Subscribe to RSS
DOI: 10.1055/s-0044-1779249
The Aortic Team Model for the Management of the Distal Arch, Descending Thoracic and Thoracoabdominal Aorta: Appraisal at 3 Years
Funding This project was funded by an internal grant from University of Calgary, Libin Cardiovascular Institute, Calgary Alberta, Canada.Abstract
Background This study aimed to assess feasibility, logistical challenges, and clinical outcomes associated with the implementation of an Aortic Team model for the management of distal arch, descending thoracic and thoracoabdominal aortic disease.
Methods An Aortic Team care pathway was implemented in November 2019. Working as a unit, two cardiac surgeons, two vascular surgeons, an interventional radiologist, a cardiologist, and an anesthesiologist collectively determined care decisions via multispecialty presence at an Aortic Clinic. Cardiac and vascular surgeons operated in tandem for open procedures. Interventional radiology participated alongside cardiac and vascular for endovascular procedures. Cardiology aided in medical therapies for heritable and degenerative disease, and had a lead role for genetics and high-risk pregnancy referrals. The model spanned three hospitals. Clinical outcomes at 3 years were assessed.
Results There were 35 descending thoracic and thoracoabdominal surgeries and 77 thoracic endovascular aortic repairs. Endoarch devices were used in 7 cases (Gore Thoracic Branch Endoprosthesis, 4, Terumo RelayBranch, 3) and an endothoracoabdominal device in 4 cases (Cook Zenith t-branch). The Aortic Clinic acquired 456 patients, with yearly increases (54 patients [year 1], 181 patients [year 2], 221 patients [year 3]). For surgery, mortality was 8.6% (3/35), permanent paralysis 5.7% (2/35), stroke 8.6% (3/35), permanent dialysis 0%, and reinterventions 8.6% (3/35). For endovascular cases, mortality was 3.9% (3/77), permanent paralysis 3.9% (3/77), stroke 5.2% (4/77), permanent dialysis 1.3% (1/77), and reinterventions 16.9% (13/77).
Conclusion An Aortic Team model is feasible and ensures all treatment options are considered. Conventional open thoracoabdominal procedures showed acceptable outcomes. Endoarch technology shows early promise.
Keywords
aorta - thoracoabdominal - thoracic endovascular repair - multidisciplinary - interdisciplinaryPublication History
Received: 02 October 2023
Accepted: 13 December 2023
Article published online:
02 May 2024
© 2024. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)
Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA
-
References
- 1 McClure RS, Berry RF, Dagenais F. et al. The many care models to treat thoracic aortic disease in Canada: a nationwide survey of cardiac surgeons, cardiologists, interventional radiologists, and vascular surgeons. CJC Open 2021; 3 (06) 787-800
- 2 Isselbacher EM, Preventza O, Hamilton Black III J. et al. 2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. Circulation 2022; 146 (24) e334-e482
- 3 Upchurch Jr GR, Escobar GA, Azizzadeh A. et al. Society for Vascular Surgery clinical practice guidelines of thoracic endovascular aortic repair for descending thoracic aortic aneurysms. J Vasc Surg 2021; 73 (1S): 55S-83S
- 4 Tenorio ER, Dias-Neto MF, Lima GBB, Estrera AL, Oderich GS. Endovascular repair for thoracoabdominal aortic aneurysms: current status and future challenges. Ann Cardiothorac Surg 2021; 10 (06) 744-767
- 5 Basha AM, Moore RD, Rommens KL, Herget EJ, McClure RS. A systematic review of total endovascular aortic arch repair: a promising technology. Can J Cardiol 2023; 39 (01) 49-56
- 6 Nana P, Spanos K, Dakis K, Giannoukas A, Kölbel T, Haulon S. Systematic review on customized and non-customized device techniques for the endovascular repair of the aortic arch. J Endovasc Ther 2022; 15 266028221133701
- 7 Lau C, Soletti Jr G, Weinsaft JW. et al. Risk profile and operative outcomes in Marfan syndrome versus non-Marfan patients undergoing thoracoabdominal aortic aneurysm repair. J Thorac Cardiovasc Surg 2023; 166 (06) 1548-1557.e2
- 8 Coselli JS, LeMaire SA, Preventza O. et al. Outcomes of 3309 thoracoabdominal aortic aneurysm repairs. J Thorac Cardiovasc Surg 2016; 151 (05) 1323-1337
- 9 Tong MZ, Eagleton MJ, Roselli EE. et al. Outcomes of open versus endovascular repair of descending thoracic and thoracoabdominal aortic aneurysms. Ann Thorac Surg 2022; 113 (04) 1144-1152
- 10 Chou E, Pirruccello JP, Ellinor PT, Lindsay ME. Genetics and mechanisms of thoracic aortic disease. Nat Rev Cardiol 2023; 20 (03) 168-180
- 11 Gregory AJ, Di Martino ES, Fedak PWM, Dobson GM. Aortic biomechanics and clinical applications. Anesthesiology 2022; 137 (03) 351-363
- 12 Kiser KA, Tanaka A, Sandhu HK. et al. Extensive cell salvage and postoperative outcomes following thoracoabdominal and descending aortic repair. J Thorac Cardiovasc Surg 2022; 163 (03) 914-921.e1
- 13 Lee WA, Martin TD, Gravenstein N. Partial right atrial inflow occlusion for controlled systemic hypotension during thoracic endovascular aortic repair. J Vasc Surg 2008; 48 (02) 494-498
- 14 McClure RS, Rommens KL, Herget EJ, Halliwell O, Moore RD. Zone 0 aortic arch reconstruction using the RelayBranch thoracic stent graft. CJC Open 2021; 3 (10) 1307-1309
- 15 Chiu P, Sailer AM, Baiocchi M. et al. Impact of discordant views in the management of descending thoracic aortic aneurysm. Semin Thorac Cardiovasc Surg 2017; 29 (03) 283-291
- 16 Rudarakanchana N, Reeves BC, Bicknell CD, Heatley FM, Cheshire NJ, Powell JT. Treatment decisions for descending thoracic aneurysm: preferences for thoracic endovascular aneurysm repair or surveillance in a discrete choice experiment. Eur J Vasc Endovasc Surg 2014; 48 (01) 13-22
- 17 Czerny M, Schmidli J, Adler S. et al; EACTS/ESVS scientific document group. Current options and recommendations for the treatment of thoracic aortic pathologies involving the aortic arch: an expert consensus document of the European Association for Cardio-Thoracic surgery (EACTS) and the European Society for Vascular Surgery (ESVS). Eur J Cardiothorac Surg 2019; 55 (01) 133-162
- 18 McClure RS, Lindsay TF, Keir M. et al The aortic team model and collaborative decision pathways for the management of complex aortic disease: clinical practice update from the Canadian Cardiovascular Society / Canadian Society of Cardiac Surgeons / Canadian Society for Vascular Surgery / Canadian Association for Interventional Radiology. Can J Cardiol 2023; 39 (11) 1484-1498
- 19 Rockley M, Rommens KL, McClure RS, Herget EJ, Smith HN, Moore RD. Aortic arch endovascular branch and fenestrated repair: Initial Canadian experience with novel technology. J Vasc Surg Cases Innov Tech 2023; 9 (04) 101274
- 20 Field ML, Kuduvalli M, Torella F, Lip GYH. Aortovascular medicine: what is it?. J R Soc Med 2021; 114 (10) 467-469
- 21 Miller DC. Another meiosis in the specialty of cardiovascular and thoracic surgery: birth of the purebred “thoracic aortic surgeon”?. J Am Coll Cardiol 2014; 63 (17) 1804-1806
- 22 Prouse G, Robaldo A, van den Berg JC, Ettorre L, Mongelli F, Giovannacci L. Impact of multidisciplinary team meetings on decision making in vascular surgery: a prospective observational study. Eur J Vasc Endovasc Surg 2023; 66 (01) 130-135