High Risk For Open Surgery Research Articles

AFX unibody stent graft: Effective and safe for the treatment of severe aorto-iliac occlusive disease.

The primary objective of this study was to determine the primary, assisted primary and secondary patency rates of the Endologix AFX stent-graft in patients considered high risk for open surgery with complex aorto-iliac occlusive disease. The secondary objective was to determine 30-day major adverse cardiovascular and cerebrovascular events. A retrospective review was undertaken of clinical records of 38 patients who underwent AFX stent-graft placement for aorto-iliac occlusive disease from 2016 to 2019. Patient data was de-identified and entered into a REDcap secure database. Descriptive statistical analysis (means and standard deviations) and Kaplan-Meier survival curves were created to determine the duration of patency of the AFX stent-graft system. Primary patency rates at 6, 12 and 24months were 92%, 92% and 84%, respectively. Assisted primary patency rates at these times were 100%, 100% and 93% with secondary patency of 100% maintained throughout. The incidence of 30-day major adverse cardiovascular and cerebrovascular events was 8% and major adverse limb events was 3%. One death unrelated to the AFX device occurred during the study period though outside of the 30-day peri-operative period. Primary, assisted primary and secondary patency rates of AFX stent-grafts, when used to treat aorto-iliac occlusive disease, are high. This study supports the use of the AFX stent-graft for the endovascular treatment of complex aorto-iliac occlusive disease as an alternative to other endovascular options as well as a safe alternative to open aorto-iliac or aorto-femoral bypass in patients who are at high risk for open procedures.

Poređenje otvorene hirurgije i endovaskularnog tretmana asimptomatske juksta- i/ili pararenalne aneurizme abdominalne aorte

Endovascular abdominal aortic aneurysm repair (EVAR) has gained widespread acceptance in the treatment of patients with abdominal aortic aneurysm (AAA). The applicability of EVAR is limited by the absence of adequate infrarenal neck or involvement of the visceral arteries, such as in juxtarenal and pararenal AAA (JAAA/PAAA). Current guidelines recommend that elective management of JAAA/PAAA and the choice of different techniques and different options should be considered based on patient status, anatomy, local routines, team expertise, and patient preference. The main advantage of endovascular techniques lies in the avoidance of aortic cross-clamping and subsequent lower risk of renal dysfunction, less surgical trauma and faster recovery, which may be advantageous for patients at high risk of open surgery. However, recent reports show that JAAA/PAAA patients can be treated in high-volume aortic centers with low short-term mortality and morbidity and good medium and long-term results that are equal in both groups. Low-surgical-risk patients might benefit from open surgery, while high-risk patients might benefit from the endovascular first approach of JAAA/ PAAA. This provides useful information to help clinicians and patients choose between the two procedures when both are available.

Results of endovascular treatments of Trans-Atlantic Inter-Society Consensus C or D aortoiliac occlusive disease involving the aortic bifurcation.

The current study aims to report midterm results of patients treated with endovascular intervention, kissing stent, or covered endovascular reconstruction of the aortic bifurcation, for Trans-Atlantic Inter-Society Consensus C or D aortoiliac occlusive disease involving the aortic bifurcation. Eighteen patients who have intermittent claudication or chronic limb threatening ischemia with Trans-Atlantic Inter-Society Consensus C or D aortoiliac occlusive disease involving the aortic bifurcation enrolled to the study between January 2018 and January 2021. Kissing stents, Advanta V12 (Atrium, Getinge Group), were used in 13 patients, and the covered endovascular reconstruction of the aortic bifurcation technique was used in 4 patients to reconstruct the aortic bifurcation. The patients were followed for a median of 49 months (min. 2, max.58 months). Patency rates, mortality, morbidities, and reinterventions were recorded. The mean age of the patients was 60.4 ± 10 years. Technical success was achieved in 94.4% of the patients, but one patient had to convert to open surgery. Primary patency rate of the remaining patients was 85.6% at 58 months. Target lesion revascularization rate was 11.7%. One patient had successful reintervention for in stent restenosis, and secondary patency rate was 93.3% at 58 months. Limb salvage rate was 84.6% during the follow-up. Two patients had myocardial infarction (11.1%) and one mortality (5.6%) occurred because of cerebrovascular event in the follow-up. Endovascular techniques can be used safely for reconstruction of the aortic bifurcation in Trans-Atlantic Inter-Society Consensus C or D aortoiliac occlusive disease in selected patients who have high risk for open surgery. Covered endovascular reconstruction of the aortic bifurcation is the only technique that showed patency rates approaching open surgery in treatment of aortoiliac occlusive disease involving the aortic bifurcation to date. Although promising patency results were achieved with kissing-covered stents, long-term patency rates were still lower than those achieved with open surgery. Further randomized controlled studies comparing the long-term results of these techniques are needed.

After a blunt trauma, xillary artery transection is repaired endovascularly with a stent graft.

Axillary artery transection injuries are uncommon and often require surgery to repair. The patient in this case was assessed to be at high risk for open surgery, and an urgent endovascular therapy option employing a stent graft is described.

Novel conformable stent-graft repair of abdominal aortic aneurysms with hostile neck anatomy: A single-centre experience.

Abdominal aortic aneurysms (AAAs) demonstrating hostile neck anatomy (HNA) are associated with increased perioperative risk and mortality. A number of these patients are not suitable for standard endovascular aneurysm repair (EVAR) and are high risk for open surgery. We present our experience with the first implantations in Scotland of a novel conformable aortic stent-graft designed to overcome some of the challenges of HNAs. From May 2018 to March 2022, 24 consecutive patients with non-ruptured AAAs demonstrating HNAs (neck length < 15mm, or angulation > 60°) were treated with GORE Excluder Conformable AAA endoprosthesis (CLEVAR) (CEXC Device, W.L. Gore and Associates, Flagstaff, AZ, USA) at a Scottish vascular centre. We assessed clinical outcomes and technical success of CLEVAR during deployment, primary admission and the post-operative period at 3- and 12-month clinical follow-up alongside CT angiography. Twenty-four patients (20 males, mean age 75.6) were included. Primary technical success of proximal seal zones and CLEVAR deployment (no type 1/3 endoleaks, no conversion to open repair, AAA excluded and patient leaving theatre alive) was achieved in 100% of patients. All patients were alive and clinically stable at 3- and 12-month follow-up. There were five patients requiring re-intervention; at the 3-month follow-up, one patient (4.2%) developed a type 1b endoleak requiring graft limb extension, one patient developed a right common femoral artery dissection requiring open repair and one patient required a limb extension of the right iliac limb due to risk of developing a type 1b endoleak. At the 12-month follow-up, two patients required embolization of type 2 endoleaks and no patients demonstrated type 1 or type 3 endoleaks.Conclusions: In-hospital and post-operative 3- and 12-month clinical and angiographic outcomes demonstrate safety and efficacy with CLEVARs in treating unruptured AAAs with HNA. Further research involving larger heterogenous sample sizes is warranted to determine long-term clinical outcomes.

Transcatheter aortic valve replacement through the carotid artery in a 60-year-old man with aortic stenosis and chronic dialysis: a case report

Transcatheter aortic valve replacement (TAVR) through the carotid artery in middle-aged patients with severe aortic stenosis and chronic hemodialysis has been a challenge in clinical practice because of the complex technique. A 60-year-old man was admitted to our hospital because of his symptomatic severe aortic stenosis. With the high risk of open surgery due to chronic hemodialysis, TAVR was selected after an in-depth discussion between the heart team and the patient. The transfemoral access route was not appropriate due to severe calcifications and tortuous iliofemoral arteries, therefore, the left carotid route was chosen. A 29-mm CoreValve Evolut R system was successfully implanted without any complications. His symptoms significantly improved at 12-month follow-up, without any major cardiovascular adverse events. TAVR via the carotid artery thus demonstrates the feasibility, safety, and effectiveness in such complex conditions.

Type B aortic dissection residual after proximal aortic repair: an innovative open surgical approach in patients not eligible for endovascular treatment.

Residual type B aortic dissection (R-TBAD) is a challenging kind of disease affecting an increasing number of patients. Management of R-TBAD has not been specifically addressed in current literature and many of those patients are not eligible for endovascular treatment. Aim of the study was to evaluate the efficacy and feasibility of a specifically conceived procedure the "saguaro branched graft technique" to treat R-TBAD distal to a proximal stent-graft. Data of patients treated between 2015 and 2019 were prospectively collected and retrospectively analyzed. Indication for surgery was R-TBAD with chronic malperfusion, aortic enlargement >55 mm or rapid growth, and symptomatic aortic enlargement. A Dacron graft with four branches has been tailored on the back table by implanting two bifurcated grafts to a tube or bifurcated graft. After left thoracoabdominal incision the proximal endograft has been used as a solid starting point for the distal branched graft. Sequential revascularization of the visceral vessels was performed step by step by suturing each artery outside the aneurysm before opening the distal aorta, while a continued retrograde aortic and visceral perfusion was maintained by a left pump atrio-femoral bypass. After that all visceral branches had been regularly perfused from above, the thoraco-abdominal aorta was open and repaired. Outcome measures were 30-day mortality and 30-day major complications as were long-term all-cause mortality, aorta-related mortality, reintervention and patency rates of the branches. Thirteen patients with R-TBAD were treated during the study period. Indication for surgery was chronic malperfusion in one patient (7.7%), aortic enlargement >55 mm or rapid growth in 9 patients (69.2%), persistent pain with aortic enlargement ≥50 mm in 3 patients (23.1%). All patients were considered not eligible for endovascular repair. At 30-days no deaths or re-interventions occurred and major complications including acute cardiovascular events and renal function impairment were not reported; one patient (7.7%) developed postoperative paraplegia. At a mean follow-up period of 19.6±10.2 (range, 8-48) months, reintervention and mortality rates were null. Visceral malperfusion and late-onset renal failure were not reported, and all visceral branches were still patent. Despite the potential high risk of open surgery, the "saguaro branched graft technique" appears to be a safe surgical solution for R-TBAD.

Long-term Results of Angulated Versus Hyperangulated Neck in Endovascular Aneurysm Repair With Endurant Endoprosthesis

Purpose: Patients with a hyperangulated (>60°) proximal aortic neck and at high risk of open surgery have been treated with endovascular aortic repair (EVAR). However, long-term outcomes are not well reported. The aim of this study is to compare the technical and clinical success of EVAR in angulated (45°-60°) and hyperangulated (>60°) proximal neck angulation. Materials and Methods: The data of all consecutive patients undergoing EVAR treated between November 2007 and February 2020 were collected. A retrospective analysis of this prospective database was performed. The primary measure outcome was technical and clinical success. In addition, we evaluated sack evolution, type IA endoleak, secondary procedures, aneurysm rupture, mortality, aneurysm-related mortality, and migration. Results: In all, 246 of 1353 EVAR patients presented with an angulation of the proximal neck >45°, 130 patients presented with an infrarenal angulation >60°, while 116 patients had an angulation between 45° and 60°. Patients with a hyperangulated infrarenal aortic neck were significantly more often women (8.6% vs 26.9%), older (73.9 vs 76.7 years), and had less often diabetes mellitus (20.7% vs 10.8%). Suprarenal neck angulation and reversed tapered neck were significantly more frequent in the hyperangulated group so that propensity scores were generated using these anatomical parameters to create a matched cohort group. No significant differences in technical (87.9% vs 94.8%) and clinical success (66.4% vs 69.8%) were observed. After a mean clinical follow-up of 58.9 months significantly more secondary procedures were performed in the hyperangulated group (23.3% vs 12.9% p=0.04); however, neck-related secondary procedures were comparable (1.7% vs 6.0%; p=0.09). Also, all-cause and aneurysm-related mortality, sack evolution, type IA endoleak, aneurysm rupture, and migration were comparable for both groups. Conclusion: Compared with less angulated proximal aortic neck, hyperangulated neck anatomy did not reduce the technical and clinical success of EVAR but increased the risk of secondary procedures. In patients who are not good candidates for open surgery, EVAR is a reasonable alternative.

Epidemiology of abdominal aortic aneurysms

Abdominal aortic aneurysm (AAA) disease remains a major source of morbidity in developed countries and can progress to life-threatening rupture if left untreated, with exceedingly high mortality. The goal of AAA management is to identify and electively repair AAAs before rupture. AAA disease burden and outcomes have improved over time with declining tobacco use and advancements in care across patients’ disease course. The introduction of endovascular AAA repair, in particular, has allowed for elective AAA repair in patients previously considered too high risk for open surgery and has contributed to lower rates of AAA rupture over time. However, these improved outcomes are not universally experienced, and disparities continue to exist in the detection, treatment, and outcomes of AAA by sex, race, and ethnicity. Mitigating these disparities requires enhanced, focused efforts at preventing disease, promoting health, and delivering appropriate care among an increasingly diverse patient population.

Sex does not have an impact on perioperative transfemoral carotid artery stenting outcomes among octogenarians

ObjectiveTransfemoral carotid artery stenting (CAS) has been validated as an acceptable alternative to carotid endarterectomy in patients at high risk for open surgery. There are variable sex- and age-based differences in transfemoral CAS outcomes of published randomized controlled trials. The aim of our study was to evaluate sex-based differences in perioperative outcomes after transfemoral CAS performed in octogenarians. MethodsThe National Surgical Quality Improvement Program targeted vascular module was queried for all patients ≥80 years of age who underwent transfemoral CAS between 2011 and 2017. Symptomatic status was defined as a history of prior ipsilateral stroke, transient ischemic attack, or amaurosis fugax. The primary outcome was a composite outcome of perioperative (30-day) stroke or death. Outcomes were compared for male vs female patients and stratified by symptomatic status using univariate and multivariable logistic regression analyses adjusting for emergent status, symptomatic status, comorbidities, and use of an embolic protection device. ResultsOverall, there were 143 patients ≥80 years of age who underwent transfemoral CAS during the study period, including 95 men (66.4%) and 48 women (33.6%). Race (white, 88.0% vs 85.4%), symptomatic status (30.9% vs 29.2%), and degree of stenosis (severe, 71.6% vs 62.5%) were not significantly different for men vs women (P ≥ .27). Periprocedural stroke/death occurred in six men (6.4%) vs two women (4.2%; P = .59) and did not significantly differ when stratified according to symptomatic (6.9% vs 7.1%; P = .98) and asymptomatic (6.2% vs 2.9%; P = .49) status. Based on multivariable analysis, independent factors associated with the composite end point included emergent vs elective status (adjusted odds ratio OR [aOR], 20.3; 95% confidence interval [CI], 2.25-183) and failure to use an embolic protection device (aOR, 2.86; 95% CI, 1.59-50.0). Sex was not significantly associated with the primary outcome after risk adjustment (aOR, 0.81; 95% CI, 0.28-3.28). ConclusionsWe found no sex-based differences in risk of perioperative stroke/death among patients ≥80 years of age undergoing transfemoral CAS. Our study validates previous studies showing a high rate of perioperative complications after transfemoral CAS in octogenarians and suggests that the decision to use this technology in older patients should be determined by patients' anatomic and medical risk factors irrespective of sex.

AAA 19. Midterm Results of Parallel Grafts in Patients With Pararenal and Type IV Thoracoabdominal Aortic Aneurysms Unsuitable for Fenestrated or Branched Endografts

The objective of this study was to evaluate the midterm outcomes of parallel grafts (PGs) in patients presenting with pararenal or type IV thoracoabdominal aortic aneurysms unsuitable for off-the-shelf or custom-made fenestrated or branched endografts. Between February 2011 and July 2019, there were 41 consecutive patients presenting with pararenal or type IV thoracoabdominal aortic aneurysms who were treated by implantation of PGs. Reasons for use of PGs were the following: patients judged unfit for open surgery; urgent or emergent procedures in which off-the-shelf graft was not applicable; and elective patients refused for manufacture of custom device because of anatomy. Different commercially available endografts and covered balloon or self-expandable stents were used. Outcomes included intraoperative technical success and early (30-day) and midterm all-cause mortality and morbidity as well as freedom from reintervention, endoleaks, and occlusions of PGs. Technical success was defined as a procedure completed as intended, without secondary interventions within 30 days. Forty-one patients were included (mean age, 76.3 ± 7.1 years; 34 male). Mean aortic aneurysm diameter was 67.2 ± 18.6 mm. Twenty-three patients were treated electively; the remaining patients were treated in emergency. Previous infrarenal aneurysm repair was reported in 11 patients (26.8%). Ninety-two target aortic branches (TABs) were treated (2.2/patient). Technical success was obtained in all patients. At 30 days, mortality was 7.4%, accounting for three emergently treated patients (two aortic infections and one rupture), and TAB occlusion rate was 2.1% (2/92). One patient required an additional embolization procedure because of a persistent gutter endoleak. At a mean follow-up of 29 ± 7 (2-96) months, freedom from mortality was 89.5%; four more patients died (one new infection, one aneurysm rupture, and two myocardial infarctions). Rate of TAB new occlusion was 1.1% (1/92). Reintervention was performed in four patients, in three for endoleaks and in one for iliac limb occlusion. During the entire study period, cumulative TAB occlusion rate was 3.2%, all renal branches. Aneurysm sac shrinkage was observed in 59.5% of patients, with a mean aneurysm diameter reduction 3.8 ± 2.1 mm. The technique of PGs seems to represent a reasonable option in patients at high risk for open surgery who are not able to be treated by fenestrated or branched endografts. Despite high clinical and anatomic risk of treated patients, TAB patency remains high at midterm follow-up.

Utility of computed tomography in cases of aortic valve stenosis before and after transcatheter aortic valve implantation.

Trans-catheter aortic valve implantation (TAVI) has been recognized as a useful treatment for patients with severe aortic valve stenosis, particularly those with moderate to high risks of open heart surgery. A thorough evaluation of the aortic valve complex, including the size or presence of calcifications of the leaflets and annulus, is important for the selection of appropriate candidates, artificial valve types and approach. Echocardiography is useful for the precise evaluation of aortic valve stenosis severity and aortic valve complex morphology, but it is not useful to evaluate three-dimensional aortic valve anatomy and pathway for the catheter of aortic valve implantation. Electrocardiography (ECG)-gating computed tomography (CT) has recently been recognized as a useful modality for evaluating significant coronary artery stenosis because of its higher spatial and temporal resolution and diagnostic accuracy based on recent studies. ECG-gating CT is also useful for evaluating aortic valve complex morphology, including calcifications and whole aorta and iliac arteries, as the access route of catheter in TAVI. TAVI candidates, who are at high risk of open surgery, tend to be old and require anti-platelet after TAVI; therefore CT, is also useful for screening for non-cardiac diseases including malignant tumors just before TAVI. Therefore, here we introduce the utility of cardiac and whole body CT in cases of severe aortic valve stenosis before and after TAVI.

Sustained Improvement of Left Ventricular Strain following Transcatheter Aortic Valve Replacement

Purpose: Left ventricular (LV) mechanics are impaired in patients with severe aortic stenosis (AS). Transcatheter aortic valve replacement (TAVR) has become a widespread technique for patients with severe AS considered inoperable or high risk for open surgery. This procedure could have a positive impact in LV mechanics. The aim of the study was to evaluate the effect of TAVR on LV function recovery, as assessed by myocardial deformation parameters, both immediately and in the long term. Methods: One-hundred nineteen consecutive patients (81.2 ± 6.9 years, 50.4% female) from 10 centres in Europe with severe AS who successfully underwent TAVR with either a self-expanding CoreValve (Medtronic, Minneapolis, MN, USA) or a mechanically expanded Lotus valve (Boston Scientific, Natick, MA, USA) were enrolled in a prospective observational study. A complete echocardiographic examination was performed prior to device implantation, before discharge and 1 year after the procedure, including the assessment of LV strain using standard 2D images. Results: Between baseline and discharge, only a modest but statistically significant improvement in GLS (global longitudinal strain) could be seen (GLS% –14.6 ± 5.0 at baseline; –15.7 ± 5.1 at discharge, p = 0.0116), although restricted to patients in the CoreValve group; 1 year after the procedure, a greater improvement in GLS was observed (GLS% –17.1 ± 4.9, p < 0.001), both in the CoreValve and the Lotus groups. Conclusions: Immediate and sustained improvement in GLS was appreciated after the TAVR procedure. Whether this finding continues to be noted in a more prolonged follow-up and its clinical implications need to be assessed in further studies.

IP091. Impact of Sex on Carotid Artery Stenting Outcomes Among Octogenarians

Carotid artery stenting (CAS) has been validated as an acceptable alternative to carotid endarterectomy in patients at high risk for open surgery. There are variable sex- and age-based differences in CAS outcomes based on published randomized control trials. The aim of our study was to evaluate sex-based differences in perioperative outcomes after CAS performed in octogenarians. The National Surgical Quality Improvement Program vascular-targeted data file was queried for all patients 80 years of age and older who underwent CAS between 2011 and 2017. Symptomatic status was defined as a history of prior ipsilateral stroke, transient ischemic attack (TIA), or amaurosis fugax. The primary outcome was a composite outcome of perioperative (30-day) stroke, TIA, death, and/or myocardial infarction (MI). Outcomes were compared for males versus females and stratified by symptomatic status using univariable and multivariate logistic regression analyses adjusting for emergent status, symptomatic status, comorbidities, and use of an embolic protection device. Overall, there were 143 octogenarian patients who underwent CAS over the study period, including 95 males (66.4%) and 48 females (33.6%). Median age was 83.9 years (range, 80-90 years), 85.3% were white, and 30.3% were symptomatic. One-third (37.1%) had anatomic high-risk criteria for CEA, while the remainder (62.9%) had high-risk medical comorbidities. Periprocedural stroke/TIA/death/myocardial infarction occurred in 10 males (10.5%) versus 5 females (10.4%; P = .98), and did not significantly differ according to symptomatic versus asymptomatic status (11.6% vs 10.0%; P = .77). Based on multivariable analysis, independent factors associated with a poor periprocedural outcome included emergent versus elective status (adjusted odds ratio [aOR], 21.3; 95% confidence interval [CI], 2.74-165.39) and failure to use an embolic protection device (aOR 4.39; 95% CI, 1.20-16.00). Sex was not associated with the primary outcome after risk adjustment (aOR 0.8; 95% CI, 0.21-2.99). Contrary to prior findings suggesting worse post-CAS outcomes among females, we found no sex-based differences in risk of perioperative stroke, TIA, death, or myocardial infarction among patients 80 years of age and older undergoing CAS. Our study validates previous studies showing a high rate of perioperative complications following CAS in an older population, and reinforces the importance of patient selection and use of an embolic protection device to reduce poor outcomes.

Endovascular Repair of Axillary Artery Transection with a Stent Graft following Blunt Trauma

Transection injuries of the axillary artery are rare and typically involve surgical repair. This case describes an emergent endovascular treatment option, using a stent graft, in a patient that was deemed as high risk for open surgery.

PP57 Outcomes On Transcatheter Aortic Valve Implantation

IntroductionSevere aortic stenosis with symptoms or left ventricular dysfunction has commonly a poor prognosis and therefore, aortic valve replacement is usually performed for patients aiming at improving their functional class and survival rate.MethodsThis retrospective study evaluated a convenience sample of patients at high risk for open surgery for the correction of aortic valve dysfunction treated with TAVI from 2013 to 2018. Data from a private healthcare organization in Belo Horizonte, Brazil were used to assess all-cause mortality. Continuous variables were expressed as mean and standard deviation. Cox proportional regression model and Log-Rank test were used to adjust the survival curve.ResultsFifty-two patients were included in the study (mean 83 ± 5.7 years of age, range 67 to 93 years; female 55.8 percent). Patients were characterized by: left ventricular ejection fraction (n = 30; mean 52.9 percent, range 26 to 81 percent); aortic valve area (n = 36; mean 0.68 cm2, range 0.4 to 1.2 cm2); left atrium size (n = 14; range 30 to 61 ml/m2); pulmonary artery pressure (n = 20; mean 53 mmHg, range 31 to 70 mmHg). Death occurred in 19 patients during the follow-up period (mean 8.4 months, range 0 to 60 months). Nine deaths occurred within the first 30 days of follow-up (17.3 percent) and 14 (26.9 percent) in the first year. Stroke occurred in three patients (5.8 percent) in the post-implant period. A pacemaker device was required for nine patients (17.3 percent).ConclusionsTranscatheter aortic valve implantation (TAVI) has become an alternative to surgical aortic valve replacement for patients at high risk for surgery. Real-world studies might result in a better understanding of the local team expertise on TAVI utilization.

Outcomes After the MitraClip Procedure in Patients at Very High Risk for Conventional Mitral Valve Surgery.

Approximately 50% of patients with severe symptomatic mitral regurgitation are deemed too high risk for surgery. The MitraClip procedure is a viable option for this population. Our goal was to assess outcomes and survival of patients who underwent the MitraClip procedure at an institution where mitral valve surgery is routinely performed. A retrospective study of patients undergoing the MitraClip procedure was performed. Baseline characteristics, perioperative outcomes, and follow-up echocardiographic and clinical outcomes were examined. Primary end point was survival. Secondary end points included technical failure (residual 3/4+ mitral regurgitation), reoperation, New York Heart Association symptoms, 30-day mortality, and other clinical outcomes. Predictors of mortality were determined using multivariable regression analysis. Fifty consecutive patients underwent the MitraClip procedure during the 4-year period. The average age was 83, the Society of Thoracic Surgeons predicted risk of mortality mean was 9.4%, 88% (44/50) had New York Heart Association III/IV symptoms, 86% (43/50) had 4+ mitral regurgitation, and 72% (36/50) had degenerative mitral disease etiology. Echocardiographic data (median [interquartile range] follow-up = 43 [26-392]) showed that 86% (43/50) of patients had 2+ or less mitral regurgitation. Sixty percent (24/40) had New York Heart Association I/II symptoms at last follow-up. Predictors of mortality were higher Society of Thoracic Surgeons predicted risk of mortality (P = 0.042, hazard ratio = 1.098) and previous cardiac surgery (P = 0.013, hazard ratio = 3.848). Survival at 1 and 2 years was 75% and 63%, respectively. Many patients with mitral valve regurgitation who are high risk for open surgery can be treated with the MitraClip procedure. In our study, most patients (86%) had a technically successful operation and postoperative outcomes including survival were acceptable.

Thoracic endovascular aortic repair for the ascending aorta: experience and pitfalls.

Thoracic endovascular aortic repair (TEVAR) of the ascending aorta is a developing alternative treatment strategy, which currently is specifically aimed at patients who are too high risk for open surgery. TEVAR has been applied to patients with a variety of pathologies of the ascending aorta including type A dissection, intramural hematoma (IMH), penetrating ulcers, aneurysm and pseudoaneurysm. Here we discuss the current evidence regarding the use of TEVAR for the ascending aorta as well as the latest techniques and pitfalls of the procedure. The challenges of this modality are considerable, and the techniques that have been applied draw from the many facets of endovascular experience. There is limited literature regarding the use of stent grafts in the ascending aorta, and the pool of patients currently considered appropriate candidates for the procedure is small. This is an evolving intervention that warrants further study and the development of devices specifically engineered to meet the anatomical and physiologic challenges of the ascending aorta.

Transcatheter aortic valve implantation in Asia.

The use of transcatheter aortic valve implantation (TAVI) to treat severe symptomatic aortic valve stenosis has increased exponentially in the last decade. This rapid expansion was seen predominantly in Western developed nations and has been fuelled by favorable results reported from a plethora of well-publicized randomized controlled trials, large retrospective series and national registries. Now, TAVI has become the standard of care for inoperable patients and an alternative to open surgery in patients who are at intermediate to high risk for open surgery. Notwithstanding these positive results, Asia has been relatively slow to adopt this technology despite a potentially large patient pool. Unique features of Asian medical environments and differences in Asian anatomy affecting TAVI uptake in Asia will be discussed. This article serves to outline the various challenging aspects of disseminating TAVI in Asian countries.

Extracranial carotid stenosis: evidence based review.

Extracranial cerebrovascular disease is one of the most important causes of death and disability worldwide and its treatment is based on clinical and surgical strategies, the latter being performed by conventional or endovascular techniques. The management of stenosis of the carotid bifurcation is mainly aimed at preventing stroke and has been the subject of extensive investigation. The role of clinical treatment has been re-emphasized, but carotid endarterectomy remains the first-line treatment for symptomatic patients with 50% to 99% stenosis and for asymptomatic patients with 60% to 99% stenosis. Stent angioplasty is reserved for symptomatic patients with stenosis of 50% to 99% and at high risk for open surgery due to anatomical or clinical reasons. Currently, the endovascular procedure is not recommended for asymptomatic patients who are able to undergo conventional surgical treatment. Brazil presents a trend similar to that of other countries in North America and Europe, keeping endarterectomy as the main indication for the treatment of carotid stenosis and reserving the endovascular procedure for cases in which there are contraindications for the first intervention. However, we must improve our results by reducing complications, notably the overall mortality rate.