Background Paget-Schroetter Syndrome (PSS) is an uncommon disorder involving thrombosis of the subclavian vein, often caused by repetitive overuse or compression by the surrounding anatomical structures. Optimal management of PSS is a subject of debate, but current trends suggest that a hybrid approach employing endovascular intervention and open decompression may yield the best clinical results. This original article examines the roles played by endovascular thrombolysis, surgical decompression, and postoperative secondary intervention in the management of PSS. Methods Current literature on the management of PSS was reviewed and evaluated to ascertain what strategy of intervention would be optimal. In addition, clinical data from the University Hospital of Wales on the clinical outcomes in PSS patients undergoing different surgical approaches for anatomical decompression are included. Results Evaluation of data from the included series and available literature seems to indicate that endovascular thrombolytic devices such as the AngioJet or mechanical thrombectomy offer superior results than traditional catheter-directed thrombolysis. In addition, adjunctive procedures such as superior vena cava filters and venous angioplasty or bypass may augment maintenance of the subclavian vein lumen. Nonetheless, the subclavian vein must still be relieved of pressure from surrounding structures for treatment to be successful. Conclusions A hybrid approach to the management of PSS, encompassing endovascular and surgical interventions could possibly offer optimal clinical outcomes as both intrinsic lesions and extrinsic compression of the subclavian vein are resolved. This article recommends prospective research to determine the ideal endovascular treatment, and best surgical approach for decompression.
Background Use of the Frozen Elephant Trunk (FET) device to manage complex surgical pathologies of the aorta (e.g. acute Type A aortic dissection) has gained popularity since its introduction in the early 2000s. Though the distal anastomosis was traditionally performed at Zone 3 (Z-3-FET), preference gradually shifted towards Zone 2 (Z-2-FET) in favour of improved surgical access and outcomes. This review seeks to elucidate whether proximalisation of arch repair to Zone 0 (Z-0-FET) would further improve postoperative outcomes. Methods We performed a review of available literature to evaluate the comparative efficacies of Z-2-FET versus Z-0-FET, in terms of surgical technique, clinical outcomes, and incidence of adverse events. Results Z-0-FET seems to be associated with a more accessible surgical approach, and shorter cardiopulmonary bypass, antegrade cerebral perfusion, and cardioplegia durations than Z-2-FET. Further, Z-0-FET is could potentially be associated with a lower incidence of neurological, renal, and recurrent laryngeal nerve injury, as well as mortality and reintervention rates than Z-2-FET. This said, Z-0-FET is itself associated with significant challenges, and efficacy in terms of postoperative true lumen integrity and false lumen thrombosis is mixed. Conclusion Current literature seems to suggest that Z-0-FET procedures are more straightforward and associated with lower rates of certain adverse events, however, the majority of data reviewed is retrospective. This review therefore recommends prospective research into the comparative strengths and limitations of Z-0-FET and Z-2-FET to better substantiate whether proximalisation of arch repair represents a concept, or a true challenge to advance surgical intervention for arch pathologies.
Background Aortic Aneurysm (AA) is a common atherosclerotic condition, accounting for nearly 6,000 deaths in England and up to 175,000 deaths globally each year. The pathological outward bulging of the aorta typically results from atherosclerosis or hereditary connective tissue disorders. AAs are usually asymptomatic until spontaneous rupture or detected on incidental screening. 8 in 10 patients do not survive the rupture and die either before reaching hospital or from complications following surgery. Similar to other cardiovascular pathologies (CVPs), AA is thought to be subject to chronobiological patterns of varying incidence. Methods We performed a literature review of the current literature to evaluate the association between circadian rhythms, seasonal variations, and genetic factors and the pathogenesis of AA, reviewing the impact of chronobiology. Results The incidence of AA is found to peak in the early morning (6 AM – 11 AM) and colder months, and conversely troughs towards the evening and warmer months, exhibiting a similar pattern of chronobiological rhythm as other CVPs such as myocardial infarcts, or cerebrovascular strokes. Conclusion Literature suggests there exists a clear relationship between chronobiology and the incidence and pathogenesis of ruptured AA; incidence increases in the morning (6am - 11am), and during colder months (December – January). This is more pronounced in patients with Marfan Syndrome, or vitamin D deficiency. The underlying pathophysiology and implications this has for chronotherapeutics, are also discussed. Our review shows a clear need for further research into the chronotherapeutic approach to preventing ruptured AA in the journey towards precision medicine.