Conventional Open Repair Research Articles

Aortoduodenal fistula after transperitoneal repair of an inflammatory abdominal aortic aneurysm: A case report

Introduction: An aortoduodenal fistula is a potentially lethal complication after transperitoneal open repair of an abdominal aortic aneurysm. Case Report: A 77-year-old Caucasian male who underwent a conventional repair of an inflammatory infrarenal aortic aneurysm, was readmitted with hematemesis only six weeks after surgery. Gastroscopy and computed tomography angiography indicated an aortoduodenal fistula and urgent aortic reconstruction was performed. An aortoduodenal fistula is a potentially lethal complication after transperitoneal open repair of an abdominal aortic aneurysm. Conclusion: An aortoduodenal fistula seldom occurs as early after conventional transperitoneal open aneurysm repair as in our case. The early occurrence of the aortoduodenal fistula can be explained by the inflammatory character of the aneurysm.

EComment. A paradigm shift in the emergent management of aortobronchial fistula

In this interesting case report, the authors described the successful management of an acquired aortobronchial fistula (ABF) using endovascular technology [1]. The authors highlighted an extremely important point in the management of this inconsistently fatal disease if left untreated, which we welcome the opportunity to re-emphasize. The treatment of thoracic aortic disease has changed radically with the advances made in endovascular therapy since the concept of thoracic endovascular aortic repair (TEVAR) was first described 15 years ago. Many studies have demonstrated excellent short- and long-term outcomes of TEVAR for the treatment of thoraco-abdominal aortic aneurysm, with reduced reported perioperative morbidity and mortality compared with conventional open repair. A number of case reports [2–3] and small series [4] describing the successful management of ABF using thoracic stent grafts have been published over the last 10 years. Although immediate and short-term outcomes are encouraging, the major concern is the durability of this approach in the setting of a contaminated milieu in the vicinity of foreign material. Recently, Canaud et al. [5] published a very interesting review of the literature about the mid-term results of TEVAR in patients with ABF because to date long-term follow-up studies are lacking. They identified 134 patients with ABF treated with TEVAR. Most reported cases included patients with secondary ABF (55%). Of note, recurrence of ABF occurred in 14 patients (11%) and this scenario was fatal in 50% of the cases. Stent-graft infection was observed in only 3 patients during the 17 month-period of follow-up; however, this complication was associated with substantial morbidity and mortality. They concluded that TEVAR should be considered as a first-line urgent procedure for ABF. The initial management should include at least 4 weeks of intravenous antibiotic therapy and a long-term and strict follow-up is mandatory to identify early complications. Unfortunately, the Achilles heel of TEVAR in ABF remains the lack of long-term clinical results. Further evidence and long-term results are needed to help us in determining what the best strategies in these very complex patients are.

Safety and Efficacy of Laparoscopic Percutaneous Extraperitoneal Closure for Inguinal Hernias and Hydroceles in Children: A Comparison with Traditional Open Repair

Laparoscopic procedures for inguinal hernias and hydroceles in children have become widespread in the past few decades. The purpose of this study was to perform a retrospective analysis of our experience in order to assess the safety and efficacy of laparoscopic percutaneous extraperitoneal closure (LPEC) and to compare the findings with those of conventional open repair (OR). We analyzed the medical records of 488 patients who underwent LPEC or OR for inguinal hernia or hydrocele at our institute between April 2008 and December 2012. The indications for the operation, length of the operation, complications, day surgery, contralateral patent processus vaginalis, and incidence of metachronous contralateral hernia were investigated. The chi-squared test, unpaired t test, and Steel-Dwass test were used to analyze the significance of the data. Among a total of 488 patients, 326 patients underwent LPEC (125 males and 201 females), and 162 underwent OR (140 males and 22 females). There was no significant difference in the incidence of recurrence (three in the LPEC and none in the OR group, P=.55) or in the success rates of day surgery (97.8% in LPEC versus 97.6% in OR). The incidence of metachronous contralateral hernias in the LPEC group was lower than that in the OR group (LPEC 0%; OR 2.2%, P=.03). Seventeen subjects with hydroceles were treated by LPEC without any complications. LPEC is safe and effective for inguinal hernias and hydroceles in children, regardless of age, sex, and incarceration and could reduce the incidence of metachronous contralateral hernias.

Spinal Cord Ischemia After Endovascular Aortic Repair Versus Open Surgical Repair for Descending Thoracic and Thoracoabdominal Aortic Aneurism

Maeda, Takuma*; Yoshitani, Kenji*; Sato, Shunsuke†; Matsuda, Hitoshi†; Inatomi, Yuzuru*; Tomita, Yukihiko*; Ogino, Hitoshi†; Ohnishi, Yoshihiko*Author Information

Hybrid Repair of Thoracoabdominal Aneurysm: A Two-Stage Approach

Despite higher standards of perioperative care and refinements in operative techniques, conventional open repair of thoracoabdominal aneurysms (TAAAs) is still associated with remarkable morbidity and mortality rates. Hybrid procedures as an option to traditional surgical procedures are still debated, especially in elderly patients with severe comorbidities. We report the experience of our institution using a hybrid technique ina subgroup of high-risk patients in an attempt to improve the results.

Improving Affordability Through Innovation in the Surgical Treatment of Mitral Valve Disease

ObjectiveTo determine whether technically innovative cardiac surgical platforms (ie, robotics) deployed in conjunction with surgical process improvement (systems innovation) influence total hospital costs to address the concern that expanding adoption might increase health care expenses. Patients and MethodsWe studied 185 propensity-matched patient pairs (370 patients) undergoing isolated conventional open vs robotic mitral valve repair with identical repair techniques and care teams between July 1, 2007, and January 31, 2011. Two time periods were considered, before the implementation of system innovations (pre-July 2009) and after implementation. Generalized linear mixed models were used to estimate the effect of the type of surgery on cost while adjusting for a time effect. ResultsBaseline characteristics of the study patients were similar, and all patients underwent successful mitral valve repair with no early deaths. Median length of stay (LOS) for patients undergoing open repair was unchanged at 5.3 days (P=.636) before and after systems innovation implementation, and was lower for robotic patients at 3.5 and 3.4 days, respectively (P=.003), throughout the study. The overall median costs associated with open and robotic repair were $31,838 and $32,144, respectively (P=.32). During the preimplementation period, the total cost was higher for robotic ($34,920) than for open ($32,650) repair (P<.001), but during the postimplementation period, the median cost of robotic repair ($30,606) became similar to that of open repair ($31,310) (P=.876). The largest decrease in robotic cost was associated with more rapid ventilator weaning and shortened median intensive care unit LOS, from 22.7 hours before July 2009 to 9.3 hours after implementation of systems innovations (P<.001). ConclusionFollowing the introduction of systems innovation, the total hospital cost associated with robotic mitral valve repair has become similar to that for a conventional open approach, while facilitating quicker patient recovery and diminished utilization of in-hospital resources. These data suggest that innovations in techniques (robotics) along with care systems (process improvement) can be cost-neutral, thereby improving the affordability of new technologies capable of improving early patient outcomes.

294 * OPEN AORTIC REPAIR FOR THORACOABDOMINAL AORTIC ANEURYSM: A SINGLE-CENTRE FIVE-YEAR EXPERIENCE WITH 250 CASES

Objectives: Recently, the technology of endovascular devices has advanced. These advances have led to alternative approaches to thoracoabdominal aortic aneurysm (TAAA) repair. However, in some cases, endovascular aortic repairs are still limited in their indications because of the morphology of the aneurysms. These innovative approaches must be compared with conventional open aortic repair. To facilitate such comparisons, we have evaluated contemporary outcomes of open TAAA repair. Methods: We retrospectively reviewed and analysed data collected from January 2008 to December 2012 on 252 consecutive patients who underwent TAAA repair with a left thoracoabdominal approach in our institution. Results: A total of 134 patients (53.2%) had atherosclerotic aneurysm without dissection, and 114 patients (45.2%) had chronic dissection. The mean maximum aneurysm diameter was 61 mm. There were 15 patients with Marfan syndrome. There were 39 (11.5%) urgent or emergency repairs. One-hundred and fifteen patients (45.6%) underwent extensive repairs (Crawford extents I and II). Two-hundred and five patients (81.3%) had cerebrospinal fluid drainage. We used left heart bypass in 231 patients (91.6%). The overall operative mortality was 7.5% (19 of 252). Mortality tended to be higher after urgent or emergency repairs (24.1%, 7 of 29) than after elective repairs (5.4%, 12 of 223). Permanent paraplegia occurred in 15 patients (6.0%). Conclusions: Open aortic repair of TAAA was characterized by acceptable early outcomes, particularly when repair is elective, in our institution. Our method can be selected regardless of the form of aneurysm in most cases. Such results should be compared with those of evolving approaches including endovascular and hybrid repairs.

Thoracic Endovascular Aortic Repair for Type B Dissection

The development of thoracic endovascular aortic repair (TEVAR) has revolutionized the field of cardiovascular surgery. Since Parodi’s first description of an intraluminal stent graft device for the treatment of abdominal aortic aneurysms,1 endovascular device technology has rapidly evolved to treat the multiple pathologies seen in the thoracic aorta. Although TEVAR for elective repair of descending thoracic aortic aneurysm has been performed worldwide with increasing frequency,2–4 it is the role of TEVAR in acute aortic syndromes, such as aortic dissections, that has gathered increasing investigation. Article see p 407 The treatment of type B aortic dissection with TEVAR has been increasingly reported in the literature during the past decade. In patients with type B aortic dissections presenting with life-threatening complications, including rupture or malperfusion syndrome, TEVAR has become the preferred therapeutic options in most specialized aortic centers.5 Multiple studies have demonstrated dramatic improvement in perioperative outcome using TEVAR when compared with conventional open repair.6 Consequently, this has resulted in a new surgical paradigm in the treatment of complicated type B aortic dissection. In contrast, the role of TEVAR in the treatment of uncomplicated type B aortic dissection has remained a controversial debate. Since first described by Wheat7 >3 decades ago, anti-impulse therapy remains the conventional treatment paradigm of uncomplicated type B aortic dissection. Although short-term results have been acceptable, suboptimal long-term results of conventional medical therapy have frankly been disappointing, with 20% of patients developing late complications requiring intervention and 30% to 40% cumulative mortality risk at 5 years.8,9 This development of late aortic complications and compromised long-term survival have prompted investigators to find a more effective therapeutic approach and evaluate the potential role of TEVAR in this patient population. In this issue of Circulation: Cardiovascular Interventions , Nienaber et al …

New vascular ring connectors in surgery for intramural haematoma of the abdominal aorta progressing to rupture : case report - online article

Aortic intramural haematoma is similar to classic aortic dissection, which causes a life-threatening medical condition, and immediate diagnosis and treatment are crucial. The optimal therapy for intramural haematoma of the abdominal aorta remains controversial. Conservative medical management is usually the first choice of treatment for uncomplicated cases. Surgical intervention is usually required for complicated intramural haematomas of the abdominal aorta, including conventional open repair and endovascular treatment with stent-grafts. A new vascular ring connector that achieves a quick, blood-sealed and sutureless anastomosis has been designed for aortic dissection. We herein report a case of intramural haematoma of the abdominal aorta, progressing to rupture on day 14 after onset, which had successful aortic repair with the new vascular ring connector. The new vascular ring connector could be an alternative method for the treatment of complicated intramural haematomas of the abdominal aorta.

The INCH-Trial: a multicentre randomized controlled trial comparing the efficacy of conventional open surgery and laparoscopic surgery for incisional hernia repair

BackgroundAnnually approximately 100.000 patients undergo a laparotomy in the Netherlands. About 15,000 of these patients will develop an incisional hernia. Both open and laparoscopic surgical repair have been proven to be safe. However, the most effective treatment of incisional hernias remains unclear. This study, the ‘INCH-trial’, comparing cost-effectiveness of open and laparoscopic incisional hernia repair, is therefore needed.Methods/DesignA randomized multi-center clinical trial comparing cost-effectiveness of open and laparoscopic repair of incisional hernias. Patients with a symptomatic incisional hernia, eligible for laparoscopic and open incisional hernia repair. Only surgeons, experienced in both open and laparoscopic incisional hernia repair, will participate in the INCH trial. During incisional hernia repair, a mesh is placed under or on top of the fascia, with a minimal overlap of 5 cm. Primary endpoint is length of hospital stay after an incisional hernia repair. Secondary endpoints are time to full recovery within three months after index surgery, post-operative complications, recurrences, mortality and quality of life.Our hypothesis is that laparoscopic incisional hernia repair comes with a significant shorter hospital stay compared to open incisional hernia repair. A difference of two days is considered significant. One-hunderd-and-thirty-five patients are enrolled in each treatment arm. The economic evaluation will be performed from a societal perspective. Primary outcomes are costs per patient related to time-to-recovery and quality of life.The main goal of the trial is to establish whether laparoscopic incisional hernia repair is superior to conventional open incisional hernia repair in terms of cost-effectiveness. This is measured through length of hospital stay and quality of life. Secondary endpoints are re-operation rate due to post-operative complications or recurrences, mortality and quality of life.DiscussionThe difference in time to full recovery between the two treatment strategies is thought to be in favor of laparoscopic incisional hernia repair. Laparoscopic incisional hernia repair is therefore expected to be a more cost-effective approach.Trial registrationNetherlands Trial register: NTR2808

Staged hybrid open and endovascular exclusion of a symptomatic thoracoabdominal aortic aneurysm in a high-risk patient

Thoracoabdominal aortic aneurysms have a higher prevalence in the elderly, who are often poor surgical candidates. These extensive aneurysms may be lethal if left untreated. Conventional open repair has proven to be a major task, involving cardiopulmonary bypass, aortic cross-clamping and expeditious repair of an inaccessible structure involving two body cavities. Endovascular repair has become a viable option to treat isolated descending thoracic aneurysms and infrarenal abdominal aortic aneurysms. However, endovascular techniques alone have been less applicable for treating complex aortic aneurysms, including those involving visceral vessels. Therefore, a hybrid open and endovascular approach with visceral debranching has become an increasingly favorable alternative for patients with these complex conditions. We report a case in which a staged hybrid approach was used for successful exclusion of an extensive thoracoabdominal aortic aneurysm in a symptomatic, high-risk patient who would not have been an appropriate candidate for open surgical repair.

Endovascular exclusion of a large spontaneous aortocaval fistula in a patient with a ruptured aortic aneurysm

A primary aortocaval fistula (ACF) is present in less than 1% of all abdominal aortic aneurysms (AAA). The case of a 62-year-old patient with a ruptured AAA and ACF was reported. A stent-graft was implanted into the abdominal aorta. An inferior vena cava filter was inserted to prevent pulmonary embolism. The patient made a smooth recovery. The follow-up computed tomographic scan three months later did not reveal any evidence of endoleaks or that the fistula was still present. Hemodynamic changes with regard to transient acute liver impairment were discovered (renal and liver parameters were presented). Endovascular exclusion appears to be an effective option in the treatment of an aortocaval fistula in comparison to conventional open repair.

Abstract 332: Genomically Enhanced Risk Stratification in Abdominal Aortic Aneurysm Repair

OBJECTIVE The purpose of this study was to investigate the association between selected single-nucleotide polymorphisms (SNPs), associated with abdominal aortic aneurysms (AAA) in previous genome-wide association studies, and major adverse events following AAA repair METHODS Genomic DNA was isolated from blood samples collected from AAA patients and used for genotyping. A genetic risk score was constructed using five SNPs known to be associated with AAA. Epidemiologic data were extracted from the electronic medical record and analyzed retrospectively. Major adverse events were defined as myocardial infarction, cardiac arrest, respiratory failure requiring tracheostomy, renal failure requiring dialysis, colonic ischemia requiring resection, limb ischemia requiring operation, multi-system organ failure or death. RESULTS Three hundred and twenty one patients (267 male, 83%) with complete genomic and clinical data underwent AAA repair from 2004-2012. Demographics were consistent with a standard AAA population. 204 patients (64%) underwent endovascular repair and 117 (36%) underwent conventional open surgical repair. Quality control checks were performed on the clinical and laboratory data and none of the 5 selected SNPs deviated from the Hardy-Weinberg Equilibrium. Stepwise logistic regression was then used to determine the most parsimonious model of variables associated with adverse outcomes from AAA repair. Serum creatinine, height, resting heart rate, diastolic blood pressure and the genetic risk score remained in the model. The Hosmer and Lemeshow test of deviation from goodness-of-fit (p = 0.56) indicated that the data fit the model well. The regression coefficients from this model will be used to construct a clinician-friendly risk calculator to help identify patients at increased risk for a major adverse event following AAA repair. CONCLUSIONS Selected SNPs help identify patients at risk for major adverse events following AAA repair. Incorporating genetic data, especially in patients with few clinical risk factors, may result in a better preoperative risk assessment.

Total aortic arch replacement in 2013: where do we go from here?

In the last 10–15 years, substantial progress has been made in the surgical treatment of patients who require open repair or replacement of the aortic arch. A number of technological advances have contributed to the improved outcomes. These include better methods of brain and myocardial protection, improved cardiopulmonary bypass circuits, impregnated polyester grafts, use of biological glues, and better identification and management of coagulopathies. Enhanced understanding of the pathophysiology and limitations of hypothermic circulatory arrest has also played a major role in the improved results. Using a variety of techniques, highly satisfactory outcomes have been achieved for patients who require partial (hemi-arch) repair, which requires relatively short periods of circulatory arrest. Total arch replacement has traditionally been associated with higher risks. However, recent reports on total arch replacement from experienced centres document operative mortality rates and stroke rates <10% for both outcomes [1–6]. These studies have included, to a variable extent, patients with acute aortic dissection who required emergent operation (2.4–19% prevalence), and it is well recognized that early mortality and morbidity are increased in this subset of patients. Some form of antegrade cerebral perfusion for brain protection was used for all of the patients in these studies, and there is emerging consensus that this represents the optimal method for brain protection. Spinal-cord ischaemic injury, in the absence of extensive resection of the descending thoracic aorta, has occurred rarely. With the advent of endovascular stent-grafting of the thoracic aorta, alternative methods for management of disorders, involving the aortic arch, have been explored. Hybrid procedures have been developed that consist of transposition of the brachiocephalic arteries, followed by synchronous or metachronous stentgrafting of the aortic arch and adjacent descending thoracic aorta with either an antegrade or retrograde approach. It was hypothesized that this technique would be a safer, less-extensive procedure with less mortality and morbidity than conventional open repair and would be particularly applicable to ‘high-risk’ patients (i.e. those considered to be at substantial risk or noncandidates for open repair).

Complications after hybrid repair of aortic arch aneurysm

Hybrid repair can be an alternative to conventional open repair of aortic arch aneurysms especially in high risk cases. A 77 year male patient presented to us with complaints of breathlessness and chest pain. Investigations revealed aortic arch aneurysm with healthy ascending and descending aorta. Hybrid repair including supra aortic debranching and relocation of the arch vessels to the ascending aorta was performed. Complications like poststent-implant syndrome, cerebrovascular accident and localized dissection of ascending aorta at the site of stenting occurred.

CRT-99 Is The Endovascular Approach Really Better Than Open Repair In Abdominal Aortic Aneurysms Of Octogenarians?

We studied the in-hospital mortality rate to access the value of conventional open repair (OR) versus endovascular aneurysm repair (EVAR) in an elderly population presenting with asymptomatic abdominal aortic aneurysm (AAA) undergoing elective repair. During the period of January 1999 to December

Intrathoracic subclavian artery aneurysm repair in the thoracic endovascular aortic repair era

Intrathoracic subclavian artery aneurysms (SAAs) are rare aneurysms that often occur in association with congenital aortic arch anomalies and/or concomitant thoracic aortic pathology. The advent of thoracic endovascular aortic repair (TEVAR) methods may complement or replace conventional open SAA repair. Herein, we describe our experience with SAA repair in the TEVAR era. A retrospective review was performed of all intrathoracic SAAs repaired at a single institution since United States Food and Drug Administration approval of TEVAR in 2005. Nineteen patients underwent 20 operations to repair 22 (13 native, nine aberrant) SAAs with an intrathoracic component. Mean SAA diameter was 3.1 cm (range, 1.6-6.0 cm). Mean patient age was 57 years (range, 24-80 years). Twenty-one percent (n = 4) of patients had a connective tissue disorder (two Loeys-Dietz, two Marfan). Thirty-six percent (n = 8) of SAAs were repaired by open techniques and 64% (n = 14) via a TEVAR-based approach. All TEVAR cases required proximal landing zone in the aortic arch (zone 0-2), and revascularization of at least one arch vessel was required in 83% (10/12) of patients. Concomitant repair of associated aortic pathology was performed in 50% (n = 10) of operations. Thirty-day/in-hospital rates of death, stroke, and permanent paraplegia/paraparesis were 5% (n = 1), 5% (n = 1), and 0%, respectively. Over mean (standard deviation) follow-up of 24 (21) months, 16% (n = 3) of patients required reintervention for subclavian artery bypass graft revision (n = 2) or type II endoleak (n = 1). This is the largest single-institution series to date of TEVAR for SAA repair. Modern endovascular techniques expand SAA repair options with excellent results. The majority of SAAs and nearly all aberrant SAAs (Kommerell's diverticulum) can now be repaired using a TEVAR-based approach without the need for sternotomy or thoracotomy.

Hybrid repair of an abdominal aortic aneurysm in a patient with a horseshoe kidney

Prior reports of conventional open abdominal aortic aneurysm repair in the setting of a horseshoe kidney have been challenging and complicated by renal infarction, neuralgia, and collecting system disruption. We aimed to demonstrate the efficacy of an alternative repair method consisting of visceral debranching followed by endovascular aneurysm repair.

Hybrid procedure in the treatment of thoracoabdominal aortic aneurysms: Case report

Treatment of thoracoabdominal aortic aneurysms is a major problem in vascular surgery. Conventional open repair is associated with significant rates of mortality and morbidity and therefore, there is a need for better solutions. One of them is a hybrid procedure that includes visceral debranching. This paper presents the first such case performed in Serbia, with a brief overview on all published procedures worldwide. A 57-year-old woman was admitted to the hospital because of thoracoabdominal aneurysms type V by Crawford-Safi classifications. Because of the significant comorbidities it was concluded that conventional treatment would bear unacceptably high perioperative risk, and that the possible alternative could be the hybrid procedure in two stages. In the first stage aortobiliacal reconstruction with bifurcated Dacron graft (16 x 8 mm) and visceral debranching with hand made tailored branched graft was done. In the second act, the thoracoabdominal aneurysm was excluded with implantation of the endovascular Valiant stent graft, 34 x 150 mm (Medtronic, Santa Rosa, CA). Control MSCT angiography showed a proper visceral branch patency and positioning of the stent graft without endoleaks. Nine months after the procedure the patient was symptom-free, with no aneurysm, diameter change and no graft-related complication. All visceral branches were patent. So far about 500 cases of visceral debranching have been published with the aim of treating thoracoabdominal aneurysms, and still we have no valid guidelines concerning this method. However, in carefully selected high-risk patients this is an excellent alternative to open surgery of thoracoabdominal aneurysms.

Single Incision Laparoscopic Transabdominal Preperitoneal Repair for Strangulated Groin Hernia

Introduction: Single incision laparoscopic surgery (SILS) has become more popular for various surgical procedures including hernia surgery. Initial results of SILS in elective hernia repair were comparable to those of conventional laparoscopic approaches. However the use of SILS in emergency case has not been widely reported. This study aimed to evaluate the feasibility of the use of single incision laparoscopic transabdominal preperitoneal (TAPP) repair for patients presenting with strangulated groin hernia. Method: Emergency single incision laparoscopic TAPP repair were performed in our unit from June 2011 onwards for selected patients. Retrospectively data including the patient demographics, operative time, type of hernia, hospital stay, complications and recurrence rate were collected and analyzed. Result: There were a total of five patients in this series from June 2011 to June 2012. The median age was 62 years old with a male to female ratio of 4:1. Four patients had unilateral hernia (one femoral and three inguinal hernias) and one had bilateral hernia (unilaterally strangulated femoral hernia and bilaterally reducible indirect inguinal hernia). The median operative time was 75 minutes for patients with unilateral repair. None of the patients required bowel resection. The conversion rate to either conventional laparoscopic or open repair was zero. The median hospital stay was 2 days. No major complication or recurrence was detected. Conclusion: This series showed that single port laparoscopic TAPP repair for strangulated groin hernia is a feasible option with no major complication reported.