Early and Long-term Outcome after Open Surgical Suprarenal Aortic Fenestration in Patients with Complicated Acute Type B Aortic Dissection

Szeberin, Zoltán; Dósa, Edit; Fehérvári, Mátyás; Csobay-Novák, Csaba; Pintér, N.; Entz, László

doi:10.1016/j.ejvs.2014.12.028

Cited by 21 publications

(12 citation statements)

References 22 publications

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“…However, the options in urgent or emergency situations are limited. Increased risks of complications after operations include subclavian steal syndrome, arm claudication, vertebral territory stroke, and spinal cord ischemia because the collateral blood supply to the spinal cord from the vertebral artery is obstructed . According to the literatures, 54% of thoracic aortic tears locate at proximity to the LSA, eliminating the 15‐ to 25‐mm proximal landing zone required by TEVAR .…”

Section: Introductionmentioning

confidence: 99%

“…Increased risks of complications after operations include subclavian steal syndrome, arm claudication, vertebral territory stroke, and spinal cord ischemia because the collateral blood supply to the spinal cord from the vertebral artery is obstructed. 7 According to the literatures, 54% of thoracic aortic tears locate at proximity to the LSA, eliminating the 15-to 25-mm proximal landing zone required by TEVAR. 8 If the distance between the proximal entry tear and the proximal seal zone is less than 15 mm, incomplete endografts implantation to the aortic arch always cause birdbeak configuration, which increases the risk of endoleaks during TEVAR.…”

mentioning

confidence: 99%

See 1 more Smart Citation

In Situ Laser Fenestration Is a Feasible Method for Revascularization of Aortic Arch During Thoracic Endovascular Aortic Repair

Qin

Zhao

Wang

et al. 2017

JAHA

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BackgroundReconstruction of the aortic major branches during thoracic endovascular aortic repair is complicated because of the complex anatomic configuration and variation of the aortic arch. In situ laser fenestration has shown great potential for the revascularization of aortic branches. This study aims to evaluate the feasibility, effectiveness, and safety of in situ laser fenestration on the three branches of the aortic arch during thoracic endovascular aortic repair.Methods and ResultsBefore clinical application, the polytetrafluoroethylene and Dacron grafts were fenestrated by an 810‐nm laser system ex vivo, which did not damage the bare metal portion of the endografts and created a clean fenestration while maintaining the integrity of the endografts. In vivo, 6 anesthetized female swine survived after this operation, including stent‐graft implantation in the aortic arches, laser fenestration, and conduit implantation through the innominate arteries and the left carotid arteries. Based on the animal experiments, in situ laser fenestration during thoracic endovascular aortic repair was successively performed on 24 patients (aged 33–86 years) with aortic artery diseases (dissection type A: n=4, type B: n=7, aneurysm: n=2, mural thrombus: n=7). Fenestration of 3 aortic branches was performed in 2 (8.3%) patients. Both the left carotid artery and the left subclavian artery were fenestrated in 6 (25%) patients. Only left subclavian artery fenestration surgery was done in 16 (66.7%) patients. Among these patients, 1 fenestration was abandoned secondary to an acute takeoff of the innominate artery in a type III aortic arch. The average operative time was 137±15 minutes. The technical success rate was 95.8% (n=23). No fenestration‐related complications or neurological morbidity occurred after this operation. During a mean postoperative 10‐month follow‐up (range: 2–17 months), 1 patient died of severe pneumonia, and all the left subclavian artery and carotid artery stents were patent with no fenestration‐related endoleaks upon computed tomography angiography images.ConclusionsIn situ laser fenestration is a feasible, effective, rapid, repeatable, and safe option for the reconstruction of aortic arch during thoracic endovascular aortic repair, which might be available to revascularize the 3 branches. However, follow‐up periods should be extended to evaluate the robustness of this technique.

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Section: Introductionmentioning

confidence: 99%

mentioning

confidence: 99%

In Situ Laser Fenestration Is a Feasible Method for Revascularization of Aortic Arch During Thoracic Endovascular Aortic Repair

Qin

Zhao

Wang

et al. 2017

JAHA

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“…Despite new emerging techniques, open surgery is still carried out. The reasons behind may be lack of endosurgical equipment in all centers, lack of skilled people or the fact that endosurgery may not necessarily be more cost-effective than surgical reconstruction [1]. The perioperative mortality rate in open surgery ranges from 5% to 10%.…”

Section: Discussionmentioning

confidence: 99%

“…Acute type B dissection is a life threatening condition that is associated with a very high mortality rate [1]. The correct diagnosis of the acute type B dissection can be a challenging job because aortic dissection has "many faces".…”

Section: Introductionmentioning

confidence: 99%

Acute Type B Dissection Complicated by Aortic Coarctation

Singh¹,

Yang²,

Zhang³

et al. 2017

ACT

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We report a case of acute type B aortic dissection complicated by coarctation of aorta in 35-year-old women. Computed tomography angiography (CTA) showed a short segment aortic narrowing with diameter of 9.2 mm a small intimal tear, a true lumen, a false lumen, a markedly thick mural thrombus and pleural effusion. Open surgical procedure was performed and the aortic coarctation (CoA) and aortic dissection were resected and a 24-mm prosthetic graft was anastomosed. No pseudo aneurysms were present at the anastomosis sites on the follow up CTA.

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“…Open surgical suprarenal aortic fenestration is one of these alternatives about which there are very few published data. As such, the publication by Szeberin et al 1 is valuable and helps fill that void.…”

mentioning

confidence: 95%

Commentary on ‘Early and Long-term Outcome after Open Surgical Suprarenal Aortic Fenestration in Patients with Complicated Acute Type B Aortic Dissection’

Gonçalves

Verhagen²

2015

European Journal of Vascular and Endovascular Surgery

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Intervention for acute complicated type B dissection has received much attention in recent years. The advent of endovascular repair has opened the door for minimally invasive alternatives to open repair, with favourable results. However, the paucity of data on the outcome of alternative treatment strategies hampers possible comparison. Open surgical suprarenal aortic fenestration is one of these alternatives about which there are very few published data. As such, the publication by Szeberin et al. 1 is valuable and helps fill that void.The study must, nevertheless, be put in perspective. Open suprarenal fenestration is undisputedly a major surgical insult, associated with significant peri-operative mortality and morbidity: one in five of patients with a mean age of 55 years died within 30 days. This procedure is unsuitable for frail patients and the risk may only be justified for hard indications such as malperfusion. Patients presenting with rupture are also not candidates for this technique, for obvious reasons.The authors' definition of complicated type B dissection is controversial. While 25% of patients reportedly had malperfusion symptoms at the time of surgery, half were treated for uncontrollable hypertension or pain, which are softer indications that are increasingly rare with contemporary medical management. In a recently published series of 102 acute complicated type B dissection patients treated in Zurich and Uppsala, only 4% were treated for intractable pain and none for uncontrollable hypertension. 2 Furthermore, a substantial proportion was considered complicated on the basis of a narrow true lumen on computed tomography angiography (CTA). Depending on cardiac phase, the mobile lamella of acute dissections may appear to occlude the true lumen completely on static CTA 3,4 ; unless dynamic CTA is used or thrombosis is evident, a narrow true lumen in the absence of symptoms should not prompt surgical repair.The disturbingly high rate of progressive aortic dilatation leading to severe late complications reported by Szeberin et al. is also noteworthy. This suggests the technique is very ineffective in preventing the delayed complications of type B dissection. In fact, it may promote aortic degeneration, and the consequent risk of late aortic related death. Results from the INSTEAD-XL study suggest that endoclosure of the primary entry tear results in favourable aortic remodelling, 5 which seems to be in sharp contrast to fenestration.Lastly, the described technique of open surgical aortic fenestration makes subsequent aortic graft replacement (primary treatment option for most late post-dissection complications in our view) exceptionally more difficult. In acute cases deemed unsuitable for endovascular methods, a more definitive strategy seems better indicated, with cardiopulmonary bypass or other shunt manoeuvres as standard adjuncts.In conclusion, the publication by Szeberin et al. is important to contextualize current management of complicated type B dissections, but primary use of open suprarenal ao...

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Early and Long-term Outcome after Open Surgical Suprarenal Aortic Fenestration in Patients with Complicated Acute Type B Aortic Dissection

Cited by 21 publications

References 22 publications

In Situ Laser Fenestration Is a Feasible Method for Revascularization of Aortic Arch During Thoracic Endovascular Aortic Repair

In Situ Laser Fenestration Is a Feasible Method for Revascularization of Aortic Arch During Thoracic Endovascular Aortic Repair

Acute Type B Dissection Complicated by Aortic Coarctation

Commentary on ‘Early and Long-term Outcome after Open Surgical Suprarenal Aortic Fenestration in Patients with Complicated Acute Type B Aortic Dissection’

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