Proximal Tear Research Articles

INVITED COMMENTARY

INVITED COMMENTARY

Staged Fenestrated/Branched Repair of Postdissecting Thoracoabdominal Aneurysm With Candy-Plug False Lumen Occlusion for Spinal Cord Preconditioning

Purpose: To describe a possible application of thoracic false lumen occlusion techniques with a Candy-Plug occluder to induce false lumen thrombosis for preconditioning the spinal cord during staged fenestrated repair of postdissecting thoracoabdominal aneurysms. Technique: A Candy-Plug occluder is deployed within the thoracic false lumen after proximal entry tear coverage with a standard thoracic stent-graft during staged repair of postdissecting thoracoabdominal aneurysms. The blockade of thoracic false lumen retrograde reperfusion from distal entry tears induces a controlled thrombosis of both the thoracic false lumen and intercostal arteries. Then, when the fenestrated device is delivered 4 to 6 weeks later, the procedure is completed with standard techniques according to the staging protocols of individual centers. Conclusion: A new possible application of a Candy-Plug false lumen occlusion technique might be an intermediate procedure aimed at preconditioning the spinal cord by occluding the thoracic false lumen during complex staged fenestrated thoracoabdominal repairs.

Paediatric proximal ACL tears managed with direct ACL repair is safe, effective and has excellent short-term outcomes.

Anterior cruciate ligament (ACL) surgery in the paediatric population has long been a challenge. Non-operative treatment will result in persistent instability which can lead to chondral and meniscal injuries. The results of primary open ACL repair are poor. Concerns of growth plate disturbance with transphyseal techniques and issues with relatively small-diameter grafts in Tanner 1 and 2 patients, which are inadequate, have contributed to these challenges. With advancing instrumentation, there is renewed interest in ACL repair. The minimally invasive approach of arthroscopic primary ACL repair retains the native ligament. The objective and subjective outcomes at 2years are presented. Paediatric patients, less than 16years of age, presenting acutely with complete proximal ACL ruptures underwent direct arthroscopic ACL repair, reinforced by a temporary internal brace, which was subsequently removed after 3months. Patient-reported outcome measures including the Lysholm, Tegner and KOOS scores were collected at 6months, 1year and 2years post-operatively. Twenty patients (age 6-16) completed data at 2years post-operatively. There were no failures, no complications and no growth disturbance out to 2years. The 2-year postoperative outcomes; Lysholm 95 (90-100), Tegner 7 (6-10), KOOS-Child 96.5 (88.9-100) demonstrated statistically significant improvements following surgery (p < 0.001). Objective measurements with an accelerometer did not demonstrate any significant side-to-side difference. ACL repair for proximal ACL tears in the paediatric population demonstrates the potential for excellent outcomes at short-term follow-up. This presents an attractive alternative to ACL reconstruction when an adequate ACL remnant permits direct repair. Our results demonstrate that paediatric ACL repair is safe and effective.

MULTI-LIGAMENT KNEE RECONSTRUCTION AND NOVEL MENISCUS RADIAL REPAIR TECHNIQUE, WITH RETURN TO OLYMPIC LEVEL SKIING: A CASE REPORT

Multi-ligament knee injuries (MLKI) can be debilitating and often career ending injuries for athletes. Current literature reports on outcomes following these injuries for return to activities of daily life; however, there is a paucity of evidence evaluating the return to sport following a MLKI. The purpose of this case report is to describe the treatment and outcome following a MLKI and novel meniscus radial repair technique in which the athlete returned to compete in the 2018 Winter Olympic Games 14 months postoperatively. Case Report. A healthy 28-year-old female Olympic alpine skier who sustained a deep knee flexion with varus force injury to her right knee during a competitive skiing event. Examination and imaging revealed a completely torn anterior cruciate ligament (ACL) and lateral collateral ligament (LCL), complex radial tear of the lateral meniscus, medial meniscus tear, popliteofibular ligament tear, proximal tibiofibular joint ligament tear, and a common peroneal nerve neuropraxia. The athlete underwent an anatomic single-stage, multi-ligament knee reconstruction surgery which consisted of a novel meniscus radial repair technique. A return to snow progression was initiated at seven months postoperatively. At 10 months postoperatively, a physical exam revealed trace effusion, no joint line tenderness, and negative stability tests. A repeat MRI revealed adequate healing of the lateral meniscus radial repair. The athlete passed a functional sports test at 10-months postoperatively and was cleared to return to ski with no restrictions. At 12 months postoperatively, the athlete placed in an Olympic qualifying ski race. At 14 months postoperatively, the athlete competed in the 2018 Olympic Winter Games. This case report highlights the ability of an athlete to return to elite level of competition following an anatomic single-stage, multi-ligament knee reconstruction with a novel meniscus radial repair in a safe but timely manner. 4.

Patients Forget About Their Operated Knee More Following Arthroscopic Primary Repair of the Anterior Cruciate Ligament Than Following Reconstruction

To assess the extent to which patients forget their operative knee joint on a daily basis following arthroscopic primary repair as compared with reconstruction of the anterior cruciate ligament (ACL) at short- to mid-term follow-up. For this retrospective study, all patients undergoing ACL surgery between May 2012 and May 2017 were identified. All patients were treated with the algorithm of undergoing arthroscopic primary repair for proximal tears and reconstruction for nonrepairable tears. Patients were contacted to complete the Forgotten Joint Score-12 questionnaire between 2 and 5 years following surgery. A greater score represents a more favorable outcome indicating the patient's ability to "forget" the joint in everyday life, whereas lower scores indicate a less-favorable outcome. Data were analyzed using independent t-tests and χ2 tests, and multiple linear regression analysis was performed to correct for potential confounders. Eighty-three patients completed the questionnaire (57%). Patients who underwent primary repair thought about their operated knee less when compared with those patients who underwent reconstruction (85.3 ± 14.2 vs 74.3 ± 23.3, P= .022). These differences were significantly greater in patients older than 30 years (85.3 ± 12.9 vs 62.6± 24.9, P= .007), male patients (85.0 ± 13.6 vs 72.5 ± 24.7, P= .037), and patients with a body mass index greater than 25 (85.9 ± 14.5 vs 64.7 ± 25.6, P= .009). After we corrected for potential confounders, the overall difference remained significant (P= .045). Based on the data in this study, patients undergoing arthroscopic primary ACL repair can expect to have less daily awareness of their operated knee at short- to mid-term follow-up as compared with patients undergoing ACL reconstruction. Retrospective comparative study, level III.

Clinical Value of an Acute Popping Sensation in Throwing Athletes With Medial Elbow Pain for Ulnar Collateral Ligament Injury.

Background:Throwing athletes sustaining an ulnar collateral ligament (UCL) injury may recall a popping sensation originating from the medial elbow at the time of injury. There are no studies available that inform clinicians how to utilize this salient anamnestic information and what amount of diagnostic weight to afford to it.Purpose:To assess the diagnostic value of a popping sensation for significant UCL injury in throwing athletes who sustained an injury causing medial elbow pain.Study Design:Cohort study (prognosis); Level of evidence, 3.Methods:A total of 207 consecutive patients with throwing-related medial elbow pain were evaluated for UCL injury by the senior author between 2011 and 2016. The presence or absence of a popping sensation was routinely reported by the senior author. Magnetic resonance imaging was evaluated for UCL injury severity and classified into intact, edema/low-grade partial-, high-grade partial-, and full-thickness tears.Results:The overall frequency of a pop was 26%. The proportion of patients who reported a pop significantly increased with UCL tear severity (P < .001), from 13% in patients with low-grade UCL injuries to 26% in patients with high-grade partial-thickness tears and 51% in patients with full-thickness tears. The positive likelihood ratio, negative likelihood ratio, and odds ratio of a popping sensation for significant UCL injury were 3.2, 0.7, and 4.4 (P < .001), respectively (P < .001). A pop was not associated with either distal or proximal UCL tears (P ≥ .999).Conclusion:A popping sensation at the time of injury in throwing athletes with medial elbow pain was associated with UCL injury severity. When a throwing athlete reports a pop, this should moderately increase a clinician’s suspicion for a significant UCL injury. Conversely, absence of a pop should not substantially decrease suspicion for significant UCL injury. The findings of this study allow for the clinical interpretation of the salient anamnestic finding of a pop at the time of injury, which can be used for diagnostic purposes as well as patient counseling. This study provides reference foundation for future studies of predictive and diagnostic factors for UCL injury in throwing athletes.

Treatment of Acute Proximal Anterior Cruciate Ligament Tears-Part 1: Gap Formation and Stabilization Potential of Repair Techniques.

Background:Recently, there has been a resurgence of interest in primary repair of the anterior cruciate ligament (ACL), with fixation techniques evolving. However, to date, there have been no biomechanical studies comparing fixed to adjustable fixation repair techniques.Hypothesis:Adjustable ACL repair provides for improved stabilization compared with fixed techniques with respect to both gap formation and residual load-bearing capability.Study Design:Controlled laboratory study.Methods:A total of 4 different ACL repair techniques (n = 5 per group), including single– and double–cinch loop (CL) cortical button fixation as well as knotless single–suture anchor fixation, were tested using a porcine model. For adjustable single-CL loop fixation, additional preconditioning (10 cycles at 0.5 Hz) was performed. The force after fixation and the actuator displacement to achieve a time-zero preload of 10 N were measured for fixed techniques. Incrementally increasing cycling (1 mm/500 cycles) from 1 to 8 mm was performed for 4000 cycles at 0.75 Hz before pull to failure (50 mm/min). The final residual peak load and gap formation for each test block were analyzed as well as ultimate strength.Results:Knot tying of a single-CL over a button (mean ± SD, 0.66 ± 0.23 mm) and knotless anchor fixation (0.20 ± 0.12 mm) resulted in significant time-zero gaps (P < .001) and significantly higher overall gap formation at reduced residual loading (analysis of covariance, P < .001) compared with both the double-CL loop and adjustable fixation techniques. The adjustable group showed the highest failure load and stiffness, at 305.7 N and 117.1 N/mm, respectively. The failure load of the knotted single-CL group was significantly reduced compared with all other groups (P < .001).Conclusion:Adjustable single-CL cortical button fixation with intraoperative preconditioning optimized time-zero ACL tension and led to significantly improved stabilization and reduced gap formation, with the highest ultimate strength. Single-CL loop knot tying over the button and knotless anchor fixation resulted in time-zero gaps to achieve slight tension on the ACL and significantly higher gap formation at reduced load-bearing capability.Clinical Relevance:Although the clinical relevance of gap formation is uncertain, a biomechanical understanding of the stabilization potential of current ACL repair techniques is pertinent to the continued evolution of surgical approaches to enable better clinical outcomes.

A Rare Case of Anterior Urinary Bladder Wall Avulsion and Proximal Urethral Tear following Spontaneous Vaginal Delivery

A Rare Case of Anterior Urinary Bladder Wall Avulsion and Proximal Urethral Tear following Spontaneous Vaginal Delivery

Arthroscopic Posterior Cruciate Ligament Primary Repair.

Injury to the posterior cruciate ligament (PCL) is most commonly seen in the setting of a multiligamentous injured knee, and isolated PCL tears are rare. PCL injuries are generally treated either conservatively or by PCL reconstruction using a graft. If a proximal or distal tear is present, the injured ligament can also be treated by primary repair, in which the ligament is reattached to the tibial or femoral insertion. This has the (theoretical) advantages of preserving the native tissue, maintaining proprioception, and can be performed in a less invasive way when compared with reconstruction surgery. In this review, the appropriate patient selection, surgical indications, surgical techniques, and outcomes of primary repair of proximal and distal PCL tears will be discussed. Primary repair may be an alternative treatment for PCL reconstruction if appropriate patient selection is applied.

Is Primary Arthroscopic Repair Using the Pulley Technique an Effective Treatment for Partial Proximal ACL Tears?

Attention has recently been paid to primary arthroscopic repair to treat ACL tears because of the disadvantages associated with reconstruction. However, there remain many unanswered questions and concerns about its application in the treatment of ACL tears. (1) Does primary arthroscopic repair using the pulley technique result in satisfactory ROM (a functional ROM with a flexion contracture of 30° or less), knee stability, and functional scores in patients with partial proximal ACL tears? (2) What complications are associated with primary arthroscopic repair using the pulley technique in patients with partial proximal ACL tears? Between January 2014 and March 2016, we treated 23 patients surgically who had partial proximal ACL tears and excellent tissue quality (defined as a remnant with mild interstitial tearing and the ability to hold sutures). All patients meeting those two criteria were treated using primary arthroscopic repair using the pulley technique. During that period, this represented 13% (23 of 183) of the patients we treated surgically for an ACL tear. Patients were excluded if they had other ACL tear types, insufficient tissue quality (defined as a severely torn remnant that was not strong enough to hold sutures), multi-ligamentous injuries, or substantial arthrosis (chondromalacia greater than Outerbridge grade 3, most of which underwent conversion to ACL reconstruction). Clinical outcomes were assessed using ROM, the anterior drawer test, the Lachman test, Lysholm score, Tegner activity score, IKDC subjective score, and radiographs. Twenty-one patients were observed for a mean (range) period of 36 months (25-49), and two were lost to follow-up. At the most-recent follow-up examination, all patients achieved full extension and only one patient lacked full flexion, with a flexion contracture of 10°. Twenty patients had no instability on the anterior drawer test and Lachman test findings, and one patient had a 1 + anterior drawer test. The mean Lysholm score improved from a mean ± SD of 71 ± 9 before surgery to 94 ± 6 (mean difference 23 points [95% CI 20 to 25]; p < 0.001) at latest follow-up. The IKDC subjective score improved from 64 ± 10 to 86 ± 11 points (mean difference 22 points; p < 0.001). We found no difference in the Tegner score from before surgery to latest follow-up (6.3 ± 1.2 versus 6.1 ± 1.2; mean difference 0.2; p = 0.056). One patient re-ruptured his ACL 2 months after surgery in military training during an obstacle race. No complications such as infection, thrombosis, stiffness, patellofemoral pain, or implant failure were observed. Primary arthroscopic repair using the pulley technique can achieve short-term clinical success in a carefully selected (the selection process includes first identifying the ACL injury pattern preoperatively with MRI, then confirming the diagnosis under arthroscopy, and deciding whether to perform a repair intraoperatively) subset of patients with partial proximal ACL tears and excellent tissue quality (defined as a remnant with mild interstitial tearing and the ability to hold sutures). Despite the promising clinical outcomes of our study, this technique should not be widely adopted unless it has been compared directly with ACL reconstruction, so future studies should be conducted to compare the clinical outcomes between this technique and ACL reconstruction, and longer-term follow-up is necessary to identify whether there is deterioration in the clinical outcomes over time. Level IV, therapeutic study.

The Impact of a Reentry Tear After Open Repair of Nonsyndromic Acute Type I Aortic Dissection

The role of a reentry tear in the descending thoracic aorta (DTA) after repair of acute aortic dissection is not well known. We therefore investigated the impact of reentry tear location on late aorta reintervention and the aortic expansion rate after open repair of acute type I aortic dissection. We analyzed 309 nonsyndromic acute type I aortic dissection patients who were treated with a repair to the proximal aorta between 1994 and 2017. The locations of reentry tears, identified with predischarge computed tomography, were the proximal DTA in 119 patients (38.5%), distal DTA in 78 (25.2%), and abdominal aorta in 129 (41.7%). Patients who had a proximal DTA reentry tear were defined as the PDR group (119 [38.5%]), and the others were defined as the non-PDR group (190 [61.5%]). The 15-year freedom from aorta reintervention was significantly lower in the PDR group (51.5% ± 0.7% vs 90.4% ± 4.4%, P < .001). The aortic expansion rates of the proximal DTA (7.6 ± 16.1 mm/y vs 0.1 ± 2.5 mm/y, P < .001) and distal DTA (6.8 ± 15.5 mm/y vs 0.3 ± 3.1 mm/y, P < .001) were significantly higher in the PDR group. The 15-year freedom from significant aortic expansion was significantly lower in the PDR group (34.6% ± 6.9% vs 83.6% ± 7.9%, P < .001). Multivariate analysis showed that a proximal DTA reentry tear was an independent risk factor for aorta reintervention (hazard ratio, 4.955; 95% confidence interval, 1.691-14.523; P= .004) and significant aortic expansion (HR, 4.214; 95% CI, 1.691-10.498; P= .002). A proximally located DTA reentry tear was associated with an increased risk of late aorta reintervention and distal aortic dilatation.

Impact of Supraaortic Intimal Tears on Aortic Diameter Changes After Nontotal Arch Replacement

This study evaluated the impact of the intimal tear location on aortic dilation and reintervention after nontotal arch replacement (non-TAR) for acute type I aortic dissection. Between 2009 and 2017, 92 patients who underwent non-TAR for acute type I aortic dissection were enrolled. Intimal tears were analyzed at the supraaortic (SA) segment; segment 1, proximal descending thoracic aorta (DTA); segment 2, distal DTA; and segment 3, abdominal aorta. Aortic diameter was measured at the pulmonary artery bifurcation, celiac axis, maximal abdominal aorta, and maximal thoracoabdominal aorta using serial follow-up computed tomographic scans. The Fisher exact or χ2 test, independent t or Mann-Whitney U test, and log-rank test were used in the statistical analyses. The significant factors for increasing aortic diameter were the first location of intimal tear in the SA segment and segments 1 and 2. In the adjusted analysis, the first location of intimal tear in the SA segment and segment 1 was statistically significant. In the additional adjusted analysis, a segment 1 tear without SA tear was the only significant factor for increasing aortic diameter. The 5-year freedom from reintervention rate was significantly higher in patients with no intimal tear than in those with a segment 1 intimal tear with/without SA tear. We confirmed that SA and proximal DTA intimal tears are associated with subsequent aortic dilation and reintervention. These proximal aortic intimal tears might warrant aggressive surgical treatment at the initial operation or close postoperative follow-up.

Parametric Color Coding of Digital Subtraction Angiography in the Evaluation of the Type B Chronic Aortic Dissection During Tevar: A Preliminary Study

Introduction - Angiografic assessment of type B chronic aortic dissection (TBCAD) can be complex in TEVAR procedures, due to the presence of true and false lumen. Quantitative digital subtraction angiography (Q-DSA) with a parametric color-coding provides a novel approach for encoding temporal information and enabling quantitative measurements. (1,2) The potential value of the use of color in the display of these parametric images was recognized (3), particularly useful in situations in which there is a complex flow pattern. (4,5) The aim of this study was to evaluate whether the use of parametric color-coding in the post processing of DSA series is advantageous in the evaluation of TBCAD during TEVAR procedures. Methods - We enrolled 11 patients treated electively for a TBCAD. All cases were treated with TEVAR for a aneurysm disease of thoracic descending aorta (> 6 cm) with the coverture of proximal entry tear. For postprocessing of digital subtraction angiography (DSA) series, a newly implemented algorithm of parametric color-coding was used, turning sequential images of two-dimensional (2D)-DSA series into a single color-coded image (Syngo I-Flow, Siemens AG, Forchheim, Germany). In consensus reading, two experienced vascular surgeons valuated the initial, interventional, and post-interventional 2D-DSA series comparing them to the color-coded images, respectively. Whether parametric color-coding could facilitate evaluation of a true and false lumen and provide a more precise estimation of proximal entry tear as well as whether flow analysis could reveal objective changes during and after TEVAR treatment were investigated. Results - In 81.8 % of the cases, parametric color coding was observed to facilitate visualization of the aortic dissection angioarchitecture in term of true e false lumen contemporary vision. Estimation of proximal entry tear was considered to be improved in 45.4 % of the cases (fig. 1. maximum intensity peak DSA (a) and parametric color elaboration with entry tear enhanced (b)). For assessment of hemodynamic changes during and after treatment, parametric color coding was assumed to be helpful in 36.3 % of the cases, especially because revealing flow changes that were not visible on 2D-DSA series were now visible. Conclusion - Without additional cost in term of x-ray and contrast medium exposure, parametric color-coding is a real time application tool that might provide additional support in the angiographic evaluation of TBCAD during TEVAR. Visualization of complex aortic dissection architecture could be facilitated, and flow analysis might improve assessment of entry tear position, thereby increasing overall diagnostic confidence. During and after treatment, hemodynamic changes that were not visible on 2D-DSA series could now be depicted.

Blood Flow Helicity Pattern in Type III Arch Configuration as a Potential Risk Factor for Type B Aortic Dissection

Introduction: Abnormal helical flow in the aortic arch has been proposed as a causative factor for aortic dilatation (1), for the formation of entry tears and consequent development of aortic dissections (AD) (2). Blood flow helicity derangements can be caused by the presence of a bicuspid aortic valve, but are also related to aortic arch morphology (3), and in particular to the presence of arch elongation and severe tortuosity (2). Previous studies showed that patients with Type B AD present a high prevalence of Type III arch configuration, which comprises recognized anatomic variables associated with an increased risk of AD, namely elongation, tortuosity, and angulation (4). Our aim was to assess whether the Type III arch configures a consistent helical flow pattern, which may account for its association with the occurrence of Type AD. Methods: Angiographic computed tomography (CT) scans of healthy aortas were selected to equally reflect Type I to III arches (each n=5). Computational fluid dynamics (CFD) was performed with LifeV open-source library to assess the intra-aortic helical flow field along the aortic Ishimaru's landing zones (5). CFD hemodynamic parameters, derived from the velocity field (V), included: vorticity (ω), the local spinning motion of the fluid; helicity (H), a measure of the V- ω alignment quantifying the corkscrew-like fluid motion about the principal flow direction; the absolute local normalized helicity (LNH) assuming values ranging between 0 (high flow rotation) and 1 (irrotational flow) (6). By novel application of the Serret-Frenet formulas to CFD results (7), curvature (κ) and torsion (τ) of blood velocity streamlines were assessed to quantify both in-plane and out-of-plane flow rotations within each zone. Results: Absolute ω distribution remained comparable within each arch Type while H significantly increased in Zone 3 of Type III (P=0.025). Overall absolute LNH was similar between the anatomies; however, the percentage of aortic region with absolute LNH above a 0.8 threshold markedly increased in Zone 3 of Type III (IQR: 29.5 ÷ 39.5 %) with respect to Type I (IQR: 21.5 ÷ 38.1 %) and Type II (IQR: 18.0 ÷ 32.0 %). Serret-Frenet elaboration of the velocity streamlines revealed the highest level of curvature in Type I for Zone 0 (P< 0.0001) and Type III for Zone 3. Within Zone 3, absolute κ significantly increased from Type I to III (P< 0.0001; median κ values equal to 0.19 mm-1, 0.26 mm-1 and 0.35 mm-1, respectively) while streamline torsion conversely decreased from Type I to III (P=0.0030; median τ values equal to 0.56 mm-1,0.44 mm-1 and 0.32 mm-1, respectively). In each arch Type, absolute κ significantly changed from Zone 0 to 3 (P=0.0069 in Type I, P=0.0179 in Type II and P< 0.0001 in Type III). Conclusion: Our proof of concept analysis detected arch-type regional differences in aortic helical bulk flow, highlighting in Type III arch a significant exacerbation of aortic helical flow localized in Zone 3, which identifies the most common site for proximal entry tear in Type B AD. Extension to in vivo scenarios is feasible exploiting velocity-encoded PC-MRI (4D Flow). Disclosure: Nothing to disclose

Endovascular Repair of a Complicated Acute Type B Aortic Dissection Using a Combination of the STABILISE and CERAB Techniques

Introduction: Endovascular treatment of type B aortic dissection has focused on covering the proximal entry tear. However, recently, concern has emerged regarding the distal aortic remodeling and new techniques such as the Stent-Assisted Balloon-Induced Intimal Disruption and Relamination (STABILISE) technique have gained acceptance. We describe a case report in which the STABILISE technique was used in addition with the Covered Reconstruction of the Aortic Bifurcation (CERAB) technique for complete aortic remodeling. Methods: Clinical data were collected from the hospital's records. Results: A 34-year-old male, with a history of hypertension was admitted at the emergency department for acute-onset back pain, severe hypertension and right lower limb ischemia. A CT-Angiography confirmed a type B aortic dissection with true lumen compression and right common iliac artery occlusion. At first, blood pressure and pain were controlled with IV drugs, however the lower limb ischemia persisted. A plan was made to first treat the limb ischemia and delay the aortic repair for the sub-acute phase, if necessary. A common iliac artery kissing stent was performed using Atrium Advanta V12® (10mm) stents and a self-expandable uncovered stent to the external iliac on the right side. The patient recovered well, however, 5 days later, refractory chest pain and hypertension developed. A CT-Angiography showed severe true lumen compression at the visceral aorta and we decided to perform an urgent repair of the aortic dissection. After true lumen catheterization, a TEVAR was performed landing over the left subclavian artery (COOK®ZTA P-32-201) followed by deployment of a bare-metal dissection stent ending 2 cm below the renal arteries (COOK®ZDES 36-180). A control angiography showed false lumen exclusion at the proximal aorta, however the distal aortic true lumen was still severely compressed. For that reason, a STABILISE was performed using a non-compliant 28mm balloon proximally and a 23mm balloon distally. Because the true lumen was still compressed at the infra-renal aorta, we decided to proceed with a CERAB technique, using a Bentley® Aortic BeGraft (18x48mm) deployed just distal to the renal arteries. Proximal flaring of the stent was performed using the 23mm non-compliant balloon. Two 10x59mm Atrium Advanta® V12 stents were used for the iliac extensions ending inside the previous iliac kissing stents. Angiographic control was optimal, and the patient recovered well. However, the patient was still dependent on 4 oral anti-hypertensive drugs, so a new CT-Angiography was performed and showed an intimal flap inside the right renal artery. Under local anesthesia, a Cordis® Palmaz Blue (6x18mm) stent was deployed in the right renal artery through the aortic dissection stent. The patient was latter discharged with adequate hypertension control under two oral anti-hypertensive drugs and the control CT one month after treatment showed complete remodeling of the aorta and perfusion of all visceral branches. Conclusion: We report a case of a combination of the STABILISE and CERAB techniques used to treat an acute type B aortic dissection. This combination allowed for a covering of both the entry tear and the distal re-entry tears resulting in a complete flap apposition, false lumen obliteration and optimal remodeling. Disclosure: Nothing to disclose

High Prevalence of Type III Arch Configuration in Patients with Type B Aortic Dissection

Introduction - Patients with Type B aortic dissection (TBD) in whom the proximal entry tear is located within 2 cm from the left subclavian (i.e. in Zone 3 for TEVAR) have been reported to have a worse prognosis suggesting the presence of an anatomic risk factor (1). We previously showed that in Type III arches, Zone 3 is associated with a consistent pattern of severe angulation and tortuosity (2), and higher pulsatile forces (3). Our aim was to investigate the prevalence of Type III arch configuration in TBD patients.

Dissection Flap as Bailout Navigator in Complicated Acute Type B Aortic Dissection (Case Presentation)

Introduction: Background: This is a case of threatening right limb ischemia due to complicated acute type B aortic dissection was reperfused utilizing reversed petticoat technique to recanalize totally collapsed infra-renal true lumen. Case presentation: A male patient 55 years old known to be deaf-mutism presented to emergency department with acute onset chest pain persisting for 2 days that was diagnosed as unstable angina, clinical examination revealed blood pressure 195/130 mm. investigations was negative for unstable angina including ECG and cardiac enzyme. Patient was admitted for treating hypertensive crisis; 2 days later patient complained right lower limb severe pain with cold extremity and raised creatinine level. Vascular consultation was done and we provisionally diagnosed the patient as acute type B aortic dissection complicated with right limb malperfusion. CT angiography confirmed the diagnosis of type B aortic dissection with intimal tear 1cm distal to left subclavian artery; all visceral branches were perfused from true lumen except renal vessels were perfused from both true and false lumen. The infra-renal true lumen (TL) was totally collapsed causing right lower limb threatening ischemia and left lower limb was perfused through false lumen. Methods: after stabilization and control of blood pressure, we made our sizing plan and strategy based on preoperative CTA with three-dimensional multiplaner reconstruction. After detecting proximal and distal landing zones, under general anaesthesia patient underwent left carotid-left subclavian bypass. Reperfusion technique utilized dual vascular access, left brachial access (percutaneous) and right femoral access (cut down). After several trials to pass the wire through totally collapsed infra-renal true lumen, we utilized the dissection flap as a navigator to guide the wire into TL then to right common iliac artery. Reversed petticoat technique was utilized (the distal bare stent (Zenith dissection metal stent) was first placed into the compressed TL and deployed at the predetermined position allowing 50-55 mm for overlap with the proximal covered stent (Zenith thoracic alpha). Completion aortography was then performed to ensure coverage of the proximal entry tear and visualization of side branches, reperfusion of the right lower limb. Results: immediate technical success was proved by successful obliteration of the intimal tear with no Type I endoleak and successful reperfusion of right lower limb with adequately perfused visceral aortic branches. The patient had an uneventful recovery in the postoperative period and discharged 24 hours after the procedure. Conclusion: thinking outside the box utilizing nonstandard techniques may be helpful in solving technically challenging complicated cases. In our case, we employed reversed petticoat technique after navigation along the dissection flap to reperfuse totally collapsed infra-renal true lumen that resulting right lower limb threatening ischemia in acute type B aortic dissection with immediate technical success in sealing of intimal tear waiting for follow up to evaluate aortic remodeling.

Branch stent-grafting for endovascular repair of chronic aortic arch dissection

BackgroundThe preliminary clinical outcomes of a novel branch stent-grafting for endovascular repair of chronic aortic arch dissection proved its safety and effectiveness. ObjectiveThe purpose of this study is to present the long-term outcomes and evaluate the durability of this novel endovascular therapy. MethodsBetween August 2009 and January 2014, 51 patients with aortic dissections involving arch branches were treated by the endovascular stent-grafting. There were 7 Stanford type A aortic dissections, 22 retrograde type A aortic dissections, and 22 Stanford type B aortic dissections. The supra-arch branch arteries were reconstructed by individualized strategies. ResultsAll the proximal entry tears in arch were successfully excluded, and no type I/III endoleaks occurred. The median follow-up period was 92 months (range, 62-114 months). A total of 7 complications, 4 deaths, and 3 reinterventions occurred. There were 2 deaths from retrograde type A aortic dissections, 1 death from cerebral infarction, and 1 death from malignant tumor. The incidence of complications, reintervention, all-cause mortality, and aorta-related mortality was 0.035%/patient-year, 0.015%/patient-year, 0.020%/patient-year, and 0.010%/patient-year, respectively. The patency rate of cervical bypass was 90.1%. The significant true lumen recovery and false lumen shrinkage were observed at the 4 designated levels of the thoracic aorta according to computed tomography angiography images. ConclusionsBased on preoperatively adequate planning and accurate measurement, endovascular repair of chronic aortic arch dissection using this branched stent-graft showed a low and an acceptable incidence of complications and mortality with positive aortic remodeling, which provided a satisfactory and promising alternative treatment option.

Long-term Results of Endovascular Treatment of Chronic Type B Aortic Dissection by Closure of the Primary Tear

The role of thoracic endovascular aortic repair (TEVAR) in the treatment of chronic type B aortic dissection is controversial. Some advocate open surgery, based on the premise that all tears must be treated, and others prefer branched endografts with the same premise. However, TEVAR, with closure of the primary tear in the thorax, has shown good results in some centers. This single-center cohort study was designed to contribute to the knowledge of the long-term evolution (mean, 4.8years) of the patients submitted to endovascular closure of the proximal intimal tear. A total of 36 patients with asymptomatic chronic aortic dissection had a successful closure of the primary tear by TEVAR and were followed up for a median time of 57.2months. In 75% of the cases, there was stabilization or decrease in the maximum diameter. Twenty-five percent had diameter increase in the thoracic or abdominal aorta and indication for one or more additional procedures. One patient refused a second procedure and died from rupture one month after the last evaluation; this was the only case of rupture in the series. One patient died of unrelated cause before having been submitted to a second procedure. Thirty-four patients survived without diameter increase in the follow-up period. Chronic type B aortic dissections can be successfully treated by the coverage of the proximal tear with an endograft. Patients shall be followed carefully, and 25% of them will require one or more additional procedures to achieve a good result.

Arthroscopic primary repair of proximal anterior cruciate ligament tears seems safe but higher level of evidence is needed: a systematic review and meta-analysis of recent literature

PurposeTo assess the outcomes of the various techniques of primary repair of proximal anterior cruciate ligament (ACL) tears in the recent literature using a systematic review with meta-analysis.MethodsPRISMA guidelines were followed. All studies reporting outcomes of arthroscopic primary repair of proximal ACL tears using primary repair, repair with static (suture) augmentation and dynamic augmentation between January 2014 and July 2019 in PubMed, Embase and Cochrane were identified and included. Primary outcomes were failure rates and reoperation rates, and secondary outcomes were patient-reported outcome scores.ResultsA total of 13 studies and 1,101 patients (mean age 31 years, mean follow-up 2.1 years, 60% male) were included. Nearly all studies were retrospective studies without a control group and only one randomized study was identified. Grade of recommendation for primary repair was weak. There were 9 out of 74 failures following primary repair (10%), 6 out of 69 following repair with static augmentation (7%) and 106 out of 958 following dynamic augmentation (11%). Repair with dynamic augmentation had more reoperations (99; 10%), and more hardware removal (255; 29%) compared to the other procedures. All functional outcome scores were > 85% of maximum scores.ConclusionsThis systematic review with meta-analysis found that the different techniques of primary repair are safe with failure rates of 7–11%, no complications and functional outcome scores of > 85% of maximum scores. There was a high risk of bias and follow-up was short with 2.1 years. Prospective studies comparing the outcomes to ACL reconstruction with sufficient follow-up are needed prior to widespread implementation.Level of evidenceIV.