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Technical eligibility for endovascular treatment of the aortic arch after open type A aortic dissection repair
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery. Aarhus University Hospital, Department of Vascular Surgery.
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Thoracic Surgery.
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.ORCID iD: 0000-0002-3273-8726
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Thoracic Surgery.
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2019 (English)In: Journal of Thoracic and Cardiovascular Surgery, ISSN 0022-5223, E-ISSN 1097-685XArticle in journal (Refereed) Submitted
Abstract [en]

Objective: To report on the technical eligibility of patients previously treated for Stanford type A aorta dissection (AAD) for endovascular aortic arch repair based on contemporary anatomical criteria for an arch inner-branched stentgraft (AIBS). 

 

Methods: All patients treated for AAD from 2004-2015 at a single aortic centre were identified. Extent of repair and use of circulatory arrest were reported. Survival and reoperation were assessed using Kaplan Meier and competing risk models. Anatomic assessment was performed using 3-dimensional CT-imaging software. Primary outcome was survival ≥ 1 year and fulfilment of the AIBS anatomical criteria. 

 

Results: A total of 198 patients were included (158 Debakey I, 32 Debakey II, and 8 Intramural hematoma). Mortality was 30-days: 16.2%, 1-year: 19.2%, 10-years: 45.0%. There were 129 patients with imaging beyond 1 year (mean, 47.8 months), while 89 (69.0%) were AIBS eligible. During follow-up, 19 (14.7%) patients met the threshold criteria for aortic arch treatment, of which 14 (73.7%) would be considered eligible for AIBS. Patients who underwent AAD repair with circulatory arrest and no distal clamp were more often eligible for endovascular repair (88.8%) than those operated with a distal clamp (72.5%), p=0.021. Among patients who did not meet the AIBS anatomical criteria, the primary reasons were mechanical valve (40%) and insufficient proximal seal (30%). 

 

Conclusion: More than two thirds of post AAD patients repair are technically eligible for endovascular AIBS repair. Development of devices that can accommodate a mechanical aortic valve and a greater awareness of sufficient graft length would significantly increase availability.

Place, publisher, year, edition, pages
2019.
National Category
Surgery
Research subject
Surgery
Identifiers
URN: urn:nbn:se:uu:diva-393182OAI: oai:DiVA.org:uu-393182DiVA, id: diva2:1352134
Available from: 2019-09-17 Created: 2019-09-17 Last updated: 2019-10-28Bibliographically approved
In thesis
1. On Surgical Treatment of Aortic Pathology
Open this publication in new window or tab >>On Surgical Treatment of Aortic Pathology
2019 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

The use of endovascular aneurysm repair (EVAR) in the treatment of abdominal aortic aneurysms has advanced from a premature characterization as a “failed experiment” in early 2000 to the predominant modern method of treatment. Technology has accommodated initial shortcomings, but it has also led to expansions in the treatment of ruptured aneurysms and complex aortic pathologies. The overall aim of this thesis is to characterize the contemporary utilization of endovascular repair in the international setting and to evaluate its expanding use in complex aortic disease treatment.

Paper I is an analysis of outcomes after intact aneurysm treatment from registries of 12 countries. From 2005 to 2013, and with 83,253 patients included, it was shown that the use of EVAR has increased while, the perioperative mortality has decreased. This was counterbalanced by a worsening mortality for those patients treated with open aortic repair.

Paper II is an analysis of ruptured aneurysms from the above-mentioned international registries. EVAR is also increasing for these patients, although open repair is still the predominant treatment strategy in most centres. Perioperative mortality was superior for EVAR patients, despite increased age and comorbidities. An association between patient-volume and perioperative mortality could be shown for open repair, but the same could not be demonstrated for EVAR.

Paper III is an evaluation of the adaptation of a total endovascular approach for the treatment of complex abdominal aortic aneurysms from a single centre. The technical success and midterm mortality, as well as post-operative complications, including spinal ischemia, were similar to those reported from large and multi-centre analyses. Previous studies reveal disparate results for centres performing open complex aortic repair. The results here suggest that a total endovascular approach is feasible for dedicated centres contemplating this strategy.  

Paper IV is an analysis of multiple pre-, peri-, and post-operative variables documented from complex aneurysm procedures. A relationship between increased complexity and variables such as anaesthesia duration, bleeding, hospital stay, and radiation exposure was found. As patients and their comorbidities increase, a decision to embark on a complex procedure should be made with due diligence to these relationships.

Paper V is a technical analysis of patients following acute treatment for Type A aortic dissections. Many patients are unfit for open aortic arch repair. Based on current availability of endovascular aortic stentgrafts, it was shown that the majority of patients can be treated endovascularly, while anticipated device improvements should further increase the proportion of eligibility. 

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2019. p. 61
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 1613
Keywords
Abdominal aortic aneurysm, EVAR, F/BEVAR, aorta dissection.
National Category
Surgery
Identifiers
urn:nbn:se:uu:diva-395964 (URN)978-91-513-0806-7 (ISBN)
Public defence
2019-12-18, Rosénsalen, entrance 95/96, NBV, Akademiska sjukhuset, Uppsala, 13:00 (English)
Opponent
Supervisors
Available from: 2019-11-26 Created: 2019-10-28 Last updated: 2020-01-13

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