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Endovascular Treatment of Acute Aortic Syndrome

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Endovascular Treatment of Acute Aortic Syndrome Endovascular treatment of acute aortic syndrome Rachel E. Clough, MB, BS, BSc, MRCS,a Kevin Mani, MD, PhD,a,b Oliver T. Lyons, MB, BS, BSc, MRCS,a Rachel E. Bell, MB, BS, MS, FRCS,a Hany A. Zayed, MD, MSc, FRCS,a Matthew Waltham, MA, PhD, FRCS,a Tom W. Carrell, MA, MChir, FRCS,a and Peter R. Taylor, MA, MChir, FRCS,a London, United Kingdom; and Uppsala, Sweden Background: The term acute aortic syndrome (AAS) encompasses a range of conditions that have a risk of imminent aortic rupture and where delays in treatment result in increased mortality. Endovascular treatment offers an attractive alternative to open surgery but little is known about the durability of the repair and the factors that predict mortality. Methods: Prospective data were collected for a cohort of 110 consecutive patients with endovascular treatment for AAS. Patient and procedural characteristics were related to short- and midterm outcome using multivariate logistic regression analysis. Results: There were 75 men and 35 women with a median age of 68 (range 57-76) years. The pathologies treated were acute dissection (35), symptomatic aneurysm (32), infected aneurysm (18), transection (12), chronic dissection (9), penetrating ulcer (3), and intramural hematoma (1). Thirty-day mortality was 12.7% and this was associated with hypotension (odds ratio [OR], 5.25), use of general anesthetic (OR, 5.23), long procedure duration (OR, 2.03), and increasing age (OR, 1.07). The causes of death were aortic rupture (4), myocardial infarction (4), stroke (3), and multisystem organ failure (3). The stroke and paraplegia rates were 7.3% and 6.4%, respectively. The 1-year survival was 81% and the 5-year survival 63%. Secondary procedures were required in 13 (11.8%) patients. Factors associated with death at 1 year were presence of an aortic fistula (OR, 9.78), perioperative stroke (OR, 5.87), and use of general anesthetic (OR, 3.76); and at 5 years were aortic fistula (OR, 12.31) and increasing age (OR, 1.06). Conclusions: Acute aortic syndrome carries significant early and late mortality. Emergency endovascular repair offers a minimally invasive treatment option associated with acceptable short and midterm results. Continued surveillance is important as secondary procedures and aortic-related deaths continue to occur throughout the follow-up period. (J Vasc Surg 2011;54:1580-7.) The concept of grouping a range of clinical conditions aortic rupture will allow early identification of patients with which share a common life-threatening risk into a single chest pain due to an aortic cause and expedite early imple- syndrome came from cardiology, where the term acute mentation of definitive treatment.4,5 Aneurysm, dissection, coronary syndrome (ACS) allowed a number of different transection, penetrating ulcer, and intramural hematoma clinical presentations of threatened coronary artery occlu- can be grouped together, not because they share the same sion to be considered together, to promote early identifi- pathology, but because in the acute setting these aortic cation and treatment and to improve survival.1-3 conditions require early identification, transfer to an appro- The concept of an acute aortic syndrome (AAS) to priate care facility, rapid institution of medical therapy and encompass those conditions where there is risk of imminent urgent aortic repair with high quality anesthesia, and a cardiovascular intensive care unit for postprocedure care.6,7 The reason for grouping these conditions into one entity is From the Department of Vascular Surgery, NIHR Comprehensive Biomed- ical Research Centre of Guy’s and St. Thomas’ NHS Foundation Trust so that specific algorithms can be developed in centers and King’s College London, King’s Health Partners, Londona; and the specializing in aortic intervention with the aim of improv- Institution of Surgical Sciences, Department of Vascular Surgery, Uppsala ing outcome.8-10 b University, Uppsala. Traditional management of AAS includes open surgical Supported by a Clinical Training Fellowship from the National Institute for Health Research (R.E.C.), Swedish Heart and Lung Foundation and the replacement of the thoracic aorta and is associated with a 11,12 Uppsala University Hospital (K.M.), and by a Clinical Research Training high perioperative mortality and morbidity. Endovas- Fellowship from the Medical Research Council (O.T.L.). cular repair of aortic pathology is increasingly being used as Competition of interest: none. an alternative to open surgery.13-15 The published litera- Presented at the meetings of the European Society for Vascular Surgery ture contains few articles on the endovascular treatment of (Amsterdam, September 2010) and the Vascular Society of Great Britain and Ireland (Brighton, UK, November 2010). patients presenting with acute conditions of the thoracic Reprint requests: Rachel E. Clough, Department of Vascular Surgery, aorta. We report the midterm follow-up of our experience NIHR Comprehensive Biomedical Research Centre of Guy’s and St. of the endovascular management of AAS and investigate Thomas’ NHS Foundation Trust and King’s College London, and King’s factors that may predict mortality. Health Partners, Westminster Bridge Road, London, SE1 7EH, UK (e-mail: [email protected]). The editors and reviewers of this article have no relevant financial relationships METHODS to disclose per the JVS policy that requires reviewers to decline review of any The cohort consisted of 110 consecutive patients with manuscript for which they may have a competition of interest. acute thoracic aortic pathology (pathology affecting the 0741-5214/$36.00 Copyright © 2011 by the Society for Vascular Surgery. aortic arch and/or descending thoracic aorta) who under- doi:10.1016/j.jvs.2011.07.034 went endovascular treatment at a single university teaching 1580 JOURNAL OF VASCULAR SURGERY Volume 54, Number 6 Clough et al 1581 hospital between August 1997 and September 2009. A Table I. Patient demographics and procedure details team of five vascular surgeons and five interventional radi- ologists provided a 24-hour emergency service. Variable The study was designed as a retrospective analysis of a Age prospectively maintained database, case notes, and imaging (median [IQR]) 68 (57-76) studies. Patient and procedural characteristics were collated Gender on a standardized pro forma. (male:female) 75:35 Preoperative imaging. All patients underwent bolus- Aortic pathology Acute dissection 35 tracked computed tomography (CT) angiography. Images Symptomatic aneurysm 32 were interpreted by both experienced radiologists and sur- Infected aneurysm 18 geons to determine suitability for endovascular repair. Du- Transection 12 plex sonography was used to assess the ascending aorta to Chronic dissection 9 exclude type A dissection and to examine the status of the Penetrating ulcer 3 Intramural hematoma 1 carotid and vertebral arteries if deliberate occlusion of the Device type arch vessels was planned. Magnetic resonance imaging was Gore TAG 66 not used due to its lack of availability in the emergency Gore Excluder 15 setting. Cook TX2 7 Medtronic Talent 9 Initial medical treatment. Patients presenting with Medtronic AneuRx 4 aortic dissection, penetrating ulcer, and intramural hema- Medtronic Valiant 1 toma were treated initially with hypotensive medication Endofit 6 and analgesia on a high dependency, intensive care, or a Gore cTAG 2 coronary care unit. Blood pressure was titrated to ensure IQR, Interquartile range. adequate urine output. Initial treatment was with ␤-blockers and ␣-blockers then angiotensin converting enzyme (ACE)- inhibitors, angiotensin-2 receptor blockers, calcium chan- clinic at 4 months. CT angiography and clinical review were nel blockers, and diuretics. However, patients presenting performed annually thereafter. Data on follow-up were with circulatory shock were taken immediately to the en- obtained from hospital electronic records and community dovascular suite after a diagnostic CT scan. hospitals and community care practitioners. Operative technique. Patients who were conscious Statistical analysis. SPSS Statistics 17.0 software gave written consent. All operative procedures were per- (SPSS, Inc, Chicago Ill) was used for statistical analysis. formed in a hybrid operating theater with fluoroscopic and Quantitative variables were expressed as median and inter- angiographic equipment available. Vascular access was quartile range (IQR). Instability was defined as systolic achieved via femoral arteriotomy or prosthetic conduit. A blood pressure Ͻ90 mm Hg. Renal disease was defined as catheter was inserted in the contralateral groin so that glomerular filtration rate (GFR) Ͻ90 mL/min/1.73m2 or continuous angiography could be performed during device a serum creatinine Ͼ120 mmol/L. The relationship be- deployment. The majority of procedures were performed tween death at 30 days, 1 year, and 5 years, and patient and under loco-regional anesthesia without routine preopera- procedural characteristics was compared, and correspond- tive placement of a cerebrospinal fluid (CSF) drain. Pro- ing odds ratios were calculated using univariate logistic phylactic spinal drain insertion was considered if the proce- regression analysis. Variables with a P value Ͻ.2 were dure was performed under general anesthetic; there was entered into a multivariate logistic regression model using long segment coverage (the descending thoracic aorta from forced entry analysis. To enable evaluation of all cases, proximal to the left subclavian to the coeliac axis),
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