Three-year follow-up of aortic arch endovascular stent grafting with the Nexus device: results from a prospective multicentre study

OBJECTIVES

Endovascular aortic arch stent grafting with branched devices has shown initial promising results. The aim of this prospective, multicentre study was to evaluate 3-year outcomes of aortic arch stent grafting with NEXUS® Aortic Arch Stent Graft System (Nexus), a single-branch, bi-modular, off-the-shelf aortic arch stent graft system in high-risk patients.

METHODS

Patients treated with Nexus, either under the feasibility clinical study or as compassionate use procedures in 5 centres, were included in this study. The primary end point was overall survival. The secondary end points included the incidence of procedure-related unplanned intervention, stroke, paraplegia and endoleak. Clinical and radiologic follow-up was performed at each study site at 30 days, 6 months and on a yearly basis thereafter up to 3 years postoperatively.

RESULTS

We analysed data from a total of 28 patients. The overall median follow-up was 1132 (interquartile range: 809-1537). There were no device or procedure-related deaths between 1 and 3 years. Overall survival at 1 and 3 years was 89% and 71%, respectively. The cumulative incidence of unplanned reintervention at 1 and 3 years was 11% and 29%, respectively. There were no reports of stroke, paraplegia, aneurysm rupture, myocardial infarction or new aortic valve insufficiency. In this study's 1-3 year follow-up period, 1 type Ib (4%), 1 type II (4%) and 2 type III (8%; between Nexus' distal end and Thoracic endovascular aortic repair (TEVAR) extensions) endoleak were detected.

CONCLUSIONS

Endovascular aortic arch exclusion with the single-branch, off-the-shelf Nexus system provides promising clinical and radiologic results at 3-year follow-up in a high-risk patient cohort.

Simultaneous Hybrid Treatment of Multilevel Peripheral Arterial Disease in Patients with Chronic Limb-Threatening Ischemia

Background: Hybrid treatments (HT) aim to reduce conventional open surgery invasiveness and address multilevel peripheral arterial disease (PAD). Herein, the simultaneous HT treatment in patients with chronic limb-threatening ischemia (CLTI) is reported. Methods: Retrospective analysis, for the period from May 2012 to April 2018, of patients presenting multilevel PAD with CLTI addressed with simultaneous HT. The outcomes of these interventions were measured the following metrics: early technical successes (within 30 days following treatment) and late technical successes (30 days or more following treatment) and included mortality, morbidity symptoms recurrence, and amputation. Survival and patencies were estimated. The median follow-up was 43.77 months. Results: In the 45 included patients, the HT consisted of femoral bifurcation patch angioplasty followed by an endovascular treatment in 38 patients (84.4%) and endovascular treatment followed by a surgical bypass in 7 patients (15.6%). Technical success was 100% without perioperative mortality. Eight (17.8%) patients presented early complications without major amputations. During the follow-up, seven (15.6%) deaths occurred and six patients (13.3%) experienced symptoms recurrence, with five of those patients requiring major amputation. An estimated survival time of 5 years, primary patency, and secondary patency was 84.4%, 79.2%, and 83.3% respectively. Conclusions: Hybrid treatments are effective in addressing patients presenting with multilevel PAD and CLTI. The common femoral artery involvement influences strategy selection. Larger studies with longer-term outcomes are required to validate the hybrid approach, indications, and results.

When Echinococcus granulosus transmigrates from the liver into the pericardium: a case report

Infection with Echinococcus granulosus is a common helminthic disease worldwide with endemic in a region with high endemic areas in Africa, Asia, Middle East, South America and southern Europe.

We report a rare case of a young patient with cystic echinococcal disease of the liver invading the pericardium. The patient initially presented with life-threatening cardiac tamponade, which resulted in the discovery of the underlying parasitic disease. He successfully underwent en-bloc hepatic pericystectomy and pericardiac resection with closure of the pericardial defect using a xenogeneic patch. After this procedure, he recovered well and had no cardiac complications in the long term. Under treatment with albendazol, the patient showed no signs of recurrent disease.

Cases of complex cystic echinococcosis, which invade adjacent organs or body cavities, often need radical surgery for definitive treatment embedded in a multidisciplinary approach in highly specialized centers.

Adipocyte-conditioned medium induces resistance of breast cancer cells to lapatinib

Background

The existence of a cross-talk between peritumoral adipocytes and cancer cells has been increasingly investigated. Several studies have shown that these adipocytes protect tumor cells from the effect of anticancer agents.

Methods

To investigate a potential protective effect of adipocyte-conditioned medium on HER2 positive breast cancer cells exposed to tyrosine kinase inhibitors (TKI) such as lapatinib, we analyzed the sensitivity of HER2 positive breast cancer models in vitro and in vivo on SCID mice in the presence or absence of adipocytes or adipocyte-conditioned medium.

Results

Conditioned medium from differentiated adipocytes reduced the in vitro sensitivity of the HER2+ cell lines BT474 and SKBR3 to TKI. Particularly, conditioned medium abrogated P27 induction in tumor cells by lapatinib but this was observed only when conditioned medium was present during exposure to lapatinib. In addition, resistance was induced with adipocytes derived from murine NIH3T3 or human hMAD cells but not with fibroblasts or preadipocytes. In vivo studies demonstrated that the contact of the tumors with adipose tissue reduced sensitivity to lapatinib. Soluble factors involved in this resistance were found to be thermolabile. Pharmacological modulation of lipolysis in adipocytes during preparation of conditioned media showed that various lipolysis inhibitors abolished the protective effect of conditioned media on tumor cells, suggesting a role for adipocyte lipolysis in the induction of resistance of tumor cells to TKI.

Conclusions

Overall, our results suggest that contact of tumor cells with proximal adipose tissue induces resistance to anti HER2 small molecule inhibitors through the production of soluble thermolabile factors, and that this effect can be abrogated using lipolysis inhibitors.

Endovascular treatment of non-dissected ascending aorta disease: a systematic review

Severe ascending aorta disease includes aneurysms, pseudoaneurysms (ascending aorta pseudoaneurysms), penetrating aortic ulcers and Type A aortic dissections. Surgical replacement of the aortic root, ascending aorta or aortic arch is the common treatment for severe ascending aortic disease involving the root, the ascending aorta and/or the arch. Despite good surgical results, there is still a risk for morbidity and mortality following surgery for ascending aorta replacement when elderly patients or patients at high risk for surgery are concerned. Less invasive endovascular treatments for ascending aorta repair are under evaluation, and some reports appeared in the available literature in the last decade. However, clinical series or randomized studies are not yet available, and the use of these techniques is still questionable. In this study, we analysed the outcomes of reported cases of endovascular treatment for ascending aorta disease, excluding Type A aortic dissection. We reviewed reports published until February 2017, and we evaluated the employed technology, the devices, the procedural steps and the outcomes. A total of 26 articles reported 67 patients (mean age 65 ± 17 years) who received endovascular treatment for ascending aorta disease: aneurysms, ascending aorta pseudoaneurysms, penetrating aortic ulcers, intramural haematoma, thrombosis, iatrogenic coarctation and aortic rupture. Complications included endoleak (9 cases), stroke (3 cases), non-ST-elevation myocardial infarction (1 case) and splenic infarction (1 case). Three patients required conversion to open surgery, and 1 patient underwent endovascular reintervention. Early mortality was 2.9%. As an alternative treatment for ascending aorta disease in selected high-risk patients, the endovascular repair will gain popularity, but further analysis is required.

Improved technique for sheath supported contralateral limb gate cannulation in endovascular abdominal aortic aneurysm repair

Background: To present a technique of sheath supported contralateral limb gate (CLG) cannulation of modular bifurcated stent-graft in endovascular abdominal aortic repair. Materials and methods: After totally percutaneous bilateral femoral access, the 9F introducer sheath is exchanged to a 30 cm 12 fr introducer sheath over a stiff wire contralateral to the intended main stent-graft insertion side and advanced into the aorta below the lowest renal artery. Parallel to the stiff wire within the sheath an additional standard J-tip guidewire with a 5 fr Pigtail angiographic catheter is advanced to the level of the renal arteries. After main body deployment, the 12 fr introducer sheath and J-tip wire with pigtail catheter are retracted until the CLG opening level, maintaining the stiff "buddy" wire in position to support the 12 fr sheath, maintaining its distal opening close to the contralateral gate opening to achieve easy cannulation. Results: Retrospective analysis of video archive from July 2016 to February 2018 evidenced 55 recorded EVAR cases. All CLG cannulations were obtained with Standard J-tip or Terumo Glidewire wires and with Pig-Tail or Berenstein catheters. Technical success was 100 %. Mean fluoroscopy time to accomplish CLG cannulation was 37.6 33 (range 1-105) seconds. The aortic carrefour angulation on coronal axis strongly correlates with cannulation time p = <.001, with longer cannulation time for higher carrefour angulations on coronal axis (Pearson correlation coefficient 0.47). Conclusions: The use of 12 fr sheath with parallel wire introduction technique, appears to be a safe and reliable tool to facilitate CLG cannulation during EVAR procedures.

Patient-Specific Rehearsal Feasibility Before Endovascular Repair of Ruptured Abdominal Aortic Aneurysm

Purpose: To evaluate the feasibility of a patient-specific rehearsal (PsR) before emergency endovascular aneurysm repairs (eEVAR) and its influence on the operation. Materials and Methods: From February 2016 to October 2016, 10 consecutive patients (mean age 75±7.4 years; 9 men) presenting with a ruptured abdominal aortic aneurysm (rAAA) suitable for standard EVAR were enrolled in the study. A 3-dimensional (3D) model of the abdominal aorta was generated on a virtual reality simulator based on the patient’s computed tomography (CT) images. Following the patient-specific simulation setup, PsR was conducted during patient admission or in parallel with the preoperative eEVAR workup. Measured outcomes were PsR feasibility only in the first 4 patients and impact on operative performance thereafter (changes in device selection, the planning process, clinical outcomes, perioperative mortality, and complication rates). Technical metrics and timing of system setup, rehearsal, interval from patient arrival to the actual procedure, and eEVAR were recorded. Results: Mean time for 3D model creation was 21.3±7.8 minutes (range 13–37); there was a significant positive relationship between aortic neck diameter and segmentation time (p=0.003). The overall mean time for simulator setup and PsR was 54±14 minutes (range 37–80); PsR alone was completed in a mean 31±40 minutes (95% confidence interval −60 to −2.2). The actual eEVAR procedure duration was 69±16 minutes (range 45–90). No delay in the actual eEVAR procedure was registered owing to the PsR pathway. In 6 patients, preprocedure rehearsal induced changes in operative strategy, including device selection, main body introduction side, and/or deployment configuration. In 4 cases, rehearsal was performed twice to achieve optimal performance. Conclusion: PsR before eEVAR was feasible in all cases and caused no time delays in the actual eEVAR procedure. PsR optimized eEVAR planning by identifying optimal strategy for stent-graft component selection and deployment.

Disparities in Contemporary Treatment Rates of Abdominal Aortic Aneurysms Across Western Countries

OBJECTIVE/BACKGROUND

Several abdominal aortic aneurysm (AAA) screening programs have demonstrated a similar prevalence of this disease in Westerns countries, ranging from 1.2% to 2.8%. However, the annual rate of AAA repair is significantly less even, and its relationship to AAA prevalence is not clear. The objective was to perform a systematic review, describing an international overview in the yearly rate of AAA repairs.

METHODS

The number of elective and emergency AAA repairs was obtained via thorough review of publications indexed in PubMed and Scopus from 2010 to October 2018. Portuguese data were obtained from the national administrative database of health care. Data from the UK were extracted from the National Vascular Registry's 2015 annual report. Each country's population was assessed from published national censuses, thus allowing estimation of the number of AAAs treated per 100,000 habitants.

RESULTS

Data from 14 countries were obtained. The yearly number of elective operations per 100,000 habitants was 2.2 in Hungary, 3.8 in Portugal, 5.3 in Spain, 5.9 in Iceland, 6.5 in Finland, 7.0 in New Zealand, 7.8 in the UK, 10.0 in Denmark, 10.2 in Sweden, 13.3 in the USA, 14.8 in Norway, 15.3 in the Netherlands, 15.6 in Italy, and 17.3 in Germany. The yearly rate of ruptured repairs was 0.5 in Hungary, 1.5 in Portugal, 1.8 in Spain, 1.7 in Iceland, 1.7 in Finland, 1.3 in New Zealand, 1.8 in the UK, 3.3 in Denmark (2013), 2.7 in Sweden (2013), 1.7 in the USA, 2.1 in Norway, 3.1 in the Netherlands, 2.3 in Italy, and 2.7 in Germany.

CONCLUSION

The rate of AAA treatment is highly variable, with a nearly eightfold variance between the countries with the highest and lowest rates of elective repair. Correlation between elective and ruptured repairs was not clear. A deeper understanding of the reasons for the disparities in AAA treatment among Western countries is of the utmost importance.

Suitability of the porcine aortic model for transcatheter aortic root repair

OBJECTIVES

To treat aortic valve disease and concomitant root disease with transcatheter techniques, 'composite graft' implants are required. Our goal was to assess the suitability of the porcine aortic root for transcatheter root repair tests.

METHODS

Eight pig hearts explanted from domestic pigs used in experimental surgery were compared to data from the literature on human hearts. The measured diameters included those of the annulus, sinuses of Valsalva, coronary ostia, sinotubular junction, ascending aorta, innominate artery and aortic arch. The measured distances were from the coronary ostia to the nadir of the corresponding annulus; from the innominate artery to the nadir of the corresponding annulus; from the small curvature of the arch to the nadir of the corresponding annulus.

RESULTS

The mean weight of the pigs was 89 ± 5.4 kg. The mean aortic annulus diameter was 20 ± 1.2 mm (human: 23.0 ± 2.5 mm), the sinus of Valsalva diameter was 20.5 ± 0.5 mm (human: 31.4 ± 3.4 mm) and the sinotubular junction diameter was 20 ± 0.9 mm (human: 27.2 ± 3.0 mm). The diameter of the mean ascending aorta was 19 ± 0.7 mm (human: 29.3 ± 4 mm); the diameter of the innominate artery was 8.5 ± 0.7 mm, that of the aortic arch was 15 ± 0.7 mm and that of the coronary ostia was 5 ± 0.5 mm (left) and 4.7 ± 0.5 mm (right) (human: 4.8 ± 0.5 mm and 3.7 ± 0.9 mm). The distances from the left and right coronary orifices to the corresponding annuli were 8 ± 1.5 mm and 14 ± 2.4 mm, respectively (human: 14.7 ± 1.3 mm; 15.4 ± 1.7 mm). The distances from the innominate artery to the nadirs of the left and right coronary annuli were 44 ± 4.3 mm and 41 ± 4 mm (human: 80 ± 17 mm). The distance from the curvature of the small arch to the annulus was 35 ± 4.9 mm.

CONCLUSIONS

The porcine heart can be used as an experimental model to design and test new devices for catheter-based composite repair of the aortic root. Nevertheless, caution is required in using devices with tailored dimensions that must be adapted to the smaller pig's root.

Primary Endovascular Elective Repair and Repair of Ruptured Isolated Iliac Artery Aneurysms Is Durable-Results of 72 Consecutive Patients

PURPOSE

To evaluate outcome of endovascular elective repair and repair of ruptured isolated iliac artery aneurysms (IIAAs) as a primary treatment strategy.

MATERIALS AND METHODS

All patients with an IIAA undergoing endovascular treatment were included. Aneurysms were classified according to an anatomic classification and treated with coiling of the internal iliac artery, stent graft placement in the common to external iliac artery, or placement of a bifurcated aortoiliac stent graft. Between November 1996 and November 2015, 72 patients with 85 IIAAs underwent endovascular repair. Mean age was 73.9 years ± 9.2. Common iliac artery was involved in 63 patients (74.1%), internal iliac artery was involved in 21 patients (24.7%), and external iliac artery was involved in 1 patient (1.2%). Mean diameter was 5 cm (range, 2.5-11 cm). Emergency repair was performed in 19 patients owing to rupture (26.4%).

RESULTS

Overall primary technical success rate was 95.8% with conversion rate to open surgery of 4.2% (all in the emergency group) and in-hospital mortality rate of 1.4%. During mean follow-up of 4.3 years ± 3.3 (median 3.8 y; range, 0-14.2 y), 17 endoleaks were observed (6 type I, 10 type II, 1 type IIIa). Overall reintervention rate was 16.7%. Primary patency rate was 98.6%. During the follow-up period, 22 deaths occurred (30.6%), including 2 aneurysm-related deaths (2.8%).

CONCLUSIONS

Primary endovascular repair of IIAAs shows excellent results and should be considered as first-line therapy. Surgical backup should be available in emergency cases.

Simplified hybrid repair with true lumen recycling for retrograde renovisceral perfusion in a complex chronic aortic dissection

A 59-year-old man was referred with complicated chronic type B aortic dissection. Despite the false lumen's being dominant in terms of caliber and limb perfusion, visceral arteries originated in a 9-mm true lumen. A staged approach was performed: open aortobi-iliac bypass with preservation of both lumens to the infrarenal aorta, with reinforcement of the aorta and anastomosis with Dacron (wrap technique); exclusion of the dissection by endografting all of the false lumen with three successive thoracic endoprostheses; and maintenance of true lumen perfusion using two periscopes with self-expanding nitinol stents. The patient remains asymptomatic after 1 year of follow-up.

Safety of percutaneous axillary artery access with a suture-mediated closing device for parallel endograft aortic procedures – a retrospective pilot study

Abstract. Background: The aim of this study was to evaluate the technical success of percutaneous ultrasound-guided access to the infraclavicular axillary artery with a suture-mediated closing device for patients requiring large-sized upper extremity access. Patients and methods: In 18 consecutive patients (17 male, one female, mean age 73.5 ± 9.6 years, range 52–88 years), artery accesses with the preclosing modification for chimney endografts was gained with 20 ultrasound-guided infraclavicular axillary. Retrospectively, the following endpoints were analysed: technical success of percutaneous ultrasound-guided puncture of the infraclavicular axillary artery as well as introduction and deployment, primary successful haemostasis by preclosing, bailout procedures, overall complication rate including local vascular, cerebrovascular, and peripheral neurological complications. Results: Ultrasound-guided puncture and preclosing procedure was successful in all patients. Mean sheath size was 9.4 ± 1.6 French. Ultrasound-guided puncture as well as introduction and deployment were successful in all patients (100 %). Primary successful haemostasis by preclosing was 70 % (14/20). Postclosing with one or two devices enabled successful haemostasis in another 15 %. Bailout stent graft implantation was necessary in three accesses (15 %), either by transfemoral (n = 2) or transbrachial (n = 1) route. Overall complication rate was 16.5 %, all of them were minor haematomas. Conclusions: Percutaneous ultrasound-guided infraclavicular axillary artery access with preclosing modification seems feasible and safe. The access related complication rate is low and complications can potentially be managed by endovascular means.

Radiographically occult perforation and dissection of the common carotid artery following stab injury to the neck

In recent years, many diagnostic algorithms have been devised to reduce the rate of negative explorations associated with indiscriminate surgical management of penetrating neck injuries. In hemodynamically stable patients, the need for surgical intervention is usually determined by integrating both clinical signs and radiological findings; if such investigations remain unremarkable, recommended treatment consists in close observation and sequential physical examinations. We report on a 29-year-old male who was admitted to a Swiss tertiary care hospital after sustaining a penetrating injury to his left neck following a knife attack. Disregarding a pre-hospital account of hemorrhage from the wound and slight dysphagia, no manifest symptoms or signs of internal organ damage were present on primary survey. Moreover, there was no evidence of vascular or aerodigestive tract injury on initial CT angiography. We nonetheless proceeded with immediate surgical exploration, exposing a significant perforation of the left common carotid artery with concomitant dissection of the said vessel. Surgical repair was successfully performed and the patient suffered no long-term sequelae. We thus recommend that a high level of suspicion be upheld in both asymptomatic and oligosymptomatic patients with PNI and that clinical practitioners remain cautious in the face of deceptively reassuring radiologic findings.

Early outcomes with a single-sided access endovascular stent

OBJECTIVE

The objective of this study was to report the 1-year follow-up study results of the new Horizon stent graft (Endospan, Herzliya, Israel) from two different prospective consecutive trials. The Horizon abdominal aortic aneurysm stent graft system is a 14F profile system requiring only a single access site. It consists of three modules, introduced separately: base limb (iliac to iliac limb); distal aortic limb; and proximal aortic limb with a bare suprarenal crown and active fixation.

METHODS

Data from the first in man (FIM) clinical study with 10 patients enrolled and the pivotal study with 30 patients were analyzed. Outcomes measured were freedom from major adverse events (MAEs) including all-cause mortality, myocardial infarction, renal failure, respiratory failure, paraplegia, stroke, bowel ischemia, and procedural blood loss ≥1000 mL. Performance end points included successful delivery and deployment of the device, freedom from aneurysm growth ≥5 mm, type I or type III endoleak, stent graft occlusion, conversion to open surgery, rupture, and stent graft migration.

RESULTS

In the FIM study, one conversion to open surgery with >1000 mL of blood loss was registered perioperatively. In the pivotal study, no perioperative MAE was registered. Overall, at 1-year follow-up, two deaths and one aneurysm growth unrelated to endoleak were registered.

CONCLUSIONS

The results of both the FIM and pivotal studies demonstrated that 39 of 40 procedures were successful for delivery and deployment of the Horizon stent graft. No MAE was registered during the follow-up. The primary safety and performance end points were met in both studies.

Hemodynamic Properties of the Hemopump HP14

Background

The Hemopump HP14 is a catheter-mounted, transvalvular, left ventricular assist device intended for femoral percutaneous insertion. The pump was developed for patients with postoperative or postinterventional low cardiac output and for CABG surgery on the beating heart. Little is known about the effect of afterload and hematocrit on the pump performance.

Methods

The influence of hematocrit and afterload on the pump flow was tested using an in vitro model filled with heparinized bovine blood. Regression analysis of the pump flow with respect to three hematocrit values (20%, 30%, 40%) and ten afterload levels (30 mmHg-120 mmHg in 10 mmHg increments) was performed for all pump speed levels (n = 7).

Results

At all pump speed levels reduction of afterload and hematocrit were significant predictors for increasing pump flow (p<0.001). For hematocrit values between 40% and 20% and highest pump speed, mean pump flow at lowest afterload ranged between 2.34 and 2.53 L/min; and at highest afterload between 1.31 and 1.53 L/min. For speed level 1, afterload of 120 mmHg and hematocrit of 40% there was a maximal retrograde flow of 230 ± 35 ml/min.

Conclusions

Pump performance is significantly improved by both afterload and hematocrit reduction. In the weaning phase and during the removal of the device, the pump should run at a speed level of at least three to prevent retrograde flow in the pump. Estimates for pump flow in vivo can be extrapolated from our diagrams. Our results show that the Hemopump HP14 is a valuable alternative to intra-aortic balloon counterpulsation.

Mortality rates and risk factors for emergent open repair of abdominal aortic aneurysms in the endovascular era

The background of this paper is to report the mortality at 30 and 90 days and at mean follow-up after open abdominal aortic aneurysms (AAA) emergent repair and to identify predictive risk factors for 30- and 90-day mortality. Between 1997 and 2002, 104 patients underwent emergent AAA open surgery. Symptomatic and ruptured AAAs were observed, respectively, in 21 and 79% of cases. Mean patient age was 70 (SD 9.2) years. Mean aneurysm maximal diameter was 7.4 (SD 1.6) cm. Primary endpoints were 30- and 90-day mortality. Significant mortality-related risk factor identification was the secondary endpoint. Open repair trend and its related perioperative mortality with a per-year analysis and a correlation subanalysis to identify predictive mortality factor were performed. Mean follow-up time was 23 (SD 23) months. Overall, 30-day mortality was 30%. Significant mortality-related risk factors were the use of computed tomography (CT) as a preoperative diagnostic tool, AAA rupture, preoperative shock, intraoperative cardiopulmonary resuscitation (CPR), use of aortic balloon occlusion, intraoperative massive blood transfusion (MBT), and development of abdominal compartment syndrome (ACS). Previous abdominal surgery was identified as a protective risk factor. The mortality rate at 90 days was 44%. Significant mortality-related risk factors were AAA rupture, aortocaval fistula, peripheral artery disease (PAD), preoperative shock, CPR, MBT, and ACS. The mortality rate at follow-up was 45%. Correlation analysis showed that MBT, shock, and ACS are the most relevant predictive mortality factor at 30 and 90 days. During the transition period from open to endovascular repair, open repair mortality outcomes remained comparable with other contemporary data despite a selection bias for higher risk patients. MBT, shock, and ACS are the most pronounced predictive mortality risk factors.

A Multicentre Trial of Patient specific Rehearsal Prior to EVAR: Impact on Procedural Planning and Team Performance

OBJECTIVE

Patient specific rehearsal (PsR) prior to endovascular aneurysm repair (EVAR) enables the endovascular team to practice and evaluate the procedure prior to treating the real patient. This multicentre trial aimed to evaluate the utility of PsR prior to EVAR as a pre-operative planning and briefing tool.

MATERIAL AND METHODS

Patients with an aneurysm suitable for EVAR were randomised to pre-operative or post-operative PsR. Before and after the PsR, the lead implanter completed a questionnaire to identify any deviation from the initial treatment plan. All team members completed a questionnaire evaluating realism, technical issues, and human factor aspects pertinent to PsR. Technical and human factor skills, and technical and clinical success rates were compared between the randomised groups.

RESULTS

100 patients were enrolled between September 2012 and June 2014. The plan to visualise proximal and distal landing zones was adapted in 27/50 (54%) and 38/50 (76%) cases, respectively. The choice of the main body, contralateral limb, or iliac extensions was adjusted in 8/50 (16%), 17/50 (34%), and 14/50 (28%) cases, respectively. At least one of the abovementioned parameters was changed in 44/50 (88%) cases. For 100 EVAR cases, 199 subjective questionnaires post-PsR were completed. PsR was considered to be useful for selecting the optimal C-arm angulation (median 4, IQR 4-5) and was recognised as a helpful tool for team preparation (median 4, IQR 4-4), to improve communication (median 4, IQR 3-4), and encourage confidence (median 4, IQR 3-4). Technical and human factor skills and technical and initial clinical success rates were similar between the randomisation groups.

CONCLUSION

PsR prior to EVAR has a significant impact on the treatment plan and may be useful as a pre-operative planning and briefing tool. Subjective ratings indicate that this technology may facilitate planning of optimal C-arm angulation and improve non-technical skills.

TRIAL REGISTRATION

URL://www.clinicaltrials.gov. Unique identifier: NCT01632631.

Predilation technique with balloon angioplasty to facilitate percutaneous groin access of large size sheath through scar tissue

Purpose

Percutaneous remote access for endovascular aortic repair is an advantageous alternative to open access. Previous surgery in the femoral region and the presence of synthetic vascular grafts in the femoral/iliac arteries represent major limitations to percutaneous remote access. The aim of this study was to evaluate an original technique used for enabling percutaneous remote access for thoracic or abdominal endovascular aortic repair in patients with scar tissue and/or a vascular graft in the groin.

Methods

Twenty-five consecutive patients with a thoracic (11/25; 44%) or an aortic aneurysm (14/25; 66%) and with a synthetic vascular graft in the groin (16/25; 64%) or a redo groin access (9/25; 36%) were managed through the percutaneous remote access. In all patients, a percutaneous transluminal angioplasty balloon was used to predilate the scar tissue and the femoral artery or the synthetic vascular graft after preclosing (ProGlide®; Abbott Vascular, Santa Clara, CA, USA). In 10 patients, requiring a 20 Fr sheath, a 6 mm percutaneous transluminal angioplasty balloon was used; and in the remaining 15, requiring a 24 Fr sheath, an 8 mm percutaneous transluminal angioplasty balloon. Preclosing was exclusively performed using ProGlide®. Mean follow-up was 15 months.

Results

In all cases, stent-graft deployment was successful. There was one surgical conversion (4%; 1/25) due to bleeding from a femoral anastomosis. Two cases required additional percutaneous maneuvers (postclosing with another system in one patient and endoluminal shielding with stent-graft in the other patient). No pseudoaneurysm or access complication occurred during the follow-up.

Conclusions

Percutaneous access in redo groins with scar tissue and/or synthetic vascular graft using ultrasound-guided punction, preclosing with ProGlide® system and predilation with percutaneous transluminal angioplasty balloon to introduce large size sheath as used for endovascular aortic repair showed to be feasible, safe and with few local complications.

Long-term results of simplified frozen elephant trunk technique in complicated acute type A aortic dissection: A case–control study

Aim

To describe the long-term experience of a simplified frozen elephant trunk technique (sFETT) used in complicated acute type A aortic dissection (AAAD) treatment.

Methods and results

Between January 2001 and December 2012, 34 patients (mean age 59.9 ± 11.0 years) with complicated AAAD (DeBakey I) underwent an emergency surgery including sFETT. sFETT consisted in gluing the dissected aortic arch wall layers with gelatine-resorcinol adhesive and video-assisted antegrade open arch aortic stent-graft deployment in the arch or proximal descending aorta. In addition to sFETT, the aortic root was addressed with standard techniques. A 30-day mortality was 14.7% (five patients) due to bleeding (1), multiple organ failure (2), and colon ischemia (2). Postoperative morbidity included neurological (2), renal (1) and cardio-pulmonary complications (4), as well as wound infection (1). Mean follow-up was 74.4 ± 45.0 months. Actual survival rates were 73.5% at 1 year, 70.2% at 5 years, and 58.5% at 13 years of follow-up. Six patients died during long-term follow-up from heart failure (1) and unknown reasons (5). Five patients required reoperation for aortic arch (3) or aorto-iliac (2) progression of aneurysm during the mid- and long-term follow-up. The remaining patients showed favorable evolution of the dissected aorta with false lumen occlusion in most cases and stable aortic diameters.

Conclusions

In AAAD patients, sFETT as used in our series is an easy and safe technique to repair the aortic arch. Long-term results after sFETT showed false lumen occlusion and stable aortic diameter in up to 13 years of follow-up.

Use of an intravascular gas exchanger: is low systemic heparinization safe?

Extracorporeal membrane oxygenation (ECMO) is a cumbersome procedure. Alternatively, mechanical lung assist can be realized with an intravascular gas exchanger (IVOX). To assess the degree of initial anticoagulation required during intravascular lung assist, we evaluated two regimens of systemic heparinization in 10 bovine experiments. The animals were randomly assigned to two groups with either full systemic heparinization (heparin loading dose 300 IU/kg bodyweight; activated coagulation time (ACT) > 480 s) or low systemic heparinization (heparin loading dose 100 IU/kg bodyweight; ACT > 180 s). The surface heparinized intravascular gas exchanger was placed in the caval axis under fluoroscopic control, and a standard battery of blood samples was drawn before and at regular intervals during the procedure. After six hours of intravascular lung assist the device was explanted, drained, weighed, and carefully analysed. Preassist haematocrit was 25 ± 5% for full versus 24 ± 7% for low (NS) as compared with 23 ± 8% for full versus 26 ± 3% for low (NS) postassist. Platelet levels were 100 ± 25 for full versus 100 ± 21 % for low (NS) preassist as compared with 64 ± 22% for full versus 78 ± 22% for low (NS) postassist. Mean ACT was 157 ± 12 s for full versus 158 ± 18 for low (NS) preassist as compared with 800 ± 244 s versus 219 ± 25 for low (p < 0.05) postassist. Thrombin time was 20 ± 2 s for full versus 23 ± 2 s for low (NS) as compared with > 200 s for both groups after assist. Relative fibrinopeptide A levels were 7.3 ± 1.1 ng/ml for full versus 6.3 ± 1.6 ng/ml for low (NS) preassist as compared with 4.7 ± 4.1 ng/ml for full versus 5.8 ± 0.9 ng/ml for low (NS) postassist. CO2 transfer was 40 ± 10 ml/min for full versus 36 ± 10 ml/min for low (NS) at the begining as compared with 45 ± 25 ml/min for full versus 46 ± 15 for low (NS) at the end. Weight increase due to device deposits (clots) was 14 ± 11 g for full versus 13 ± 10 g for low systemic heparinization (NS). Intravascular lung assist with low versus full systemic heparinization appeared to result in similar activation of the coagulation system, device deposits and gas transfer rates. Considering our clinical experience we can say that application of the device with reduced systemic heparinization is useful in selected patients.

VI2TA2 S2C2ORE: a new score system for in hospital mortality in acute aortic dissections

INTRODUCTION

Aortic dissections classification systems have always been an argument of debate. It is well known that none of the described classifications is complete and easy at the same time. While the more used classification is currently the Stanford classification, it is clear that type A and B dissections prognosis can dramatically vary, depending on many different characteristics that they can present. The aim of this study was to propose a new severity score system that could reflect the risk of in hospital mortality of acute aortic dissections.

EVIDENCE ACQUISITION

Through a review of the literature, studies describing significant predictors of in hospital mortality of any type of aortic dissection were searched and selected by predefined selection criteria.

EVIDENCE SYNTHESIS

Nine studies met the criteria and were finally analyzed. The Odds Ratios of the reported predictors were the basis to the drawing of the score system. Sixteen main in hospital mortality predictors were found, 14 of which described in more than one study. They were combined into a new severity score system that we named VI2TA2 S2C2ORE.

CONCLUSIONS

This is a simple risk score that we propose as a first assessment risk-evaluating tool. We look forward to validate it and to describe specific in hospital mortality risk ranges once it will be adopted.

Treatment of isolated ascending aortic aneurysm by off-pump epiaortic wrapping is safe and durable

OBJECTIVES

Isolated ascending aortic aneurysm (iAA) is usually treated by open graft repair requiring sternotomy, cardiopulmonary bypass (CPB) and cardioplegia. This approach carries significant mortality in older patients or those presenting with comorbidities. We report an original series of patients presenting with iAA and treated with epiaortic wrapping by using a synthetic mesh. This less invasive aortic repair technique allows reducing the aortic diameter to a predefined value and is performed without CPB.

METHODS

Data from patients presenting with an iAA and treated with the wrapping technique (WT) by polypropylene/polyester mesh from November 2006 to July 2015 were collected. The end-points that were analysed included maximal aortic transverse diameter, perioperative mortality and morbidity, survival, freedom from reinterventions and aortic valve function during follow-up. The maximal aneurysm transverse diameter was analysed based on contrast-enhanced computed tomography (CTA) or magnetic resonance (MR) performed preoperatively, and during the follow-up.

RESULTS

The off-pump WT was used in 33 cases with no perioperative mortality. The median radiological follow-up was 33.47 (range: 1-106) months. Overall, the WT achieved a 30% diameter reduction. The mean preoperative and postoperative ascending aortic transverse diameter was 5.5 cm [standard deviation (SD): 0.6] and 3.7 cm (SD: 0.30), respectively (P = 0.001). In addition, CTA or MR follow-up showed stable diameters at the level of the aortic root and the distal ascending aorta. No death occurred during the follow-up. At 5 years, the estimated freedom rate from reinterventions of the aortic root and ascending aorta was 94%.

CONCLUSIONS

This series shows that the WT with a polypropylene/polyester mesh allows safe off-pump treatment of patients with iAA. Mid- and long-term results are promising. This technique could be an attractive alternative, especially for patients unfit for aortic surgery with CPB and cardioplegia.

Endovascular grafts for abdominal aortic aneurysm

During the last two decades, endovascular technology has revolutionized the management of patients with abdominal aortic aneurysm (AAA). Today, endovascular aortic repair (EVAR) is the treatment of choice for the majority of patients with an AAA. Randomized controlled trials provide robust evidence for the indication of AAA repair and the rationale for the use of EVAR in selected patients. However, despite that, practice varies and several areas need further elucidation. Important future challenges and areas of research include the role of medical therapy in AAA, whether the indication for repair should be any different in women and in the elderly, and long-term follow-up of patients undergoing complex EVAR with adjuncts, both for elective treatment and for ruptured AAA. Continuous rapid technical and clinical development is to be expected. In this paper, we review the current practice and evidence of stenting in AAA.

Aortic rupture following an EVAR secondary to graft erosion

Significant type 3 endoleak as a defect in the graft material, especially associated with endograft rupture, is a rare complication. A 68-year-old male patient with aortic plaque rupture was treated with endovascular graft placement. The patient was readmitted two years later with severe abdominal pain, a large retroperitoneal hematoma and contrast extravasation below the location where the aortic plaque had presented. Before an aortic infrarenal cuff could be placed during a control angiography, a large graft hole and a significant type 3 endoleak were observed. The sharp aortic plaque may have been responsible for the endograft tear.

Risk Stratification of Patients with Peripheral Arterial Disease and Abdominal Aortic Aneurysm Using Aortic Augmentation Index

Background

Central augmentation index (cAIx) is an indicator for vascular stiffness. Obstructive and aneurysmatic vascular disease can affect pulse wave propagation and reflection, causing changes in central aortic pressures.

Aim

To assess and compare cAIx in patients with peripheral arterial disease (PAD) and / or abdominal aortic aneurysm (AAA).

Methods

cAIx was assessed by radial applanation tonometry (Sphygmocor) in a total of 184 patients at a tertiary referral centre. Patients were grouped as having PAD only, AAA only, or both AAA and PAD. Differences in cAIx measurements between the three patient groups were tested by non-parametric tests and stepwise multivariate linear regression analysis to investigate associations with obstructive or aneurysmatic patterns of vascular disease.

Results

In the study sample of 184 patients, 130 had PAD only, 20 had AAA only, and 34 patients had both AAA and PAD. Mean cAIx (%) was 30.5 ± 8.2 across all patients. It was significantly higher in females (35.2 ± 6.1, n = 55) than males (28.4 ± 8.2, n = 129), and significantly higher in patients over 80 years of age (34.4 ± 6.9, n = 22) than in those under 80 years (30.0 ± 8.2, n = 162). Intergroup comparison revealed a significant difference in cAIx between the three patient groups (AAA: 27.3 ± 9.5; PAD: 31.4 ± 7.8; AAA & PAD: 28.8 ± 8.5). cAIx was significantly lower in patients with AAA, higher in patients with both AAA and PAD, and highest in patients with PAD only (beta = 0.21, p = 0.006).

Conclusion

Non-invasive assessment of arterial stiffness in high-risk patients indicates that cAIx differs according to the pattern of vascular disease. Measurements revealed significantly higher cAIx values for patients with obstructive peripheral arterial disease than for patients with aneurysmatic disease.

Value and limitations of chimney grafts to treat arch lesions

AIM

The endovascular debranching with chimney stents provides a minimally invasive alternative to open surgery with readily available devices and has extended the option of endoluminal therapy into the realm of the aortic arch. But a critical observation at the use of this technique at the aortic arch is important and necessary because of the lack of long-term results and long term patency of the stents. Our study aims to review the results of chimney grafts to treat arch lesions.

METHODS

A systematic health database search was performed in December 2014 according to the Prisma Guidelines. Papers were sought through a meticulous search of the MEDLINE database (National Library of Medicine, Bethesda, MA) using the Pubmed search engine.

RESULTS

Twenty-two articles were eligible for detailed analysis and data extraction. A total of 182 patients underwent chimney techniques during TEVAR (Thoracic Endovascular Aneurysm Repair). A total of 217 chimney grafts were implanted: 36 to the IA, 1 to the RCCA, 91 to the LCCA and 89 to the LSA. The type of stent-graft used for TEVAR was described in 132 patients. The type and name of chimney graft was described in 126 patients. In 53 patients information was limited to the type. Primary technical success, defined as a complete chimney procedure was achieved in 171 patients (98%). In 8 patients it was not clearly reported. The overall stroke rate was 5.3%. The overall endoleak rate, in those papers were it was clearly reported, was 18.4% (31 patients); 23(13,6%) patients developed a type IA endoleak, 1 patient (0.6%) developed type IB endoleak and 7 patients (4.1%) developed a type II endoleak

CONCLUSION

The total endovascular aortic arch debranching technique represent a good option to treat high-risk patients, because it dramatically reduces the aggressiveness of the procedure in the arch. Many concerns are still present, mainly related to durability and material interaction during time. Long-term follow-up is exceptionally important in light of the interactions of the stents, the thoracic endograft, the aortic arch, and every variation in systolic and diastolic pressure. Actually this technique has acceptable short and mid-term results. Long term data are available just from a very small number of patients and more data from a wider number are needed in order to embrace this method as a safe one.

Popliteal Artery Aneurysm Repair in the Endovascular Era: Fourteen-Years Single Center Experience

To compare outcomes of popliteal artery aneurysm (PAA) repair by endovascular treatment, great saphenous vein (GSV) bypass, and prosthetic bypass.Single center retrospective analysis of patients presenting PAA from 2000 to 2013. Patients were divided into endovascular treatment (group A); GSV bypass (group B); and prosthetic graft bypass (group C). Outcomes were technical success, perioperative mortality, and morbidity. Survival, primary and secondary patency, and freedom from reintervention rate were estimated. Differences in ankle-brachial index (ABI), in-hospital length of stay (InH-Los), red blood cell (RBC) transfusion, and limb loss were reported. Mean follow-up was 49 (median: 35; 1-145; SD 42) months.Sixty-seven patients were included; 25 in group A, 28 in group B, and 14 in group C. PAA was symptomatic in 23 (34%) cases. Technical success was 100%. No perioperative death occurred. Three (4.5%) perioperative complications were reported with no significant difference between groups (P = 0.866). Five-years estimated survival was 78%. Estimated 5-years primary patency for groups A, B, and C was 71%, 81%, and 69%, respectively (P = 0.19). Estimated 5-years secondary patency for groups A, B, and C was 88%, 85%, and 84% (P = 0.85). Estimated 5-years freedom from reintervention for groups A, B, and C was 62%, 84%, and 70%, respectively (P = 0.16). A significant difference between preoperative ABI versus postoperative ABI was observed (P = 0.001). InH-LoS was significantly shorter in group A (P < 0.001). RBC transfusions were required significantly less in group A when compared to group C (P = 0.045). Overall limb salvage was achieved in all but 1 patient.PAA repair has good early and long-term outcomes with different treatment options. Endovascular treatment was not inferior to surgical repair with a reduced InH-LoS and RBC transfusion. It can be successfully employed even in nonelective setting. A randomized controlled trial with long-term follow-up and appropriate patient inclusion criteria is necessary to compare these 3 treatment options.