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Endovascular treatment in thoracic aortic diseases has increased in use exponentially since Dake and colleagues first described the use of a home-made transluminal endovascular graft on 13 patients with descending thoracic aortic aneurysm at Stanford University in the early 1990s. Thoracic endovascular aneurysm repair (TEVAR) was initially develope...
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Citations
... [1][2][3] Complications after TEVAR include endoleak, access site complications, renal injury, stroke, spinal cord ischemia, device migration, and aortoesophageal and aortobronchial fistulas. [3][4][5][6][7] Although uncommon, infection of the thoracic stent graft can occurdand can be associated with high morbidity and mortality. Mid-and long-term TEVAR infections represent a complex and devastating complication. ...
... Mid-and long-term TEVAR infections represent a complex and devastating complication. 4,8,9 Management is complex. It includes conservative management with long-term antibiotics for patients who are not surgical candidates, endovascular treatment, which is usually used as a bridging procedure, and explanation of the infected graft, with in situ or extra-anatomic bypass reconstruction. ...
... It includes conservative management with long-term antibiotics for patients who are not surgical candidates, endovascular treatment, which is usually used as a bridging procedure, and explanation of the infected graft, with in situ or extra-anatomic bypass reconstruction. 4,[10][11][12] When choosing graft explantation with in situ reconstruction, adjunct procedures, such as the use of an omentum flap or a muscle flap, are required to decrease the risk of reinfection. 13,14 We report the case of a patient with an infected TEVAR who underwent open repair with explanation of an infected stent graft, in situ reconstruction, and latissimus dorsi muscle flap (LDMF) coverage. ...
A male patient, 70 years of age, was evaluated for an infected thoracic endovascular aneurysm repair (TEVAR). After presenting with persistent fever, a positron emission tomography scan found an infected aortic stent graft. The patient underwent open repair with explantation of the infected TEVAR, extensive periaortic debridement, graft replacement with a Dacron graft, and complete coverage with a latissimus dorsi muscle flap. Tissue culture revealed Clostridium spp. He was discharged home with long-term ampicillin and sulbactam. A postoperative computed tomography scan showed no recurrence of infection. Open surgery with latissimus muscle flap coverage is an achievable option for infected TEVAR.
... 17 In the treatment of vascular pathologies, post-TEVAR complications are common and patients suffer from endoleaks, stent-graft migration, infections, and severe cardiovascular effects such as coronary malperfusion and ventricular hypertrophy. 18,19 With the current technology, artificial implants are made of foreign materials and can naturally cause pathophysiological and inflammatory responses, but the extent of these physical reactions can be controllable. To reduce complications, implantable devices of any kind must undergo preclinical and comprehensive in vitro evaluation. ...
Implantable cardiovascular devices must undergo evaluation prior to animal testing and clinical trials to ensure their performance and efficiency. Mock circulation loops (MCLs) are on-demand tools capable of reproducing physiological conditions in vivo and are also devices for preventative testing. Recognition of their success as useful tools comes from the fact that over 100 MCLs have been submitted for device assessment in recent years. Mock circulation loops could detect malfunctions that patients might otherwise experience. Thus, MCLs can complement preclinical and prototype evaluation rather than being mutually exclusive. In this review, we emphasize the experimental value of MCLs while providing a brief overview of the history of the field. In addition, the necessary hemodynamic parameters are analyzed to reproduce physiological scenarios in vitro. We also discuss the relevant setups when evaluating devices to assist heart failure and aortic pathologies, namely artificial hearts, left ventricular assist devices, stent-grafts, and artificial heart valves. Finally, we report novel setups developed to evaluate soft biological tissues for translational research.
Clinical Impact
On needs-based ex vivo monitoring of implantable devices or tissues/organs in cardiovascular simulators provides new insights and paves new paths for device prototypes. The insights gained could not only support the needs of patients, but also inform engineers, scientists and clinicians about undiscovered aspects of diseases (during routine monitoring). We analyze seminal and current work and highlight a variety of opportunities for developing preclinical tools that would improve strategies for future implantable devices. Holistically, mock circulation loop studies can bridge the gap between in vivo and in vitro approaches, as well as clinical and laboratory settings, in a mutually beneficial manner.
... Our data also showed the favorable transition rate of post-P-TEVAR treatment (rate of CRT/CT after TEVAR: 75%, rate of esophagectomy after TEVAR: 52%). Although our data might support the feasibility of P-TEVAR, several complications of TEVAR have been reported, including spinal cord ischemia, stroke, endoleaks, access site complications, guidewire injuries, retrograde dissections, renal injury, unintentional great vessel coverage, aorto-esophageal and aorto-bronchial fistulas, and device failure [22]. The indication of P-TEVAR remains to be determined, and careful patient selection is needed. ...
Aorto-esophageal fistula (AEF) due to esophageal cancer (EC) is a life-threatening condition characterized by sudden hemorrhage, which often causes sudden death. To evaluate the efficacy and safety of thoracic endovascular aortic repair (TEVAR) for AEF due to EC, we performed a systematic review and meta-analysis. We searched the MEDLINE (PubMed) databases, the Cochrane Library databases, Ichushi-Web (the databases of the Japan Medical Abstract Society), and CiNii (Academic information search service of the National Institute of Information from Japan) from January 2000 to November 2023 for articles about TEVAR for an emergent aortic hemorrhage (salvage TEVAR [S-TEVAR]), and the prophylactic procedure (P-TEVAR). Six studies (140 cases) were eligible for meta-analysis. The 90-day mortality of S-TEVAR and P-TEVAR was 40% (95% CI 23–60, I2 = 36%) and 8% (95% CI 3–17, I2 = 0%), respectively. Post-S-TEVAR hemorrhagic and infectious complications were 17% (95% CI 3–57, I2 = 71%) and 20% (95% CI 5–57, I2 = 66%), respectively. Post-P-TEVAR hemorrhagic and infectious complications were 2% (95% CI 0–10, I2 = 0%) and 3% (95% CI 1–12, I2 = 0%), respectively. TEVAR for AEF due to EC may be a useful therapeutic option to manage or prevent hemorrhagic oncological emergencies.
... Lengthy operation times and complications such as stroke, access site complications, paraplegia, endoleaks, device migration, persistent aneurysm sac enlargement, and graft collapse need skilled surgeons in operation. [18][19][20][21][22][23][24][25] Patients who have underwent TAA repair surgery are more likely to have co-morbidities, including pre-operative acute renal failure and peripheral vascular disease (PVD). [26] The mortality rate for elective and urgent TAA repair cases was reported to be 10% and 35%, respectively, in earlier studies conducted in Germany. ...
BACKGROUND
Work relative value unit (wRVU) is a tool for assessing surgeons’ performance, compensation, and productivity. It appears that wRVU for cardiovascular procedures does not consider complexity and its value for lengthy operations is low. The aim of the study is to determine wRVU for cardiovascular procedures in Iran according to the proposed approach.
MATTERIALS AND METHODS
This study was conducted as a mixed method in teaching hospitals in Tabriz in the period of September 2020 to December 2021. According to Hospital Information System and expert opinions, six procedures in cardiovascular surgery were included in the study. They were compared with 18 procedures in neurosurgery, orthopedics, and otorhinolaryngology in terms of the operation time and wRVU/min. Then, we calculated new wRVUs for the selected procedures based on surgeons’ opinions, time measurements, and anesthetists’ points of view by content analysis in qualitative and statistical analysis in quantitative parts.
RESULTS
Among the six cardiac procedures, the wRVU for five was under-estimated. The wRVU/min value ranged from 0/28 to 1/15 in the studied procedures. Findings demonstrate no significant relationship between the length of operations and the wRVU announced by the Ministry of Health and Medical Education (P value >0/05). Compared to studied procedures in four specialties, thoracoabdominal aortic aneurysm repair has the longest surgery time at 417 minutes. According to anesthesiologists, cardiovascular; orthopedics; ear, nose, and tongue; and neurosurgery specialties obtained 4/2, 2/9, 2/8, and 4, respectively, in terms of surgery duration, complexity, risk, and physical effort.
CONCLUSION
Despite policymakers’ attempts to bring justice to payments, it seems that there has been little progress in paying cardiovascular surgeons. Improper payment to cardiovascular surgeons will affect the future of the workforce in this specialty. Today, the need to reconsider the wRVUs in heart specialty is felt more than before.
... On the other hand, there are some disadvantages. Firstly, the TEVAR procedure has its own potential complications including endoleaks, endograft collapse, and vascular access-related adverse events such as arterial rupture, perforation or dissection which can lead to retroperitoneal hemorrhage and lower limb ischemia requiring the prompt implementation of necessary measures (19). Secondly, TEVAR necessitates a relatively wide access vessel due to the larger diameter of its delivery system compared to some transcatheter procedures (20). ...
Patent ductus arteriosus (PDA) is a common congenital heart disease affecting roughly one in every 2,000 term births. Although most of the patients are diagnosed and treated during childhood, few cases may persist into adulthood. We presented a 27-year-old male patient with a 20.2 mm diameter PDA who was referred to our hospital with progressive fatigue and exertional dyspnea. Given the potential complications, usual techniques such as coil occlusion and duct occluders were deemed inappropriate for this patient. Thoracic endovascular aortic repair (TEVAR) using a non-touch exclusion technique was successfully performed for this patient. The patient was discharged with no major post-surgical complications. TEVAR could be a new, safe, and effective alternative treatment to other transcatheter procedures for complicated PDAs in some patients.
... Despite improvements in medical management and optimization of underlying health diseases and advances in device technology and operative technique, there still remain significant complications rates associated with TEVAR. 16 When we separated out postoperative outcomes by presenting diagnosis, we found the TBAD group more often suffered postoperative complications overall, and in certain circumstances the difference was stark. For instance, myocardial infarction occurred in 62% of those with TBAD but only in 4% in those with DTA. ...
... Although the superiority of early outcomes of TEVAR over open thoracic aortic repair have been demonstrated, there still remain significant complications and high readmission rates after TEVAR. 8,16 The present study finds outcomes after TEVAR vary significantly based on aortic disease. Patients presenting with type B aortic dissection undergoing TEVAR have a higher mortality risk than patients with aneurysmal disease. ...
Background
Because thoracic endovascular aortic repair (TEVAR) has become the standard of care for complicated type B aortic dissection (TBAD) and descending thoracic aortic (DTA) aneurysm, it is important to understand outcomes and use of TEVAR across thoracic aortic pathologies.
Methods and Results
This was an observational study of patients with TBAD or DTA undergoing TEVAR from 2010 to 2018, using the Nationwide Readmissions Database. In‐hospital mortality, postoperative complications, admission costs, and 30‐ and 90‐day readmissions were compared between the groups. Mixed model logistic regression was used to identify variables associated with mortality. An estimated total of 12 824 patients underwent TEVAR nationally, of which 6043 had an indication of TBAD and 6781 of DTA. Patients with aneurysms were more likely to be older, women, have cardiovascular disease, and have chronic pulmonary disease compared with patients with TBAD. Weighted in‐hospital mortality was higher for TBAD (8% [1054/12 711] versus 3% [433/14 407], P <0.001), compared with DTA, as were all postoperative complications. Patients with TBAD had a higher cost of care during their index admission (57.3 versus 38.8 × $1000, P <0.001), compared with DTA. The 30‐day and 90‐day weighted readmissions were more frequent for the TBAD group compared with DTA (20% [1867/12 711] and 30% [2924/12 711] versus 15% [1603/14 407] and 25% [2695/14 407], respectively, P <0.001). On multivariable adjustment, TBAD was independently associated with mortality (odds ratio, 2.06 [95% CI, 1.68–2.52]; P <0.001).
Conclusions
After TEVAR, patients who presented with TBAD had higher rates of postoperative complications, in‐hospital mortality, and cost compared with DTA. The incidence of early readmission was substantial for patients undergoing TEVAR, faring worse for those undergoing TEVAR for TBAD as compared with DTA.
... Local endograftinduced biomechanical events within the aortic wall might be re-sponsible for global graft-related complications such as endoleaks, graft migration, and infolding. Insufficient understanding of these vascular ramifications makes it difficult to manage them and achieve long-term successful repair [4,5] . The clinical TEVAR success is determined by the interaction of the rigid shape-memory stent-graft and the impact on the mechanical properties of the aorta; related to blood pressure and pulse wave velocity (PWV) after the implantation as well as the stent-graft design itself [4,6] . ...
... Insufficient understanding of these vascular ramifications makes it difficult to manage them and achieve long-term successful repair [4,5] . The clinical TEVAR success is determined by the interaction of the rigid shape-memory stent-graft and the impact on the mechanical properties of the aorta; related to blood pressure and pulse wave velocity (PWV) after the implantation as well as the stent-graft design itself [4,6] . Technological advances have resulted in self-expandable endografts that perform closer to, but fall short of, native compliance. ...
The effects of thoracic endovascular repair (TEVAR) on the biomechanical properties of aortic tissue have not been adequately studied. Understanding these features is important for the management of endograft-triggered complications of a biomechanical nature. This study aims to examine how stent-graft implantation affects the elastomechanical behavior of the aorta. Non-pathological human thoracic aortas (n=10) were subjected to long-standing perfusion (8h) within a mock circulation loop under physiological conditions. To quantify compliance and its mismatch in the test periods without and with a stent, the aortic pressure and the proximal cyclic circumferential displacement were measured. After perfusion, biaxial tension tests (stress-stretch) were carried out to examine the stiffness profiles between non-stented and stented tissue, followed by a histological assessment. Experimental evidence shows: (i) a significant reduction in aortic distensibility after TEVAR, indicating aortic stiffening and compliance mismatch, (ii) a stiffer behavior of the stented samples compared to the non-stented samples with an earlier entry into the nonlinear part of the stress-stretch curve and (iii) strut-induced histological remodeling of the aortic wall. The biomechanical and histological comparison of the non-stented and stented aortas provides new insights into the interaction between the stent-graft and the aortic wall. The knowledge gained could refine the stent-graft design to minimize the stent-induced impacts on the aortic wall and the resulting complications. STATEMENT OF SIGNIFICANCE: Stent-related cardiovascular complications occur the moment the stent-graft expands on the human aortic wall. Clinicians base their diagnosis on the anatomical morphology of CT scans while neglecting the endograft-triggered biomechanical events that compromise aortic compliance and wall mechanotransduction. Experimental replication of endovascular repair in cadaver aortas within a mock circulation loop may have a catalytic effect on biomechanical and histological findings without an ethical barrier. Demonstrating interactions between the stent and the wall can help clinicians make a broader diagnosis such as ECG-triggered oversizing and stent-graft characteristics based on patient-specific anatomical location and age. In addition, the results can be used to optimize towards more aortophilic stent grafts.
... There are no long-term data compared with the open surgical approach yet, but it is a known fact that morbidity and mortality are superior in most cases, so the treatment range is highly likely to expand in the future. Arterial dissection, iliac artery rupture, and arterial perforation are classified as complications as possible device delivery injuries during TEVAR implementation [5]. However, there is no literature review on catheterinduced aortic valve injury related to TEVAR. ...
Background
Acute aortic regurgitation (AR) is uncommon condition and usually results in an emergent situation because the left ventricle does not adapt quickly due to a sudden increase in end-diastolic volume caused by the regurgitant flow. Thoracic endovascular aortic repair (TEVAR) is a procedure that places a stent-graft on the lesion of thoracic aorta through a minimally invasive approach.
Case presentation
Here we report that a catheter-induced aortic valve injury associated with TEVAR can cause delayed AR, exemplified by the case of a patient who developed acute AR 42 months after TEVAR. For this, aortic valve replacement was performed and the patient was discharged without complications.
Conclusion
Our results demonstrate that when a catheter-related procedure is performed around the aortic valve, slight injury of the valve can cause aortic insufficiency even 3 years after surgery. Consequently, when performing a catheter-related procedure around the aortic valve, special attention is always required.
... Despite the increasing experience of the operator and refinement of technology, endovascular repairs continue to be plagued by some specific complications like stroke, paraplegia, endoleaks, RTAD, stent induced new entry tears (SINE), stent-graft migration, device malfunction, stent-graft infection, fistulae formation and access-site issues (43). Crowding of the origin of the supra-aortic arteries and curvature of the aortic arch, along with higher blood velocity and increased pulsatility makes hybrid repairs more complex and prone to complications then a TEVAR procedure. ...
Even with increasing operator experience and a better understanding of the disease and the operation, intervention for aortic arch pathologies continues to struggle with relatively higher mortality, reintervention, and neurologic complications. The hybrid aortic arch repair was introduced to simplify the procedure and improve the outcome. With recent industry-driven advances, hybrid repairs are not only offered to poor surgical candidates but have become mainstream. This review discusses the evolution of hybrid repair, terminology pertinent to this technique, and results. In addition, we aim to provide a pervasive review of hybrid aortic arch repairs with reference to relevant literature for a detailed understanding. We have also discussed our institutional experience with hybrid repairs.
... OR 0.37 (0.20-0.66), p 0.001) [16]. Among early vascular complications, vascular access injuries are the most frequent (15-20%) together with lower limb ischemia [15,17]. The use of large delivery catheters, inserted in a retrograde manner via the iliofemoral vessels, can cause arterial dissection, arterial perforation or iliac artery rupture; retrograde arterial dissection can cause mesenteric or renal ischemia and iliac artery laceration or rupture results in retroperitoneal hematoma or hemorrhage [17]. ...
... Among early vascular complications, vascular access injuries are the most frequent (15-20%) together with lower limb ischemia [15,17]. The use of large delivery catheters, inserted in a retrograde manner via the iliofemoral vessels, can cause arterial dissection, arterial perforation or iliac artery rupture; retrograde arterial dissection can cause mesenteric or renal ischemia and iliac artery laceration or rupture results in retroperitoneal hematoma or hemorrhage [17]. Stent graft migration, endoleaks with aneurysm expansion and rupture, stent graft infection and erosion into the esophagus are the most frequent late complications. ...
Vascular surgery patients have multiple comorbidities and are at high risk for perioperative complications. Aortic repair surgery has greatly evolved in recent years, with an increasing predominance of endovascular techniques (EVAR). The incidence of cardiac complications is significantly reduced with endovascular repair, but high-risk patients require postoperative ST-segment monitoring. Open aortic repair may portend a prohibitive risk of respiratory complications that could be a contraindication for surgery. This risk is greatly reduced in the case of an endovascular approach, and general anesthesia should be avoided whenever possible in the case of endovascular repair. Preoperative renal function and postoperative kidney injury are powerful determinants of short- and long-term outcome, so that preoperative risk stratification and secondary prevention are critical tasks. Intraoperative renal protection with selective renal and distal aortic perfusion is essential during open repair. EVAR has lower rates of postoperative renal failure compared to open repair, with approximately half the risk for acute kidney injury (AKI) and one-third of the risk of hemodialysis requirement. Spinal cord ischemia used to be the most distinctive and feared complication of aortic repair. The risk has significantly decreased since the beginning of aortic surgery, with advances in surgical technique and spinal protection protocols, and is lower with endovascular repair. Endovascular repair avoids extensive aortic dissection and aortic cross-clamping and is generally associated with reduced blood loss and less coagulopathy. The intensive care physician must be aware that aortic repair surgery has an impact on every organ system, and the importance of early recognition of organ failure cannot be overemphasized.
