Open Aortic Reconstruction Research Articles

Factors that impact kidney function during open and endovascular reconstruction of aortic aneurysms.

To analyze the factors that influence the deterioration of postoperative renal function in patients undergoing open or endovascular aortic reconstruction, and the impact on survival. Retrospective review of patients who underwent invasive treatment was conducted. Demographics, laboratory data, clinical, intraoperative and postoperative variables were recorded; renal function was determined, Fisher's exact test was used to find associations and Kaplan Meier analysis to estimate survival. From 2007 to 2017, 80 patients (mean age: 70 years) were studied. Fifty-eight (73%) were male, none of these patients had known diagnosis of chronic kidney insufficiency. Twelve (15%) patients had elevated creatinine in the postoperative period; variables such as intraoperative bleeding greater than 1500 ml were associated with acute renal failure (p = 0.005). During the follow-up period of 60 months, 8 (10%) patients progressed to chronic renal failure, 2 (2.5%) requiring hemodialysis, 18 (22%). Age, gender, comorbidities and anatomic characteristics of the aneurysm, type of intervention or level of aortic cross-clamping did not impact the postoperative renal function. The repair of complex aortic aneurysms continues to be a challenge. Intraoperative bleeding greater than 1500 ml and the need of blood transfusion was associated with deterioration of postoperative renal function, affecting the 5-year survival of patients.

Endovascular treatment of para-anastomotic aneurysms after open abdominal aortic surgery.

The repair of long-term complications of open abdominal aortic repair such as para-anastomotic aneurysm (PAA) and pseudoaneurysm (PSA) is very challenging. The aim of this study was to assess the outcomes of endovascular repair of PAA/PSA after previous open aortic surgery for aneurismal or occlusive disease. A systematic review was undertaken; a search was performed (PRISMA) in MEDLINE, CENTRAL, Cochrane databases and key references of all studies of endovascular treatment of PAA/PSA after open aortic surgery. Eighteen studies included totally 433 patients (86.3% males) with mean age of 71±2.5 years were identified. Most of the patients were asymptomatic (76%) and diagnosed with PAA (60.5%), while 81.6% had history of open aortic reconstruction for aneurismal disease. The mean diameter of para-anastomotic aneurysms was 59.7 mm (from 23 mm to 110 mm) and the mean duration until their diagnosis was 10±2 years. Standard bifurcated (23.7%), fenestrated (23.4%) and aorto-uni-iliac stent-grafts (16.3%) were mostly used. The technical success rate was 97.8% (391/400) with 1.4% (6/433) 30 day-mortality rate and mean hospital stay of 6±3 days. The mean 1- and 2- year survival rate was 87.8% and 78.8%, respectively. The follow-up ranged from 9 to 43 months, with presenting complications such as endoleak type I (24/378; 6.3%), type II (15/354; 4.3%), type III (3/378;0.8%), migration (4/378; 1%) and limb occlusion (5/310;1.6%). Additionally, 5.7% (19/332) of the patients underwent open conversion, while the total re-intervention rate was 11.4% (39/340; time of reintervention ranged from 7 to 30 months). In cases in which a stent was used for splanchnic vessels (renal artery: 188, superior mesenteric artery: 98, celiac artery: 64), the primary patency rate was 97.4% (341/350). Endovascular treatment of PAAs and PSAs after previous open aortic surgery is a feasible and efficient option with high technical success rate, low 30-day mortality and good mid-term outcomes.

Predicting Distal Aortic Remodeling After Endovascular Repair for Chronic DeBakey III Aortic Dissection

Chronic DeBakey III aortic dissection is typically managed with open aortic reconstruction. Thoracic endovascular aortic grafting (TEVAR) has been attempted in patients with chronic DeBakey III with improved outcomes over medical management, however with frequent failures. This study investigates factors associated with positive aortic remodeling from a large aortic center. Three-dimensional reconstructions (M2S, West Lebanon, NH) of computed tomography angiography scans of 48 patients who underwent TEVAR from 2005 to 2015 were analyzed. The dissection was characterized, and measurements were obtained from preoperative and postoperative scans at four time points. Standard univariate Wilcoxon rank sum and Fisher's exact tests were used to analyze continuous and ordinal/nominal data, respectively. Multivariable logistic regression was performed. In a multivariate logistic model, having fewer than two visceral vessels off the true lumen was a negative predictor of total thrombosis (odd ratio [OR] 0.01, 95% confidence interval [CI]: <0.01 to 0.84, p= 0.04). In a logistic model that predicted total thrombosis in zones 3 and 4, maximum diameter 2 cm above the celiac axis was a significant negative predictor (OR 0.75, 95% CI: 0.57 to 0.99, p= 0.05). In a model that predicted failure of the maximum overall diameter of the descending aorta to regress within 1 year after TEVAR, maximum overall diameter preoperatively (OR 1.19, 95% CI: 1.02 to 1.29, p= 0.03) and tear location on the greater curve (OR 18.1, 95% CI: 1.3 to 243, p= 0.03) were significant positive predictors. TEVAR is feasible in chronic dissection but is limited by complex dissection-related anatomy. Increasing number of visceral vessels off the false lumen, maximum preoperative aortic size, and location of the primary tear on the greater curve were associated with poorer remodeling.

Iatrogenic Major Venous Injury Is Associated with Increased Morbidity of Aortic Reconstruction

Major venous injury during open aortic reconstruction though uncommon often result in sudden and massive blood loss resulting in increased morbidity and mortality. This study details the etiology, management, and outcome of such injuries. A retrospective review of 945 patients (1981-2017) undergoing aortic reconstruction from 2 midsized (350 bed each) teaching hospitals was conducted. Seven hundred twenty-three patients (76.5%) underwent open abdominal aortic aneurysm (AAA) repair/iliac aneurysm repair, 222 patients (23.5%) underwent aortofemoral grafting (AFG). Patients sustaining major venous injury (sudden loss of more than 500mL of blood) during major aortic reconstruction were studied. The number of units of packed red blood cells transfused, location of injured vessel, type of repair, postoperative morbidity, and mortality were collected in our vascular registry on a continuous basis. All patients identified with iliac vein/inferior vena cava/femoral vein injury had follow-up noninvasive venous examination of the lower extremities. Eighteen major venous injuries (1.9%) occurred during aortic reconstruction in 17 patients (1 patient had 2 major venous injuries): IVC (n=4), iliac vein (n=10), left renal vein (n=4, this includes a posterior retroaortic renal vein injury n=1). Of the 18 major venous injuries, 7 occurred during open AAA repair for ruptured AAA and another 9 occurred during repair of intact AAA (P=0.001), 2 venous injuries occurred after AFG, and 1 after primary AFG (P=0.05). Using multivariate regression analysis, periarterial inflammation had significant association with major venous injury (P<0.001). The presence of associated iliac aneurysm with abdominal aortic aneurysm also increased the incidence of major venous injury during AAA surgery (P=0.05). Two patients (11.8%) died, one from uncontrolled bleeding due to tear of right common iliac vein during ruptured AAA repair and second patient from disseminated intravascular complication following repair of ruptured AAA. Intraoperative transfusion requirements were 3-28 units, (median 8 units). Three of 9 (33%) surviving patients developed iliofemoral venous thrombosis following repair of iliac/femoral vein injury. Major venous injury during aortic reconstructions occurs more commonly during the repair of ruptured AAA and redo AFG. Following repair of iliac/femoral vein injury,surveillance for possible deep venous thrombosis by duplex imaging should be considered.

A 10-year institutional experience with open branched graft reconstruction of aortic aneurysms in connective tissue disorders versus degenerative disease

ObjectiveAortic reconstruction for complex thoracoabdominal aortic aneurysms (TAAAs) can be challenging, especially in patients with connective tissue disorders (CTDs) in whom tissue fragility is a major concern. Branched graft reconstruction is a more complex operation compared with inclusion patch repair of the aorta but is frequently necessary in patients with CTDs or other pathologies because of anatomic reasons. We describe our institutional experience with open branched graft reconstruction of aortic aneurysms and compare outcomes for patients with CTDs vs degenerative pathologies. MethodsWe retrospectively analyzed all patients undergoing open aortic reconstruction using branched grafts at our institution between July 2006 and December 2015. Postoperative outcomes, including perioperative morbidity and mortality, midterm graft patency, and the development of new aneurysms, were compared for patients with CTD vs degenerative disease. ResultsDuring the 10-year study period, 137 patients (CTD, 29; degenerative, 108) underwent aortic repair with branched graft reconstruction. CTD patients were significantly younger (39 ± 1.9 vs 68 ± 1.0 years; P < .001) and had fewer comorbidities (hypertension, chronic obstructive pulmonary disease, coronary artery disease; P < .05) but a higher prevalence of aortic dissections (55% vs 16%; P < .001) and aneurysms involving the thoracic aorta (90% vs 60%; P = .003) than patients with degenerative disease. Perioperative mortality (CTD: 10% [n = 3] vs degenerative: 6% [n = 6]; P = .40) and any complication (62% vs 55%; P = .47) were similar between groups. At a median follow-up time of 14.5 months (interquartile range: 6.5, 43.9 months), CTD patients were more likely to develop both new aortic (21%) and nonaortic (14%) aneurysms compared with the degenerative group (7% and 4% for aortic and nonaortic aneurysms, respectively; P = .02). Loss of branch graft patency occurred in 0 of 99 grafts (0%) in CTD patients and in 13 of 167 grafts (7.8%) in degenerative disease patients (P = .005). Loss of branch graft patency occurred most commonly in left renal artery bypass grafts (77%) and was clinically asymptomatic (creatinine: 1.77 ± 0.13 mg/dL currently vs 1.41 ± 0.25 preoperatively; P = .22). ConclusionsCTD patients with aortic aneurysms who undergo open branched graft reconstruction have reasonable outcomes compared with patients with degenerative pathology, including better branched graft patency and a similar risk of perioperative mortality and complications. Open repair of aortic aneurysms with branched graft reconstruction can be performed safely in both populations with low perioperative mortality, but ongoing surveillance is critical for the detection of new aneurysms, especially among patients with CTD.

Open aortic arch reconstruction for acute type a aortic dissection: a single-center experience with 267 consecutive patients.

BackgroundThis study aimed to analyze the mortality and morbidity of patients undergoing open aortic arch reconstruction for acute type A aortic dissection.MethodsBetween September 2005 and January 2012, 267 consecutive patients underwent open aortic arch reconstruction for acute type A aortic dissection at our center. The mean age was 51.2 ± 10.0 years, and 200 patients were male. Sixty-three and 184 patients underwent hemiarch replacement and total arch replacement, respectively, whereas the remaining 20 patients underwent single- or triple-branched stent graft implantation. Long-term mortality was estimated by Kaplan–Meier method.ResultsThe in-hospital and operative mortality rates within 30 days were 11.2 % and 8.2 %, respectively. The cardiopulmonary bypass, myocardial ischemic, and antegrade cerebral perfusion times were 150.2 ± 43.3, 71.9 ± 33.2, and 33.6 ± 14.4 min, respectively. The overall in-hospital and intensive care unit durations and mean ventilation time were 23.9 ± 18.4 and 9.5 ± 12.7 days and 122.7 ± 183.4 h, respectively. We observed new postoperative permanent neurological dysfunction in 29 patients and temporary neurological dysfunction in 17 patients. The mean follow-up duration was 52.4 ± 27.9 months; 76.4 % of patients completed follow-up and 143 remained alive. Overall long-term survival was 82.2 % at 5 years.ConclusionsThe open aortic arch reconstruction technique for acute type A dissection carries a relatively high in-hospital mortality risk, although the late results are encouraging. Patients with an advanced age or impaired renal function may opt for endovascular or modified single- or triple-branched stent graft implantation therapy.

Open Reconstruction of Huge Abdominal Aortic Aneurysms: Postoperative Complications

Purpose: Was to study the results of open surgical reconstruction of huge abdominal aortic aneurysms (HAAAs) & their complications. Patients and methods: Twenty eight patients with huge abdominal aortic aneurysms were studied in the period from October 2012- March 2015. The diagnosis was done by: history, clinical examination, various imaging which included: Duplex Ultrasound, CTA, MRA, DSA & Mid-stream aortography. Open aortic reconstruction was done by using Bifurcated graft (Collagen coated or PTFE ) or aneurysmorrhaphy in two cases of mycotic saccular aneurysms. Results: The age incidence ranged from 45-78 years with a mean of 64 years. Male sex was predominant than female sex with M:F ratio 6:1. There was a history of Diabetes mellitus, smoking, hypertension, hypercholesterolaemia, obesity, myocardial infarction (seven cases) & renal impairment (two cases). The most common presentation of AAAs were abdominal pain, back pain, pulsating abdominal mass & acute abdomen (in two leaking AAAs). The size of the aneurysm (diameter) ranged between 12-22 cm with a mean of 16 cm, the size was measured by Duplex Ultrasound & CTA. Postoperative Morbidity: lower limb ischemia due to arterial thrombosis was present in two cases & distal embolization in two cases, thrombectomy & embolectomy were done respectively & successfully except one big toe amputated after embolectomy. Myocardial infarction occurred in four cases, two of them died. Another two cases developed uraemia, one of them died. Leaking abdominal aortic aneurysms occurred in two cases, one of them died. The overall all mortality rate within thirty postoperative days was four cases (14.3%), no intraoperative mortality. Conclusion: The morbidity & mortality rates were proportional with increase in size of the aneurysm & increase with the presence of preoperative cardiac, renal dysfunction & risk factors.

Comparison of supramesenteric aortic cross-clamping with supraceliac aortic cross-clamping for aortic reconstruction

Supraceliac aortic cross-clamping (SCXC) is routinely used during open aortic reconstruction (OAR) of pararenal aortic disease when suprarenal control is not feasible. On occasion, however, aortic control may be obtained at the supramesenteric level by supramesenteric cross-clamping (SMXC) between the superior mesenteric artery and the celiac axis. The purpose of this study was to compare outcomes between patients who had SMXC vs SCXC during OAR for both aneurysmal and occlusive diseases. A retrospective chart review identified 69 patients who underwent elective OAR requiring SMXC (n= 18) or SCXC (n= 51). All patients with thoracoabdominal aneurysms and those who had inframesenteric (suprarenal and infrarenal) aortic control were excluded. Propensity score-based matching was performed to adjust for confounding factors in a 1:1 ratio to compare outcomes. Late survival was estimated by Kaplan-Meier methods. Propensity score-based matching was performed at a 1:1 ratio; 18 SMXC cases were matched with 18 SCXC cases. The average age was 66.7years, and men constituted 72%. Baseline characteristics were matched, except for the incidence of peripheral vascular occlusive disease (72.2% in the SMXC group vs 33.3% in the SCXC group; P= .04). A majority (80.6%) of patients underwent OAR for aneurysmal disease (72.2% in the SMXC group, 88.9% in the SCXC group). Intraoperatively, there were no differences in operative times (325minutes for SMXC vs 298minutes for SCXC; P=.48), but the SMXC group had a longer renal ischemia time (40minutes vs 28minutes; P= .03). There were no significant differences in intraoperative blood loss (2.4L vs 1.6L; P= .2) or blood product transfusion requirements (packed red blood cells, 2.2 units vs 1.6 units [P= .5]; Cell Saver, 1.3L vs 0.7L [P= .09]). Overall complication rates did not differ significantly (27.8% for SMXC vs 44.4% for SCXC; P= .24). Thirty-day mortality rates did not differ between the two groups (0% for SMXC vs 5.6% for SCXC; P= 1). In this study, there were no differences in early morbidity or mortality between SMXC and SCXC during aortic reconstruction. SMXC, however, can be performed safely and effectively in properly selected patients. A larger, multicenter prospective study would help elucidate the potential benefits.

Minimally Invasive Techniques for Total Aortic Arch Reconstruction.

The cumulative experience with endovascular aortic repair in the descending thoracic and infrarenal aorta has led to increased interest in endovascular aortic arch reconstruction. Open total arch replacement is a robust operation that can be performed with excellent results. However, it requires cardiopulmonary bypass and circulatory arrest and, therefore, may not be tolerated by all patients. Minimally invasive techniques have been considered as an alternative and include hybrid arch debranching, parallel stent graft deployment in the chimney and snorkel configurations, and complete endovascular branched reconstruction with multi-branched devices. This review discusses the evolving use of endovascular techniques in the management of aortic arch pathology and considers their relevance in an era of safe and durable open aortic arch reconstruction.

Open Aortic Arch Reconstruction After Coronary Artery Bypass Surgery: Worth the Effort?

Open aortic arch surgery after coronary artery bypass grafting (CABG) is considered a high-risk operation. We reviewed our surgical approach and outcomes to establish the risk profile for this patient population. In methods, from 2000-2014, 650 patients underwent aortic arch surgery with circulatory arrest. Of these, 45 (7%) had previous CABG. Complete medical record was available for review including all preoperative coronary angiograms and detailed management of myocardial protection. In results, the mean interval from previous CABG to aortic arch surgery was 6.8 ± 7.1 years. At reoperation, 33 (73%) patients had hemiarch replacement and 12 (27%) had a total arch replacement. The following were the indications for surgery: fusiform aneurysm in 20 (44%), pseudoaneurysm in 6 (13%), endocarditis in 4 (9%), valvular disease in 5 (11%), and acute aortic dissection in 10 (22%). There were 6 perioperative deaths (13%) and 1 stroke (2.2%). Selective antegrade cerebral perfusion was used in 13 patients (28.9%) and retrograde perfusion in 6 (13.3%). Survival was 74%, 65%, and 52% at 1, 3, and 5-year follow-up, respectively. Only predictors of early mortality were age (odds ratio = 1.20, CI: 1.01-1.44; P = 0.04) and nonuse of retrograde cardioplegia for myocardial protection (odds ratio = 6.80, CI: 1.06-43.48; P = 0.04). Intermediate survival of these patients was significantly lower than those of a sex-matched and age-matched population (P < 0.001). In conclusion, aortic arch surgery after previous CABG can be performed with acceptable early and midterm results and low risk of stroke. Perfusion strategies and myocardial protection contribute to successful outcomes.

Postoperative renal dysfunction independently predicts late mortality in patients undergoing aortic reconstruction

Preoperative chronic kidney disease (CKD) has been shown to predict postoperative renal complications and mortality after open aortic surgery; the impact of postoperative renal complications less severe than permanent dialysis are unknown. We evaluated the impact of postoperative renal dysfunction severity on survival using a regional quality improvement registry. Patients undergoing intact open aortic reconstruction in the Vascular Study Group of New England registry (2003-2012) were stratified by severity of postoperative renal complications; none, creatinine increase of greater than 0.5 mg/dL (incCr), or any hemodialysis (HD). Predictors of renal dysfunction and impact of renal complications on survival were analyzed using multivariable methods. We included 2695 patients, of which 65% (n = 1733) underwent open abdominal aortic aneurysm repair, and 35% (n = 962) open aortoiliac reconstruction. At baseline, 15% of patients had preoperative moderate CKD and 1.2% had severe CKD. Postoperative renal complications of incCr occurred in 8.5% of patients, and 1.5% required HD. Multivariable cumlogit regression identified severe baseline CKD (odds ratio [OR], 15; 95% confidence interval [CI], 6.4-34; P < .001, moderate CKD (OR, 2.8; 95% CI, 1.9-3.3; P < .001), suprarenal clamp use (OR, 2.2; 95% CI, 1.6-2.9; P < .001), perioperative vasopressor requirements (OR, 2.2; 95% CI, 1.6-2.9; P < .001), operating time (OR, 1.004 per minute; 95% CI, 1.003-1.006; P < .001), and chronic obstructive pulmonary disease (OR, 1.5; 95% CI, 1.2-1.8; P < .001) as independent predictors of worsening strata of postoperative renal dysfunction. Multivariable logistic regression analysis showed that patient age (OR, 1.06 per year; 95% CI, 1.01-1.1; P = .01), baseline chronic obstructive pulmonary disease (OR, 1.6; 95% CI, 1.2-2.2; P < .01), incCr (OR, 3.7; 95% CI, 1.8-7.4; P = .009), and HD (OR, 4.8; 95% CI, 1.8-12.7); P = .009) independently increased 30-day mortality. Risk-adjusted multivariable Cox regression showed that incCr (hazard ratio, 1.8; 95% CI, 1.3-2.6; P < .001) and HD (hazard ratio, 4.4; 95% CI, 2.8-6.9; P < .001) increased risk of late death independent of a variety of other clinical variables, including baseline CKD. The 5-year survival was lower (log-rank P < .001) in patients with incCr (66% ± 4%), and HD (38% ± 10%) compared with those with no renal complications (77% ± 1%). Increasing severity of postoperative renal dysfunction independently predicts increased risk of late mortality after open aortic surgery. Perioperative measures to decrease renal complications may potentially prolong the survival of patients after open aortic surgery.

Endovascular repair of proximal para-anastomotic aneurysms after previous open abdominal aortic aneurysm reconstruction.

To evaluate the safety, efficacy and durability of endovascular repair for proximal para-anastomotic aneurysms after previous open abdominal aortic aneurysms prosthetic reconstruction and share our experience. We retrospectively reviewed the data of all patients with previous open abdominal aortic aneurysms prosthetic reconstruction who underwent endovascular repair for proximal para-anastomotic aneurysms between May 2003 and January 2013 in our center (Nuremberg South Hospital). Key clinical outcomes included technical success rate, peri-operative morbidity and mortality, mid-term complications, reinterventions and open conversion rates. Totally, 24 patients of proximal para-anastomotic aneurysm were treated by endovascular repair. Successful deployments of stent graft were achieved in all patients (100%). Median hospital stay was 6.7 days. One patient had minor type Ia endoleak and one patient developed wound infection. There were no early open conversions and deaths. During a median follow-up of 43 months (range, 7-67 months), computed tomography angiography revealed type Ia endoleaks in four patients (16.7%). The overall reintervention and open conversion rates during follow-up were 16.7% (4/24) and 4.2% (1/24), respectively. Estimates of freedom from reintervention were 91.7% at 1 year, 87.1% at 3 years and 80.9% at 5 years. There was significant difference in freedom from reintervention between proximal para-anastomotic aneurysms patients treated with tube and unibody bifurcated stent grafts (p = 0.034). The cumulative mortality rate was 12.5% (3/24), actuarial analysis for all patients estimated survival rates of 95.8% at 1 year and 87.3% at 5 years. Proximal para-anastomotic aneurysms are severe complications after abdominal aortic aneurysm open reconstruction. Closer follow-up and prompt treatment are necessary. Endovascular treatment for proximal para-anastomotic aneurysms is effective, safe and durable. Unibody bifurcated stent graft proved to be suitable for most proximal para-anastomotic aneurysms with various anatomical features.

PC84. Inferior Mesenteric Artery Reimplantation During Aortic Aneurysm Surgery

The role of inferior mesenteric artery (IMA) reimplantation (IMAR) during open aortic reconstruction is debated. We assessed outcomes following IMAR for aortic aneurysmal disease to help shed light on this question. Single-center retrospective review was done of all IMARs performed during open aortic surgery over a 10-year period between 2000 and 2009. Of 840 elective aortic aneurysmal reconstructions performed during this period, 70 underwent IMAR. Indications for IMAR included intraoperative colonic ischemia (n = 24), poor back bleeding (n = 52), large IMA (n = 5), internal iliac disease (n = 5), and prior colon surgery (n = 1). Follow-up imaging studies were available in 35 of 70 patients (computed tomography in 30 [86%] and duplex in 5 [14%]). Primary outcome was patency, while secondary outcomes included colonic ischemia and overall survival. Analysis was performed using Cox models and Kaplan-Meier estimates. Patency was confirmed in 32 of 35 patients (91%) over a median follow-up of 98 months. Both losses in patency were at 4 months and did not require an operation. One patient underwent left colon resection on postoperative day 9 due to ischemia (patency could not be confirmed). No statistically significant predictor of patency was noted. Incidence of colonic ischemia was 1.4% in patients undergoing IMAR. Incidence of colonic ischemia in patients without indications for IMAR was 0.26%. Overall mortality was 51% in patients undergoing IMAR over the median follow-up period. Nature of aneurysm (juxtarenal or higher [JRAAA]) was a predictor of mortality, with a hazard ratio (HR) of 1.8 (P = .08). Ten-year survival was worse if IMAR was performed for intraoperative colonic ischemia (26% vs 34%) or in JRAAA (19.0% vs 38%). Overall 10-year survival was 30% in patients undergoing IMAR for aortic aneurysmal disease. Age per year was the only statistically significant predictor of survival (P < .001). Inferior mesenteric artery reimplantation for aortic aneurysmal disease is indicated in select patients. Reimplantation is associated with excellent long-term patency, low risk of colonic ischemia, and minimal risk of surgical reintervention.

VS2. Open Repair of Distal Aortic Failure Following TEVAR for Type B Aortic Dissection

This case illustrates the management of distal aortic failure following previous proximal thoracic endovascular aortic repair (TEVAR) for type B aortic dissection via an open approach. The patient is a 59-year-old woman with chronic hypertension and multiple previous aortic interventions, including ascending and arch repair related to acute intramural hematoma. After many years of stability, she developed an acute type B dissection distal to her previous repair with right lower extremity malperfusion and was treated with TEVAR. On routine surveillance imaging, a 7.2-cm type V thoracoabdominal aneurysm distal to her stent grafts rapidly developed due to a new entry tear. Her anatomy was not suitable for Food and Drug Administration-approved endovascular therapy. After extensive counseling discussing the risks and benefits, she elected to proceed with definitive open aortic reconstruction. Our standard thoracoabdominal incision was made, and the aorta was exposed via retroperitoneal approach. The left inferior pulmonary vein and left femoral artery were cannulated to provide partial heart bypass and distal perfusion. The aorta was doubly clamped, and an aortotomy was made and extended appropriately, exposing the distal extent of the previous TEVAR. The distal portion of the TEVAR was resected, and reconstruction was performed using a Dacron graft. The proximal anastomosis was incorporated into the remaining distal TEVAR graft, and a beveled distal anastomosis was fashioned to the visceral aortic segment. The left renal artery was reimplanted as a Carell patch. The patient tolerated the procedure well, aside from brief need for hemodialysis therapy. By postoperative day 7, the patient had returned to her baseline renal function. She was discharged to a rehabilitation facility on postoperative day 12 for further convalescence.

Cumulative Incidence of Graft Infection after Primary Prosthetic Aortic Reconstruction in the Endovascular Era

The introduction of endovascular techniques has had a major impact on the case mix of patients that undergo open aortic reconstruction. Hypothetically, this may also have increased the incidence of aortic graft infection (AGI). The aim of this study was to report on the short and mid-term incidence of AGI after primary open prosthetic aortic reconstruction in the endovascular era. From 2000 to 2010, all 514 patients in a tertiary referral university hospital, undergoing primary open prosthetic aortic reconstruction for aneurysmal or occlusive aortic disease with at least one aortic anastomosis were included. Data were obtained by retrospectively analyzing the medical records, by contacting patients or their general practitioner by telephone, and by merging the dataset with the national Cause of Death Register. AGI was defined as proven by cultures or clinically in combination with positive imaging results. The 30 day, 1 year, and 2 year incidence rates were computed using life table analysis and expressed as percentages with 95% confidence intervals (CI). AGI was diagnosed in 23 of the 514 included patients. 56% of the patients underwent elective surgery and 86% underwent surgery for an abdominal aortic aneurysm. The 30 day incidence was 1.6% (95% CI 0.4-2.8%), 1 year incidence was 3.6% (95% CI 1.7-5.5%), and 2 year incidence for AGI was 4.5% (95% CI 2.4-6.6%). The total number of person years (1058) yielded an AGI rate of 2.2 per 100 person years. The 2 year cumulative incidence of AGI following primary, open aortic procedures with at least one aortic anastomosis is considerable, at around 1 in 20.

Open aortic arch reconstruction after previous cardiac surgery: Outcomes of 168 consecutive operations

Open arch interventions after previous cardiac surgery are considered high risk. We reviewed our outcomes in patients requiring aortic arch reconstruction after previous cardiovascular surgery. From March 2000 to March 2014, the data from 168 patients with previous sternotomy requiring aortic arch replacement were reviewed. The indications for surgery, perioperative data, and outcomes of reoperation were analyzed. The mean age was 61 ± 14 years, and 119 were men (70%). The indications for reoperation were aneurysm (57%), valvular disease (13%), impending rupture (12%), aortic dissection (9.0%), and endocarditis (7.7%). The median time from the previous operation to reoperation was 7 years. The mean aortic diameter was 55 mm. Total or partial arch replacement was performed in 38% and 62% of patients, respectively. Fifty-five patients (32.7%) had undergone previous ascending dissection repair and 45 (26.8%) had previous coronary bypass surgery. Deep hypothermic circulatory arrest was used in all. Selective cerebral perfusion was used in 39% and retrograde cerebral perfusion in 14%. The incidence of permanent stroke was 5.4%. Operative mortality (30-day) was 8.3%. Older age (odds ratio, 1.05; 95% confidence interval, 1.00-1.10; P = .04), New York Heart Association class III/IV (odds ratio, 3.15; 95% confidence interval, 1.01-9.86; P = .04), and extracorporeal circulation time (odds ratio, 1.01; 95% confidence interval, 1.00-1.02; P = .001) were predictors of perioperative death. The median follow-up was 3.0 years. Survival was 85%, 78%, and 68% at 1, 3, and 5 years, respectively. Reoperations to address the aortic arch have acceptable mortality and morbidity. Open repair under circulatory arrest is the benchmark to which endovascular therapies should be compared.

Postoperative Renal Dysfunction Independently Predicts Late Mortality in Patients Undergoing Aortic Reconstruction

Preoperative chronic kidney disease (CKD) has been shown to predict postoperative renal complications and late survival following aortic surgery, whereas the impact of postoperative renal complications less severe than permanent dialysis are unknown. We evaluated the effect of increasingly severe postoperative renal dysfunction on survival using a regional quality improvement registry. Patients undergoing intact open aortic reconstruction in the Vascular Study Group of New England registry (2003-2012) were stratified by severity of postoperative renal complications; none, creatinine increase >0.5 mg/dL (IncCr), or any dialysis (HD). Predictors of renal dysfunction and impact of renal complications on survival were analyzed using multivariable methods. A total of 2095 patients were included, of which 72% had open abdominal aortic aneurysm repair, and 28% open aortoiliac reconstruction. Of these, 15% of patients had moderate CKD, and 1.2% had severe CKD at baseline. Postoperatuve renal complications were none in 90%, IncCr in 8.6%, and HD in 1.6%. Multivariable cumlogit regression identified moderate CKD (odds ratio [OR], 2.7; 95% confidence interval [CI], 1.8-3.9; P < .01), severe CKD (OR, 17; 95% CI, 7-41; P < .01), operating room time (OR, 1.004 minutes; 95% CI, 1.003-1.006; P < .01), and supra-renal clamp use (OR, 2.1; 95% CI, 1.4-2.9; P < .01) as independent predictors of worsening strata of postoperative renal dysfunction. Risk-adjusted multivariable Cox regression showed that IncCr (hazard ratio, 1.6; 95% CI, 1.1-2.3; P = .01) and HD (hazard ratio, 3.2; 95% CI, 1.8-5.7; P < .01) increased risk of late death independent of age, gender, baseline moderate or severe CKD, congestive heart failure, chronic obstructive pulmonary disease, and postoperative myocardial infarction or death. Five-year survival was lower (log rank P < .01) in patients with IncCr (71% ± 4%), and HD (29% ± 10%) compared with those with none (79% ± 1%; Fig). Increasing severity of postoperative renal dysfunction independently predicts increased risk of late mortality after open aortic surgery. Perioperative measures to reduce renal complications may potentially prolong the survival of patients following open aortic surgery.

Use of Flow-Diverting Stents to Treat Para-Anastomotic Iliac Artery Aneurysms After Previous Open Aortic Prosthetic Reconstruction

To present a series of para-anastomotic iliac artery aneurysms treated with flow-diverting stents. Three patients (2 men, 1 woman; ages 70, 73, and 78 years) with previous open aortoiliac reconstructions received a 12-mm-diameter Cardiatis Multilayer Stent to treat 4 para-anastomotic iliac artery aneurysms in an attempt to preserve their ipsilateral hypogastric arteries. After 1-year follow-up, all aneurysms were successfully excluded, with complete sac thrombosis in three and partial thrombosis in one. The diameter of the aneurysm was reduced in all by a median 6 mm. At 1 year, patency of the hypogastric artery was maintained in only the patient with partial sac thrombosis. No patient developed buttock claudication. The use of flow-diverting stents for para-anastomotic iliac artery aneurysms resulted in reduction of iliac aneurysm diameter. However, intended patency of the ipsilateral hypogastric artery was not always observed. The feasibility of the technique has therefore not been shown for this specific indication.

Open aortic arch reconstruction.

were constructed to identify factors that were independently associated with each of the outcomes of interest. Survival was analyzed by Kaplan-Meier methods. All results with P<0.05 were considered statistically significant. Results Demographics and comorbidities are listed in Table 1. The procedure was elective in 404 (56%), urgent in 128 (17.8%) and emergent in 188 (26.1%). Early results Early mortality was seen in 36 patients (5.0%). By multivariate analysis, older age (P=0.001; OR, 1.07; 95% CI, 1.0-1.2), lower ejection fraction (P=0.02; OR, 0.97; 95% CI, 0.95-0.99), prolonged cardiopulmonary bypass (P<0.0001; OR, 1.01; 95% CI, 1.007-1.02) and hypothermic circulatory arrest time (P=0.02; OR, 1.03; 95% CI, 1.0041.05) were independently associated with early mortality. Stroke was identified in 34 patients (4.7%). By multivariate analysis, independent predictors of stroke included history of COPD (P=0.01; OR, 3.3; 95% CI, 1.3-8.2), procedure for type A dissection (P=0.003; OR, 4.05; 95% CI, 1.610.1), prolonged HCA time (P=0.03; OR, 1.02; 95% CI, 1.002-1.04), resection into proximal descending aorta (P=0.03; OR, 4.63; 95% CI, 1.12-19.1), and occurrence of permanent postoperative dialysis (P=0.003; OR, 7.14; 95% CI, 2.0-26.1). Finally, other early adverse events included the occurrence of postoperative renal failure in 42 patients (5.8%), with permanent dialysis required in only 14 (1.9%).

Removal of an Infected Aortic Endograft and Open Aortic Reconstruction: Technical Remarks

Infection of an aortic endoprosthesis is a potentially lethal complication of an endovascular abdominal aortic aneurysm repair (EVAR). Surgical treatment usually involves excision of the infected endograft and vascular reconstruction, either in-line or extraanatomic. We present a case of severe infection of an endograft with suprarenal fixation. The one-stage procedure describes an in-line aortic reconstruction using a hybrid allograft composed of cryopreserved segments of cadaveric thoracic aorta and superficial femoral vein. A novel device for the removal of suprarenal fixating struts is described, as well as other technical maneuvers related to the removal of the struts used by surgeons in the community. The technique and surgical approach should be individualized based on patient characteristics, preoperative imaging, and knowledge of endograft construction.