Aortic Wall Injury Research Articles

Five-year outcomes of coarctoplasty with stent in the paediatric population, results from a retrospective single-centre cohort with centrally-adjudicated outcomes

Abstract Background Stenting is being increasingly used as a therapeutic option for coarctation of aorta (CoA) in paediatric patients. Although the short and mid-term outcomes are well-documented, data on long-term results are scant. Purpose The current study aimed to determine the long-term safety and efficacy of aortic coarctation stenting via centrally-adjudicated outcomes. Methods The present study is a retrospective cohort conducted at a large tertiary cardiovascular centre. All patients aged up to 15 years who had undergone de novo stenting for CoA between 2006 and 2017 were recruited. Both immediate and 5-year outcomes were investigated. Immediate outcomes, including procedural and in-hospital, were retrieved from electronic medical records, re-analysed, and finally adjudicated by the clinical event committee (CEC). The rates of five-year recoarctation, stent fracture, aneurysmal/pseudoaneurysmal formation, and all-cause mortality were reported as the main long-term outcomes. The first three mentioned outcomes were adjudicated only in patients with available predefined appropriate imaging follow-up tests (Figure 1). Patients who had available recorded 5-year clinical visits and those who answered the phone interview were evaluated for the 5-year mortality. Results A total of 274 patients (98 [35.8%] were female with median [interquartile range] age of 9 [6-12] years) who underwent de novo coarctoplasty with stent were included. Procedural success was achieved in 251 (91.6%) of the patients. Immediate complications were observed in a total of 24 (8.75%) as follows: There were 1 (0.3%) stent migration, 3 (1.1%) small, non-expanding non-flow-limiting aortic wall injuries, and 2 (0.7%) ischemic strokes. Also, there were 18 (6.6%) major vascular access complications, the most common of which was acute limb ischemia in 8 (2.9%) patients, followed by 5 (1.8%) pseudoaneurysms, 3 (1.1%) retroperitoneal haemorrhages, 1 (0.3%) arteriovenous fistula, and 1 (0.3%) large hematoma. A total of 4 (1.4%) in-hospital mortality occurred. The 5-year cumulative incidence of stent fracture, recoarctation of the aorta, and aneurysm/pseudoaneurysm of the aorta were 17/100 (17%), 73/154 (48%), and 8/101 (7.92%), respectively. Five-year all-cause mortality occurred in 4/251 (1.6%) (Table 1). Conclusion In our study, coarctoplasty with stent was safe and effective in the paediatric population during long-term follow-up. Developmental changes in childhood resulting in stent-size mismatch are suggested as a potential aetiology for a high re-intervention rate. Of note, re-intervention was safe and effective.Figure 1Table 1

Stenting of coarctation of the aorta-"Once and for all?"

Key Points Long term hemodynamic benefit and survival are sustained in patients undergoing stenting of coarctation of the aorta with bare metal and covered Cheatham‐Platinum (CP) stents. Reintervention and complication rates are similar with both bare metal and covered CP stents. Routine advanced imaging should be performed periodically in the long‐term to assess for stent integrity and aortic wall injury, and to guide treatment/reintervention, when necessary.

Evolving Utilization of Covered Stents for Treatment of Aortic Coarctation: Report From the IMPACT Registry.

Covered stent (CS) use for the transcatheter treatment of coarctation of the aorta (COA) was first described over 20 years ago. The covered Cheatham-platinum stent received Food and Drug Administration approval for COA treatment in 2016. Data collected as part of the National Cardiovascular Data Registry IMPACT registry were evaluated for contemporary usage patterns of CS for the treatment of COA from 2016 to 2021. Version 2 of the IMPACT registry was queried for all patients who underwent stent placement for treatment of COA from 2016 to 2021. Trends in CS use were evaluated by year and age of patient at the time of implant. Analysis was limited to clinical factors collected as part of the registry and was performed to identify factors associated with CS use. Data were available for 1989 case entries. Most patients (92%) received a single stent. The overall percentage of CS use in the cohort was 23% and remained consistent throughout the study period. The probability of CS use was significantly associated with increasing patient age at implant. Additional factors associated with CS use included smaller initial COA diameter, native COA, and the presence of a pseudoaneurysm. Procedural adverse event rates were low. CS use to treat COA was more common in adult patients and remained stable over the study period. Factors associated with CS use, including smaller COA diameter and aortic pseudoaneurysm, demonstrate the perceived value of CS as a tool to reduce the risk of aortic wall injury during treatment of COA.

De novo acute type B aortic dissection in two patients with previous infrarenal endovascular aortic aneurysm repair with EndoAnchors

<h2>Abstract</h2> Acute aortic dissections in the immediate postoperative period following endovascular abdominal aortic aneurysm repair (EVAR) have been linked to technical factors such as excessive endograft oversizing or aortic wall injuries during the procedure, whereas dissections that occur later are more likely to be de novo. Regardless of their etiology, aortic dissections can extend in the abdominal aorta, causing collapsing and occlusion of the endograft with devastating complications. There have been no reports of aortic dissections in EVAR patients in whom endoanchors were used. We present two cases of de novo type B aortic dissection (TBAD) after EVAR with entry tears in the descending thoracic aorta. Interestingly in both of our cases the dissection flap appeared to stop abruptly at the site of endograft fixation with the endo-anchors, suggesting that end-anchors might prevent propagation of aortic dissections beyond the endoanchor fixation level and thus protect the EVAR from collapsing.

Aortic Wall Abrasion Caused by Needle Injury after Endoscopic Ultrasound-Guided Fine Needle Aspiration of a Mediastinal Hemangioma

Benign mediastinal cysts are challenging to diagnose. Although Endoscopic Ultrasound (EUS) and EUS-guided fine needle aspiration (FNA) can accurately diagnose mediastinal foregut cysts, little is known about their complications. This paper reports a rare case in which EUS-FNA performed on mediastinal hemangioma resulted in an aortic hematoma. A 29-year-old female patient was commissioned for EUS of an asymptomatic accidental mediastinal lesion. Chest CT revealed a 4.9×2.9×10.1 cm thin-walled cystic mass in the posterior mediastinum. EUS revealed a large, anechoic cystic lesion with a regular thin wall with negative Doppler. EUS-guided FNA was performed using a single-use 19-gauge aspiration needle (EZ Shot 3; Olympus, Tokyo, Japan), and approximately 70 cc of serous pinkish fluid was aspirated. The patient was in a stable condition with no signs of acute complication. One day after EUS-FNA, thoracoscopic resection for mediastinal mass was conducted. The purple and multi-loculated large cyst was removed. Upon removal, however, an aortic hematoma caused by a focal descending aortic wall injury was observed. After a few days of close observation, the patient was discharged upon stable 3D aorta angio CT findings. This paper reports a rare and severe complication of EUS-FNA, in which an aspiration needle caused a direct injury to the aorta. The injection must be performed carefully to avoid damaging the adjacent organs or digestive tract walls.

Lactobacillus rhamnosus TR08 Improves Dyslipidemia in Mice Fed with a High Fat Diet by Regulating the Intestinal Microbiota, Reducing Systemic Inflammatory Response, and Promoting Sphingomholipid Metabolism.

Dysbiosis is a crucial manifestation of dyslipidemia; however, oral supplementation of probiotic modulates the intestinal commensal composition. The protective mechanism of probiotics against hyperlipidemia is still under investigation. To elucidate the hypolipidemic effect of Lactobacillus rhamnosus TR08 through the analysis of gut microbiota and lipid metabolomics, we investigated changes in gut microbiota and lipid metabolomic phenotypes in mice by real time quantitative PCR and untargeted metabolomics analysis. High fat diet-induced dyslipidemia mice were orally administered with TR08 for 8 weeks. The proinflammatory cytokines (interleukin-2 and interferon-γ) levels in spleen and aortic wall injury in the mice fed with a high-fat diet were inhibited after treatment with TR08 at 1 × 108 CFU per day per mouse. TR08 also reshaped the gut microbiota with increases of the relative abundances of Bifidobacterium and Bacteroides, reduced the abundance of the pro-pathogen bacterial Enterococcus, increased the serum level of short chain fatty acids (SCFAs) contents, and promoted sphingomholipid metabolic pathway. The results indicated that TR08 could improve the intestinal microbiota of mice to increase the production of SCFAs, and then play the anti-inflammation induced by hyperlipidemia and reduce the inflammatory injury of blood vessel wall. Therefore, TR08 can potentially be used as a hypolipidemic effect probiotic in further interventions.

The clinical characteristics and surgical treatment for delayed blunt thoracic aortic injury-a case series.

Delayed thoracic aortic injury (DTAI) induced by left closed rib fractures (RFs) is a clinically rare blunt injury to the thoracic aorta with an insidious onset. DTAI is very prone to missed diagnosis due to the unreliability of using the initial post-injury computed tomography (CT) scan to explicitly detect any signs of an aortic injury, potentially leading to a fatal hemorrhage. Timely diagnosis and treatment are therefore key to preventing such deadly complications. With that said, not all cases of left RFs lead to delayed aortic injuries, so how can surgeons tell which cases are to be culled and focused on? Also, what kinds of treatment should be administered upon detection? A retrospective analysis was performed on the clinical data of DTAI cases induced by left closed RF that were admitted to our Hospital from June 2015 through June 2020. Injuries to the aortic tunica adventitia or the elastic layer were intraoperatively confirmed. CT scan findings, locations and numbers of RFs, as well as the choices of surgical procedure were reviewed postoperatively. In addition, a literature review was conducted to analyze characteristics shared by similar cases. This study included 7 patients treated by our hospital and 8 reported in the literature. The broken ends of RFs causing aortic wall injury (including the tunica adventitia) were all found in the medial to the lateral erector spinae. All patients in our hospital received internal fixation for RFs and thoracoscopic removal of free bone fragments (if any). Concomitant injuries were managed either by simultaneous or staged surgery. For multiple left RFs with the broken ends located in the inside of the lateral erector spinae, the number of fractured ribs ≥4 and a smaller number of fractured ribs with multiple fractures in a single rib are important factors for DTAI. Active surgical intervention is recommended for patients with these important factors. The specific intervention is tailored to each patient's particular needs to eliminate the risk of developing life-threatening thoracic aortic injury (TAI) and rupture.

Endovascular Treatments for Coarctation of the Aorta with Concurrent Poststenotic Aneurysms in Adults

Coarctation of the aorta with poststenotic aneurysms is rare and complex. Here we report a relatively large group of endovascular treatments for the disease. Fifteen patients from two centers between 2006 and 2019 were included in the study. The patients were retrospectively divided into two groups. Patients in the complex group had insufficient proximal landing zone (<2cm) or the zigzag shape of aorta. Their demographics, clinical manifestations, endovascular procedures, and follow-up results were analyzed. There were 7 patients in the simple group and 8 patients in the complex group. Eleven patients were symptomatic. Despite the unfavorable anatomy in the complex group, technical success reached 100%. The diameter of coarctation increased from 8.6mm to 16.7mm with poststenotic aneurysms successfully excluded at the same time. In patients without sufficient proximal landing zone, left subclavian artery was covered by the stent grafts and then sacrificed (three patients) or revascularized (four patients). Other than one patient who suffered iliac artery rupture and received open repair, there was no other perioperative complications. Computed tomography angiography repeated at mean 42months postoperation confirmed patency of stents and the exclusion of aneurysms with no aortic wall injury. Mild endoleaks occurred in two patients in the complex group and were left to observation. During 55.0months follow-up, except for one patient who received secondary left subclavian artery fenestration, all other patients remained asymptomatic. Endovascular treatments for coarctation of the aorta with poststenotic aneurysm showed a high technical success and could be an alternative solution for such disease.

Late open conversion after endovascular treatment for the coarctation of aorta in adult due to restenosis with thrombus

A 22-year-old man was referred to our hospital for rib notching found on a radiograph and hypertension. Computed tomography revealed coarctation of the descending aortic isthmus. Because he refused open surgery, endovascular treatment was performed. The 2-year follow-up computed tomography scan showed infolding of the stent graft and thrombus formation. He had presented with intermittent claudication; therefore, graft interposition was performed. Endovascular surgery plays an important role in the treatment of coarctation of the aorta. However, insufficient dilatation can lead to restenosis accompanied by thrombus formation, and excess ballooning can cause aortic wall injury. Careful performance of the procedure and close postoperative follow-up are essential.

Managing placenta accreta spectrum in low-resource settings using a novel dissection-free aorta clamp: Operative technique.

Surgical management of Placenta accreta spectrum (PAS) is associated with profuse bleeding and increased risk of operative injury to the adherent pelvic structures. We propose using a novel aorta clamp that can occlude the abdominal aorta without retroperitoneal dissection, thereby making it easy for an obstetrician-gynecologist to use it. The novel Paily aorta clamp (PAC) is applied just above the bifurcation of the abdominal aorta. This was a retrospective study of 33 women with varying grades of histopathology-confirmed PAS, who were managed as an elective or emergency procedure in a tertiary center in India. Twenty-nine women with advanced grades of PAS underwent sub-total/total hysterectomies, while four women with low-grade PAS underwent a conservative procedure. The procedures were associated with median estimated intra-operative blood loss of 1000 ± 1500 ml, with only 21.2% (n= 7) requiring a transfusion of four or more units packed red blood cells. PAC was applied for a median of 55 ± 20min and was not associated with any perioperative aortic wall injury or distal thromboembolic phenomenon. Our experience using the novel PAC, in the current series and across multiple centers in India, demonstrates that the sizeable abdominal aorta can be clamped safely and effectively without retroperitoneal dissection-with no incidence of vascular injury so far. However, we would urge only designated centers with experienced obstetrician-gynecologists-backed by a urologist, adequate blood bank and intensive care facilities-to tackle PAS procedures using the PAC technique.

Aortic Wall Injury After Thoracic Stent Grafts: Vigilance Is Required!

The occurrence of stent-induced new entry tears (SINE) in patients undergoing thoracic endovascular aortic repair (TEVAR) for aortic dissection is an important complication associated with high reintervention and death. In this issue of The Annals of Thoracic Surgery, by systematically reviewing all cross-sectional imaging after TEVAR for all indications, Doberne and colleagues,1 from Duke University, have identified the occurrence of stent-graft induced aortic wall injury, or SAWI, a broader term that encompasses all forms of aortic wall injury after TEVAR—including SINE, which occurs at the interface of a stent graft with a pre-existing dissection membrane.

Stent Graft-induced Aortic Wall Injury: Incidence, Risk Factors, and Outcomes

BackgroundStent graft-induced new entry has been described in thoracic endovascular aortic repair for aortic dissection. The incidence of stent graft-induced aortic wall injury (SAWI) related to iatrogenic injury in nondissections is incompletely described. We describe incidence, risk factors, and outcomes of SAWI. MethodsAll post-thoracic endovascular aortic repair computed tomography angiograms (January 2005 to December 2018) were reviewed for radiographic evidence of SAWI. Endograft-induced aortic dissections were likewise considered SAWI. Patient characteristics, time to SAWI, and need for reintervention were noted. Cox proportional hazards modeling was used to identify risk factors for SAWI. ResultsWithin the study cohort (n = 430), 38 patients (9%) had SAWI during a median follow-up of 2.3 years (interquartile range, 4.8); 42% (n = 16) were proximal, 53% (n = 20) distal, and 5% (n = 2) both proximal and distal. Nine (23%) were distal intimal flap injuries in dissection cases, thus subclassifying them as stent graft-induced new entry. Twenty-nine percent of SAWI (n = 11) required reintervention. Of these, 45% (n = 5) were open, and 55% (n = 6) were endovascular. Thoracic endovascular aortic repair for acute dissection had a higher incidence of SAWI development (hazard ratio 4.6; 95% confidence interval, 2.4 to 9; P < .001) as compared with other indications. Use of devices with proximal bare springs or barbs was also associated with increased SAWI incidence (hazard ratio 5.3; 95% confidence interval, 2.6 to 11.0; P < .001). ConclusionsThe rate of SAWI after thoracic endovascular aortic repair is low (9%), but nearly one third will require reintervention. Thoracic endovascular aortic repair in the setting of acute dissection and use of devices with proximal bare springs or barbs were associated with an increased incidence of SAWI.

Covered Stents in the Management of Aortic Coarctation and Right Ventricular Outflow Tract Obstruction.

To review the use of covered stents in the treatment of coarctation of the aorta (CoA) and right ventricle to pulmonary artery (RV-PA) conduit obstruction. The only commercially available covered stent approved for treatment of CoA and dysfunctional RV-PA conduits is the covered Cheatham-Platinum stent (CCPS). Early outcomes have demonstrated its safety and have suggested its efficacy in treating or preventing aortic wall injury (AWI) or conduit disruption. A recent study of CCPS use for CoA reported a progressive risk of stent fracture over time and a risk of AWI despite the purported protection that the CCPS provides. The use of other covered stents has been reported, but large, systematic studies are lacking. CCPS use may reduce but does not eliminate the risk of conduit disruption or AWI. Structural limitations of the CCPS may predispose it to stent fracture. Access to a broad range of covered stents continues to be an unmet need in the field of congenital interventional cardiology.

Large Diameter Advanta V12 Covered Stent Trial for Coarctation of the Aorta: COARC Study.

Covered stent implantation for treatment of coarctation of the aorta (CoA) is effective and can prevent aortic wall injury. Prospective studies with long-term follow-up, including imaging, are lacking. We report the acute and long-term outcomes for use of the Large Diameter Advanta V12 covered stent for treatment of native and recurrent CoA. A prospective, multicenter, nonrandomized study was performed including 70 patients (43 male), median age 17 years, median weight 57.4 kg with CoA who underwent implantation of the Large Diameter Advanta V12 covered stent. Annual follow-up for 5 years included Doppler echocardiography to calculate diastolic velocity: systolic velocity ratio. CoA diameter increased from 5.6±3.6 to 14.9±3.9 mm (P<0.0001) and the pressure gradient decreased from 35.8±16.2 to 5.6±7.9 mm Hg (P<0.0001). Preimplantation diastolic velocity:systolic velocity of 0.6±0.16 dropped to 0.34±0.13 (P<0.0001) and was maintained at 5 years. Computed tomography angiograms at 12 months postimplantation demonstrated the stent:transverse arch diameter to be similar, 0.91±0.09 to postprocedure 0.86±0.14. Major adverse vascular events at 30 days and 12 months were 1.4% and 4.3%, respectively. Significant adverse events included three patients who required stent implantation to treat infolding. There were no mortalities. The Large Diameter Advanta V12 covered stent is safe and effective for the treatment of CoA with an immediate and sustained reduction of the pressure gradient over 12 months and 5 years as assessed by preimplantation and postimplantation Doppler echocardiography and 12-month computed tomography angiography. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT00978952. URL: http://www.anzctr.org.au; Unique identifier: ACTRN12612000013864.

Fcγ receptor activation mediates vascular inflammation and abdominal aortic aneurysm development.

BackgroundAbdominal aortic aneurysm (AAA), a degenerative vascular pathology characterized by permanent dilation of the aorta, is considered a chronic inflammatory disease involving innate/adaptive immunity. However, the functional role of antibody‐dependent immune response against antigens present in the damaged vessel remains unresolved. We hypothesized that engagement of immunoglobulin G (IgG) Fc receptors (FcγR) by immune complexes (IC) in the aortic wall contributes to AAA development. We therefore evaluated FcγR expression in AAA lesions and analysed whether inhibition of FcγR signaling molecules (γ‐chain and Syk kinase) influences AAA formation in mice.MethodsFcγR gene/protein expression was assessed in human and mouse AAA tissues. Experimental AAA was induced by aortic elastase perfusion in wild‐type (WT) mice and γ‐chain knockout (γKO) mice (devoid of activating FcγR) in combination with macrophage adoptive transfer or Syk inhibitor treatment. To verify the mechanisms of FcγR in vitro, vascular smooth muscle cells (VSMC) and macrophages were stimulated with IgG IC.ResultsFcγR overexpression was detected in adventitia and media layers of human and mouse AAA. Elastase‐perfused γKO mice exhibited a decrease in AAA incidence, aortic dilation, elastin degradation, and VSMC loss. This was associated with (1) reduced infiltrating leukocytes and immune deposits in AAA lesions, (2) inflammatory genes and metalloproteinases downregulation, (3) redox balance restoration, and (4) converse phenotype of anti‐inflammatory macrophage M2 and contractile VSMC. Adoptive transfer of FcγR‐expressing macrophages aggravated aneurysm in γKO mice. In vitro, FcγR deficiency attenuated inflammatory gene expression, oxidative stress, and phenotypic switch triggered by IC. Additionally, Syk inhibition prevented IC‐mediated cell responses, reduced inflammation, and mitigated AAA formation.ConclusionOur findings provide insight into the role and mechanisms mediating IgG‐FcγR‐associated inflammation and aortic wall injury in AAA, which might represent therapeutic targets against AAA disease.

Long-Term Outcomes of the Coarctation of the Aorta Stent Trials.

Long-term outcome data of stent-implantation for coarctation of the aorta are limited. We report up to 5 years of postimplant follow-up in patients enrolled into the COAST (Coarctation of the Aorta Stent Trial) and the COAST II trial (Covered Cheatham-Platinum Stents for Prevention or Treatment of Aortic Wall Injury Associated With Coarctation of the Aorta), evaluating the bare and Covered Cheatham-Platinum Stents for the treatment of coarctation of the aorta and associated aortic wall injury. Data was prospectively collected during the 2 multi-center studies, enrolling 248 patients (COAST: n=121, COAST II: n=127). Late follow-up data (48–60 month) was compared with immediate (1 month) and early (12 months) follow-up. There was a notable decrease in the use of antihypertensive medication, from 53% at immediate, to 42% at early, and 29% at late follow-up. The cumulative incidence of stent fractures was 0% immediately, 2.9% at early, and 24.4% at late follow-up. Independent predictors for stent fractures at late follow-up were age <18 years, male sex, minimum stent diameter ≥12 mm, and use of bare metal stent. The cumulative incidence of reintervention was 1.6% at immediate, 5.1% at early, and 21.3% at late follow-up. Independent predictors for reinterventions at late follow-up were age <18 years, post implantation systolic arm-leg blood pressure gradient ≥10 mm Hg, minimum stent diameter at implantation <12 mm, and initial coarctation minimum diameter <6 mm. There were 13 patients with aortic aneurysms, with a cumulative incidence of 6.3% at late follow-up. Coarctation stenting is effective at maintaining obstruction relief up to 60 months postimplant with reduction in the number of patients requiring antihypertensive medication. However, an increase in-stent fractures and reinterventions were observed between medium and long-term follow-up. Covered stents appear to confer some protection from the development of stent fractures but do not provide complete protection from late aneurysm formation. URL: https://www.clinicaltrials.gov; Unique identifiers: NCT00552812 and NCT01278303.

Blood Pressure Behavior After Correction Adult Coarctation of Aorta Short Term Follows Up

Background:Coarctation of aorta (CoA) is a relatively common congenital cardiac defect often causing few symptoms and therefore can be challenging to diagnose. Usually, untreated CoA may lead to a renal, vascular and cardiac complication that starts to appear at beginning of the fourth decade of life. Several methods have been proved as a modality for the treatment of CoA like balloon dilation, stenting, and surgery, etc.Objective:To assess the hypertensive condition after endovascular stenting adult with CoA in short term follow up.Methods:We report the outcome in 75 patients, out of these 30 male patients (40%) and 45 female patients (60%) were involved in this prospective longitudinal study, their age range between 16 to 41 years. Stenting of simple coarctation was performed on 75 patients at the Cardiology consult department in Al-najaf cardiac center or from a private clinic between January 2018 to January 2019. For the treatment of all patients, echocardiography, CT chest done to confirm diagnosis then all undergo catheterization of aorta with two sheaths one femoral and other radial to measure pressure gradient across the stenosis and stent localization follow by stenting with pre and post-dilation if needed then measure pressure gradient across stent.Results:Out of 75 patients 69 patients (92%) returned for the 6-month follow-up evaluation and 53 patients (70%) returns for the 1-year follow-up evaluation with stent implantation, interrupted coarctation immediately after stent pressure gradient falls in almost all our patient. The patient returns at the time of 6 months and one year follow up, the assessment was done through CT angiography. At the time of six months, 39/69 patients (52%) and at the time of 1 year 18/45 patients (24%) show no aortic wall injury or aneurysm development.Conclusion:Uncovered stents appear to be safe in treating CoA with less morbidity and mortality. Stent adult with CoA hasthe advantage of lowering blood pressure in those suffering from hypertension.

Covered stent placement for treatment of coarctation of the aorta: immediate and long-term results

Objectives This study aimed to describe the safety and efficacy of covered stents in patients with coarctation of aorta (CoA) for immediate and long-term follow-up. Background Covered stents are increasingly being used in (re)CoA, mainly to reduce the risk of aortic wall injuries (AWI). However, limited data are available on intermediate and long-term outcome. Methods In 89 patients (67.4% male) with a mean age of 23.9 ± 15.8 (min max range 5.1–71.6) years were 102 covered stents implanted (January 2003 – December 2017). Short-term pre/post-implant hemodynamics and angiographic data were reported. Changes in blood pressure, the use of antihypertensive drugs and complications were recorded during follow-up. Results The procedural success rate was 100%. The mean invasive ascending-to-descending aorta systolic gradient under general anaesthesia decreased from 25 ± 16 mmHg to 4 ± 7 mmHg (p < 0.001). After a mean follow-up time of 6.6 ± 3.7 years, there was a persistent improvement of the mean systolic blood pressure gradient between right arm and leg (−7 ± 18 vs 38 ± 24 mmHg; p < 0.001). A larger proportion of patients required antihypertensive medication (33.7% vs 50.0%, p = 0.017) and needed ≥ 2 drugs (20.2% vs 27.4%, p = 0.066) to control blood pressure. Long-term adverse events were found in 4.5% of patients [covered stent fracture (n = 3), aneurysm formation (n = 2)]. Conclusions Covered stent implantation for CoA is highly successful, safe and results in a persistent hemodynamic improvement in the immediate and long-term outcome. Lifelong follow-up with additional antihypertensive drug treatment is mandatory to maintain favourable hemodynamic results after stenting. CONDENSED ABSTRACT Long-term follow-up data on covered stents in patients with coarctation of the aorta are scarce. A cohort of 89 patients was reviewed. The procedural implantation success rate was 100%. The invasive gradient decreased from 25 ± 16 mmHg to 4 ± 7 mmHg (p < 0.001). After follow-up of 6.6 ± 3.7 years, there was a persistent improvement of the clinical systolic blood pressure gradient (−7 ± 18 vs 38 ± 24 mmHg; p < 0.001). However, a larger proportion of patients required antihypertensive medication (33.7% vs 50.0%, p = 0.017). Covered stent implantation results in favourable hemodynamic effects, but lifelong follow-up with additional antihypertensive drug treatment is mandatory to maintain these results.

Aortic Rupture during Endovascular Aneurysm Repair. Report of Our Experience and Review of the Literature.

Background Aortic neck wall rupture during endovascular repair of abdominal aortic aneurysms (EVAR) is an underreported potentially fatal complication. Only a few cases have been reported. The main cause of this complication is repeated attempts at balloon inflation or overdilation to treat an intraoperative Type 1a endoleak. We report three cases complicated by procedure-related aortic neck wall rupture during EVAR. We also review the literature regarding the causes and outcomes of this complication. Methods Medical records of all patients undergoing EVAR between January 2009 and March 2019 were retrospectively reviewed. Results Overall, 824 EVAR procedures were performed, and rupture of the aortic neck wall was observed in three patients. In all cases, a Type 1a endoleak was observed and, in all cases, repeated ballooning attempts had been performed to resolve the endoleaks. In all cases, conversion to open repair was performed and all patients survived. Conclusion In cases of Type 1a endoleak, a maximum of two ballooning attempts should be performed even if a Type 1a endoleak persists. In case of intraoperative aortic neck wall rupture, control of the hemorrhage should be achieved immediately by advancing the balloon above the site of rupture. Emergency surgical conversion in case of hemodynamic stability is the first choice. According to the literature, emergency surgical conversion, especially in cases of endograft with suprarenal fixation, is associated with significant morbidity and mortality rates, mainly due to hemorrhage and to the length of the procedure required to repair the aortic neck wall injury.

Early and late outcome of covered and non-covered stents in the treatment of coarctation of aorta- A single centre experience

ObjectiveStenting of coarctation of aorta with covered or uncovered stents is the accepted modality of treatment in older children and adults. The indications which mandate the use of covered stents are still unclear. We attempted to study the early and late outcomes after stenting of native and recurrent coarctation of aorta with uncovered and covered stents. MethodThis is a retrospective study of patients who underwent stenting for coarctation of aorta with covered or non-covered stents at our institute. Early and late outcome for both the groups were studied. ResultsTwenty patients underwent implantation of covered stent and twenty five patients had uncovered stent implantation. Patients in the covered stent group were older and had greater basal pressure gradient. More patients in the covered stent group had residual gradient >10 mm Hg after the procedure. There was no mortality or aortic wall injury in either group. Four patients in the covered stent group underwent planned re-intervention and two had unplanned re-intervention. None of the patients in the uncovered stent group had re-intervention. Higher incidence of late lumen loss was noted in the covered stent group. ConclusionUncovered stents can be safely implanted with minimal risk of aortic wall injury in patients with low risk anatomic features. Covered stent implantation is associated with higher incidence of planned and unplanned re-intervention.