Aneurysmal Degeneration Research Articles

A Hybrid Approach to Treatment of a Superior Mesenteric Artery Aneurysm

Superior mesenteric artery (SMA) aneurysms represent ∼6% of mesenteric aneurysms and carry a risk of rupture. These can be repaired with open surgery or endovascular repair. We present the case of a patient who had developed aneurysmal degeneration of the SMA after dissection requiring hybrid open and endovascular repair. A 54-year-old man had presented to the emergency department with epigastric pain. He was noted to have a 7-cm-long SMA dissection with aneurysmal dilatation. He was treated nonoperatively with anticoagulation and serial imaging until his SMA aneurysm had increased to 2 cm. Preoperative imaging showed the patient had two major jejunal branches originating from the true lumen, with the remaining branches fed from the false lumen. In addition, the aneurysm degeneration extended through the SMA to just distal to the origin (Fig 1). Because of this complex anatomy, we believed a hybrid approach would be needed with a short interposition bypass, reimplantation of jejunal branches, and covered stent placement for proximal coverage. The patient underwent laparotomy with anterior exposure of the SMA. After establishing proximal and distal control, a longitudinal arteriotomy was made. The true and false lumens were noted and fenestrated. An 8-mm polytetrafluoroethylene graft was sewn in an end to end fashion. This was followed by reimplantation of the two jejunal branches as a patch. Flow was confirmed with Doppler ultrasound. Next, the polytetrafluoroethylene graft was accessed with a needle, and a sheath was placed. Angiography and intravascular ultrasound were used to confirm and delineate the anatomy. Next, we upsized to an 8F sheath and placed two 10 × 5 Viabahn stents (W.L. Gore & Associates, Flagstaff, Ariz) overlapping into the aorta and covering the proximal SMA. We postdilated with a 9-mm balloon. Completion imaging revealed good flow with exclusion of the aneurysm (Fig 2). The bowel appeared healthy at that time. The patient tolerated the procedure well and was extubated at the conclusion of the case. He required a nasogastric tube postoperatively until the return of bowel function, at which point he was allowed a regular diet. He was discharged home in sTable condition on postoperative day 6 from the hospital. A hybrid approach to complex SMA aneurysms is a feasible option for repair.Fig 2Completion angiogram at conclusion of the case.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Modified Scalloped Endograft for Failed Endovascular Repair of an Aortic Arch Dissection

We reviewed a modified, proximal scalloped, arch endograft, the Terumo RelayPro Plus (Terumo Aortic, Bolton Medical, Sunrise, Fla; Fig A), used for endovascular salvage after thoracic endovascular aneurysmal repair (TEVAR). Current endovascular repair of proximal arch pathology has been limited by patient anatomy and the availability of Food and Drug Administration–approved devices. Through Food and Drug Administration–authorized compassionate use, we were able to repair a type Ia endoleak in a patient with continued rapid proximal arch aneurysmal degeneration after open type A dissection repair complicated by vocal cord paralysis and TEVAR failure (Fig B).

Carotid endarterectomy with saphenous vein patch angioplasty: a single-center experience.

When performing a conventional CEA it is recommended the use of patch angioplasty (PA), since previous meta-analyses have shown PA to be superior to primary closure (PRC) in terms of stroke and restenosis rates. Different materials patches can be employed although none of them has been proved to be superior. Although autologous veins are potentially more resistant to immediate thrombosis as well as infection, cons may be represented by patch rupture and late dilatation. Aim of this study is to evaluate immediate and long-term results of CEA with saphenous vein patch angioplasty (SVPA) in a single-center experience. A retrospective study was performed analyzing all patients undergoing CEA with SVPA at our institution from January 2012 to March 2020. CEA was performed in symptomatic patients with 50-99% carotid stenosis degree or asymptomatic patients with 70-99% stenosis degree. Exclusion criteria were critical limb ischemia, varicose disease, unavailability of saphenous veins, vein diameter <3.5 mm. All CEAs were performed under general anesthesia with routine shunting. Primary endpoints were perioperative stroke, death, carotid thrombosis and hematoma requiring surgery rates. Secondary endpoints included the rate of recurrent stenosis >70%, patch aneurysm/rupture/infection at follow-up. Overall, 488 interventions were performed on 461 patients. Most patients were male (77.8%) with a mean age of 71.2±8.3 years. Thirty-day mortality and stroke rates were 0.4% and 1.2% respectively. Carotid thrombosis occurred in five patients (1%). Five patients (1%) developed a surgical site hematoma requiring surgical drainage. At a mean follow-up of 34.4±25.8 months 12 restenoses (2.5%) were detected. Five-year freedom from restenosis rate was 96.7%. Restenosis at follow-up was more frequent in patients who had contralateral carotid stenosis (P=0.019). Two patients (0.4%) developed carotid patch aneurysmal degeneration at a mean follow-up of 78.7 months. No infection nor patch disruption were detected. CEA with SVPA resulted safe and effective in terms of early and late results. The perioperative complications rates we recorded were quite similar to those reported by other larger reviews and meta-analyses.

Abstract P102: False Lumen Volume Is A Predictor Of Successful Thoracic Endovascular Aortic Repair

Objectives: Thoracic endovascular aortic repair (TEVAR) is becoming the treatment modality of choice for type B aortic dissection (TBAD). Using CTA imaging, clinicians track dissection evolution; however, clinical imaging analysis is limited to linearized measurements of maximum diameter that poorly predict post-operative outcomes. Achieving post-operative thrombosis of the false lumen is a desired characteristic that is thought to prevent aneurysmal degeneration, complication, and reintervention. We hypothesize that decrease in false lumen volume can be used to accurately predict successful TEVAR, as defined by lack of reintervention. Methods: We studied 20 TBAD patients that underwent TEVAR, 10 with desired outcomes, defined by the absence of post-operative reintervention, and 10 with failed outcomes, defined by the presence of reintervention. Utilizing CTA imaging, we performed pre- and post-operative segmentations of the false lumen for each patient. We calculated the volume of the false lumen of each scan. We performed two-sample t-tests on the null hypothesis that false lumen volume does not change post-TEVAR. We also tested the null hypothesis that patients with desired outcomes and poor outcomes have equal false lumen volumes. Results: We found a statistically significant difference in the pre-operative false lumen volume of patients with desired outcomes post-TEVAR versus patients with failed outcomes (p=0.014). However, we found no statistically significant change in false lumen volume of patients with successful or failed TEVAR. Conclusions: Pre-operative false lumen volume distinguishes desired versus failed post-TEVAR outcomes. While our initial hypothesis was not proven, our results identify that pre-operative false lumen volume is a viable predictor of TEVAR success. The clinical implication of our finding is that patients with a large false lumen volume may not be ideal candidates for an endovascular approach to TBAD repair.

Abstract MP24: Disruption Of Actin Remodeling Intensifies Aneurysm-promoting Signals In Smooth Muscle Cells

Mutations within proteins coding for extracellular matrix assembly or those in the transforming growth factor beta (TGFβ) signaling pathway lead to aneurysm formation in patients and mice. As the SMC cytoskeletal network is intricately linked to TGFβ and ECM signaling, we sought to determine if disruption of the cytoskeletal filaments would alter how SMCs respond to angiotensin II, an important mediator of aneurysm formation. C57BL/6 mice lacking Tgbfr1 in SMCs (SMC- Tgbr1 iko ) generated by Jiang et al. have been shown to develop rapid and severe aortic aneurysm degeneration with 100% penetrance. Analysis was conducted on aneurysm and control mouse and human aortic tissue sections. We observed that SMC- Tgbr1 iko mice had reduced expression of filamentous (f-) and α-actin protein in the aortic media than control mice. Primary Tgbr1 iko SMCs also had higher levels of pRelA expression, less α-actin mRNA, and less f-actin than control SMCs. Tissue sections from aneurysm patients had reduced f-actin staining relative to controls. Disruption of f-actin with the destabilizer latrunculin A in vitro led to increased RelA and ERK activation in the presence of AngII, which was further augmented in the presence of a neutralizing antibody for TGFβ. In contrast, jasplakinolide—an f-actin stabilizer—prevented TGFβ blockade induced pRelA expression, suggesting that altered/inhibited TGFβ signaling modulates NFkB through actin depolymerization. While stabilization and disruption of microtubules led to RelA activation, no effect was observed on TGFβ blockade-induced pRelA expression. The phosphoantibody array revealed that f-actin disruption in the presence of AngII activated the CREB, AKT1/2/3, ERK1/2, and STAT3 pathways in mouse aortic SMCs. SMC- Tgbr1 iko mice treated with cytochalasin B suffered significantly greater mortality and had increased aortic growth over a 30-day follow-up period. Aortic aneurysms are coincident with reduced f-actin expression in murine and human aortic SMCs. Chemical deconstruction of actin filaments promotes an inflammatory phenotype in mouse SMCs in vitro , and aggravates aneurysm formation in vivo . Aberrant or inhibited TGFβ signaling potentiates NFkB activation in SMCs, which may be dependent on f-actin disassembly.

Endovascular Therapies for Type B Aortic Dissection.

Aortic dissection is a life-threatening condition resulting from a tear in the intimal layer of the aorta, requiring emergent diagnosis and prompt multi-disciplinary management strategy for best patient outcomes. While type A dissection involving ascending aorta is best managed surgically due to high early mortality, Type B Aortic Dissection (TBAD) involving descending aorta generally has better outcomes with conservative management and medical therapy as a primary strategy is favored. However, there has been a recent paradigm shift in the management of TBAD due to late aneurysmal degeneration of TBAD, increasing morbidity and mortality in the long term. Late surgical intervention can be prevented by early endovascular intervention when combined with optimal medical therapy. In this narrative review, we explore available literature on different endovascular therapies for TBAD in different populations of patients.

Fenestrated-Branch Endovascular Repair After Prior Abdominal Aortic Aneurysm Repair

To report the outcome of fenestrated and branch endovascular aortic repair (FEVAR-BEVAR) for asymptomatic and acute symptomatic proximal aortic pathology in patients with prior open (OSR) or endovascular (EVAR) abdominal aortic aneurysm (AAA) repair. This was a single centre retrospective study of consecutive patients with non-ruptured (asymptomatic and acute symptomatic) proximal aortic pathology after prior OSR or EVAR treated between December 2007 and February 2020. The primary endpoint was 30 day/in hospital mortality. Secondary endpoints were technical success, primary clinical success, and Kaplan-Meier estimates of medium term survival and freedom from re-intervention. Data are presented as median (interquartile range [IQR]). The effect of covariates on medium term survival was estimated using multivariable (Cox proportional hazards model) analysis. A p value < .05 was considered to be statistically significant. Ninety-two patients (83 men; median age 75 years [IQR 71 - 80 years]; median diameter 73 mm [IQR 64 - 89 mm]; 82 elective, 10 acute) underwent FEVAR-BEVAR after prior OSR (n= 47) or EVAR (n= 45). Indications for intervention were aneurysmal degeneration with or without type 1a endoleak (n= 57; four juxtarenal [JR] AAA, 21 extent II/III, 32 extent IV thoraco-abdominal aortic aneurysms); type 1a endoleak alone (n= 27) and to create a more durable repair after acute infrarenal EVAR (n= 8; JRAAA). In total, 348 renovisceral vessels were targeted for preservation and 324 were stent grafted. Twenty-four unstented vessels comprised one bypass, 11 scallops and six fenestrations intentionally not stent grafted, two vessels occluded before graft implantation, and four vessels occluded intra-operatively. Primary technical success was 95.6%. The thirty day mortality rate was 1.1% and one patient each (1.1%) required permanent dialysis or developed temporary spinal cord ischaemia. Early primary clinical success was 94.6%. Median follow up was 36 months (IQR 23 - 64 months). Estimated overall survival (± standard error) at one, two, and three years was 86% ± 4%, 85% ± 4%, and 70% ± 5%, respectively. Multivariable analysis did not demonstrate any independent predictors of survival. Four target vessels occluded during follow up. Nineteen patients underwent 28 late re-interventions, with almost half performed for issues arising distal to the FEVAR-BEVAR. Patients treated with a cuff were statistically significantly more likely to require distal re-intervention compared with those treated by relining (9/49 vs. 1/43, p= .018 [odds ratio 9.3, 95% confidence interval 1.2 - 423]). In patients with prior EVAR alone, this did not reach statistical significance (cuff 7/25 vs. relining 1/20, p= .059 [odds ratio 7.1, 95% confidence interval 0.8 - 350]). Estimated freedom from re-intervention at one, two, and three years was 88% ± 3%, 81% ± 4%, and 81% ± 4%, respectively. FEVAR-BEVAR after prior OSR or EVAR is associated with low peri-operative morbidity and mortality, and acceptable medium term survival and freedom from re-intervention. Treatment with a FEVAR-BEVAR cuff is associated with a higher requirement for distal re-intervention than relining of the original repair.

Recombinant Interleukin-19 Suppresses the Formation and Progression of Experimental Abdominal Aortic Aneurysms.

BackgroundInterleukin‐19 is an immunosuppressive cytokine produced by immune and nonimmune cells, but its role in abdominal aortic aneurysm (AAA) pathogenesis is not known. This study aimed to investigate interleukin‐19 expression in, and influences on, the formation and progression of experimental AAAs.Methods and ResultsHuman specimens were obtained at aneurysm repair surgery or from transplant donors. Experimental AAAs were created in 10‐ to 12‐week‐old male mice via intra‐aortic elastase infusion. Influence and potential mechanisms of interleukin‐19 treatment on AAAs were assessed via ultrasonography, histopathology, flow cytometry, and gene expression profiling. Immunohistochemistry revealed augmented interleukin‐19 expression in both human and experimental AAAs. In mice, interleukin‐19 treatment before AAA initiation via elastase infusion suppressed aneurysm formation and progression, with attenuation of medial elastin degradation, smooth‐muscle depletion, leukocyte infiltration, neoangiogenesis, and matrix metalloproteinase 2 and 9 expression. Initiation of interleukin‐19 treatment after AAA creation limited further aneurysmal degeneration. In additional experiments, interleukin‐19 treatment inhibited murine macrophage recruitment following intraperitoneal thioglycolate injection. In classically or alternatively activated macrophages in vitro, interleukin‐19 downregulated mRNA expression of inducible nitric oxide synthase, chemokine C‐C motif ligand 2, and metalloproteinases 2 and 9 without apparent effect on cytokine‐expressing helper or cytotoxic T‐cell differentiation, nor regulatory T cellularity, in the aneurysmal aorta or spleen of interleukin‐19–treated mice. Interleukin‐19 also suppressed AAAs created via angiotensin II infusion in hyperlipidemic mice.ConclusionsBased on human evidence and experimental modeling observations, interleukin‐19 may influence the development and progression of AAAs.

Aortic septotomy to optimize landing zones during thoracic endovascular aortic repair for chronic type B aortic dissection

ObjectiveThe role of thoracic endovascular aortic repair for chronic type B aortic dissection remains controversial. Clinical outcomes of thoracic endovascular aortic repair with recently implemented aortic septotomy strategy were compared with stand-alone thoracic endovascular aortic repair. MethodsBetween 2008 and 2020, 88 patients with chronic type B aortic dissection and degenerative aortic aneurysm underwent a thoracic endovascular aortic repair with or without adjunctive aortic septotomy, consisting of 36 (41%) with de novo chronic type B aortic dissection and 52 (59%) with residual chronic type B aortic dissection after type A aortic dissection repair. ResultsAortic septotomy was performed in 31 patients (35%) to optimize the proximal (3/31;10%) and distal (31/31;100%) landing zones. The aortic septotomy techniques comprised laser aortic septotomy in 16 patients (52%) and cheese wire septotomy in 15 patients (48%) with a 97% overall technical success rate. The median time interval between aortic dissection occurrence and thoracic endovascular aortic repair was 1.2 years. During follow-up, there were 12 (21%) sudden deaths and 17 (30%) combined aorta-related and sudden deaths in the nonaortic septotomy group, whereas there were no deaths in the septotomy group (P < .001). Patients without aortic septotomy required aortic reinterventions more frequently than those with aortic septotomy (30% vs 7%; P = .014), and 77% of these procedures were related to residual retrograde false lumen flow. Positive aortic remodeling was confirmed in 90% and 37% in the aortic septotomy and nonseptotomy groups, respectively (P < .001). ConclusionsStand-alone thoracic endovascular aortic repair outcomes without adjunctive procedures for chronic type B aortic dissection remain unfavorable. In contrast, landing zone optimization using aortic septotomy resulted in a remarkably higher positive aortic remodeling rate. Routine aortic septotomy strategy may positively affect long-term chronic type B aortic dissection survival and expand thoracic endovascular aortic repair candidacy.

Association of Mental Health Disorders and Aortic Dissection

Mental health disorders (MHD), including substance abuse, have been associated with aortic dissection (AD). Aneurysmal degeneration in the residual untreated aorta after both open and endovascular treatment is not uncommon in AD. Thus, diligent long-term follow-up is necessary and MHD may play a role in treatment plan and surveillance. The impact of MHD on management, outcomes and follow-up after AD treatment is unknown and here we sought to evaluate these associations. A retrospective review was performed on all patients diagnosed with Stanford Type A and B dissections from 2008 to 2018 at a tertiary referral center. MHD was defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM-V). Patient demographics, procedural characteristics, and outcomes were analyzed. A total of 649 non-traumatic aortic dissections were identified in the study timeframe. The cohort consisted of 51% Type A (n=334) dissection and 49% Type B (n=315) dissection. Mental health disorders were present in 49.3% of the cohort. Notably, the timing of MHD diagnosis relative to development of AD is unknown in the majority of patients. Within the Type A population, a MHD was present in 50.6% (N=162) of patients, of which the most common indication for MHD was the presence of antidepressant or antipsychotic medication (28.6%). In patients with Type A dissections, the presence of a MHD did not significantly affect the rate of index hospitalization intervention (68%) or long-term mortality (12.5% in patients with a MHD). Within the Type B population, a MHD was present in 49.4% (n=158) of patients, of which the most common indication for MHD was the presence of antidepressant or antipsychotic medication (30.5%). In patients with Type B dissections, the presence of a MHD did not significantly affect the rate of index hospitalization intervention (50.3% in patients with a MHD) or long-term mortality (10.1% in patients with a MHD). The overall participation in follow-up care was not significantly decreased based on the presence of a MHD compared to those without a MHD (1.66 ± 2.16 years vs. 1.68 ± 2.20 years, P=0.93). MHD is more prevalent in AD patients than in the general population, but demonstrating a causal relationship between MHD and development/progression of AD is challenging. Despite a high prevalence of MHD in AD patients, in-hospital mortality and follow-up compliance was similar to non-MHD patients.

A Population-Based Study of the Incidence and Natural History of Degenerative Thoracic Aortic Aneurysms

ObjectiveTo investigate the incidence and natural history of degenerative thoracic aortic aneurysms (TAAs) and compare results between ascending (aTAAs) and descending TAAs (dTAAs). Patients and MethodsThis population-based cohort study used the Rochester Epidemiology Project database from January 1, 1995, through December 31, 2015. Patients were classified as the aTAA or dTAA group. ResultsOf 238 Olmsted County residents studied, 131 (55.0%) were women; 154 (64.7%) were in the aTAA group, and 84 (35.3%) were in the dTAA group. Median age was 77.0 years (interquartile range, 69.1-83.8 years). The overall age- and sex-adjusted incidence rate was 13.8 per 100,000 person-years (95% CI, 12.1 to 15.6) and varied from 9.9 in 1995 to 1999 to 19.0 in 2005 to 2009. It was 9.0 (95% CI, 7.5 to 10.4) for the aTAA and 4.9 (95% CI, 3.8 to 5.9) for the dTAA group. Overall 5-year survival was 62.5%, lower than the expected survival of 73.7% for the US 2010 census population (P<.001). The 5-year survival was 42.9% for the aTAA and 73.4% for the dTAA group (P<.001). On multivariable analysis, advanced age and smoking status were associated with all-cause mortality. The 5-year estimate of freedom from an aortic-related event was 80.0%, lower for dTAAs (67.8%) than for aTAAs (85.2%; P<.001). Maximal aortic diameter and dTAAs were associated with aortic-related events. ConclusionThe incidence of TAAs was stable from 1995 to 2015 and mortality for those with TAAs remains higher than for the general population. Older age and smoking status were associated with overall mortality, whereas larger aneurysms and dTAAs were associated with aortic-related events.

Contemporary Outcomes of Precision Banding for High-Flow Hemodialysis Access

High-flow hemodialysis accesses are increasingly recognized as the source of complications (cardiopulmonary, hand ischemia, access aneurysmal degeneration). Among management strategies (access elongation, revision-using-distal-inflow), precision banding (inflow constriction based on real-time physiologic flow monitoring) offers a technically straightforward approach with potentially low morbidity. However, large contemporary series on banding outcomes (and their predictors) are lacking.

Long-term outcomes of hemiarch replacement with hypothermic circulatory arrest and retrograde cerebral perfusion

ObjectiveThis study sought to report outcomes of hemiarch replacement with hypothermic circulatory arrest and retrograde cerebral perfusion, and secondarily, to report outcomes of this operative approach by type of underlying aortic disease. MethodsThis was an observational study of aortic surgeries from 2010 to 2018. All patients who underwent hemiarch replacement with retrograde cerebral perfusion were included, whereas patients undergoing partial or total arch replacement or concomitant elephant trunk procedures were excluded. Patients were dichotomized into 2 groups by underlying aortic disease; that is, acute aortic dissection (AAD) or aneurysmal degeneration of the aorta. These groups were analyzed for differences in short-term postoperative outcomes, including stroke and operative mortality (Society of Thoracic Surgeons definition). Multivariable Cox analysis was performed to identify variables associated with long-term survival after hemiarch replacement. ResultsA total of 500 patients undergoing hemiarch replacement with hypothermic circulatory arrest plus retrograde cerebral perfusion were identified, of whom 53.0% had aneurysmal disease and 47.0% had AAD. For the entire cohort, operative mortality was 6.4%, whereas stroke occurred in 4.6% of patients. Comparing AAD with aneurysm, operative mortality and stroke rates were similar across each group. Five-year survival was 84.4% ± 0.02% for the entire hemiarch cohort, whereas 5-year survival was 88.0% ± 0.02% for the aneurysm subgroup and was 80.5% ± 0.03% for the AAD subgroup. On multivariable analysis, AAD was not associated with an increased hazard of death, compared with aneurysm (P = .790). ConclusionsMorbidity and mortality after hemiarch replacement with hypothermic circulatory arrest plus retrograde cerebral perfusion are acceptably low, and this operative approach may be as advantageous for AAD as it is for aneurysm.

Statin Therapy in Patients Undergoing Thoracic Aorta Replacement for Aortic Aneurysms.

Background Patients undergoing surgery for thoracic aortic aneurysms receive statin therapy out of proportion to cardiovascular comorbidity. We sought to determine the prevalence of statin use among patients presenting for thoracic aortic aneurysm surgery and investigate its effect on outcomes. Methods From January 1, 2005 to January 1, 2011, 1,839 consecutive patients underwent aortic replacement for degenerative thoracic aortic aneurysm at Cleveland Clinic. Of these, 771 (42%) were on statins preoperatively. Statin users (vs. nonstatin users) were older (65 ± 11 vs. 56 ± 16 years) and had more hypertension (78 vs. 59%). Propensity matching based on 56 preoperative variables other than lipid levels was used to compare outcomes among 570 matched patient pairs (74% of possible pairs). Results Propensity-matched statin and nonstatin users were aged 64 ± 11 years, 394 (69%) versus 387 (68%) were male, and 437 (77%) versus 442 (78%) had ascending aortic aneurysms, respectively. Overall, 25% of patients were followed for more than 8.2 years and 10% for more than 10 years. Perioperative outcomes were similar, including hospital mortality (11 [1.9%] vs. 5 [0.88%]) and stroke (22 [3.9%] vs. 13 [2.3%]), but 16 statin users (2.8%) versus 5 nonstatin users (0.88%) required temporary dialysis after surgery ( p = 0.02). At 6 years, 3.7% of statin users versus 5.1% of nonstatin users ( p [log-rank] = 0.5) underwent further aortic surgery, and at 10 years, mortality was 25% in both groups ( p > 0.5). Conclusion Patients presenting for thoracic aortic aneurysm surgery frequently receive unnecessary statins. Additionally, statin use was associated with more postoperative renal failure, but not less intermediate-term risk for aortic reintervention or all-cause mortality after surgery. Therefore, presence of a thoracic aortic aneurysm should not be considered an indication for statin therapy in the absence of well-established indications.

Short- and mid-term outcomes of the frozen elephant-trunk procedure for degenerative aortic arch aneurysm.

The frozen elephant-trunk (FET) procedure is used widely in total aortic arch replacement (TAR) surgery; however, its safety, effectiveness, and long-term outcomes compared with those of the conventional elephant trunk (cET) procedure for degenerative aneurysms are unclear. Between July, 2011 and August, 2019, 126 patients underwent elective total aortic arch replacement at our institution. We compared the short- and mid-term outcomes of 60 patients who underwent the FET procedure (FET group) with those of 66 patients who underwent cET (cET group). The in-hospital mortality rate tended to be lower in the FET group than in the cET group (p = 0.12). There were two cases of paraplegia (3.3%) in the FET group and in none in the cET group. The all-cause mortality at the 3-year follow-up did not differ significantly between the groups (p = 0.31). The FET group required more unexpected interventions at the surgical site in the mid-term period. FET was associated with a shorter operative time and lower surgical mortality than cET. Although the mid-term total aortic arch replacement outcomes of FET were acceptable, careful imaging observation is necessary because reinterventions were required more frequently.

Bilateral Bidirectional Glenn Anastomosis in an Adult Patient with Aneurysmal Degeneration after an Original Blalock-Taussig Shunt

Bilateral Bidirectional Glenn Anastomosis in an Adult Patient with Aneurysmal Degeneration after an Original Blalock-Taussig Shunt

Hybrid repair of aortic arch with zone zero endografting-Case series with review of the literature.

We present single-institution results of types I and II hybrid procedures for aortic arch disease with 30-day and long-term results and review of the literature. This is a retrospective study of all patients that underwent zone 0 endografting and open bypass from ascending aorta to the arch vessels at our institution between January 2013 and 2020. The following data for the systematic review were extracted from eligible studies: 30-day/in-hospital mortality, stroke rate, spinal cord ischemia (SCI) rate, renal failure requiring dialysis, development of retrograde dissection, early (<30 days) types I and III endoleak, follow-up length, late (>30 days) endoleak, and late (>30 days) mortality. Twelve patients underwent hybrid aortic arch treatment in our institution. The most common aortic arch pathology was degenerative aortic aneurysm. The rate of retrograde dissection and SCI was 8.33%. Regarding the literature data, a total of 768 patients undergoing types I and II hybrid aortic arch debranching procedure. The pooled rate of 30-day/in-hospital mortality was 10.96% (95% confidence interval [CI], 8.21-14.06), SCI pooled rate was 2.91% (95% CI, 1.76%-4.33%), and retrograde dissection pooled rate was 3.22% (95% CI, 1.99-4.72). Hybrid arch techniques provide safe alternative to open repair with acceptable short- and midterm results.

Machine learning to automatically detect anatomical landmarks on phase-contrast enhanced magnetic resonance angiography

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Guala A. received funding from the Spanish Ministry of Science, Innovation and Universities Introduction The heterogeneous characteristic of the thoracic aorta implies that all biomarkers with potential for risk stratification need to be references to a specific location. This is the case, for example, of diameter [1], stiffness [2] and wall shear stress [3]. This is normally achieved by the manual identification of a limited number of key anatomic landmarks [4], which is a time-demanding task and may impact biomarkers accuracy and reproducibility. Automatic identification of these anatomic landmarks may speed-up the analysis and allow for the creation of fully automatic image analysis pipelines. Machine learning (ML) algorithms might be suitable for this task. Purpose The aim of this study was to test the performance of a ML algorithm in localizing key thoracic anatomical landmarks on phase-contrast enhanced magnetic resonance angiograms (PC-MRA). Methods PC-MRA of 323 patients with native aorta and aortic valve and a variety of aortic conditions (141 bicuspid aortic valve patients, 60 patients with degenerative aortic aneurysms, 82 patients with genetic aortopathy and 40 healthy volunteers) were included in this study. Four anatomical landmarks were manually identified on PC-MRA by an experienced researcher: sinotubular junction, the pulmonary artery bifurcation and the first and third supra-aortic vessel braches. A reinforcement learning algorithm (DQN), combining Q-learning with deep neural networks, was trained. The algorithm was tested in a separate set of 30 PC-MRA with similar distribution of aortic conditions in which human intra-observer reproducibility was quantified. The distance between points was used as quality metric and human annotation was considered as ground-truth. Repeated-measures ANOVA was used for statistical testing. Results ML algorithm resulted in performance similar to the intra-observer variability obtained by the experienced human reader in the identification of the sinotubular junction (11.1 ± 8.6 vs 11.0 ± 8.1 mm, p = 0.949) and first (6.8 ± 5.6 vs 6.6 ± 3.9 mm, p = 0.886) and third (8.4 ± 7.4 vs 6.8 ± 4.0 mm, p = 0.161) supra-aortic vessels branches. However, the algorithm did not reach human-level performance in the localization of the pulmonary artery bifurcation (15.2 ± 13.1 vs 10.2 ± 7.0 mm, p = 0.008). The time needed to the ML algorithm to locate all points ranged between 0.8 and 1.6 seconds on a standard computer while manual annotation required around two minutes to be performed. Conclusions The rapid identification of key aortic anatomical landmarks by a reinforced learning algorithm is feasible with human-level performance. This approach may thus be used for the design of fully-automatic pipeline for 4D flow CMR analysis.

Aneurysmal degeneration of fluoropolymer-coated paclitaxel-eluting stent in the superficial femoral artery: a rising concern

BackgroundAlthough several clinical reports demonstrated a durable patency rate after a novel fluoropolymer-coated paclitaxel-eluting stent (Eluvia; Boston Scientific, Marlborough, MA, USA) placement, aneurysmal degeneration after drug-eluting stent (Eluvia) placement has raised clinical concerns. Here, we report a case with progressive aneurysm formation on serial angiography and intravascular ultrasound over 50 months after drug-eluting stent (Eluvia) placement for a superficial femoral artery atheromatous plaque.Case presentationA 79-year-old woman with right leg intermittent claudication at 100 m distance was referred to our hospital. Pre-procedural angiography showed long-segment severe stenosis from the middle-to-distal part of the right superficial femoral artery, and a 7 mm wide drug-eluting stent (Eluvia) was placed. However, the patient had a recurrence of intermittent claudication in the right lower extremity 25 months thereafter. Angiography revealed de novo stenosis in the distal part of the popliteal artery and proximal superficial femoral artery in-stent restenosis. Subsequently, the patient underwent endovascular therapy for these lesions. In addition, intravascular ultrasound at the time of endovascular therapy revealed femoral artery enlargement with a maximum vessel diameter of 10.0 mm at the distal edge of the stent. Intermittent claudication on the right side recurred again 50 months after drug-eluting stent (Eluvia). Angiography demonstrated de novo severe stenosis from the distal part of the superficial femoral artery to the middle part of the popliteal artery. Peri-stent contrast staining was found at the distal part of the drug-eluting stent (Eluvia) site. Intravascular ultrasound showed a further enlargement of maximum vessel diameter to 12.0 mm at the distal edge of the stent.ConclusionsWe report a case with progressive aneurysm degeneration on serial angiography and intravascular ultrasound over 50 months after drug-eluting stent (Eluvia) placement for a superficial femoral artery stenosis.

A Case of Brachial Artery Infected Aneurysm Secondary to Infective Endocarditis from Intramuscular Steroid Use

Infected aneurysms are a subset of aneurysms associated with infection. Approximately 10% of infected aneurysms involve the upper extremity. Infected aneurysms present a management challenge as patients are often unwell with concomitant infective endocarditis or septicemia. We present a case of a brachial artery infected aneurysm secondary to mitral valve infective endocarditis likely due to intramuscular anabolic steroid use. A 52-year-old male presented with a 24-h history of lethargy, blurred vision, and ataxia. He had a background history of intramuscular anabolic steroid use for the past 5 years. Swelling of his left arm localized to his cubital fossa was noted. Blood cultures were positive for Cardiobacterium hominis. Transthoracic echocardiography demonstrated a large vegetation on the mitral valve. Magnetic resonance imaging angiography demonstrated a right middle cerebral artery aneurysm. Computed tomography angiography of the left arm demonstrated an abrupt filling defect of the distal 2 cm of the brachial artery, with surrounding fat stranding and aneurysmal degeneration of the artery. Following successful aneurysm coiling, the patient underwent excision and debridement of the infected aneurysm. Histopathology was consistent with infected thromboembolism with aneurysmal degeneration of the artery. The patient underwent mitral valve replacement 10 days later. The brachial artery is the most common site of upper extremity infected aneurysms. Open surgical resection of the infected tissue is accepted as the gold standard. The rich collateral supply of the upper extremity permits ligation and debridement without needing simultaneous revascularization. We present this case to draw attention to an interesting manifestation of a rare pathology.