May 2011. Rates of reintervention were noted. Overall and aortic-specific survival were determined using Kaplan-Meier methods. Log-rank tests were used to compare survival between groups. Results During the study interval, 332 TEVAR procedures were performed in 297 patients. Reintervention was required after 12% of procedures at a mean of 8 ± 14 months after initial TEVAR and was higher in the initial tercile of patients (15.0% vs 9.9%). The 6-year freedom from reintervention was 84%. Type I endoleak was the most common cause of reintervention (5%). Six-year overall survival was 54%, and aorta-specific survival was 92%. Long-term survival was significantly lower than that of an age- and sex-matched United States population (p < 0.001). Survival was similar between patients requiring a reintervention vs those not (p = 0.26). Survival was different based on indication for TEVAR (p = 0.007), and patients with degenerative aneurysms had the lowest survival (47% at 6 years). Cardiopulmonary pathologies were the most common cause of death (27 of 93 total deaths). Conclusions Long-term aortic-related survival after TEVAR is high, and the need for reintervention is infrequent. However, overall long-term survival is low, particularly for patients with degenerative aneurysms, and additional work is needed to identify patients unlikely to derive a survival benefit from TEVAR.

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Section: Commentmentioning

confidence: 96%

Results of Thoracic Endovascular Aortic Repair 6 Years After United States Food and Drug Administration Approval

Shah¹,

Barfield²,

Andersen³

et al. 2012

The Annals of Thoracic Surgery

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“…1 Other techniques, such as intercostal artery reimplantation, evoked potential monitoring, epidural cooling, and hypothermic circulatory arrest also appear to modestly reduce risk of spinal cord injury. [2][3][4] Unfortunately, no pharmacological adjuncts have proven clinically efficacious in attenuating this injury. Moreover, once the injury has clinically manifested, no pharmacological or surgical intervention (other than attempts to modify parenchymal perfusion) is currently available.…”

mentioning

confidence: 99%

The Evolution of Chemokine Release Supports a Bimodal Mechanism of Spinal Cord Ischemia and Reperfusion Injury

et al. 2012

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Background-Paraplegia remains a devastating complication of thoracic aortic surgery. The mechanism of the antecedent spinal cord ischemia and reperfusion injury (IR) remains poorly described. IR involves 2 injuries, an initial ischemic insult and subsequent inflammatory amplification of the injury. This mechanism is consistent with the clinical phenomenon of delayed onset paraplegia. This study sought to characterize the inflammatory response in the spinal cord after IR and hypothesized that this would support a bimodal mechanism of injury. Methods and Results-Male C57Bl/6 mice were subjected to 5 minutes of aortic arch and left subclavian occlusion with subsequent reperfusion to generate spinal cord ischemia. Functional outcomes were scored at 12-hour intervals. Spinal cords were harvested after 0, 6, 12, 18, 24, 36, and 48 hours of reperfusion. Cytokine levels were analyzed using a mouse magnetic bead-based multiplex immunoassay. Inflammatory chemokine concentrations (interleukin [IL]-1␤, IL-6, keratinocyte-derived cytokine, macrophage inflammatory protein-1␣, monocyte chemotactic protein-1, RANTES, and tumor necrosis factor-␣) peaked at 6 hours and 36 to 48 hours after reperfusion. Functional scores reflected initial gain in function with subsequent decline, inversely proportional to cytokine levels. Immunofluorescent staining demonstrated microglia activation at 12 and 48 hours. Conclusions-Spinal cord ischemia and reperfusion injury occurs in 2 phases, correlating to increases in inflammatory chemokines release and microglial activation. These observations chronologically parallel the too-common clinical syndrome of delayed-onset paraplegia. Understanding the molecular pathogenesis of this injury may allow future intervention to prevent this devastating complication. (Circulation. 2012;126[suppl 1]:S110 -S117.)

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“…Regional or systemic hypothermia of the cord is also theoretically believed to be protective. Although excellent results have been reported, complications associated with general deep hypothermia [45,46] and complexity of the catheter systems [47,48] in epidural space negate the general use of hypothermia. Numerous pharmacological agents, such as papaverine, naloxone, corticosteroids, oxygen radical scavenger [49], prostaglandin, excitatory amino acid antagonist, and even ''a non-specific flu medicine'' have been tried.…”

Section: Thoracoabdominal Aortic Aneurysmmentioning

confidence: 99%

Surgery for thoracic aortic disease in Japan: evolving strategies toward the growing enemies

Okita

2014

Gen Thorac Cardiovasc Surg

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Early and late results of descending thoracic and thoracoabdominal aortic aneurysm open repair with deep hypothermia and circulatory arrest

Cited by 73 publications

References 42 publications

Results of Thoracic Endovascular Aortic Repair 6 Years After United States Food and Drug Administration Approval

Results of Thoracic Endovascular Aortic Repair 6 Years After United States Food and Drug Administration Approval

The Evolution of Chemokine Release Supports a Bimodal Mechanism of Spinal Cord Ischemia and Reperfusion Injury

Surgery for thoracic aortic disease in Japan: evolving strategies toward the growing enemies

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