Farinetti, A.

Manco, G.

Manenti, A.

Mattioli, A. V.

Roncati, L.

English

Farinetti A.

Roncati L.

Manco G.

Manenti A.

Mattioli A. V.

Archivio istituzionale della ricerca - Università di Modena e Reggio Emilia

Table. Included studies characteristics and quality of studies scoringSource Country Study designName of trial,database, andrecruitment periodNo. ofpatientsSurgicalinterventionOutcomes ofinterest Selection Comparability Outcome SumArya 20185 United States Retrospective National veterans’healthadministrationcorporate data152,010 Amputation Amputation 3 2 3 8Durham20102United States Retrospective Single Institution 187 Femoropoplitealrevascularization(open andendovascular)Primary-assistedpatency related tothe initial treatmentmodality3 0 3 6Ferguson20103UnitedKingdomRetrospective OPCS4 163 Lower limb amputation Lower limb amputationrate3 0 3 6Hawkins20196United States Retrospective VQI (Virginia QualityInitiative)40,109 Infrainguinal bypass Major adverse limbevents4 0 3 7Henry20114United States Retrospective NIS (NationwideInpatientSample)475,802 Lower extremityrevascularization,major amputationMajor lower extremityamputation4 1 3 8Hughes20197United States Retrospective NIS (NationalInpatientSample)83,242 Major amputation,revascularization(open orendovascular)Incidence ofamputations andrevascularizations,patient comorbidconditions,postoperativecomplications3 1 3 7McGinigle20148United States Retrospective North CarolinaInpatientDischargeDatabase222,920 Amputation Number of majoramputations4 2 3 9Minc20209United States Retrospective West Virginia HealthCare AuthorityData458,776 Amputation Amputation rate 4 1 3 8Rowe201010United States Retrospective NationwideInpatient Sample29,768 Bypass graft,amputation,endovascularUse of amputation,revascularization, orendovascular3 0 2 5Tunis199311United States Prospective Single Institution 7080 Amputation orrevascularizationAmputation orrevascularization3 0 3 6Ultee 20151 Netherlands Retrospective Single Institution 324 Bypass, amputation Amputation, mortality 3 2 3 8Selection: Adequate case definition, representative of nonexposed cohort, ascertainment of exposure; demonstration of outcome was not present atthe start of the study.Comparability: Comparability of cohort based on the design or analysis controlled for confounders.Outcome: Assessment of outcome, sufficient, and adequate follow-up.Sum Mean: Sum of selection, comparability, and outcome score.Risk of bias was defined as low (Newcastle-Ottawa Score [NOS] score $8), moderate (NOS score 6-7), and high (NOS score #5).NOTE: All outcomes reported in these 11 studies were recorded for transparency and completeness. Some outcomes (eg, primary-assisted patency)may not be analyzed because of the insufficient number of studies for meta-analysis.1122 Letters to the Editor Journal of Vascular SurgeryMarch 202210. Rowe VL, Weaver FA, Lane JS, Etzioni DA. Racial and ethnic differ-ences in patterns of treatment for acute peripheral arterial disease inthe United States, 1998-2006. J Vasc Surg 2010;51(Suppl):21S-6S.11. Tunis SR, Bass EB, Klag MJ, Steinberg EP. Variation in utilization ofprocedures for treatment of peripheral arterial disease. A look atpatient characteristics. Arch Intern Med 1993;153:991-8.https://doi.org/10.1016/j.jvs.2021.10.032Changed pathophysiology of thoracic aortaafter aortic arch repairThe interesting paper by Tenorio et al1 demonstrates astoday possible the total endovascular aortic arch repair,although entailing hemodynamic changes in this vessel.In fact, rigid endoprosthesis implants cause completeloss of elasticity of the corresponding vascular, also ifresidual to a pre-existing pathology, typically atheroscle-rotic.2 It follows that a grafted aortic arch becomesunable to accumulate energy during systole and give itback in diastole, through the “windkessel” phenomenon.Reflection waves, generated inside rigid walls, differ fromthe physiological ones by having a decreased energy anddifferent synchronism with the normal systolic peaks ofthe aortic blood flow. In particular, their vectors, whenincident with an angle >90 on the aortic stream, nega-tively impact on its dynamics: this typically occurs in thedescending part of the aortic arch. Moreover, the newreflection waves miss their diastolic component, occur-ring after the aortic valve closure, greatly reducing thecoronary perfusion. The aortic blood flow, a non-Newtonian fluid, through a high Reynolds number, canchange from a laminar to a turbulent flow, wastingmore energy and becoming a possible mechanical factorof endoleak, mainly of type 1b.3 These hemodynamic fac-tors translate in an increased afterload to the leftventricle, in the long-term remodeling through a thick-ened parietal wall, that can lead to a discrepant coronaryJournal of Vascular Surgery Letters to the Editor 1123Volume 75, Number 3blood inflow.4,5 Cleary, also an intrinsic aortic pathology cancause similar adverse effects, but often with a slower pro-gression and a delayed incidence. On the contrary, thesedisadvantages become clinically more evident whenadded one to another in quick succession, such as afteran open- or endovascular procedure, also reducing therheological advantages obtained by correcting anabnormal morphology of the corresponding aortic tract.Considering all these characteristics, we identified a partic-ular “stiff aorta cardiomyopathy,” to be evaluated whenplanning an extended grafting in the thoracic aorta andrequiring a careful intra- and postoperative monitoringand follow-up in each patient. In respect to open surgicalprocedures, the endovascular treatments avoid the draw-backs of the cardiopulmonary bypass, which would addto thoseofa suddenlychangedaorticarchhemodynamics.In perspective, this newly emergent pathologymerits to befurther investigated in its multifaceted features, throughmorphological and functional researches.Alberto Farinetti, MDDepartment of SurgeryUniversity of Modena and Reggio EmiliaPolyclinic HospitalModena, ItalyLuca Roncati, MDDepartment of PathologyUniversity of Modena and Reggio EmiliaPolyclinic HospitalModena, ItalyGianrocco Manco, MDAntonio Manenti, MDDepartment of SurgeryUniversity of Modena and Reggio EmiliaPolyclinic HospitalModena, ItalyAnna Vittoria Mattioli, MDDepartment of CardiologyUniversity of Modena and Reggio EmiliaPolyclinic HospitalModena, ItalyREFERENCES1. Tenorio ER, Oderich GS, Kölbel T, Dias NV, Sonesson B,Karelis A, et al. Multicenter global early feasibility study toevaluate total endovascular arch repair using three-vessel innerbranch stent grafts for aneurysms and dissections. J Vasc Surg2021;74:1055-65.2. Wang M, Monticone RE, McGraw KR. Proinflammatory arterialstiffness: a signature of large arterial age. J Vasc Res 2018;55:210-33.3. Belvroy VM, de Beaufort HWL, van Herwaarden JA, Trimarchi S, Moll FL,Bismuth J. Type 1b endoleaks after thoracic endovascular aortic repairare inadequately reported: a systematic review. Ann Vasc Surg2020;62:474-83.4. Tigkiropoulos K, Sigala F, Tsilimigras DI, Moris D, Filis K, Melas N,et al. Endovascular repair of blunt thoracic aortic trauma: is post-implant hypertension an incidental finding? Ann Vasc Surg 2018;50:160-6.5. van Bakel TMJ, Arthurs CJ, Nauta FJH, Eagle KA, van Herwaarden JA,Moll FL, et al. Cardiac remodelling following thoracic endovascularaortic repair for descending aortic aneurysms. Eur J Cardiothorac Surg2019;55:1061-70.https://doi.org/10.1016/j.jvs.2021.11.039

Changed pathophysiology of thoracic aorta after aortic arch repair

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Changed pathophysiology of thoracic aorta after aortic arch repair

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