Aortic Intervention Research Articles

PS64 Iliac Injury During Abdominal and Thoracic Aortic Endovascular Intervention

Iliac injury is a devastating and potentially avoidable complication of endovascular aortic intervention. To our knowledge, this study is the first investigation of demographic, anatomic, and device factors related to iliac injury in vascular surgery patients. We retrospectively examined 1859 endovascular aortic interventions and found 42 iliac injuries, including 21 ruptures. Demographic, anatomic, and device data were extracted from these patients and a cohort of 200 case-matched control patients derived from the group of uninjured patients. Anatomic data includes centerline and straight distance measurement of the iliac system from the aortic bifurcation to the inguinal ligament. The ratio of the two (“tortuosity index”) was calculated. Additional data includes midpoint and narrowest diameters in the iliac system along with the most acute angle. Each measurement was taken for the side through which the main body was introduced (“device side”) and the contralateral side. Demographic factors associated with injury were female gender (P < .001) and non-Caucasian race (P = .028). None of the examined comorbidities were associated with iliac injury. Increasing sheath size was associated with injury (P < .001). Device-side anatomic factors associated with injury were decreasing iliac midpoint (P = .002) and narrowest diameters (P < .001). Contralateral-side anatomic variables associated with injury were iliac centerline distance (P = .030), decreasing midpoint (P < .001), narrowest diameters (P < .001), and angularity (P = .036). Injury is associated with inpatient death (P < .001), with iliac rupture conferring an odds ratio of 15.3 (P < .001). Iliac injury is associated with death on the index admission. Female gender, non-Caucasian race, large sheath sizes, and iliac occlusive disease and angularity are associated with iliac injury. These findings should be prospectively evaluated along with interventions to reduce injury.

Early Aortic Repair Worsens Concurrent Traumatic Brain Injury

Blunt thoracic aortic injury (BTAI) and traumatic brain injury (TBI) are the leading causes of death after blunt trauma, and TBI is common among patients with BTAI. Although aspects of aortic management, such as repair timing and procedural anticoagulation therapy, may complicate TBI, the optimal management of these patients is undefined. Adults with BTAI and moderate to severe TBI admitted to a level I trauma center over 12 years were retrospectively analyzed; patients presenting in extremis were excluded. The primary outcome was neurologic progression within 48 hours of aortic repair. Patients undergoing nonoperative aortic management served as controls for baseline TBI progression. Secondary outcomes were aortic morbidity and mortality and overall inpatient survival. Of 309 patients with BTAI, 138 had concurrent TBI, and 75 were included for analysis. Twenty-two (29%) were treated nonoperatively, 29 (39%) had early aortic repair (17 open, 12 endovascular), and 24 (32%) had delayed repair (3 open, 21 endovascular). The severity of TBI was similar between groups. Early aortic repair within 24 hours of admission was independently associated with worsening TBI, regardless of repair modality or anticoagulation use. In contrast, patients undergoing delayed repair had no perioperative neurologic progression despite procedural anticoagulation therapy. Early aortic repair was also associated with increased aortic morbidity and mortality. For patients with BTAI and TBI, early aortic intervention is associated with progressive TBI regardless of repair modality, as well as increased aortic morbidity and mortality. Patients not requiring emergent intervention can undergo delayed repair with full anticoagulation therapy.

A Review of Catheter Related Complications During Minimally Invasive Transcatheter Cardiovascular Intervention with Implications for Catheter Design

The objectives of this study are to identify the most important complications associated with transcatheter cardiovascular intervention and to obtain insights into those complications which are directly related to mechanical interaction between the blood vessel and the catheter, by performing a literature review. Using the insights gained, several generic strategies for improving catheter design to minimize mechanical interaction are proposed, which are aimed at reducing complication prevalence and mortality during transcatheter cardiovascular intervention. Data were gathered from the literature on complications associated with four common transcatheter cardiovascular intervention procedures, including percutaneous coronary intervention, trans-catheter aortic valve implantation and structural heart disease interventions, radiofrequency current ablative cardiac catheterization and endovascular aneurysm repair. To gain insight into the relative importance of each complication and the influence of catheterization, the range of prevalence and mortality rates, from the lowest to the highest, were determined for each procedure considered. Additional insights were obtained by plotting the highest prevalence and mortality rates graphically, while also differentiating between complications which are directly and indirectly or unrelated to mechanical interaction between blood vessels and the catheter. The data revealed that mechanical interaction between endovascular catheters and the blood vessel lumen is one of the most important sources of transcatheter cardiovascular intervention complications. Among the most prevalent mechanically-related complications are vascular trauma, hemorrhage and arterial spasm. Improvements to endovascular catheter design which passively protect against complication occurrence and those that actively prevent the operator from causing harm may help to significantly reduce the prevalence as well as mortality of many transcatheter cardiovascular intervention complications.

New Frontiers in Aortic Therapy: Focus on Deliberate Hypotension During Thoracic Aortic Endovascular Interventions

From the *Department of Surgery, AHEPA Hospital, Aristotle University, Thessaloniki, Greece, Department of Surgery, McMaster University, Hamilton, Ontario, Canada, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, Division of Cardiac Surgery, Bad Neustadt, Germany; and ‖Division of Vascular Surgery, Thriasseio General Hospital, Athens, Greece. Address reprint requests to John G. Augoustides, MD, FASE, FAHA, Perelman School of Medicine, University of Pennsylvania, Department of Anesthesiology and Critical Care, 680 Dulles, HUP, 3400 Spruce Street, Philadelphia, PA 19104. E-mail: viandoc@hotmail.com © 2014 Elsevier Inc. All rights reserved. 1053-0770/2601-0001$36.00/0 http://dx.doi.org/10.1053/j.jvca.2014.01.005

Prograde Transcatheter Aortic Arch Intervention in Patients with Single-Ventricle Physiology: A Word of Caution

We sought to review and analyze the hemodynamic derangements during prograde transcatheter aortic intervention (PTAI) in single ventricle patients. Although PTAI for postsurgical recurrent coarctation in single ventricle patients has been described; hemodynamic instability during the intervention is variably reported. Pre-, intra-, and postprocedural records and outcomes of patients with SVP undergoing PTAI for post-Norwood aortic coarctation were retrospectively reviewed. The full disclosure waveform review was used to further categorize hemodynamic derangements during the intervention. A total of 26 PTAIs were performed in 11 patients between October 2007 and December 2013. The median age and weight was 4.2 (2.3-43) months and 5.3 (3.2-15.7) kg. PTAI included balloon angioplasty (BA) in 73% of procedures (n = 19) and stent implantation (SI) in 27% (n = 7). Hemodynamic derangement was more severe in the SI group compared with the BA group. Two of seven (29%) of the SI group required cardiopulmonary resuscitation. Hemodynamic instability during PTAI is common in patients with SVP and more profound during SI. These findings have important implications for informed consent, anesthetic considerations, inotropic support, additional central venous access, and extracorporeal support/surgical backup.

Elective EVAR in Nonagenarians Is Safe in Carefully Selected Patients

Nonagenarians are typically considered poor operative candidates for major aortic intervention because of shorter life expectancy, multiple comorbidities, and increased perioperative morbidity and mortality. Endovascular abdominal aortic aneurysm repair (EVAR) has clearly been associated with a lower perioperative morbidity and mortality in most anatomically suitable patients. There have been many reports of the technical success of EVAR in octogenarians, but few documenting EVAR in nonagenarians. In this study, we sought to review our experience with elective EVAR in nonagenarians to determine outcomes, complications, and long-term survival after repair. We retrospectively reviewed our prospectively maintained aneurysm database from 2000 to 2010 at an academic referral center. Fifteen patients ≥90 years old underwent elective EVAR. No symptomatic or ruptured abdominal aortic aneurysm patients >90 years old were treated. Comorbidities, preoperative and postoperative functional status, aneurysm size, and technical success rate were all recorded in accordance with Society for Vascular Surgery reporting guidelines. Follow-up was performed within 30 days, 6 months, and annually thereafter unless more frequent follow-up was indicated. Of the 749 EVAR procedures performed in the decade-long experience, 15 nonagenarians underwent repair (14 male, 93%; mean age, 90.3 ± 0.6 years). Mean aneurysm diameter was 6.4 ± 1.45 cm with a median diameter of 5.8 cm (range 4.5-8.8 cm). All patients were offered repair because of having good to excellent preoperative functional status with an average number of comorbidities per patient of 2.7. Immediate technical success rate was 100%. Median intensive care unit stay was 1 day (range 1-17 days). Mean length of stay was 4.6 ± 5.3 days with a median of 3.5 days. Thirty-day mortality was 0%. Mean follow-up was 35 months. Mean survival was 56 months. Overall survival estimated annually extending out to 5 years was 91.7%, 83.3%, 71.4%, 57.1%, and 38.1%, respectively. Thirty-day rate of any complication was 40%, with a 20% readmission rate, with many of the issues being related to wound complications. On follow-up imaging there were noted to be 4 (27%) type I, 9 (60%) type II, and no type III or type IV endoleaks identified. Overall reintervention rate was 27%. No ruptures were noted in the postoperative period or long-term follow-up, and there were no conversions to open surgery. We found a median survival of 56.2 months in this carefully selected cohort of EVAR in nonagenarians. As techniques and technology improve and evolve, and particularly as devices become lower profile, there is the potential to apply EVAR to the increasingly older population. If perioperative morbidity can be minimized and the patient has good functional status, EVAR can be a safe procedure and provide rupture-free survival.

EComment. A note on proximal aortic control in the era of increasing endovascular aortic interventions

I read with keen interest the article by Matsagkas and colleagues [1] proposing a bail-out technique in the management of open explantation of endografts with suprarenal fixation. The authors were able to successfully control the aorta in the supracoeliac position by puncturing the endograft after open exposure of the infrarenal aorta, facilitating explantation. The use of balloon occlusion catheters for control of the proximal aorta has been previously described [2], and is standard in the endovascular management of ruptured abdominal aortic aneurysms. The transfemoral route is generally utilized contralateral to the anticipated deployment of the main body; this is preferred in order to avoid potential complications due to risk of injury to the smaller calibre upper extremity arteries, as well as minimizing the stroke risk with manipulations near the aortic arch when a transbrachial or transaxillary route is selected [3]. Unfortunately, the increased emphasis given to training on the endovascular treatment of aortic aneurysms has made younger vascular surgery trainees more uncomfortable navigating the abdomen and the retroperitoneum for quick and adequate open aortic exposure. This is a double-edged situation: more endografts are being placed but fewer individuals feel experienced or comfortable enough to manage open explantation with open supracoeliac control. Although ultimately vascular surgery trainees obtain the necessary operative open case volume, the frequency of repetition of open aortic procedures has decreased, in keeping with current management trends. Therefore, the proposed bail-out technique is quick and efficient, and should be in the armamentarium of any vascular surgeon. Conflict of interest: none declared

Setting up and utilizing a service for measuring perioperative transcranial motor evoked potentials during thoracoabdominal aortic surgery and thoracic endovascular repair

Paraplegia is a complication that may occur following surgery or endovascular stenting of thoracic and thoracoabdominal aortic pathology. Measuring transcranial motor evoked potentials (tcMEPs) has been shown to provide a reliable measure of spinal cord function during such procedures allowing interventions to protect cord function. In the spirit of sharing experience and eliminating the learning curve for others, this manuscript describes our experience of setting up a service for tcMEP monitoring as well as the documents and algorithms for measuring, recording and acting on the patient data, the so-called 'MEP Pathway'. Recording and interpretation of tcMEP during thoracoabdominal aortic intervention requires training of staff and close team working in the operating theatre and postoperative intensive care unit. Providing consistent, reliable, specific and sensitive information on spinal cord function and its safe and effective use to alter patient outcomes requires a protocol. The MEP pathway was developed by medical and paramedical staff at our institution based on clinical experience and literature reviews over a 1-year period (2012-2013). The tcMEP pathway comprises six documents that guide staff in: (a) assessing suitability of patients, (b) setting up hardware, (c) preparing algorithms for management, (d) documenting intervention (left heart bypass, cardiopulmonary bypass or endovascular stenting) as well as (e) documenting postoperative intensive care processes. The tcMEP pathway acts as a guide for safe introduction and use of tcMEPs in thoracoabdominal aortic interventions. tcMEP-led guidance of intraoperative and postoperative management in thoracic aortic surgery is an important adjunct in caring for this patient group.

Reproducable Paraplegia by Thoracic Aortic Occlusion in a Murine Model of Spinal Cord Ischemia-reperfusion

Lower extremity paralysis continues to complicate aortic interventions. The lack of understanding of the underlying pathology has hindered advancements to decrease the occurrence this injury. The current model demonstrates reproducible lower extremity paralysis following thoracic aortic occlusion. Adult male C57BL6 mice were anesthetized with isoflurane. Through a cervicosternal incision the aorta was exposed. The descending thoracic aorta and left subclavian arteries were identified without entrance into pleural space. Skeletonization of these arteries was followed by immediate closure (Sham) or occlusion for 4 min (moderate ischemia) or 8 min (prolonged ischemia). The sternotomy and skin were closed and the mouse was transferred to warming bed for recovery. Following recovery, functional analysis was obtained at 12 hr intervals until 48 hr. Mice that underwent sham surgery showed no observable hind limb deficit. Mice subjected to moderate ischemia for 4 min had minimal functional deficit at 12 hr followed by progression to complete paralysis at 48 hr. Mice subjected to prolonged ischemia had an immediate paralysis with no observable hind-limb movement at any point in the postoperative period. There was no observed intraoperative or post operative mortality. Reproducible lower extremity paralysis whether immediate or delayed can be achieved in a murine model. Additionally, by using a median sternotomy and careful dissection, high survival rates, and reproducibility can be achieved.

Aortic arch surgery in octogenarians: is it justified?

Elderly patients are sometimes denied aortic arch surgery because of the perception of poor outcomes and an unacceptable quality of life (QOL). In this study, we evaluated the early clinical outcomes, long-term survival and QOL following surgical treatment for aortic arch disease in octogenarian patients. A total of 47 consecutive patients over the age of 80 years were referred to our institutions. Of these patients, 20 underwent surgical intervention (surgical group) and 27 were treated medically (medical group). Kaplan-Meier survival analysis was performed between the two groups, and the results were compared with age-matched population data. The risk factors for mortality were determined using a Cox regression analysis. A QOL assessment was performed using the 36-item Short Form Health Survey. The patient characteristics at baseline were not significantly different between the two groups. In the surgical cases, conventional total aortic arch replacement was performed in 15 patients, debranched thoracic endovascular aortic repair (TEVAR) in 2 and chimney TEVAR in 3. Emergency procedures were performed in 3 patients. No hospital deaths occurred in the surgical groups. Reoperation for bleeding was required in 2 patients, and prolonged mechanical ventilation was required in 4 patients. The 5-year survival was 61.5% in the surgical group and 14.2% in the medical group (P = 0.02). Freedom from aorta-related death at 5 years was 92.3% in the surgical group and 32.3% in the medical group (P = 0.01). There were no differences in the 5-year survival between patients undergoing surgical intervention and the sex- and age-matched population (P = 0.80), whereas the 5-year survival was significantly lower in patients who received medical therapy relative to the sex- and age-matched population (P < 0.001). Medical therapy was the sole risk factor for mortality (hazard ratio: 3.16, P = 0.04). Among the survivors at mid-term, the quality-of-life measures were similar between those in the surgical group and those in the medical group. Surgical intervention for aortic arch disease in octogenarians can yield satisfactory early clinical outcomes and acceptable mid-term survival with adequate daily activity. This study indicates that among octogenarians, age alone should not disqualify a patient from receiving an aortic arch intervention.

Pathology-specific secondary aortic interventions after thoracic endovascular aortic repair

Despite improved short-term outcomes, concerns remain regarding durability of thoracic endovascular aortic repair (TEVAR). The purpose of this analysis was to evaluate the pathology-specific incidence of secondary aortic interventions (SAI) after TEVAR and their impact on survival. Retrospective review was performed of all TEVAR procedures and SAI at one institution from 2004-2011. Kaplan-Meier analysis was used to estimate survival. Of 585 patients, 72 (12%) required SAI at a median of 5.6 months (interquartile range, 1.4-14.2) with 22 (3.7%) requiring multiple SAI. SAI incidence differed significantly by pathology (P = .002) [acute dissection (21.3%), postsurgical (20.0%), chronic dissection (16.7%), degenerative aneurysm (10.8%), traumatic transection (8.1%), penetrating ulcer (1.5%), and other etiologies (14.8%)]. Most common indications after dissection were persistent false lumen flow and proximal/distal extension of disease. For degenerative aneurysms, SAI was performed primarily to treat type I/III endoleaks. SAI patients had a greater mean number of comorbidities (P < .0005), stents placed (P = .0002), and postoperative complications after the index TEVAR (P < .0005) compared with those without SAI. Freedom from SAI at 1 and 5 years (95% confidence interval) was estimated to be 86% (82%-90%) and 68% (57%-76%), respectively. There were no differences in survival (95% confidence interval) between patients requiring SAI and those who did not [SAI 1-year, 88% (77%-93%); 5-year, 51% (37%-63%); and no SAI 1-year, 82% (79%-85%); 5-year, 67% (62%-71%) (log-rank, P = .2)]. SAI after TEVAR is not uncommon, particularly in patients with dissection, but does not affect long-term survival. Aortic pathology is the most important variable impacting survival and dictated need, timing, and mode of SAI. The varying incidence of SAI by indication underscores the need for diligent surveillance protocols that should be pathology-specific.

Recommendations for transoesophageal echocardiography: EACVI update 2014

With this document, we update the recommendations for transoesophageal echocardiography (TOE) of the European Association of Cardiovascular Imaging. The document focusses on the areas of interventional TOE, in particular transcatheter aortic, mitral, and left atrial appendage interventions, as well as on the role of TOE in infective endocarditis, adult congenital heart disease, and aortic disease.

Aortic leaflet interventions for aortic valve repair: How much is too much?

Objectives: Aortic valve repair (AVR) is an attractive alternative to valve replacement. We present our single center experience and lessons with isolated aortic leaflet interventions in 158 patients undergoing aortic valve repair.

Novel approaches to spinal cord protection during thoracoabdominal aortic interventions

Spinal cord ischemia after thoracoabdominal aortic interventions is a devastating complication because it significantly worsens the perioperative morbidity and mortality. Long-term outcome is also affected because of medical complications which are directly related to the neural deficits. Paraplegia has significant medical, social, and financial aspects. Limited mobility, the need for assistance in activities of daily living, makes paraplegia an important target for prevention. An understanding of spinal cord blood supply, risk factors for spinal ischemia, and strategies for spinal cord rescue in this setting can help minimize the negative outcome effects of this important complication. The vascular supply of the spinal cord is via an extensive collateral arterial network with multiple auxiliary arterial supplies. Risk factors for spinal cord ischemia include extensive aortic repair, prior aortic repair, spinal cord malperfusion on clinical presentation, systemic hypotension, acute anemia, prolonged aortic clamping, and vascular steal. Spinal rescue strategies include systemic hypothermia, endovascular aortic repair, permissive systemic hypertension, cerebrospinal fluid drainage, pharmacologic neuroprotection, and intensive neuromonitoring. The progression of spinal cord ischemia after thoracoabdominal aortic interventions can frequently be arrested before irreversible infarction results. This spinal cord rescue depends on the early detection and immediate multimodal intervention to maximize spinal cord oxygen supply. The devastating outcomes associated with spinal infarction in this setting offset the risks and knowledge gaps currently associated with contemporary interventions.

Transcatheter aortic valve implantation in patients with ascending aortic dilatation: safety of the procedure and mid-term follow-up

Transcatheter aortic valve implantation (TAVI) does not enable concomitant or simultaneous ascending aortic intervention. This investigation evaluates the safety of TAVI in patients with ascending aortic dilatation and demonstrates mid-term follow-up. From November 2007 to December 2012, among 1143 patients with severe aortic stenosis screened for TAVI, a cohort of 457 patients met the inclusion criteria. Of these, a total of 98 patients [71% males, median age 85.0 (9.0) years] were diagnosed with concomitant ascending aortic dilatation (4.0-5.0 cm). An additional 2 patients had an ascending aortic diameter of >5.0 cm. The mid-term follow-up (652.2 patient-years) was 100% complete. There was no iatrogenic dissection in patients with dilatated ascending aorta. Intraoperative aortic rupture occurred in 1 patient with mildly dilatated ascending aorta. One-year survival rates in patients with dilatated and non-dilatated ascending aorta were 65 of 75 (87%) and 201 of 242 (83%, P = 0.573). The mean ascending aortic diameter remained stable at 4.1 (0.2) and 4.7 (0.2) cm in patients with mild and moderate dilatation, respectively, with a median follow-up of 14 months after TAVI. Two patients with an aortic diameter of over 5.0 cm survived the procedure and expired 7 and 20 months after TAVI due to tumour and heart failure, respectively. Ascending aortic dilatation is diagnosed in almost one-fourth of patients treated with TAVI. Their intraprocedural risk of adverse aortic events is low. The ascending aortic dilatation does not affect mid-term survival in the TAVI population.

Therapeutic Opinion on Endovascular Repair for Mycotic Aortic Aneurysm

Our aim in this study was to assess the feasibility of endovascular repair for mycotic aortic aneurysms (MAAs) and to provide a therapeutic opinion. We retrospectively reviewed the records of 12 patients who underwent endovascular repair for MAAs between September 2006 and June 2011. Patients consisted of 9 men and 3 women, with a median age of 64.6 years (range 45-75 years). The aortic aneurysms were in the thoracic/thoracoabdominal aorta in 5 patients, juxtarenal aorta with visceral involvement in 2 patients, and infrarenal abdominal aorta in 5 patients. Blood cultures of 10 patients (83.3%) were positive for bacteria and showed Salmonella species (8 patients), Klebsiella pneumonia (1 patient), and Escherichia coli (1 patients). Eight patients with active sepsis or active bleeding underwent emergent endovascular repair because of unstable hemodynamics. Notably, 2 patients required adjuvant surgery for complete removal of infectious foci. No deaths occurred within 30 days after intervention. We recorded 2 late deaths: 1 patient died of progressive pneumonia on day 39 after intervention and the other died of liver failure on day 58 after intervention. Late complications were observed in 3 patients, 1 of whom needed an aortic revision for late prosthesis infection. The mean follow-up time was 24 ± 19.7 months. Endovascular repair is a feasible therapeutic option for MAAs in that it can both stop bleeding and exclude the aneurysms. Although the aortic interventions performed were successful, the patients had an immunocompromised status and a difficult postoperative recovery. "Aggressive" surgical drainage may be necessary in some patients and may lead to a better outcome.

Comparison of colour duplex ultrasound with computed tomography to measure the maximum abdominal aortic aneurysmal diameter.

Introduction. Maximum diameter of an abdominal aortic aneurysm (AAA) is the main indication for surgery. This study compared colour duplex ultrasound (CDU) and computed tomography (CT) in assessing AAA diameter. Patients and Methods. Patients were included if they had both scans performed within 90 days. Pearson's correlation coefficient, paired t-test, and limits of agreement (LOA) were calculated for the whole group. Subgroup analysis of small (<5.0 cm), medium (5.0–6.5 cm), and large (>6.5 cm) aneurysms was performed. A P value of <0.05 was considered statistically significant. Results. 389 patients were included, giving 130 pairs of tests for comparison. Excellent correlation was in the whole group (r = 0.95) and in the subgroups (r = 0.94; 0.69; 0.96, resp.). Small LOA between the two imaging modalities was found in all subgroups. Conclusion. Small aneurysms can be accurately measured using CDU. CDU is preferable for small AAAs, but cannot supplant CT for planning aortic intervention.

Prevalence and factors associated with false positive suspicion of acute aortic syndrome: experience in a patient population transferred to a specialized aortic treatment center.

Acute aortic syndrome (AAS) is a medical emergency that requires prompt diagnosis and treatment at specialized centers. We sought to determine the frequency and etiology of false positive activation of a regional AAS network in a patient population emergently transferred for suspected AAS. We evaluated 150 consecutive patients transferred from community emergency departments directly to our Cardiac Intensive Care Unit (CICU) with a diagnosis of suspected AAS between March, 2010 and August, 2011. A final diagnosis of confirmed acute Type A, acute Type B dissection, and false positive suspicion of dissection was made in 63 (42%), 70 (46.7%) and 17 (11.3%) patients respectively. Of the 17 false positive transfers, ten (58.8%) were suspected Type A dissection and seven (41.2%) were suspected Type B dissection. The initial hospital diagnosis in 15 (88.2%) patients was made by a computed tomography (CT) scan and 10 (66.6%) of these patients required repeat imaging with an ECG-synchronized CT to definitively rule out AAS. Five (29.4%) patients had prior history of open or endovascular aortic repair. Overall in-hospital mortality was 9.3%. The diagnosis of AAS is confirmed in most patients emergently transferred for suspected AAS. False positive activation in this setting is driven primarily by uncertainty secondary to motion-artifact of the ascending aorta and the presence of complex anatomy following prior aortic intervention. Network-wide standardization of imaging strategies, and improved sharing of imaging may further improve triage of this complex patient population.

Laryngopharyngeal dysfunction independent of vocal fold palsy in infants after aortic arch interventions

Laryngopharyngeal dysfunction contributes significantly to morbidity, length of stay, and increasedresource utilization after aortic arch interventions in infants. Previous studies have focused on postoperative evaluation of selected symptomatic patients with vocal fold palsy (VFP). A prospective evaluation of laryngopharyngeal function was undertaken to assess and determine its importance in perioperative management. A routine preoperative and postoperative assessment was done by flexible fiber optic laryngoscopy, oral feeding evaluation (OFE), and modified barium swallow (mBS) on 101 infants undergoing 113 procedures on the aortic arch (2003 to 2011). The primary outcome was the ability to take full nutrition orally at discharge. Preoperative OFE was abnormal in 33.3% of patients. VFP occurred in 39.3%, 30 of 57 patients had an abnormal OFE. Factors predictive of abnormal postoperative feeding evaluation included genetic syndromes(odds ratio [OR], 5.1; confidence interval [CI], 1.1-23.2) and preoperative mechanical ventilation (OR, 24.1; 95% CI, 2.5-226.6). An abnormal postoperative OFE was highly predictive (OR, 7.0; 95% CI,1.8-27.1) of an abnormal postoperative mBS. There was a trend toward decreased long-term survival among patients who were intubated or had an abnormal preoperative feeding evaluation (P=.07). Postoperative laryngopharyngeal dysfunction is common among infants undergoing aortic arch interventions, and is largely independent of vocal fold function. Preoperative evaluation demonstrates significant intrinsic abnormalities in sensory and motor function. Routine, comprehensive, multimodality preoperative andpostoperative evaluation is required to identify at-risk children and reduce morbidity and resource utilization.

Successful management of aorto-oesophageal fistula with dual oesophageal and aortic intervention

Figure 1: The patient underwent an emergency oesophageal endoscopy after swallowing a fish bone. At oesophagoscopy, a fish bone situated 25 cm from the incisors was removed uneventfully. Seven days later, she developed retrosternal pain and haematemesis. She vomited 200 ml of bright red blood. Bilateral oesophageal perforations with local fester were found 25 cm away from the incisors in oesophagoscopy examination. A diagnosis of aorto-oesophageal fistula was made. A removable oesophageal stent (long arrow (A)) was implanted to isolate the oesophageal perforation. Axial CT angiography revealed a rupture of the thoracic aorta (short arrow (A)) and numerous air bubbles and fluid collection around the thoracic aorta. Sagittal reconstruction (B) and volume rendering (C) of CT angiography showed an aortic pseudoaneurysm (arrow) at the anterior wall of the thoracic aorta.