Aortic Repair Research Articles

Apixaban removal during emergency surgery for type a acute aortic dissection. a prospective cohort study

Background: Acute type A aortic dissection (ATAAD) has a high mortality, and acute aortic repair is the only curative treatment. In patients treated with factor Xa (FXa) inhibitors, the risk of severe disease-related complications such as cardiac tamponade and hemodynamic shock must be balanced against the potential for severe perioperative bleeding. The aim was to study intraoperative changes in plasma levels of the FXa inhibitor apixaban when using hemoadsorption during acute thoracic aortic repair. Materials and Methods: This is a single-center prospective cohort study. Eight apixaban-treated patients presenting with ATAAD underwent acute thoracic aortic repair with intraoperative hemoadsorption with CytoSorb®. Apixaban concentrations were measured at the start of cardiopulmonary bypass (CPB), and after 5, 15, 30, 60 and 90 minutes of CPB, at CPB weaning, 30 minutes after CPB weaning and 24 hours postoperatively, using ultraperformance liquid chromatography mass spectrometry (UPLC-MS). Results: After 30 minutes of CPB with hemoadsorption, mean apixaban concentration (± SD) was reduced by 59% from 108 (± 69) µg/L to 44 (± 20) µg/L (P = 0.009). There was a further reduction to 37 (± 17) µg/L at CPB weaning (P = 0.008). Apixaban concentration displayed an increase to 56 (± 29) µg/L 24 hours postoperatively (P = 0.01). In-hospital mortality was 25%. Mean 24H chest tube drainage volume was 621 (± 136) mL. Conclusion: Intraoperative hemoadsorption lowers apixaban levels in patients undergoing emergency surgery for ATAAD. Further research is needed to determine its impact on perioperative bleeding complications and mortality.

Aortoesophageal fistula nineteen years after radiotherapy for esophageal cancer: a case report

Abstract Background Aortoesophageal fistula (AEF) is a life-threatening disease that causes massive bleeding, sepsis, and ultimately death. Therefore, emergency treatments are required. Recently, cases of AEF treated with thoracic endovascular aortic repair (TEVAR) have been reported. Case Summary An 84-year-old man was referred to a local hospital with massive hematemesis and transient loss of consciousness. The patient’s medical history included radiotherapy for esophageal cancer 19 years before presentation. Gastrofiberscopy revealed an ulcer in the thoracic esophagus and no recurrence of esophageal cancer. Computed tomography (CT) showed that the same area was adjacent to the thoracic aorta and that there was no thoracic aortic aneurysm. The patient was then transferred to our institution for surgical treatment. We diagnosed the patient with an aortoesophageal fistula caused by radiotherapy of the esophagus. Therefore, thoracic endovascular aortic repair (TEVAR) was performed. Due to the patient’s advanced age, condition, and the possibility of strong adhesions, there was a high risk that they would be unable to tolerate esophagectomy to prevent stent graft infection. Therefore, antibiotic therapy was initiated. However, CT revealed a stent graft infection 24 days after TEVAR. The patient died of sepsis 27 days after the procedure. Discussion We describe the first case of AEF as a very late complication of radiotherapy for esophageal cancer. Surgery to repair esophageal defects is necessary to prevent stent graft infection. However, the decision for such surgery should be made on a case-by-case basis, taking into account the patient’s condition and ability to tolerate the procedure.

Endovascular intervention in patients with blunt traumatic thoracic aortic injury: Early results

Aim: Mortality rates are high in thoracic aortic injuries caused by blunt trauma. Thoracic endovascular aortic repair (TEVAR) is the most commonly employed surgical strategy for patients with blunt traumatic thoracic aortic injuries (BTTAI) due to its favorable outcomes. This study aims to present our endovascular experience in treating Type B aortic dissections resulting from blunt trauma. Material and Methods: Our retrospective study included 70 patients who underwent TEVAR for Stanford Type B aortic dissection due to blunt aortic injury. Patients who were under 22 and over 70 years of age, those who underwent emergency TEVAR, died in a hospital emergency, and had penetrating aortic injury, head traumas with neurological symptoms and requiring intervention, aortic pathology other than Type B aortic dissection, or aortic rupture were excluded from the study. Results: Of the patients, 34.3% (n=24) were female, and 65.7% (n=46) were male, with a mean age of 48.54±10.00 years. The most common cause of injury was motor vehicle accidents (81.4%, n=57). No statistically significant difference was found between patients regarding the locations of the landing zones (p>0.05). Conclusion: Early outcomes in selected patients demonstrate high survival rates following TEVAR for trauma-induced Type B dissections.

Endovascular Repair of Zone 0 Ascending Aortic Aneurysm: A Review of Current Knowledge and Developing Technology.

Aortic aneurysms represent the 15th leading cause of death in men and women over 55 years of age. Where historically these lesions were all addressed via an open approach, endovascular aortic repair has entirely altered the way that surgeons approach aortic lesions. Although it was initially employed for patients who were poor surgical candidates, endovascular repair is now standard for abdominal aortic aneurysms and aneurysms in the descending thoracic aorta. Open surgery remains the gold standard for management of ascending aneurysms, in part due to the limitations portended by the anatomy of the ascending aorta, although increasing evidence suggests that endovascular approaches are feasible and may sometimes be optimal for patient outcomes. Here, we present some of the anatomical and technical challenges of the endovascular approach to these "Zone 0" aneurysms, the associated complications, and the current state of device development.

Predictive factors of extremity graft occlusion after endovascular repair of abdominal aortic aneurysm: A 13-year single center experience

Aim: Graft leg thrombosis (GLT) after Endovascular Aortic Repair (EVAR) is an important problem affecting morbidity/mortality. In addition to anatomical factors such as aortic neck angle and diameter in graft leg thrombosis; we aimed to convey the roles of graft extension to the external iliac artery and the effect of graft type selection on the results. Material and Methods: Analysis of 512 patients who underwent EVAR between 2010 and 2023 was performed. The effects of anatomical factors, graft material, underlying diseases, age and gender on the development of graft leg thrombosis were evaluated. Anatomical measurements were evaluated in terms of their predictive power for graft leg thrombosis by Receiver Operating Characteristic (ROC) analysis. Results: The prevalence of graft leg occlusion was significantly associated with some anatomical factors, especially increased aortic neck angle (OR=1.07, p<0.001) and descent to the external iliac artery (OR=13.43, p<0.001). Poliytetrafluoroethylene (PTFE) grafts were associated with a reduced risk of graft leg occlusion (OR=0.26, p=0.002). ROC analysis showed that aortic neck angle had the highest predictive accuracy for GLT (AUC=0.817, p<0.001). There were no significant differences in age, gender, smoking status, diabetes, and hypertension as comorbidities. Peripheral artery disease was shown to increase the risk. Conclusion: Our findings highlight the role of aortic anatomy and graft material selection in the risk of graft leg thrombosis. The use of PTFE grafts appears to be protective against graft leg thrombosis. This information highlights the importance of personalized surgical planning and postoperative management to optimize patient outcomes. Future research should focus on developing models that include these factors.

Blue toe syndrome - systemic cholesterol crystal embolism secondary to cardiovascular procedures: a forensic autopsy report of two cases.

Blue toe syndrome, also referred to as cholesterol crystal embolism is characterized by the distal embolization of cholesterol crystals originating from ruptured atherosclerotic plaques. This condition commonly arises in the context of cardiovascular procedures. Emboli from the thoracoabdominal aorta primarily affect the downstream extremities and intra-abdominal viscera, often resulting in fatal atheroembolic renal failure. Owing to its insidious and delayed onset, antemortem diagnosis of cholesterol crystal embolism is often underrecognized. Two cases of blue toe syndrome secondary to cardiovascular procedures are presented. In Case 1, the patient died 35 days after coronary angioplasty, whereas in Case 2, the patient developed toe necrosis 95 days after endovascular aortic repair, leading to progressive renal failure over the following five years. A comprehensive forensic autopsy included external examination, skin biopsy, histopathological examination of major organs, and serum biochemical evaluation of renal function parameters. Two cases of blue toe syndrome secondary to cardiovascular procedures are presented. In Case 1, the patient died 35 days after coronary angioplasty, whereas in Case 2, the patient developed toe necrosis 95 days after endovascular aortic repair, leading to progressive renal failure over the following five years. A comprehensive forensic autopsy included external examination, skin biopsy, histopathological examination of major organs, and serum biochemical evaluation of renal function parameters. This report underscores the importance of including systemic cholesterol crystal embolism in the differential diagnosis of blue toe syndrome, particularly in patients with a history of cardiovascular procedures. Fingertips serve as reliable indicators of impaired blood perfusion. To assess blue toe syndrome accurately, we highlight the value of focusing on the toe tips where cholesterol crystal embolism can be consistently detected.

Does the type of aortic pathology affect periprocedural outcomes in patients undergoing thoracic endovascular aortic repair?

Aim: To examine whether the type of aortic pathology affects periprocedural outcomes in patients undergoing thoracic endovascular aortic repair (TEVAR). Material and Methods: This retrospective observational cohort study included 47 TEVAR patients in total. Based on the kind of aortic pathology, the patients were categorized into three groups: Group 1 (n=23) included patients with type B aortic dissection (TBAD), Group 2 (n=14) included patients with descending thoracic aortic aneurysm (DTAA), and Group 3 (n=10) included patients with thoracic aortic mural thrombus (TAMT). Preprocedural basic clinical features, procedural data, and postprocedural outcomes and complications were compared between the groups. Results: The study population consisted of 36 males and 11 females, with a mean age of 62.48±14.2 years. Most of the patients in Groups 1 and 2 were male (82.6% and 92.8%), while 40% of the patients in Group 3 were male, and this difference was statistically significant. Compared to patients in other groups, individuals in Group 2 were significantly older and exhibited a higher incidence of chronic obstructive pulmonary disease and coronary artery disease. Group 3 required thromboembolectomy more frequently during the postprocedural period. In terms of other postprocedural outcomes, complications and mortality, there were no significant differences between the groups. Conclusion: Our study demonstrated that the type of aortic pathology did not significantly influence periprocedural outcomes in patients undergoing thoracic endovascular aortic repair (TEVAR). The TEVAR procedure can be effectively performed in suitable patients with various pathologies of the descending thoracic aorta.

Early outcomes of treatment selections for infrarenal abdominal aortic aneurysms: The first five year experience of a single center

Aim: We examined the criteria governing patient selection in contemporary practice in cases of infrarenal abdominal aortic aneurysm (AAA) treated electively or urgently in our Cardiovascular Surgery Clinic (CVSC). Material and Methods: From January 2019 to January 2024, we retrospectively evaluated infrarenal AAA patients treated either electively or urgently with Open Surgical Repair (OSR) or standard Endovascular Aortic Repair (EVAR) at our CVSC. The primary endpoints are distribution of AAA patients by treatment modality, early morbidity and mortality. The secondary endpoints were intensive care unit (ICU) duration and length of hospital stay (LOS). Results: A total of 332 patients received EVAR (Group 1), including 296 elective cases, while 90 patients underwent OSR (Group 2), with 66 being elective. Early mortality rates were significantly lower in the EVAR group (1.3% for elective and 27.8% for emergent) compared to the OSR group (6.1% for elective and 54.2% for ruptured cases, p=0.001). Major postoperative complications occurred in 12.5% of elective EVAR patients and 39.4% of elective OSR patients (p=0.001), while in ruptured cases, the rates were 11.1% and 58.3%, respectively (p=0.001). Comparisons of ICU duration and LOS also favored EVAR (p=0.001). Conclusion: EVAR offers a survival benefit in the early period compared to OSR. The choice of treatment should be tailored to the patient's comorbidities, preferences, and the vascular surgeon's expertise. Advanced aortic centers with hybrid operating rooms (HOR) and specialized CVSCs should aim for optimized patient outcomes and cost-effectiveness in our country.

Orexin concentrations and diurnal variation in the cerebrospinal fluid of intensive care unit patients undergoing aortic surgery with spinal drainage.

Cerebrospinal fluid (CSF) levels of orexin show a cyclic diurnal variation in healthy subjects, which is diminished in patients with certain diseases. However, possible circadian variations in orexin levels in critically ill patients remain unknown. In this study, we evaluated the orexin concentrations in the CSF and their diurnal variation in patients undergoing thoracic aortic aneurysm repair with lumbar intrathecal catheterization for CSF drainage after non-neurosurgery. Eligible patients with a lumbar intrathecal catheter placed for CSF drainage following aortic surgery at a single-center ICU between September 2019 and February 2020 were included. Catheters were placed before anesthesia induction, and CSF was collected at the time of catheter placement, ICU admission, and daily at 6:00, 12:00, 18:00, and 24:00 until the catheter was removed or for up to 5 days after admission to the ICU. Three patients (Patients A, B, and C) who underwent thoracic aortic aneurysm repair were included. Patients B and C received sedatives or hypnotics during the orexin measurement period. The baseline orexin levels for Patients A, B, and C were 219.9, 312.3, and 403.8 pg/mL, while the mean orexin levels were 319.4 ± 82.6, 372.4 ± 56.0, and 306.3 ± 48.3 pg/mL, respectively. For all three patients, orexin levels showed diurnal variations, but no consistent periodic changes. CSF orexin concentrations for patients undergoing thoracic aortic aneurysm repair in the ICU were within the reported range compared to those of previously reported healthy subjects; however, consistent periodic diurnal variations were not observed.

Multidisciplinary Approach to Direct Segmental Artery Revascularization to Prevent Spinal Cord Ischemia Associated With Endovascular Thoracoabdominal Aortic Repair.

Despite advances in complex endovascular aortic repair techniques, spinal cord ischemia (SCI) remains a devastating complication following endovascular thoracoabdominal aortic repairs. Novel strategies to preserve key intercostal/lumbar arteries have been described. We report our early results of patients who underwent direct intercostal/lumbar artery revascularization using endovascular incorporation of fenestrations/branches or extra-anatomic approaches for fenestrated-branched endovascular aortic repairs (FBEVARs). A retrospective review of consecutive patients who underwent FBEVAR with intercostal/lumbar artery revascularization from 2018 to 2022 was performed. Patient characteristics, intraoperative details, and outcomes including SCI and branch occlusions were evaluated. Among 317 patients who underwent FBEVAR during the study period, 12 patients were included. Aortic pathologies consisted of degenerative aneurysms (33%), postdissection aneurysms (33%), extensive penetrating aortic ulcers with intramural hematoma (25%), and visceral patch pseudoaneurysm (8%). Full thoracoabdominal coverage was required in 8 patients and supraceliac coverage >10 cm was required in 4. Nine patients received endovascular incorporation, including directional branches (5/9), unstented fenestrations (2/9), and stented fenestration (2/9). Three patients received extra-anatomic subcutaneous femoral-to-radicular artery bypass using a composite graft of polytetrafluoroethylene (PTFE) and venous conduit. Our institutional SCI prevention protocol, consisting of prophylactic cerebral spinal fluid drain (CSFD) for high-risk patients, hemodynamic augmentation, and oxygen supplementation, was followed. Prophylactic CSFD was placed in 9 patients. One patient had unsuccessful drain placement attempts. The other 2 patients had previous unsuccessful attempts at CSFD placement. Median number of target vessels for FBEVAR was 4 with fluoroscopy time 66±31 minutes, contrast usage 109±51 ml. There were no in-hospital mortalities. Tarlov grade II SCI (ASIA grade D) were seen in 2 patients (1 endovascular and 1 extra-anatomic bypass), which resolved before discharge. At mean follow-up of 472±447 days, 3 patients had thrombosed intercostal/lumbar branches (1 extra-anatomic bypass and 2 endovascular branches) with no new SCI symptoms. In patients at high risk for SCI undergoing FBEVAR, direct revascularization of an intercostal or lumbar artery is feasible using endovascular or extra-anatomic bypass approach. Further studies are planned to identify key contributing segmental arteries and optimization of revascularization strategies. This study demonstrates the feasibility of Endovascular and extra-anatomic bypass to preserve segmental artery flow, aimed at reducing the risk of spinal cord ischemia during endovascular thoracoabdominal aortic repairs.

Predictors for length of stay after surgical aortic valve replacement.

Aortic valve replacement improves and prolongs lives of patients with aortic valve disease, but requires significant healthcare resources, which are mainly determined by the length of associated hospital stays. Therefore, this study aims to identify risk factors for extended length of stay after surgical aortic valve replacement. Between 2018 and 2023, 458 consecutive patients underwent isolated surgical aortic valve replacement at our center and were included in our analysis. To identify independent predictors for hospital and intensive care unit stay, multivariable linear regression analysis using backward elimination process was performed. Upon multivariable linear regression, endocarditis [regression coefficient (β) 2.98; 95% confidence interval (CI) 1.51, 4.45; p<0.001)] and prior aortic valve surgery (β 1.72; 95% CI 0.18, 3.26; p=0.029) were associated with prolonged hospital stay. Prior aortic valve surgery was associated with prolonged intensive care unit stay (β 0.99; 95% CI 0.39, 1.59; p=0.001) as well as chronic obstructive pulmonary disease (β 1.61; 95% CI 0.66, 2.55; p=0.001), smaller prosthetic valve sizes (β -0.18; 95% CI -0.30, -0.06; p=0.003), preoperative atrial fibrillation (β 1.06; 95% CI 0.32, 1.79; p=0.005), and reduced left ventricular ejection fraction (β -0.03; 95% CI -0.05, -0.01; p=0.006). Pending further validation, structured programs aiming to accelerate intensive care unit and hospital discharge after surgical aortic valve replacement should focus on patients with prior cardiac surgery, atrial fibrillation, and chronic obstructive pulmonary disease. Surgeons should aim to implant large-diameter valves. Furthermore, the identified predictors should be used to discuss surgical versus transcatheter procedures in the interdisciplinary heart team.

Endovascular abdominal aortic aneurysm repair (EVAR) outcomes of unibody and single/double docking limb endografts in Medicare beneficiaries between 2012 and 2018.

The evaluation of perioperative and long term outcomes for endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms (AAA) using anatomic (unibody) and proximal neck fixated (docking limbs) endografts across consecutive time cohorts. This study compares the outcomes of EVAR in Medicare patients stratified by mode of fixation. All patients who underwent EVAR between 2012 and 2018 were identified in the Medicare database. Anatomic fixation (AF) and proximal fixation (PF) grafts were differentiated using Current Procedural Terminology (CPT) codes. The AF population was divided into three-time cohorts based on iterative changes in graft design: Cohort 1: (01/01/2012-20/07/2014); Cohort 2: (21/07/2014-09/05/2016); and Cohort 3: (10/05/2016-31/12/2017). The PF cohort was similarly divided into these three periods. Outcomes were evaluated through 31/12/2020 and included all-cause mortality, aortic rupture, and aortic-related reintervention. 32,031 patients underwent EVAR during the study period; 4729 were AF and 27,302 were PF. There were more women (p < .001) and patients with peripheral vascular disease (PVD) (p < .001) in the AF group. There were no group differences in perioperative outcomes. In Cohort 1, there was a higher rate of reintervention (11.9% vs 7.6%; p < .001) and aortic rupture (5.3% vs 4.0%; p = .019) in the AF group compared to the PF group. In Cohort 2, reintervention, aortic rupture, and reintervention rates were similar between the two groups (p = NS). In Cohort 3, the reintervention and aortic rupture rates were similar between the two groups (p = NS). The higher rates of aortic rupture and reintervention seen in the AF group in Cohort 1 when compared with the PF group did not persist in Cohorts 2 and 3. This suggests that improvements in graft design may have led to durability which is similar to that of PF grafts. However, late aneurysm related complications are inherent risks after EVAR and long-term surveillance remains necessary.

TIPS, a Trick for Transcaval TEVAR Access.

We described an alternative access for thoracic endovascular aortic repair (TEVAR) deployment using a transjugular intrahepatic portosystemic shunt (TIPS) needle for gaining transcaval access to the abdominal aorta. A 63-year-old man presented with a penetrating atherosclerotic ulcer in the descending aorta. Traditional transfemoral and transaxillary access were not possible. A transcaval access was established using a TIPS needle to puncture from the caval vein to the aorta. Next, the access was gradually upsized until a 22 french large-bore transcaval access was achieved. Afterwards the thoracic endograft was positioned and deployed accustomed. The infrarenal aortocaval fistula was closed with a covered stent. When classic TEVAR access is not possible, transcaval access is a valuable and minimally invasive alternative access. We prefer the use of a TIPS needle for gaining access and use a covered stent for closing the aortic access site when possible instead of using electrified wires nor a transseptal occluder device. Preoperative planning remains key. We discribe a transcaval access with a TIPS needle and closing of the aortocaval fistula with a covered stent. We are one of fiew reports of transcaval puncturing instead of using an electrified wire and the first using a TIPS needle for gaining transcaval access. We hope this case and our comments help other surgeons, radiologists and patients when they are in need of a transcaval access and contribute to a successful procedure.

Long Term Outcomes of Endovascular Repair in Blunt Traumatic Aortic Injury: A Twenty Year Multicentre Follow Up Study.

This retrospective, multicentre, observational study analysed patients who underwent endovascular repair for blunt traumatic aortic injury at four tertiary trauma referral centres over twenty years. It aimed to determine early and long term survival, analyse aortic and device related complications, and assess the re-intervention rate after endovascular repair for blunt traumatic aortic injury. All patients treated from 1 January 2001 to 31 October 2021 were identified using local hospital registries and two national registries: the Swedish vascular registry (Swedvasc) and Swedish trauma registry (SweTrau). Patient, treatment, and follow up data were extracted from medical records and radiology data by review of congregated imaging. The report was structured according to the STROBE checklist. Ninety five patients were included: 80 were male (84%), median age was 42 years (IQR 27, 64), and median follow up time was 6.1 years (IQR 0.7, 12.4). Thirty day mortality was 16% (15 of 93), 40% of these were caused by traumatic brain injury and 33% of aortic related causes. Estimated overall survival was 57% (SE 6.6) at fifteen years after index treatment. Aortic re-intervention procedures (re-stenting, coiling, or explantation) were performed in 14 of 86 (16%) patients, six of whom underwent stent graft explantation. Seven of the 14 patients (50%) who underwent aortic re-intervention presented with symptoms and six of 14 had a device related complication. All complications that required aortic re-intervention were diagnosed within 18 months after the index procedure. There was no association between injury grade and aortic re-intervention. Thoracic endovascular aortic repair is an effective treatment for patients with blunt traumatic aortic injury needing intervention. It carries low rates of device related complications and mortality, and the long term outcomes are acceptable. As all aortic complications requiring re-intervention were identified during the first two years after index treatment, with half of the patients reporting symptoms, future follow up protocols should be adjusted accordingly.

Dynamic Morphology of Dilated Ascending Aorta and its Implications for Proximal Landing During Thoracic Endovascular Aortic Repair.

To improve the outcomes of thoracic endovascular aortic repair (TEVAR), we investigated the dynamic morphology of dilated and nondilated ascending aortas (AAs) to determine whether an appropriate proximal landing zone for TEVAR exists if the middle AA is dilated. Patients with dilated (diameter 40-50 mm) and nondilated (<40 mm) AAs underwent electrocardiogram-gated computed tomography angiography of the entire AA in the systolic and diastolic phases. For each plane of each AA segment, the maximal and minimal diameters in systole and diastole were recorded. A total of 105 patients were enrolled (54% male; median age: 80 years [IQR 78-85]). A total of 35 patients were included in the dilated AA group (DG), and 70 patients were included in the nondilated AA group (n-DG). The aortic planes of the AA segment at the sinotubular junction (STJ) showed a more oval-shaped morphology compared with the distal planes of the same segment (the differences between the maximum and minimum diameters were 8.9% to 9.4% and 4.8% to 5.6%, respectively). If the mid-ascending aorta was dilated, the aortic segment at the STJ showed a more pronounced reversed-funnel 3D morphology, with a 14% (IQR 11%-19%) difference in diameters between the proximal and distal segmental planes shown in the n-DG and 18% (IQR 16%-22%, p<0.001) in the DG. If the middle AA is dilated, it is considered unsuitable to perform TEVAR using conventional endografts without additional proximal fixation in the aortic segment at the STJ due to its pronounced reversed-funnel segmental morphology. By contrast, the aortic segment at the brachiocephalic trunk seems to be promising for performing TEVAR using an endograft of the appropriate size and conformability. Moreover, endograft sizing using the average aortic diameter instead of the maximal AA diameter in an oval-shaped aortic plane morphology should be considered. If the middle ascending aorta is dilated, it is considered unsuitable to perform TEVAR with a proximal landing in the aortic segment at the sinotubular junction due to its pronounced reversed-funnel segmental morphology and high risk of type Ia endoleak and endograft migration. By contrast, the aortic segment at the brachiocephalic trunk seems to be promising for performing TEVAR due to its moderate funnel morphology using an endograft of appropriate size and conformability.

Abstract 4141445: Long-Term Predictive Value of 4D Flow MRI in Bicuspid Aortic Valve Patients: A 10-Year Assessment for Aortic Surgery Risk

Introduction: Bicuspid aortic valve (BAV) is associated with progressive ascending aorta (AAo) dilation, often leading to aneurysms, dissections, and ruptures. Thus, current guidelines recommend preventive surgery for AAo dilation. Recent 4D flow MRI studies show that BAV morphology causes abnormal transvalvular flow patterns, increasing wall shear stress (WSS), a trigger of aortic growth. Further studies have delineated areas of abnormally high WSS by comparing to estimates of matched controls, and show promise in detecting risk for aortic growth. However, since the long-term prognostic significance of this marker is unclear, we aimed to quantify WSS in BAV patients to assess its value in predicting the need for aortic surgery up to 10 years post-4D flow MRI acquisition. Methods: BAV patients without prior surgical intervention scanned before April 1, 2014 were identified. Using medical records, patients were categorized as ‘operated’ if they underwent aortic surgery post-scan and ‘non-operated’ if they were surgery-free for at least 10 years post-scan. 4D flow MRIs were processed with an AI pipeline, including 3D segmentation of the aorta, followed by peak velocity (PV) and WSS quantification in the AAo (Fig. 1A-C). Patient-specific WSS heatmaps were computed relative to a map based on the WSS of 10 or more sex and age-matched controls. Relative areas of elevated WSS in the AAo were then calculated (Fig. 1D-F). Results: 115 patients were included, with 73 non-operated (age: 42.5±11.5y, 49M) and 42 operated patients (age: 53.5±12.1y, 34M). The mean baseline mid-AAo diameters for non-operated and operated patients were 3.8±0.6 cm and 4.1±0.5 cm, respectively. Among operated patients, the mean scan to surgery time was 5.7±3.3y. All three 4D flow metrics were significantly higher in operated compared to non-operated patients: PV: 2.6±0.6 vs. 1.7±0.4 m/s (p&lt;0.01); WSS: 2.2±0.5 vs. 1.6±0.4 Pa (p&lt;0.01); relative area of high WSS on heatmaps: 31±12 vs. 15±13% (p&lt;0.01). Conclusions: 4D flow MRI parameters provide long-term predictive value in BAV patients, as elevated peak velocity, wall shear stress, and relative area of high wall shear stress on heatmaps are associated with subsequent aortic surgery within 10 years post-scan.

Chlorhexidine-alcohol compared with povidone-iodine-alcohol skin antisepsis protocols in major cardiac surgery: a randomized clinical trial.

Whether skin disinfection of the surgical site using chlorhexidine-alcohol is superior to povidone-iodine-alcohol in reducing reoperation and surgical site infection rates after major cardiac surgery remains unclear. CLEAN 2 was a multicenter, open-label, randomized, two-arm, assessor-blind, superiority trial conducted in eight French hospitals. We randomly assigned adult patients undergoing major heart or aortic surgery via sternotomy, with or without saphenous vein or radial artery harvesting, to have all surgical sites disinfected with either 2% chlorhexidine-alcohol or 5% povidone-iodine-alcohol. The primary outcome was any resternotomy by day 90 or any reoperation at the peripheral surgical site by day 30. Of 3242 patients (1621 in the chlorhexidine-alcohol group [median age, 69 years; 1276 (78.7%) men] and 1621 in the povidone-iodine-alcohol group [median age, 69 years; 1247 (76.9%) men], the percentage required reoperation within 90days was similar (7.7% [125/1621] in the chlorhexidine-alcohol group vs 7.5% [121/1621] in the povidone-iodine-alcohol group; risk difference, 0.25 [95% confidence interval (CI), -1.58-2.07], P = 0.79). The incidence of surgical site infections at the sternum or peripheral sites was similar (4% [65/1621] in the chlorhexidine-alcohol group vs 3.3% [53/1621] in the povidone-iodine-alcohol group; risk difference, 0.74 [95% CI -0.55-2.03], P = 0.26). Length of hospital stay, intensive care unit or hospital readmission, mortality and surgical site adverse events were similar between the two groups. Among patients requiring sternotomy for major heart or aortic surgery, skin disinfection at the surgical site using chlorhexidine-alcohol was not superior to povidone-iodine-alcohol for reducing reoperation and surgical site infection rates.

Results of a German nationwide survey on perioperative cardiac management in vascular surgery.

This article is based on a survey from 2018 of heads of German vascular surgical departments or units regarding their experience with perioperative cardiac management. The questionnaire asked about the experience with preoperative cardiac evaluation and its extension, awareness of perioperative myocardial ischemia, the art of postoperative monitoring and the routine use of the best medical treatment. In total, 62% of responders agreed that perioperative myocardial ischemia is a relevant postoperative problem in their clinic after open abdominal aortic surgery, while 47% stated the same after vascular surgery (VS) like carotid endarterectomy, peripheral arterial surgery or EVAR. Preoperative cardiological evaluations are performed routinely by 87% of responders before open abdominal aortic surgery and by 42% before VS. Preoperative cardiac evaluation included cardiac echography in 92% and stress diagnostics (stress echography, stress ECG) in 38%. Routine preoperative cardiac catheterisation is performed in 4% before OAS and only 0.5% before VS. In addition, 79% of participants initiate acetylsalicylic acid routinely and 68% use statins preoperatively. The serum troponin diagnostic test in asymptomatic patients was routinely applied by 19% of responders after OAS and by 6% after VS. Perioperative myocardial ischemia is considered a relevant problem, primarily after aortic surgery. The preoperative cardiac stress diagnostics among vascular surgeons does not seem to be sufficiently widespread. The preoperative initiation of acetylsalicylic acid and statins is not routine in 30% of hospitals.

Abstract 4137441: Online Cognitive Behavioral Therapy Targeting Psychological Distress Following Open Heart Surgery: An Uncontrolled Pilot Study

Background: Cardiac surgery is a significant procedure that reduces mortality and alleviates symptom burden in individuals with cardiovascular diseases. However, many patients develop depression and cardiac-related anxiety postoperatively, which negatively affects long-term prognosis and rehabilitation. There is a clinical need to develop scalable psychological treatments to mitigate these negative health effects. Objective: To investigate the feasibility and potential efficacy of a brief internet-delivered cognitive behavioral therapy (internet-CBT) intervention to reduce psychological distress in patients following cardiac surgery. Methods: The pilot study included 32 cardiac surgery patients (i.e., CABG, heart valve repair/replacement, aortic repair, or combined CABG and valve repair/replacement) with endorsed postoperative psychological distress and/or interference with daily life who underwent surgery from eight weeks to nine months prior to enrollment. Exclusion criteria included prior cardiac surgery with a ventricular assist device or heart transplant and severe medical or psychiatric illness. The internet-CBT targeted cardiac anxiety and depressive inactivity, lasted for five weeks, and was guided by clinical psychologists via text-based interactive online treatment modules. It included interoceptive exposure, in-vivo exposure, and behavioral activation. Self-assessments were completed at pre-treatment, post-treatment, and at 6-month follow-up. Results: Preliminary analyses post-treatment showed substantial pre-post improvements across multiple domains. Notable findings included significant reductions in depressive symptoms (Cohen’s d = 0.70; p = 0.04), cardiac anxiety (Cohen’s d = 1.53; p &lt; 0.001), and perceived severity of post-operative symptoms (Cohen’s d = 1.06; p = 0.006). Participants demonstrated high adherence to the treatment, with the large majority of participants completing all five treatment modules (83.3%). Satisfaction with the treatment was also high (25.5 points out of 32), as measured by the Client Satisfaction Questionnaire, and no adverse events were reported. Conclusion: This novel internet-CBT intervention post-cardiac surgery appears to be feasible, acceptable, and clinically promising in reducing postoperative psychological distress. It could be used as a viable adjunct treatment to enhance recovery post-cardiac surgery. These preliminary findings warrant further testing in a randomized controlled trial.

Abstract 4138449: High Output Heart Failure from an Aortocaval Fistula

Introduction: High output heart failure (HOHF) due to a post-traumatic aortocaval fistula is a rare entity. This case seeks to explore the presentation as well as complexities of management of these patients. Case Presentation: A 50-year-old male with a prior right abdominal stab wound requiring exploratory laparotomy 20 years ago presented with worsening dyspnea on exertion and palpitations. Physical examination was remarkable for jugular venous distention, lower extremity edema, and a pulsatile mass in the right abdomen with an audible bruit. A 12-lead ECG showed rapid atrial flutter. A transthoracic echocardiogram (TTE) showed a reduced left ventricular ejection fraction (LVEF) of 30-35%, severely dilated atria and inferior vena cava (IVC) with high velocity flow. Abdominal computed tomography venogram showed dilation of the IVC up to 8cm and an aortocaval fistula at the level of the right renal vessels, resulting in an atrophic right kidney. Cardiac catheterization was notable for a cardiac output (CO) of 12L/min, cardiac index (CI) of 7L/min/m2 and reduced systemic vascular resistance (SVR). He was managed with beta blockers and diuretics, followed by TEE-guided cardioversion for atrial flutter to restore sinus rhythm. Vascular surgery performed a successful, first of its kind endovascular repair of the abdominal aorta with stenting of the right common iliac artery and placement of a 20mm Amplatzer Septal Occluder device in the right renal artery. He tolerated the procedure well, and post-operative TTE showed a recovered LVEF of 55-60% and CO of 6L/min. Discussion: HOHF is defined by a CO more than 8L/min or CI more than 4L/min/m2 along with clinical symptoms. Decreased SVR leads to sympathetic activation and stimulation of the renin-angiotensin-aldosterone system, leading to fluid retention, cardiac remodeling, and exacerbation of symptoms. Challenges present in the management of HOHF and the use of vasodilatory agents should be avoided, as they can exacerbate the problem. In our case, limitations were also faced in the use of many traditional HF therapies due to renal dysfunction as a result of the fistula. Therefore, repair was the only viable long-term solution. Conclusion: This case displays an uncommon etiology of HOHF, emphasizing the need for meticulous evaluation to ensure proper management. Early detection of aortocaval fistulas is crucial to prevent worsening cardiac dysfunction, with symptoms resolving rapidly post-repair.