RESUMEN
BACKGROUND: Acute traumatic injury of the thoracic aorta (TAI) is a life-threatening complication in patients who sustain deceleration or crush injuries. This study was conducted to examine the results in patients who underwent endovascular repair with the Talent (Medtronic/AVE, Santa Rosa, CA) thoracic stent graft for acute traumatic injury. METHODS: Out of 457 consecutive endograft patients, 41 (9%) were treated for traumatic aortic conditions. There were 36 males with a mean age of 36 +/- 14 years. Mean aortic diameter at the time of intervention was 34 mm +/- 9 (range, 20 to 70 mm). The mean length of covered aorta was 106 mm (range, 5 to 130 mm) with only one stent graft used in 98% (40) of all cases. Median follow-up period for hospital survivors was 13 months (1.0 to 69.0 months). RESULTS: Stent graft implantation was technically successful in all cases (100%). One patient died during hospitalization, yielding an overall in-hospital mortality rate of 2.4%. Procedural-related paraplegia was zero and a primary endoleak was observed in 1 patient. Postoperative complications occurred in 4 patients (3 respiratory failures, 1 multiorgan failure). No patient required conversion to open surgical repair. CONCLUSIONS: The treatment of acute traumatic injuries of the descending thoracic aorta with the Talent stent graft is a feasible and safe technique; it provides low morbidity and mortality rates in the early postoperative period, and early results are encouraging. However, long-term studies are worthwhile to evaluate the effectiveness and the durability of this procedure.
Asunto(s)
Aorta Torácica/lesiones , Rotura de la Aorta/cirugía , Prótesis Vascular , Sistema de Registros , Stents , Traumatismos Torácicos/cirugía , Enfermedad Aguda , Adulto , Anciano , Anciano de 80 o más Años , Rotura de la Aorta/diagnóstico por imagen , Rotura de la Aorta/mortalidad , Europa (Continente)/epidemiología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Tasa de Supervivencia , Traumatismos Torácicos/diagnóstico por imagen , Traumatismos Torácicos/mortalidad , Factores de Tiempo , Tomografía Computarizada por Rayos X , Resultado del Tratamiento , Adulto JovenRESUMEN
OBJECTIVE: This study examined midterm results after treatment with the endovascular Talent thoracic stent graft (Medtronic/AVE, Santa Rosa, Calif) in patients with acute or chronic aortic dissection. METHODS: In the Talent Thoracic Retrospective Registry, 180 patients were treated for acute or chronic aortic dissection (mean age: 59.6 +/- 13.0 years). Thirty-seven (20.6%) patients had acute aortic complications with signs of rupture, distal malperfusion, or persistent pain; the remainder were in stable condition. Aortic diameter was 53.5 +/- 14.3 mm, the distance from the left subclavian artery to the proximal entry tear was 44.1 +/- 41.9 mm, and dissection extended beyond the celiac axis in 88.3% of cases. Length of covered aorta measured 138.9 +/- 45.7 mm, with one stent graft used in 125 (69.4%) patients. RESULTS: Procedural success was 98.3%. Nine patients died within 30 days, yielding an overall early mortality of 5.0%. For in-hospital outcome, multivariate analysis showed that age greater than 75 years (odds ratio [OR] 4,9; 95% confidence intervals [CI] 1.6-15.1; P = .006), American Society of Anesthesiologists class greater than III (OR 2.8; 95% CI 1.0-7.5; P = .04), and emergency status (OR 3.5; 95% CI 1.3-8.9; P = .01) were independent predictors of major adverse events. Compared with electively treated patients, emergency status was associated with a higher incidence of in-hospital mortality (13.5% vs 2.1%; P = .003) and neurologic events (16.2% vs 4.2%; P = .01). However, patients with acute dissection had a smaller baseline diameter and were less often identified to have secondary endoleaks and progressive enlargement. Average follow-up for hospital survivors was 22.3 +/- 17.0 months with an estimated survival of 94.9% +/- 1.7% at 30 days, 90.6% +/- 2.3% at 12 months, 90.6% +/- 2.3% at 24 months, and 81.8% +/- 4.8 % at 36 months. During follow-up, 30 patients required a total of 32 secondary interventions including 12 open and 20 endovascular procedures, accounting for an estimated 71.5% freedom from reinterventions at 36 months. Follow-up imaging revealed stable or decreasing thoracic aortic diameter in 80.5% of patients. CONCLUSION: Endovascular treatment for aortic dissection is associated with reasonably low morbidity and mortality. Long-term surveillance is crucial to define more comprehensively the durability of stent graft treatment of aortic dissection and to determine which patients are appropriate candidates for stent graft therapy.
Asunto(s)
Aneurisma de la Aorta Torácica/cirugía , Disección Aórtica/cirugía , Implantación de Prótesis Vascular , Stents , Enfermedad Aguda , Adulto , Anciano , Anciano de 80 o más Años , Disección Aórtica/diagnóstico , Aneurisma de la Aorta Torácica/diagnóstico , Rotura de la Aorta/etiología , Implantación de Prótesis Vascular/efectos adversos , Enfermedad Crónica , Medios de Contraste , Femenino , Humanos , Imagen por Resonancia Magnética , Masculino , Persona de Mediana Edad , Reoperación , Stents/efectos adversos , Tomografía Computarizada por Rayos X , Adulto JovenRESUMEN
BACKGROUND: Elective thoracic endovascular aortic repair in selected patients with suitable aortic anatomy is associated with low morbidity and mortality, and is gaining widespread acceptance. Its benefit in acute thoracic aorta diseases, however, has not yet been demonstrated in high-numbered studies. This report presents data of the Talent Thoracic Retrospective Registry (TTR) of all patients who underwent endovascular stent grafting for acute thoracic aorta pathology. METHODS: Between December 1996 and July 2004 data were collected regarding 113 consecutive patients who underwent emergent endovascular stent grafting of the thoracic aorta using the Talent thoracic stent graft (Medtronic, Inc., Santa Rosa, California) in 7 European referral centers. Acute thoracic aorta pathology consisted of 41 (36.3 %) traumatic aortic injuries, 37 (32.7 %) Stanford type B dissections, 5 (4.4 %) intramural hematomas, 18 (15.9 %) thoracic aorta aneurysms, 4 (3.5 %) pseudoaneurysms and 8 (7.1 %) penetrating ulcers. RESULTS: In all patients the stent graft system could be introduced via the common femoral artery. Conversion to open surgical repair was necessary in 2 patients, one in the early phase due to persistent bleeding via backflow in the false lumen from a distal entry tear, and another patient in a late phase due to retrograde dissection. Intraoperative mortality was 1.8%, one patient suffered a massive myocardial infarction, and another died of tamponade secondary to retrograde dissection. Overall hospital mortality was 8.0% (9 patients). In only 2 of them, it was considered a stent graft procedure related death. New neurological symptoms were seen in 6.2% (7 patients), with complete recovery in 5 patients. Mean follow-up was 15 months (range 1-69 months). Late mortality was 8.7% (9 patients). Only one late death was considered aorta related. Overall re-intervention rate was 8.9% (n=10) and was mainly for type I endoleak or persistent false lumen perfusion. CONCLUSION: Sub-analysis of the Talent Thoracic Retrospective Registry for endovascular stent grafting of acute thoracic aorta pathology in over 100 consecutive patients demonstrated its feasibility, with low morbidity and acceptable low mortality rates.
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Aorta Torácica/cirugía , Aneurisma de la Aorta Torácica/cirugía , Disección Aórtica/cirugía , Implantación de Prótesis Vascular/métodos , Adulto , Anciano , Anciano de 80 o más Años , Disección Aórtica/diagnóstico por imagen , Aorta Torácica/diagnóstico por imagen , Aneurisma de la Aorta Torácica/diagnóstico por imagen , Aortografía , Urgencias Médicas , Métodos Epidemiológicos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Reoperación/métodos , Stents , Tomografía Computarizada por Rayos X , Resultado del Tratamiento , Adulto JovenRESUMEN
Management of acute ST elevation myocardial infarction (STEMI) demands rapid and complete reperfusion of the infarct-related artery (IRA). With postinfarction prognosis depending on time delay from onset of symptoms to complete reperfusion (TIMI 3 flow) of the IRA, primary percutaneous coronary intervention (PPCI) performed by an experienced team has been shown to be superior to thrombolytic therapy with lower mortality, less frequent occurrence of nonfatal reinfarction and stroke, and thus represents the preferred treatment strategy according to the national and international guidelines. For regional implementation of PPCI, particularly in rural areas, information and transfer logistics within networks of care and direct transport of an infarction patient to a PCI hospital rather than to the closest hospital are a challenge. With successful implementation of network logistics and standardized therapeutic pathways, current guidelines and requested timelines versus thrombolysis could be met. The implemented logistics comprised 24 h/7 days stand-by services of an experienced PCI team, direct telephone hotline contact between rescue service/emergency physician and interventional cardiologist on call, and direct open access to a catheterization laboratory at any time. Within the Drip&Ship network Rostock, to date (July 2007) 1,022 consecutive patients with PCI for STEMI were documented and analyzed over 5 years; of these, 490 patients were transferred from a community hospital to the PCI center and 532 patients were admitted directly to the interventional center. In 95.1% of all transferred and in 94.8% of all directly admitted patients, PCI was successfully accomplished upon arrival. A normalized flow to the IRA after PCI was documented in 96% of both groups, no patient was subjected to thrombolytic therapy. At 12-month follow-up, there were no differences between both groups with respect to infarct size and mortality. Moreover, there was no evidence of differences in left ventricular ejection fraction between groups. Thus, transportation of STEMI patients within an established PCI network did not result in any prognostic disadvantage. Efficient network logistics with transportation for PPCI in acute STEMI ensure both safety and outcome profiles similar to patients treated by PCI in metropolitan areas.
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Aterectomía , Cardiología/organización & administración , Redes Comunitarias/organización & administración , Sistemas de Apoyo a Decisiones Clínicas , Infarto del Miocardio/terapia , Regionalización/organización & administración , Terapia Trombolítica , Vías Clínicas/organización & administración , Atención a la Salud/organización & administración , Prestación Integrada de Atención de Salud/organización & administración , Alemania , Humanos , Modelos OrganizacionalesRESUMEN
BACKGROUND: Endovascular treatment of thoracic aortic diseases demonstrated low perioperative morbidity and mortality when compared with conventional open repair. Long-term effectiveness of this minimally invasive technique remains to be proven. The Talent Thoracic Retrospective Registry was designed to evaluate the impact of this therapy on patients treated in 7 major European referral centers over an 8-year period. METHODS: Data from 457 consecutive patients (113 emergency and 344 elective cases) who underwent endovascular thoracic aortic repair with the Medtronic Talent Thoracic stent graft (Medtronic/AVE, Santa Rosa, Calif) were collected. Follow-up analysis (24 +/- 19.4 months, range 1-85.1 months) was based on clinical and imaging findings, including all adverse events. To ensure consistency of data interpretation and event reporting, one physician reviewed all adverse events and deaths for the whole cohort of patients. In the case of discrepancies, the treating physicians were queried. FINDINGS: Among 422 patients who survived the interventional procedure (in-hospital mortality 5%, 23 patients), mortality during follow-up was 8.5% (36 patients), and in 11 of them the death was related to the aortic disease. Persistent endoleak was reported at imaging follow-up in 64 cases: 44 were primary (9.6%) and 21 occurred during follow-up (4.9%). Seven patients with persistent endoleak had aortic rupture during follow-up, at a variable time from 40 days to 35 months, and all subsequently died. A minor incidence of migration of the stent graft (7 cases), graft fabric alteration (2 cases), and modular disconnection (3 cases) was observed at imaging. Kaplan-Meier overall survival estimate at 1 year was 90.97%, at 3 years was 85.36%, and at 5 years was 77.49%. At the same intervals, freedom from a second procedure (either open conversion or endovascular) was 92.45%, 81.3%, and 70.0%, respectively. CONCLUSION: Endovascular treatment for thoracic aortic disease with the Talent stent graft is associated with low early morbidity and mortality rates also for patients who are at high risk and treated on an emergency basis. Follow-up data indicate a substantial durability of the procedure with a high freedom from related death and secondary interventions.