Aortic Repair Research Articles

Redo aortic arch repair using trifurcated hybrid prosthesis after failed Ascyrus medical dissection stent treatment

BackgroundThe management of acute type A aortic dissection (ATAAD) using the Ascyrus Medical Dissection Stent (AMDS) can lead to complications due to the persistence of the false lumen (FL). This case report presents two instances of failed AMDS treatment for ATAAD, highlighting the novel use of a trifurcated hybrid prosthesis for redo aortic arch repair using a minimally invasive frozen elephant trunk (FET) technique.Case PresentationCase 1: A 57-year-old male, previously treated with AMDS for ATAAD, presented with an enlarging aortic arch and persistent FL two years post-surgery caused by re-entry in the distal aortic arch. Redo surgery using the FET technique with an E-vita OPEN NEO Trifurcated hybrid prosthesis resulted in successful repair and partial FL thrombosis. Case 2: A 51-year-old male with prior AMDS treatment for ATAAD presented with severe aortic valve regurgitation and a maintained FL perfusion due to a residual re-entry in the proximal region of the descending aorta. Redo surgery using the FET technique with the same hybrid prosthesis led to successful repair and good recovery, confirmed by follow-up imaging.ConclusionsThe use of the E-vita OPEN NEO Trifurcated hybrid prosthesis in the FET technique offers a promising solution for redo aortic arch repair in cases of failed AMDS treatment for ATAAD. This approach can improve patient outcomes by addressing complications associated with persistent FL and enhancing long-term survival.

Influence of vascular graft type for ascending aorta replacement on the early postoperative outcome.

Aim of this study was to find out if the type of vascular prosthesis used, especially collagen impregnated polyester versus gelatin impregnated woven fabric graft, has any impact on the early postoperative bleeding rate, blood product consumption and re-thoracotomy rate in isolated ascending aortic surgery. n = 46 consecutive patients who received a supra-commissural replacement of the ascending aorta between 01/2016 - 01/ 2021 were included in this retrospective single-center study. The underlying pathology was an aortic aneurysm in 36 (81 %) and/or an acute type A aortic dissection (ATAAD) limited to the ascending aorta in 7 (15 %) and/or a penetrating aortic ulcer (PAU) with intramural hematoma in 6 (13 %) patients. According to the type of vascular graft used, the cohort was divided as follows: 25 patients (54%) received a double velour woven, collagen impregnated polyester graft (Hemashield, Getinge; CI-Group) whereas in 21 patients (46 %) a gelatin impregnated woven fabric graft was used (Gelweave, Vascutek / Terumo; GI-group). As primary endpoints class 3 bleeding according to the Valve Academic Research Consortium (VARC3) criteria and freedom from re-intervention were assessed. As secondary endpoints, 30-day mortality and stroke were defined. Preoperative risk assessment (EuroSCORE II), gender-, BMI-stratification and NYHA-classification as well as mean CPB-times (114 ± 44min vs 110 ± 48min) and aortic cross-clamp times (71 ± 28min vs 66 ± 30min) were similar in both groups. Bleeding, measured by drainage volume output within the first postoperative 24h (480 ± 426mL vs 389 ± 169mL), erythrocytes concentrate consumption (2,4 vs 2,3) and similar re-thoracotomy rates (4 vs 4.7 %) showed no difference between groups. 30- day mortality (12 vs 5 %; p = 0.614) and stroke rates (4 vs 9.5; p = 0,4) showed no differences between groups. Regarding postoperative bleeding no difference were seen between the two graft types. Long-term follow-up and larger prospective randomized studies are requested to prove these findings.

A New Bailout Maneuver to Manage Type IIIa Endoleak Due to Displaced Renal Bridging Stent Graft in Narrow Aorta.

To present endovascular management of an intraoperative type IIIc endoleak (EL) in a patient with migration of the right renal artery (RRA) bridging stent graft (BSG) during branched aortic aneurysm repair. The technique is demonstrated in an 80-year-old woman who underwent branched endograft repair of a symptomatic 6-cm type II TAAA. The t-Branch thoracoabdominal stent graft was positioned without difficulty. A "partial graft deployment" was performed, with the distal portion of the device remaining inside the delivery system and the right renal and superior mesenteric arteries were stented. When the constraining wires were removed, the RRA BSG migration from the branch was displayed, due to endograft twisting resulting in a horizontal rotation of the t-Branch. The RRA BSG remained oriented upward with the proximal edge positioned above the distal edge of the directional branch, making cannulation very difficult. This bailout technique uses a balloon placed at the level of the RRA BSG through the celiac artery (CA) directional branch; keeping the balloon inflated and in thrust, the edge of the BSG has moved downward making it possible to engage it and relining through the RRA directional branch. This paper describes an endovascular bailout technique for relining a displaced bridging stent graft, oriented upwards with the proximal edge positioned above the distal edge of the directional branch. This sophisticated technique adds to the spectrum of bailout techniques that can be applied in cases of type IIIa EL with migration and complete separation of BSG.

Prevalence, Clinical Features and Outcomes of Patients with Acute Aortic Dissection and Concomitant Lower Extremity Malperfusion

Objective: The aim of this study was to describe the prevalence and clinical characteristics of patients presenting with lower limb malperfusion (LLM) following an aortic dissection, and the outcomes of the patients repair of the dissection as the initial operative procedure. Method: We performed a retrospective medical record review at our single center of patients who presented with an aortic dissection complicated by LLM from January 2019 to June 2023, and analyzed the incidence, clinical characteristics, prognosis and reintervention of these patients. Result: The incidence of patients with an aortic dissection complicated by LLM was 6.3% (39/617) with mortality rate of 23% (9/39). LLM cases were associated with malperfusion of other organs in 77% (30/39) of patients. All surgical patients underwent initial aortic central repair, with a mortality rate of 26% (8/30). Mortality rates were 31.8% (7/22) for type A dissections and 12.5% (1/8) for type B dissections. Immediate femoral-femoral bypass grafting was performed in 10% (3/30) of cases following aortic central repair, with the majority of patients experiencing significant improvement in LLM with aortic central repair alone. The postoperative readmission rate due to LLM was 6.7% (2/30). Conclusion: Aortic dissection with lower limb malperfusion (LLM) is associated with increased pre- and postoperative mortality, especially in Type A aortic dissections versus Type B. However, for survivors of initial central aortic repair surgery, the rates of amputation and readmission for LLM are low.

Del Nido versus conventional blood cardioplegia in patients with combined aortic root surgery: A retrospective study.

This study aimed to compare the safety and efficacy of Del Nido cardioplegia (DNC) and conventional blood cardioplegia (CBC) in combined aortic surgery. This retrospective study involved elective patients who underwent combined aortic root surgery between September 2017 and July 2023. Patients were divided into two groups: the DNC and the CBC group. The primary outcome was high-sensitivity cardiac troponin I and creatine kinase-MB levels at the 0, 1, 2, and three postoperative days. The secondary outcomes contained postoperative left ventricular ejection fraction, return to spontaneous rhythm after aortic de-clamping, postoperative myocardial infarction, new-onset atrial fibrillation, postoperative mechanical circulatory support, mechanical ventilation duration, intensive care unit stay, postoperative hospital stay, and the reduction of left ventricle end-diastolic diameter at 3months after surgery. 223 patients were included and divided into the CBC (n = 111) and the DNC group (n = 112). There was no statistical difference in patients' demographics and preoperative parameters between the two groups. No in-hospital mortality. The total cardioplegia volume [35.25 (30.30,43.65) ml/kg versus 21.43 (18.42,25.62) ml/kg, p < 0.001] and infusion times [2 (2,3) times versus 1 (1,2) times, p < 0.001] were less and the incidence of return to spontaneous rhythm after de-clamping was higher in the DNC group [59.5% versus 83%, p < 0.001]. Postoperative high-sensitivity cardiac troponin I and creatine kinase-MB levels were comparable between the two groups. DNC is related to a shorter duration of mechanical ventilation, intensive care unit stay, and hospital stay than CBC. The rate of return to spontaneous rhythm after aortic de-clamping seemed to decrease with the prolongation of aortic cross-clamping (ACC) duration, and there was no difference between the two groups when the time exceeded 120min. The safety and efficacy of using DNC were comparable to CBC in combined aortic surgery. The rate of return to spontaneous rhythm after aortic de-clamping seemed to decrease with the prolongation of ACC time. Further studies may be needed to fully elucidate the advantages of DNC in postoperative recovery and its long-term effects on patient outcomes.

Therapeutic results of three-dimensional aortic valve anatomic repair for regurgitant bicuspid aortic valve

Objective: To explore the surgical technique and results of three-dimensional aortic valve anatomic repair for bicuspid aortic valve (BAV) with aortic regurgitation (AR). Methods: This is a retrospective case series study. From August 2021 to December 2023, 130 consecutive patients with BAV-AR underwent aortic valve anatomic repair at the Department of Cardiothoracic Surgery, Zhongshan Hospital, Fudan University,and the data were retrospectively analyzed. There were 115 males and 15 females, aged (38.6±11.7) years (range: 15 to 67 years). All patients received modified aortic root reconstruction, to do three-dimensional root remodeling, including the basal ring, sinus of Valsalva and sino-tubular junction simultaneously. Perioperative and follow-up data were collected and analyzed. Comparisons between groups were performed using independent samples t-test, Wilcoxon paired signed-rank test, or χ² test. Results: No patient transferred to valve replacement during the operation. The cardiopulmonary bypass time (M(IQR)) was 109 (34) minutes (range:67 to 247 minutes), and the aortic cross-clamp time was 76 (26) minutes (range: 32 to 158 minutes). Preoperative transesophageal echocardiography showed 123 patients (94.6%) presented with moderate or severe regurgitation. Immediately postoperative transesophageal echocardiography showed no regurgitation in 22 patients (16.9%), trace regurgitation in 81 patients (62.3%) and mild regurgitation in 27 patients (20.8%). Follow up was complete in all patients, with a follow-up of 5.5 (9.4) months (range: 0.1 to 27.6 months). No mortality was observed during follow-up. Echocardiography was obtained in 112 patients at the latest follow-up, including no regurgitation in 4 patients (3.6%), trace regurgitation in 58 patients (51.8%), mild regurgitation in 45 patients (40.2%), moderate regurgitation in 4 patients (3.6%), and severe regurgitation in 1 patient (0.9%). Conclusion: For patients with BAV-AR who have good valve quality and no severe aortic sinus dilation, the recent outcomes of three-dimensional anatomical repair technique, focusing on overall remodeling of the aortic root, are satisfactory.

Simultaneous Endovascular Aortic Repair Expands Transcatheter Aortic Valve Replacement Eligibility to Patients With Hostile Aortic Pathology.

In recent years, Transcatheter Aortic Valve Replacement (TAVR) has become a primary modality of therapy in moderate-high risk patients with symptomatic aortic stenosis. Although clinicians remain vigilant about screening for both aortic stenosis, many patients still, nevertheless, often present only when they are symptomatic. Unfortunately, when isolated TAVR is performed in the context of hostile aortic pathology, it has been reported that patients suffer from higher rates of complications such as rupture, dissection, or death post-operatively. To explore the utility of a simultaneous TAVR and endovascular aortic repair in addressing symptomatic aortic stenosis in challenging patients with hostile aortic pathology. Retrospective case series within a tertiary care hospital between May 2017 and December 2023. A total of 11 patients underwent simultaneous endovascular aortic repair and TAVR. TAVR was performed first in 9/11 (82%) of the procedures while endovascular aortic repair was performed first in 2/11 procedures (18%). The median age was 84years old (IQR = 77-86years old). The median LOS was 3 days (IQR = 2-10days). The median procedure time was 155 minutes (IQR = 111-202minutes) and the median contrast amount was 100 CC (IQR = 65-139 CC). 2 patients (18%) experienced post-operative complications. Both of these patients required re-intervention. This cohort of patients did not experience any mortality at 30days related to pertinent complications or adverse MACE events. All patients were transferred to the PACU and ultimately discharged home. Extending TAVR eligibility to high-risk patients with hostile aortic pathology through the implementation of simultaneous endovascular aortic repair, performed via the same access site, is an effective strategy for management of symptomatic aortic stenosis in the context of extensive cardiovascular co-morbidities.

Hybrid Stent Graft Technique in Bridging Hostile Renal Arteries in Thoraco-abdominal Branched Endografting

Patency of target arteries is crucial for fenestrated and branched endovascular aortic repair (F/B-EVAR) in thoracoabdominal aortic aneurysms (TAAAs). Occlusions more frequently occur in renal arteries (RAs) than in coeliac and superior mesenteric arteries, especially in patients with hostile anatomy treated by BEVAR. This study aimed to report RA outcomes using a hybrid bridging stent graft technique with distal self expandable (SE) combined with proximal balloon expandable (BE) stent graft during BEVAR with hostile RA anatomies. Clinical data from consecutive patients treated for TAAA by F/B-EVAR in three aortic centres (two in the USA, one in Europe) from 2016 to 2022 were prospectively collected. Renal artery orientation was defined as hostile in case of upward (type B) or downward + upward (type D) orientation. Hostile RAs accommodated by BEVAR and combination of SE + BE stent grafts were retrospectively evaluated. Intra-operative RA related complications, technical success, and branch occlusions were assessed as early outcomes. Primary and secondary RA patency, freedom from RA related re-interventions, and freedom from RA instability were assessed during follow up. Of 584 TAAAs managed by F/B-EVAR, 83 patients (14.2%) had 125 hostile RAs (type B, 45.6%; type D, 54.4%) managed by BEVAR with hybrid SE + BE stent grafts. Intra-operative complications occurred in three RAs (2.4%), including two dissections and one disconnection, all successfully managed with additional stent. Technical success was achieved in all cases, with no RA occlusions at 30 days. The median follow up was 21 (interquartile range 4, 38) months. Estimated three year RA primary patency was 97 ± 2%. Re-interventions were performed in five RAs (4.0%), including two RA branch embolisations for bleeding, two catheter thrombectomies with stent relining (bilateral occlusion in one patient), and one revision of type Ic endoleak. Freedom from RA related re-interventions and RA instability was 95 ± 2% and 91 ± 3% at three years, respectively. Renal artery secondary patency was 99 ± 1% at three years. In hostile RA anatomies, a combination of distal SE and proximal BE stent grafts as bridging stenting in BEVAR is safe and effective, with low rates of occlusion, re-interventions, and branch instability at midterm follow up.

Low-Profile Minos TM Stent Graft System for Endovascular Abdominal Aorta Aneurysm Repair—Early and Late Outcomes in Elective and Emergent Situations

BackgroundThe aim of the study was to present the results of a novel abdominal stent graft for patients with Abdominal aortic aneurysm (AAA), through 2 years follow-up. MethodsA single-center retrospective review with prospectively collected data was performed to assess the safety and effectiveness of the Minos Abdominal stent device for treating abdominal aortic aneurysms. We estimated technical success rate, in-hospital and 30-day mortality, and mortality at the end of follow-up as well as complication and reintervention rate in our study cohort. Follow-up imaging assessments consisted of computed tomography angiography (CTA) at 1 and 6 months and yearly thereafter. ResultsA total of 52 patients (92% males; mean age, 74±6 years) were enrolled with Minos Abdominal stent device from July 2020 until September 2023. Thirty one (60%) patients were asymptomatic while 21 (40%) were symptomatic. The technical success of the endovascular aortic repair (EVAR) was 95% (49/52 patients). In 5% (3/52) of the cases, cannulation of the contralateral limb was unsuccessful and was converted to aorto-uni-iliac graft (AIU). Two (4%) aortic related death were recorded during the 30-day period. The major adverse event rate was 3.8%. The overall mean follow-up was 30±6 months; no aorta-related deaths or graft related complications were observed. Sac shrinkage (>5mm) has been observed in 70% of patients. ConclusionsMinos endoprosthesis seems to be safe, effective and durable for treating AAA either in elective or emergent situations.

Impact of Combining Iliac Branch Endoprosthesis and Physician-Modified Fenestrated-Branched Endovascular Repair for Complex Abdominal and Thoracoabdominal Aortic Aneurysms with Concomitant Iliac Artery Aneurysms

ObjectivesTreatment of iliac artery aneurysms (IAA) with the Iliac Branch Endoprosthesis (IBE) during endovascular repair of infrarenal abdominal aortic aneurysm (EVAR) has been well-documented as effective. However, limited data exists evaluating the safety and efficacy of treating complex abdominal (cAAA) and thoracoabdominal aortic aneurysms (TAAA) with associated IAA with combined physician-modified fenestrated branched endovascular aortic repair (PM-FBEVAR) and IBE. Moreover, limited studies exist assessing the impact of adding IBE on the outcomes following PM-FBEVAR. Therefore, we compared the clinical outcomes of patients who underwent PM-FBEVAR with and without IBE for the treatment of cAAA and TAAA. MethodsA single institution retrospective review of consecutive patients who underwent PM-FBEVAR between September 2015 and February 2021 was conducted. Patients with both unilateral and bilateral IBE implantation were included. Infected aneurysms and pseudoaneurysms were excluded. Demographics, technical success, and operative factors were analyzed. Primary outcomes were incidence of pelvic ischemia including buttock and thigh claudication, bowel and spinal cord ischemia, patency of internal and external limbs of IBE, and target vessel instability. Secondary outcomes included technical success, 30-day major adverse events (MAE), 30-day and all-cause mortality, and endoleaks. ResultsAmong 183 patients identified who underwent PM-FBEVAR, 22 patients underwent PM-FBEVAR and IBE with 3 patients treated with bilateral IBEs. There was no pelvic ischemia in the PM-FBEVAR and IBE group. Technical success, fluoroscopy time, and procedure time were comparable between the two groups. Contrast usage was higher in the PM-FBEVAR and IBE group (p=0.01). Thirty-day MAE and mortality were not statistically different between the two groups. At mean follow-up of 23 months, all-cause mortality was similar for both groups (21% vs 27%; p=0.47). Patency of internal iliac artery limb and external iliac artery limb of the IBE were 96% (24 of 25) and 100%, respectively, during mean follow-up of 23 months. The patient with occlusion of internal iliac limb was asymptomatic and received no re-intervention. ConclusionTreatment of cAAA and TAAA associated with IAA using combined PM-FBEVAR and IBE is feasible with high efficacy and safety, and without adverse effect on outcomes. Long-term follow-up is planned to assess durability of repair with PM-FBEVAR and IBE.

Women Experience Higher Rates of Mortality Following Thoracic Endovascular Aneurysm Repair

ObjectivesThoracic endovascular aortic repair (TEVAR) and complex endovascular thoraco-abdominal aneurysm repair (cEVAR) has been increasingly adopted in the treatment of thoracic and thoracoabdominal aorta aneurysms, offering a less invasive approach for patients with appropriate anatomy. Women usually present with smaller aortic diameter. However, they usually have greater aneurysm growth rates. How sex can affect postoperative and short-term outcomes after TEVAR is not well reported. The aim of this study was to assess outcomes in female versus male patients undergoing TEVAR for treatment of thoracic and thoracoabdominal aneurysms in a Medicare-linked database. MethodsWe retrospectively reviewed patients undergoing TEVAR for thoracic and thoracoabdominal aneurysm repair in the Vascular Quality Initiative (VQI) Vascular Implant Surveillance and Interventional Outcomes Network (VISION) database from 2003 to 2018. Patients were divided into males and females. Patients presented with ruptured aneurysm were excluded from the analysis. Postoperative outcomes included in-hospital stroke, myocardial infarction (MI), spinal cord ischemia, and 30-day mortality. One-year outcomes included mortality, aneurysmal rupture, and reintervention. Postoperative outcomes were assessed using multivariable logistic regression analysis and one-year outcomes were evaluated using Kaplan Meier Survival and Cox regression analyses. ResultsA total of 3,058 males and 1,843 females were available for the analysis. Female patients had smaller median aortic diameter, were more likely to be black, with chronic obstructive pulmonary disease, and chronic kidney disease, and to be symptomatic on presentation. Male patients were more likely to be on preoperative medications such as aspirin, beta-blockers, angiotensin-converting enzyme inhibitors, P2Y12 antagonists, and anticoagulants. After adjusting for potential confounders, female gender was associated with double the risk of in-hospital stroke (OR: 2.3, 95%CI ((1.5-3.7), P<0.001) and 80% increase in 30-day mortality (OR: 1.8, 95%CI (1.3-2.6), P=0.001). At one year, female gender was associated with a higher risk of mortality (HR: 1.2, 95%CI (1.05-1.4), P=0.011). There was a trend towards higher risk of reintervention (HR: 1.2, 95%CI (0.97-1.6), P=0.079). ConclusionsMortality after TEVAR seems to be higher in female patients at 30 days and up to one year of follow-up. Female patients also face a two times higher risk of in-hospital stroke. Future studies with a larger female population should aim to identify and potentially ameliorate the factors associated with these unfavorable outcomes in females.

Impact of a New Preoperative Stratification Based on Cardiac Structural Compromise in Patients with Severe Aortic Stenosis Undergoing Valve Replacement Surgery

Introduction and objectives: Aortic valve replacement surgery (SAVR) remains a recommended indication, though its pre-surgical stratification is an ongoing challenge. Despite the widespread use of scores like the STS and EuroSCORE II, they have a number of limitations, while often neglecting structural parameters like left ventricular hypertrophy or left atrium volume. This study aimed to evaluate whether a new adaptation of the Généreux classification in the preoperative risk stratification of severe aortic stenosis (AS) is associated with the primary outcome, and to compare it with the original classification versus the traditional scores in short- and long-term follow-up. Methods: We conducted a retrospective, single-center study involving patients with confirmed severe AS who underwent SAVR. The new stratification categorized patients into three stages. Cox regression analyses were conducted to identify factors associated with mortality, with survival analysis performed using Kaplan–Meier curves. A p-value &lt; 0.05 was considered statistically significant. Results: A total of 508 patients were included. Stage 3 patients had a lower median age (67 years). The median EuroSCORE II and STS scores were 2.75 and 2.62%, respectively (p ≤ 0.001). Over a median follow-up of 81 months, 56 deaths occurred (11%). Kaplan–Meier curve analysis revealed significant differences in all-cause mortality among the three groups (HR 4.073, log-rank p ≤ 0.001). Multivariable analysis identified the three preoperative stages (HR 3.22, [95% CI 1.44–7.20], p = 0.004) and mean transaortic gradient (HR 0.96, [95% CI 0.92–0.99], p = 0.021) as independent variables of mortality. The original Généreux scale AUC was higher (AUC: 0.760, 95% CI: 0.692–0.829) compared to the modified Généreux scale (AUC: 0.758, 95% CI: 0.687–0.829). However, no statistical differences were found between the different scales. Conclusions: Preoperative three-stage classification and low transaortic gradient are factors associated with increased all-cause mortality in patients undergoing SAVR. The proposed staging system performed better in the mortality analysis than EuroSCORE II and STS and was similar to the original classification.

Massive thoracic aortic dissection in the subacute postpartum period in a patient with Marfan syndrome

Aortic dissection is a life-threatening condition that can result in rupture, massive hemorrhage, and death. Parturients with Marfan syndrome are at increased risk of aortic dissection due to connective tissue dysfunction and physiologic changes secondary to pregnancy. Aortic dissection typically manifests during the intrapartum period, rather than the postpartum course. This article discusses a case of a parturient with Marfan syndrome who suffered a massive thoracic aortic dissection in the subacute postpartum period after an uncomplicated vaginal delivery. Abbreviations: CT - computerized tomography; AD - Aortic dissection; MFS - Marfan syndrome; PPD - postpartum day; TEVAR - thoracic endovascular aortic repair; TTE - transthoracic echocardiogram; VAVD - vacuum assisted vaginal delivery; VD - vaginal delivery Keywords: Marfan Syndrome; Pregnancy; Aortic Dissection; Neuraxial Anesthesia Citation: Dhoon T, Crain NA, Rahimian R, Rajan GR. Massive thoracic aortic dissection in the subacute postpartum period in a patient with Marfan syndrome. Anaesth. pain intensive care 2024;28(5):964−968; DOI: 10.35975/apic.v28i5.2564 Received: May 09, 2024; Reviewed: August 15, 2024; Accepted: August 15, 2024

Bicuspid Valve Aortopathy: Is It Reasonable to Define a Different Surgical Cutoff Based on Different Aortic Wall Mechanical Properties Compared to Those of the Tricuspid Valve?

In this study, we examined and compared ex vivo mechanical properties of aortic walls in patients with bicuspid (BAV) and tricuspid (TAV) aortic valve aortopathy to investigate if the anatomical peculiarities in the BAV group are related to an increased frailty of the aortic wall and, therefore, if a different surgical cutoff point for ascending aortic replacement could be reasonable in such patients. Ultimate stress tests were performed on fresh aortic wall specimens harvested during elective aortic surgery in BAV (n. 33) and TAV (n. 77) patients. Three mechanical parameters were evaluated at the failure point, under both longitudinal and circumferential forces: the peak strain (Pstr), peak stress (PS), and maximum elastic modulus (EM). The relationships between the three mechanical parameters and preoperative characteristics were evaluated, with a special focus on evaluating potential risk factors for severely impaired mechanical properties, cumulatively and comparatively (BAV vs. TAV groups). The patient populations were inhomogeneous, as BAV patients reached surgical indication, according to the maximum aortic dilatation, at a younger age (58 ± 15 vs. 64 ± 13; p = 0.0294). The extent of the maximum aortic dilatation was, conversely, similar in the two groups (52 ± 4 vs. 54 ± 7; p = 0.2331), as well as the incidences of different phenotypes of aortic dilatation (with the ascending aorta phenotype being the most frequent in 81% and 66% of the BAV and TAV patients, respectively (p = 0.1134). Cumulatively, the mechanical properties of the aortic wall were influenced mainly by the orientation of the force applied, as both PS and EM were impaired under longitudinal stress. An age of >66 and a maximum dilatation of >52 mm were shown to predict severe Pstr reduction in the overall population. Comparative analysis revealed a trend of increased mechanical properties in the BAV group, regardless of the position, the force orientation, and the phenotype of the aortic dilatation. BAV aortopathy is not correlated with impaired mechanical properties of the aortic wall as such. Different surgical cutoff points for BAV aortopathy, therefore, seem to be unjustified. An age of >66 and a maximum aortic dilatation of >52 mm, however, seem to significantly influence the mechanical properties of the aortic wall in both groups. These findings, therefore, could suggest the need for more accurate monitoring and evaluation in such conditions.

Abdominal aortic aneurysm repair in Sweden vs. Finland: benefits of population-wide screening.

In 2006, screening of 65-year-old men for abdominal aortic aneurysm (AAA) was started in Sweden. Decline in aneurysm-related mortality has been reported since, but aneurysm incidence has been diminishing globally. Neighbouring Finland with similar population structure and health care system has no AAA screening programme. The aim of this study was to compare incidence and results of AAA repair in Sweden and Finland to differentiate the effect of screening from other changes in the epidemiology and treatment of AAA. All repairs for intact AAA (iAAA) or ruptured AAA (rAAA) from 1998 to 2017 were identified from national registers, and mortality data for these patients were collected. A total of 15 927 operations for iAAA were performed in Sweden and 6933 in Finland. In Sweden, the yearly operation volume increased after introduction of screening. Both countries showed a decrease in number of rAAA operations, but the decrease was more pronounced in Sweden. Sweden had a higher proportion of all AAA repairs because of rupture in the start of the study but by the end, the proportions were similar in both countries. Long-term survival improved for 65-79-old men in Sweden after start of screening. This study reveals improvements in results of AAA repair in Sweden. A decrease in rAAA repair and increase in iAAA repair were evident after AAA screening was started in 2006 and resulted in better outcomes. These changes are likely the result of AAA screening as they cannot be seen in neighbouring Finland that is lacking an AAA screening programme.

Time critical diagnoses and transfers of patients with acute type A aortic dissection in the UK: national audit of current practice*

SummaryBackgroundType A aortic dissection repair is one of the most common emergency cardiac surgical procedures undertaken in the UK and has a high mortality. Early diagnosis and prompt surgery by an expert cardiac surgical team is crucial. Little is known about the patient's journey from first symptoms until surgery.MethodsThe Association for Cardiothoracic Anaesthesia and Critical Care undertook a prospective national audit of the management of type A aortic dissection in the UK.ResultsThe details of 334 patients with type A aortic dissection were reported by 28 UK cardiac centres over 12 months. Median (IQR [range]) time from onset of symptoms until arrival in an emergency department was 2.3 (1.4–4.7 [0.1–491.6]) h. Median (IQR [range]) time between arrival in the emergency department and the start of surgery was 9.5 (6.1–18.2 [0.8–363.5]) h. Delays in diagnosis and transfers were reported in 158 (47.3%) patients. Fifty‐two patients (15.6%) had an initial misdiagnosis. The condition of 56 patients (16.8%) deteriorated clinically before arrival in the operating theatre. A medical doctor accompanied 50 patients (15.0%) during transfer. Sixty‐four patients (19.2%) died in hospital with 41 (12.3%) dying within the first 5 days after surgery.ConclusionsThis audit provides a snapshot of current practice for patients with type A aortic dissection in the UK. Our findings show the acuity, clinical severity and vulnerability of patients with type A aortic dissection, and the deficits in the process of diagnosis and the quality of transfer. This audit demonstrates the need for the implementation of comprehensive, regionally governed, interdisciplinary medical management for every patient with type A aortic dissection.

Infrarenal Aortic Treatment With AFX2 Endograft: Results From a Multicentric, International, Non-Randomized, Prospective Registry-the AFX2-LIVE Study.

To confirm real-world clinical practice results reported with anatomically fixed bifurcated endograft, a physician-initiated study was designed-AFX2-LIVE registry. From November 2019 to August 2021, investigators enrolled all consecutive patients treated with AFX2 (Endologix Inc., Irvine, CA, USA) endograft. Patients with abdominal aortic aneurysms (AAAs), penetrating aortic ulcers (PAU), and isolated infrarenal aortic dissections were included. Clinical and anatomical data, including baseline, intraoperative, and in-hospital details, as well as follow-up data, were collected in an anonymized prospectively compiled database. The primary endpoint of this study was to evaluate the technical and clinical success of endovascular aortic repair (EVAR) using AFX2 endograft. A total of 535 patients were enrolled from 43 Italian and Spanish centers and analyzed according to the protocol. Four hundred eighty-nine patients were male (91.4%), with a mean age of 75±8.92 years (range 52-94). Four hundred sixty-six patients (87.1%) were treated for AAA, 49 (9.3%) for PAU, and 20 (3.6%) for isolated abdominal aortic dissection. A proximal extension was needed in 48% of the cases. Assisted technical success was achieved in all but one patient (99.8%). At 30 days follow-up, no AAA-related deaths were recorded, and nine patients (1.6%) required reintervention. At a mean follow-up period of 15.22±13.65 (range 1-53) months, data were available for 479 patients (89.5%). Clinical success was achieved in 98.2% (95% confidence interval [CI]: 96.4-99.1) at 3 months, 93.9% (95% CI: 90.1-96.1) at 1 year, and 74.1% (95% CI: 62.8-82.4) at 4 years follow-up. The estimated freedom from all-cause mortality was 97.7%, 93.4%, 81.6%, 77.5%, and 70.9%, and freedom from AAA-related mortality was 100%, 99.6%, 99.6%, 99.6%, and 97.3% at 3, 12, 24, 36, and 48 months, respectively. Twenty reinterventions (3.7%) were required in 19 patients, of which 3 late open conversions (0.6%) were performed, and 2 AAA-related deaths were observed. This study demonstrated excellent clinical and technical success rates of EVAR with anatomically fixed endografts, providing valuable insights into real-world clinical outcomes. The AFX2-LIVE study could have a significant impact by providing robust evidence supporting the effectiveness and safety of EVAR using bifurcated endografts with anatomical fixation in real-world clinical practice, ultimately leading to improved outcomes and enhanced patient care in the management of abdominal aortic pathologies.

One-Step Cannulation and Distance Measurement during Aortic Branched Endograft Repair: The Neuron Catheter Trick.

This paper aims to describe a straightforward, efficient, and reliable technique to simplify cannulation maneuvers during aortic branched endograft repair. The suggested approach utilizes the Penumbra Neuron Select catheter, which combines diagnostic, sizing, and support capabilities in one. This has the potential to reduce procedural time and minimize the need for serial catheter and guidewire exchanges. The proposed technique offers a simple yet effective tool to mitigate the risk of vessel loss and injury, and to streamline complex aortic repair procedures.

12391 When Pressure Drops, Consequences Rise: A Case Of Pituitary Apoplexy And Watershed Infarcts

Abstract Disclosure: D. Moreno Watashi: None. H.R. Alkaissi: None. M.B. Sharma: None. Introduction: Pituitary apoplexy (PA) results from sudden hemorrhaging and infarction of the pituitary gland, typically within a pituitary adenoma. The primary symptom is a sudden, severe headache, often followed by acute endocrine dysfunction, ophthalmoplegia and visual or neurological disturbances. Case Description: A 68-year-old male with a past medical history of hypertension presented to the emergency department with acute chest and upper back pain, beginning one day prior. No history of smoking, alcohol intake or drug use. Blood pressure (BP) on arrival was 180/95 mmHg. Initial labs revealed mild electrolyte abnormalities. Troponins were normal, but ECG showed diffuse T wave inversion and ST depression. CT angiography revealed a type B aortic dissection. He was managed in the critical care unit with continuous esmolol intravenous (IV) infusion and planned for endovascular repair. During his stay, he became disoriented and hypotensive. MRI from the brain incidentally discovered a pituitary macroadenoma measuring 2.9x2.2x3cm and recent infarcts, with a distribution concerning for hypoperfusion. Fundoscopy concerning for optic chiasm compression. Labs indicated secondary hypothyroidism and hypogonadism (TSH 0.3 uUI/ml, free T4 0.88 ng/dL, total testosterone 56.3 ng/dL). Neurosurgical intervention was deferred until after aortic repair. Endovascular aortic repair was performed with episodes of hypotension. Post-procedure, the patient developed fever (39.5°C) and worsening mental status. Head CT revealed an increased suprasellar extension of the pituitary macroadenoma and vasogenic edema, consistent with hemorrhage of the lesion. He was started on stress doses of hydrocortisone, levothyroxine 125mcg and managed conservatively due to a high surgical risk. Discussion: PA's extrinsic risk factors include angiographic procedures, endocrinological dynamic tests, anticoagulation therapy, exogenous estrogen administration, orthopedic and cardiac surgeries (due to BP fluctuations). The intrinsic risk factors are non-functioning adenomas, macroadenomas and suprasellar extension. Treatment is focused on immediate correction of endocrine derangements and relieving local compression. Stress dosage of corticosteroids should be administered IV as soon as the diagnosis is confirmed to prevent life-threatening corticotropic deficiency. Neurosurgical decompression via a transsphenoidal approach is the definitive therapy to relieve local compression with severe visual loss, obtundation or rapidly progressive course. The potential outcomes are based on the extent of hemorrhage, necrosis, and edema. PA should be treated as a medical emergency in the setting of hemodynamic changes from acute corticotropic deficiency and irreversible neurological damage from acute intracranial compression. The risk factors for PA should be known to assist in early diagnosis. Presentation: 6/1/2024

7698 A case of Pheochromocytoma in a patient with severe aortic stenosis

Abstract Disclosure: C. Lane: None. L.E. Aguirre: None. J. Azocar-Villalobos: None. R.I. Dorin: None. Background: Pheochromocytomas are rare neuroendocrine tumors derived from chromaffin tissue of the adrenal medulla and can secrete catecholamines. Pre-operative management of pheochromocytoma involves initiation of a- followed by b-adrenergic receptor blockade. In critical aortic stenosis (AS), adrenergic blockade may be complicated by decreased cardiac output and hypotension owing to dependence of venous return on maintenance of high afterload (1). We report a case of critical AS and incidentally discovered pheochromocytoma and describe our management strategy, which involved prioritization of aortic valve repair prior to adrenal surgery and multidisciplinary approach to initiation and titration of a- and b-adrenergic blockade prior to cardiac catheterization and transcutaneous aortic valve replacement (TAVR) procedures. Clinical Case: A 75-year-old Caucasian male with past medical history of obstructive sleep apnea, tobacco use, and cocaine use disorder was admitted with progressive dyspnea, decreased exercise tolerance, and involuntary weight loss of 18 kg over 3 months, and community acquired pneumonia. On admission, he was found to have critical aortic stenosis (valve area of 0.59 cm2, mean gradient 83 mmHg) and new HFrEF (EF 40-45%). CT chest demonstrated incidental right adrenal mass (5.6 x 5.0 x 4.7 cm) with central necrosis, HU units &amp;gt;10, and evidence of internal hemorrhage. Subsequent laboratory and functional imaging studies confirmed diagnosis of pheochromocytoma. Pre-procedural a-adrenergic blockade with doxazosin followed by beta-blockade was managed by a multidisciplinary team with ICU admission for monitoring and uncomplicated completion of cardiac catheterization and TAVR. Conclusions: Pre-procedural diagnosis of pheochromocytoma, multidisciplinary management, and intensive care setting for monitoring hemodynamic response to initiation and titration of a and b-adrenergic blockade appeared to be key factors in achieving uncomplicated completion of cardiac interventions prior to surgical resection of pheochromocytoma and critical AS. Successful TAVR was associated with marked improvement in hemodynamic status. Maintenance of b-adrenergic blockade to reduce myocardial contractility was critical to preservation of the prosthetic aortic valve and in preparation for planned robotic resection of the pheochromocytoma.