RESUMO
The surgical repair of type A aortic dissection often involves prosthetic proximal aortic and arch reconstruction. Hypothermic circulatory arrest is typically used in these complex surgeries given the required prolonged ischaemia and the associated morbidity and mortality. A novel vascular anastomoses device (Device) has been developed to rapidly connect a native vessel to a polyester graft. This study describes deployment of the Device in the ovine model (n = 3; 6 carotid arteries). Anastamoses were created rapidly, and brain ischaemia time was limited to 6 min in all but one vessel. All vessels remained fully patent with normal blood flow and thrombus-free transitions through 6 months. Results thus suggest that this Device has the potential to reduce anastomosis time versus conventional suturing techniques and thereby reduce hypothermic circulatory arrest time.
Assuntos
Aneurisma da Aorta Torácica , Dissecção Aórtica , Implante de Prótese Vascular , Isquemia Encefálica , Anastomose Cirúrgica , Dissecção Aórtica/cirurgia , Animais , Aorta/cirurgia , Aorta Torácica/cirurgia , Aneurisma da Aorta Torácica/cirurgia , Implante de Prótese Vascular/métodos , Humanos , Ovinos , Resultado do TratamentoRESUMO
OBJECTIVE: Endovascular repair of the ascending aorta is currently limited to patients at high surgical risk with aortic diseases originating above the sinotubular junction. A number of different endovascular technologies and approaches have been used, although no consensus exists regarding a standardized technique. To better understand real-world endovascular approaches to the ascending aorta, we performed a comprehensive review of the types of endovascular aortic stents and associated vascular access used in repair of the ascending aorta. METHODS: A search of the MEDLINE database was conducted from January 1, 1995, through January 31, 2017, with the search term "ascending aortic stent." Studies involving endovascular stenting in which the primary therapy was confined exclusively to the ascending aorta were included. Studies involving hybrid arch procedures and surgical replacement of the ascending aorta associated with aortic stenting were excluded. The type of aortic stent, underlying aortic disease, and surgical approach were recorded along with outcomes, need for reinterventions, and follow-up. RESULTS: A total of 46 publications that focused on primary endovascular repair of the ascending aorta were identified. Thirteen different aortic stent grafts of various designs were used in 118 total patients. The most commonly used device types were thoracic stents (n = 84 [71.2%]) along with abdominal cuffs (n = 13 [11%]) and custom-made grafts (n = 12 [10.2%]). The most commonly treated aortic disease was type A aortic dissection (n = 59 [50%]), followed by aortic pseudoaneurysm (n = 35 [29.7%]), aortic aneurysm (n = 6 [5.1%]), penetrating atherosclerotic ulcer (n = 5 [4.2%]), and acute aortic rupture (n = 3 [2.5%]). Femoral arterial access was used in 62.7% of patients (n = 74); transapical (n = 17 [14.4%]), carotid (n = 15 [12.7%]), and axillary (n = 8 [6.8%]) approaches were also used. The overall type I endoleak rate was 18.6% (n = 22), with 11 patients (9.3%) requiring reintervention. Other complications included all-cause mortality (n = 18 [15.2%]), conversions to open surgery (n = 4 [3.4%]), and cerebrovascular complications (n = 4 [3.4%]). Aorta-related mortality was 5% (n = 6), and average follow-up was 17.2 months. CONCLUSIONS: Despite the absence of a dedicated aortic stent graft for the ascending aorta, patients with a range of ascending aortic diseases are being successfully treated by endovascular technologies. For optimal outcomes, patient selection is critical to align aortic anatomy with the limited device sizing options, and it should be reserved for patients at high surgical risk.
Assuntos
Aorta/cirurgia , Doenças da Aorta/cirurgia , Implante de Prótese Vascular/métodos , Procedimentos Endovasculares/métodos , Complicações Pós-Operatórias/epidemiologia , Doenças da Aorta/mortalidade , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/instrumentação , Implante de Prótese Vascular/normas , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/instrumentação , Procedimentos Endovasculares/normas , Humanos , Seleção de Pacientes , Complicações Pós-Operatórias/etiologia , Reoperação/estatística & dados numéricos , Stents/efeitos adversos , Resultado do TratamentoRESUMO
PURPOSE: Involvement of qualified specialists with proficiency in endovascular therapies has created flux regarding the role of cardiothoracic surgeons, vascular surgeons, and other catheter-skilled specialists in the management of type B aortic dissections. We used manuscript authorship trends and recent match data in order to study how multi-specialty involvement in treating aortic dissections has changed in the endovascular era. METHODS: A PubMed review of published literature between 1998 and 2015 was performed with "aortic dissection" in the title. Case studies and entries with incomplete author or identifying information were excluded. Author number, specialty affiliation, and treatment focus were recorded. Available residency match data were obtained from the National Resident Matching Program (NRMP). RESULTS: Cardiothoracic surgeons represented 38.5% (10/23) of the authors for papers with an endovascular focus in 1998 compared with 27.7% (59/213) in 2015. Vascular surgeons represented 19.2% (5/23) and 37.1% (79/213) of authors in 1998 and 2015, respectively. Radiologists accounted for 30.4% (7/23) of authorship in 1998 and 8.9% (19/213) in 2015. NRMP match data revealed a 10.6% decrease in thoracic surgery matches from 2004 to 2015, while vascular surgery and interventional radiology increased by 74.7% and 191.1%, respectively. CONCLUSIONS: Endovascular technologies have resulted in significant changes as to which specialties manage complicated type B aortic dissections. Vascular surgeons, with both open and extensive endovascular training are optimally positioned to assume a major role in the care of aortic dissection patients. Continued emphasis on endovascular training and multispecialty collaboration is essential for cardiothoracic surgeons in the endovascular era.
Assuntos
Aneurisma Aórtico/cirurgia , Dissecção Aórtica/cirurgia , Bases de Dados Bibliográficas , Procedimentos Endovasculares/educação , Internato e Residência , Colaboração Intersetorial , Cirurgia Torácica/educação , Bases de Dados Bibliográficas/estatística & dados numéricos , Bases de Dados Bibliográficas/tendências , Procedimentos Endovasculares/tendências , Humanos , Internato e Residência/estatística & dados numéricos , Papel do Médico , Especialidades Cirúrgicas , Recursos HumanosRESUMO
OBJECTIVE: Aortic occlusion with an endoballoon is a well-established technique to facilitate robotic and minimally invasive mitral valve surgery. Use of the endoballoon has several relative contraindications including ascending aortic dilatation greater than 38 mm in size. We sought to review our experience using the endoballoon in cases of totally endoscopic mitral valve surgery with aortic diameters greater than 38 mm. METHODS: A retrospective review of our single-site database was conducted to identify patients undergoing totally endoscopic mitral valve surgery by a single surgeon using an endoballoon and who had ascending aortic dilation. We defined aortic dilation as greater than 38 mm. Computed tomography was done preoperatively on all patients to evaluate the aortic anatomy as well as iliofemoral access vessels. Femoral artery cannulation was done in a standardized fashion to advance and position the endoballoon, to occlude the ascending aorta, and to deliver cardioplegia. RESULTS: From October 2011 through June 2015, 196 patients underwent totally endoscopic mitral valve surgery using an endoballoon at our institution. Twenty-two patients (11.2%) had ascending aortic diameters greater than 38 mm (range, 38.1-46.6 mm; mean, 40.5 ± 2.5 mm). In these cases, there were no instances of aortic dissection or other injury due to balloon rupture, balloon migration, device movement leading to loss of occlusion, or inability to complete planned surgery due to occlusion failure. CONCLUSIONS: Our experience suggests that it is possible to successfully use endoaortic balloon occlusion in patients with ascending aortic dilation with proper preoperative imaging and planning.
Assuntos
Aorta/anormalidades , Doenças da Aorta/terapia , Oclusão com Balão/métodos , Procedimentos Cirúrgicos Cardíacos/instrumentação , Doenças das Valvas Cardíacas/cirurgia , Valva Mitral/cirurgia , Procedimentos Cirúrgicos Robóticos/métodos , Idoso , Dilatação Patológica , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Minimamente Invasivos/instrumentação , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos , Resultado do TratamentoRESUMO
As more challenging aortic arch anatomy is being treated using aortic stent-grafts, there is an increased risk for proximal Type I endoleaks at the proximal seal zone or subsequent graft migration. We report a case of an endoanchor-assisted thoracic endovascular aneurysm repair of a patient with an aberrant right subclavian artery (ARSA) and aortic arch aneurysm who developed a proximal Type I endoleak in the aortic arch which was subsequently treated with endoanchors.
Assuntos
Aorta Torácica/cirurgia , Aneurisma da Aorta Torácica/cirurgia , Divertículo/cirurgia , Endoleak/cirurgia , Procedimentos Endovasculares/efeitos adversos , Stents , Artéria Subclávia/anormalidades , Adulto , Aorta Torácica/diagnóstico por imagem , Aneurisma da Aorta Torácica/diagnóstico , Prótese Vascular/efeitos adversos , Divertículo/congênito , Divertículo/diagnóstico por imagem , Endoleak/diagnóstico , Endoleak/etiologia , Humanos , Masculino , Desenho de Prótese , Artéria Subclávia/diagnóstico por imagem , Artéria Subclávia/cirurgia , Tomografia Computadorizada por Raios XRESUMO
BACKGROUND: Tricuspid regurgitation (TR) is an under treated disease. Although surgery for TR remains an effective therapy, many patients are considered to be at a high risk or otherwise inoperable. Caval valve implant (CAVI) offers an alternative to surgery in these patients. Trials assessing the safety and efficacy of caval valve implant are lacking. METHODS: The Heterotopic Implantation Of the Edwards-Sapien XT Transcatheter Valve in the Inferior VEna cava for the treatment of severe Tricuspid Regurgitation (HOVER) trial is an FDA approved, physician initiated, prospective, non-blinded (open label), non-randomized safety and feasibility study to determine the safety and efficacy of the heterotopic implantation of the Edwards-Sapien XT valve in the inferior vena cava for the treatment of severe TR in patients who are at high risk or inoperable. Patients with severe TR in the absence of severe pulmonary hypertension will be recruited. They will be evaluated by a multi-disciplinary team who will agree by consensus that the patients' symptoms are from TR. They will undergo imaging to assess the size of the inferior vena cava (IVC) to determine feasibility of the procedure. If patients meet the inclusion criteria and are free from exclusion criteria, after informed consent they will be eligible for enrollment in the study. A total of 30 patients will be enrolled. The primary objective of the study will be to demonstrate procedural success at 30-days and patient success at 1-year. CONCLUSION: Caval valve implant may present an alternative for patients who are at high risk or inoperable for tricuspid valve surgery (TVS) for TR. © 2016 Wiley Periodicals, Inc.
Assuntos
Cateterismo Venoso Central/instrumentação , Cateterismo Venoso Central/métodos , Implante de Prótese de Valva Cardíaca/instrumentação , Implante de Prótese de Valva Cardíaca/métodos , Próteses Valvulares Cardíacas , Insuficiência da Valva Tricúspide/terapia , Valva Tricúspide , Veia Cava Inferior , Cateterismo Venoso Central/efeitos adversos , Protocolos Clínicos , Estudos de Viabilidade , Implante de Prótese de Valva Cardíaca/efeitos adversos , Hemodinâmica , Humanos , Estudos Prospectivos , Desenho de Prótese , Projetos de Pesquisa , Índice de Gravidade de Doença , Resultado do Tratamento , Valva Tricúspide/diagnóstico por imagem , Valva Tricúspide/fisiopatologia , Insuficiência da Valva Tricúspide/diagnóstico por imagem , Insuficiência da Valva Tricúspide/fisiopatologia , Veia Cava Inferior/diagnóstico por imagem , Veia Cava Inferior/fisiopatologiaRESUMO
We aimed to develop a method that provides an alternative cannulation site in robotic mitral valve surgery that allows simultaneous endo-occlusion and antegrade perfusion. A 71-year-old man with severe mitral regurgitation and history of coronary artery bypass grafting underwent totally endoscopic robotic mitral valve repair. A 23-mm endoreturn cannula was placed through a 10-mm graft that was sewn to the left axillary artery. An endoballoon was passed through the Dacron/cannula complex and into the ascending aorta. This complex was used for simultaneous antegrade perfusion, endoballoon occlusion, and antegrade cardioplegia. Completion transesophageal echocardiography showed no evidence of mitral regurgitation. The patient had an uneventful postoperative course and was doing well at his 2-month follow-up appointment. The left axillary artery is a viable option for simultaneous endoballoon occlusion, antegrade perfusion, and antegrade cardioplegia in robotic mitral valve surgery. This has the potential benefit of providing antegrade perfusion, which some studies have shown to be associated with a decreased risk of complications when compared with retrograde perfusion specifically in patients with severe peripheral vascular disease.
Assuntos
Artéria Axilar/cirurgia , Oclusão com Balão/métodos , Implante de Prótese de Valva Cardíaca/métodos , Insuficiência da Valva Mitral/terapia , Procedimentos Cirúrgicos Robóticos/métodos , Idoso , Terapia Combinada , Ecocardiografia Transesofagiana , Humanos , Masculino , Insuficiência da Valva Mitral/diagnóstico por imagem , Perfusão/métodosAssuntos
Anormalidades Múltiplas , Aneurisma/cirurgia , Aorta Torácica/cirurgia , Aneurisma Aórtico/cirurgia , Dissecção Aórtica/cirurgia , Implante de Prótese Vascular , Anormalidades Cardiovasculares/cirurgia , Transtornos de Deglutição/cirurgia , Divertículo/cirurgia , Procedimentos Endovasculares , Artéria Subclávia/anormalidades , Humanos , MasculinoRESUMO
BACKGROUND: Although orthotopic heart transplantation (OHT) remains the preferred treatment for end-stage heart failure, there continues to be a critical shortage of organ donors. The goal of this study is to examine outcomes after orthotopic OHT using heavy drinking donors (HDDs) in a large, national database. METHODS: The United Network for Organ Sharing database was examined for all primary, adult OHT carried out from 2005 to 2012. RESULTS: There were 14,928 total OHT performed during the study period with 2,274 (15.2%) using HDD. Recipients of HDD were older (53.4 vs. 51.9 years, P < 0.001), more likely men (80.7 vs 74.4%, P < 0.001), less likely sex mismatched (21.5 vs 27.5%, P < 0.001), more likely race mismatched (57.4 vs 52.4%, P < 0.001), and had less total HLA mismatches (4.55 vs 4.65, P < 0.001). The HDD were older (37.0 vs 30.5 years, P < 0.001), more likely men (82.2 vs 69.9%, P < 0.001), and more likely to have heavy cigarette use (38.1 vs 13.2%, P < 0.001). Length of stay was not different (20.3 vs 19.7 days, P = 0.02). On multivariate analysis, use of HDD was not associated with mortality at 30 days (hazards ratio [HR], 1.12; 95% confidence interval [95% CI], 0.90-1.39; P = 0.30), 1 year (HR, 0.96; 95% CI, 0.83-1.11; P = 0.56), and at 5 years (HR, 1.02; 95% CI, 0.91-1.13; P = 0.79). Variables associated with mortality at 5 years included increasing donor age, prolonged ischemic time, worsening recipient creatinine, recipient black race, sex mismatch, and extracorporeal membrane oxygenation or mechanical ventilation as a bridge to transplantation. CONCLUSION: Heart transplantation can be performed using carefully selected HDDs with good outcomes.