Thoracic Aortic Aneurysm Repair Research Articles

An observational study examining the effects of a surgically induced inflammatory response on the distribution of morphine and its metabolites into cerebrospinal fluid

Morphine is administered intravenously for pain management in the perioperative period. The effect of the inflammatory response to surgery on morphine distribution across the blood-brain barrier (BBB) in humans was investigated. We hypothesized that a graded surgically induced, systemic inflammatory response alters cerebrospinal fluid (CSF) levels of morphine, morphine-3-glucuronide (M3G), and morphine-6-glucuronide (M6G) through a temporary reduction in BBB drug efflux transporter function. We conducted a prospective pharmacokinetic study of the plasma and CSF distribution of the P-glycoprotein (PGP) substrate morphine in 33 patients undergoing open thoracic (n=18) or endovascular (n=15) aortic aneurysm repair. Morphine was administered with induction of anesthesia and in the intensive care unit. Plasma and CSF concentrations of interleukin (IL)-6, morphine, M3G, M6G, and albumin were measured prior to surgery (baseline), during surgery, and postoperatively every six hours until removal of the CSF drain. The area under the curve (AUC) was determined for plasma and CSF IL-6, morphine, M3G, and M6G concentrations vs time. The primary endpoint measures were the correlations between the morphine, M6G, and M3G AUC CSF/plasma ratios and systemic inflammation as quantified by the time-normalized IL-6 exposure, which was calculated for each individual by dividing the total exposure (AUC) by time (t). A Bonferroni corrected P<0.017 indicated a significant correlation. Plasma and CSF IL-6 concentrations increased postoperatively. The median [interquartile range] IL-6 exposures were significantly higher in the open vs endovascular surgical group for plasma (105 [40-256] pg·mL-1 vs 29 [16-70] pg·mL-1, respectively; P=0.013) and CSF (79 [26-133] pg·mL-1 vs 16 [9-80] pg·mL-1, respectively; P=0.013). For the primary endpoint, the plasma IL-6 AUC/t did not correlate with the CSF accumulation of morphine (r=-0.009; P=0.96) or M3G (r=0.37; P=0.04) when corrected for surgical procedure, age, and sex. There were insufficient data on CSF concentration to complete the primary analysis for M6G. Morphine distribution into the CSF was not significantly altered in patients undergoing thoracic aortic aneurysm repair. This suggests that BBB PGP function may not be affected by the perioperative inflammatory response. www.clinicaltrials.gov , NCT 00878371. Registered 7 April 2009.

Elephant Trunk Technique with a Handmade Skirted Tube Graft: How Do We Prepare It?

The surgical treatment of diffuse thoracic aortic pathologies remains a challenge in aortic surgery for surgeons. Traditionally, these aortic diseases are treated with a 2-step approach known as the "elephant trunk procedure." This technique gives us an opportunity for the construction of the distal anastomosis during the initial operation. However, this staged approach is associated with a substantial overall mortality and morbidity. In order to improve the outcomes, few single-stage repair methods have been tried. Most of them are performed through a clamshell incision, and for this reason, it is potentially associated with a high incidence of pulmonary complications. Repair techniques of diffuse thoracic aortic pathologies have changed substantially over the last decade; these techniques appear to have a significant lower operative risk for patients. "Frozen elephant trunk" (FET) technique was developed for combined lesions of the thoracic aorta as a single-stage procedure which is a combination of endovascular treatment and conventional surgery. However, experiences are limited in the field of FET and endovascular techniques that is why traditional 2-staged approach still remains as a first choice in our clinic like many centers. In eligible patients, we use a handmade skirted tube graft for conventional technique in 2-staged repair for diffuse thoracic aortic aneurysm. In this report, we aim to explain the possible advantages of this graft and how we do it.

Thoracic endovascular aortic repair with branched Inoue Stent Graft for arch aortic aneurysms

BackgroundThoracic endovascular aortic repair (TEVAR) for thoracic aortic aneurysms (TAAs) is in rapid expansion due to its minimal invasiveness. However, TEVAR for an arch aneurysm with a straight stent graft needs surgical reconstruction for supra-aortic vessels. A branched stent graft pioneered by Inoue (branched Inoue Stent Graft [ISG]) has been expected to resolve this problem, but its utility remains to be established in the real clinical setting. This study evaluated the long-term clinical outcome of branched ISGs for TAAs. MethodsAmong 217 consecutive patients who underwent TEVAR with ISGs between March 2003 and September 2013, 89 patients with TAAs were treated with implantation of the branched ISG (single branch: n = 64; double branch: n = 18; triple branch: n = 7). The primary end point was freedom from aneurysm-related death. Secondary end points included periprocedural adverse events, freedom from all-cause death and major adverse events (composite of aneurysm-related death, surgical conversion, aneurysm rapture, persistent type I or III endoleak, graft infection, graft occlusion, graft migration, and aneurysm expansion), changes of aneurysm diameter, stroke, and any endovascular reintervention during follow-up. ResultsAll deployments of branched ISGs were successful. The 30-day mortality was 4.5% (single branch, 3.1%; double branch, 0%; triple branch, 29%), and periprocedural stroke was 16% (single branch, 7.8%; double branch, 33%; triple branch, 42%). At 1 and 5 years, freedom from aneurysm-related death was 93% and 93%, respectively, and freedom from all-cause death was 85% and 59%, respectively. Survival free of major adverse events was 76% at 5 years. The cumulative incidence of stroke was 11% at 5 years. Three patients underwent surgical conversion because of persistent type I endoleak. One branch graft occlusion was observed at the left subclavian artery in a patient who received a double-branched graft. ConclusionsPeriprocedural outcome of the single-branched ISG was acceptable, and long-term safety and efficacy were demonstrated. However, the procedural complications of the multibranched ISG leave room for improvement.

Outcome of endovascular repair for intact and ruptured thoracic aortic aneurysms

ObjectiveThe objective of this study was to assess long-term outcome after thoracic endovascular aortic repair (TEVAR) for thoracic aortic aneurysm (TAA). MethodsAll patients who underwent TEVAR for TAA at Uppsala University Hospital from December 1999 to December 2014 were included. Characteristics of the patients and outcome data were collected from medical records, national population registry, and cause of death registry. Perioperative survival was analyzed with the χ2 test, and 5-year survival was estimated with Kaplan-Meier analysis. Predictors of long-term survival were assessed with Cox regression. ResultsThere were 77 patients included in the study, 49 with intact TAAs (iTAAs) and 28 with ruptured TAAs (rTAAs). Mean follow-up was 83.7 months for iTAA patients and 82.0 months for rTAA patients (P = .853). Mean age was 71.5 years for iTAA patients and 74.8 years for rTAA patients (P = .04). Survival after iTAA repair was 95.9% at 30 days, 91.8% at 90 days, and 62.5% at 5 years. After rTAA repair, survival was 71.4% at 30 days and decreased to 57.1% at 90 days (P < .01), with most deaths after 30 days being related to the aortic event. The 3-year survival rate after rTAA repair was 27.8%, and only one rTAA patient with 5 years of follow-up remained alive. Six aorta-related deaths occurred after 90 days (three iTAA patients, three rTAA patients); five were due to rupture of nontreated aortic segments. The 5-year reintervention rate was 13.2% for iTAA patients and 17.9% for rTAA patients (P = .682). All reinterventions occurred within 14 months of TEVAR. The age-adjusted hazard ratio for long-term mortality was 4.4 after rTAA repair compared with iTAA repair. ConclusionsTEVAR for iTAA was associated with low perioperative mortality and acceptable 5-year survival at 62.5%. Results were more pessimistic after rTAA repair, however, for which two-thirds of the patients were deceased at 3-year follow-up. Improved selection of patients is necessary to identify patients who are likely to truly benefit from rTAA repair.

Haem-Enzymes Predictive of Coronary Artery Disease Are Present in Thoracic and Abdominal Aortic Aneurysm

Purpose: A reliable plasma biomarker for aortic aneurysm has proven elusive. Elevated plasma levels of the oxidative or immune regulatory haem-enzymes myeloperoxidase (MPO) or indoleamine 2,3-dioxygenase (IDO) can predict disease prevalence and clinical risk in coronary artery disease patients. We therefore studied the relationship of MPO and IDO with thoracic or abdominal aortic aneurysm. Methodology: In patients undergoing elective surgical or endovascular repair of thoracic (n = 14) or abdominal (n = 18) aortic aneurysm, preoperative plasma was analysed for MPO protein levels by ELISA or IDO activity (indexed as a ratio of IDO's product kynurenine and substrate tryptophan) and compared with healthy controls (n = 15). Plasma levels of other inflammatory markers (CRP, neutrophil elastase) were also measured. Surgically resected aortic wall samples were analysed for MPO protein by immunohistochemistry. Results: Patients with abdominal aneurysms [72 yrs (67-76)] were significantly older than those with thoracic aneurysms [57 yrs (52-70)] and healthy controls [31 years (29-36)] and more likely to have atherosclerosis as the aetiology of aortic disease (88.9% vs. 28.6% in thoracic aneurysm). Plasma IDO activity and CRP levels, but not MPO or elastase, were significantly elevated in patients with aortic aneurysm vs. healthy controls. MPO protein, however, was expressed in the intima and media of all aortic aneurysm specimens but not non-diseased aorta. Conclusion: The haem-enzymes MPO and IDO may be involved in human aortic aneurysm and their roles warrant further study in experimental animal models of aneurysm. Measurement of plasma IDO activity and CRP, but not MPO, may represent potential useful biomarkers for aortic aneurysm.

Takotsubo Cardiomyopathy after Hybrid Repair of Thoracic and Thoracoabdominal Aortic Aneurysm

Context: Takotsubo cardiomyopathy is characterized by transient and acute left ventricular dysfunction with apical dyskinesia in the absence of coronary artery disease. The pathophysiology of this rare disease is considered to be associated with physical and psychological stress. Recently published case reports have described the association between Takotsubo syndrome and various surgical procedures as the causative stress factors. However, Takotsubo cardiomyopathy is extremely rare in patients who have undergone cardiovascular surgery. Case report: Here, we report a rare case of Takotsubo cardiomyopathy developing after thoracic endovascular aortic repair for chronic dissecting aortic aneurysm. Conclusion: This patient developed Takotsubo cardiomyopathy 14 days after thoracic endovascular aortic repair, potentially because of the prolonged perioperative physical and psychological stress induced by multi-stage surgery. To our knowledge, this is the first report of Takotsubo cardiomyopathy after thoracic endovascular aortic repair. Through this report, we emphasize the importance of considering the possibility of Takotsubo cardiomyopathy in patients presenting symptoms of cardiogenic shock and unexplained hemodynamic deterioration, despite having undergone relatively less-invasive cardiovascular surgery. Early diagnosis is required to initiate appropriate treatment and to minimize the chance of complications.

Review of Thoracic Endovascular Aneurysm Repair (TEVAR), Spinal Cord Ischemia (SCI), Cerebrospinal Fluid (CSF) Drainage and Blood Pressure (BP) Augmentation

The object of this review is to examine the role of TEVAR in causing SCI. The anatomy and physiology of blood flow to the spinal cord is examined. The role of auto regulation of blood flow within the spinal cord is also examined. This review examines the reported results from the scientific literature of the effect of thoracic aortic aneurysm repair on spinal cord blood flow. In the light of the-se findings several conclusions can reasonably be reached. These conclusions are that the development of SCI can reasonably be predicted based on complexity and extent of the TEVAR procedure performed and BP augmentation and CSF drainage can significantly reduce the impact of SCI.

A “Hybrid” Hybrid Approach - Aortic Debranching Using a Trifurcate Graft for Arch and Descending Thoracic Aortic Aneurysm Repair With the Thoraflex™ Hybrid Graft

Purpose: Pathology of the aortic arch and descending thoracic aorta poses many unique challenges for the cardiovascular surgeon. The Thoraflex™ hybrid device for the “frozen elephant trunk” procedure simplifies management of the descending thoracic aorta, whilst allowing anastomosis of the head and neck vessels to the proximal graft. We report our modification to the technique, involving the use of the Trifurcate Graft with Side Branch (Vascutek-Terumo Ltd, Ann Arbor, MI, USA) to improve the ease of arch vessel control and ensure continuous selective anterior cerebral perfusion. Methodology: Via median sternotomy and central cannulation, the patient is placed on cardiopulmonary bypass and cooled to 20 °C. The arch and neck vessels are identified. After cross-clamping and administration of cardioplegia, the brachiocephalic and left common carotid artery are anastomosed to the trifurcate graft between clamps, and perfusion to the head is maintained via the side branch. Following this, the arch is excised under a short period of circulatory arrest, and the Thoraflex™ hybrid graft is deployed into the descending aorta, and an anastomosis made to the sewing cuff. The proximal anastomosis is then made to the ascending aorta after re-establishment of systemic perfusion. The left subclavian artery is then anastomosed to the trifurcate graft, and the trifurcate graft is anastomosed to residual ascending aorta in an end-to-side fashion. Results: We have two cases that have been solved using this approach. We present surgical pictures, and intraoperative imaging.

Redo Thoracoabdominal Aortic Aneurysm Repair: A Single-Center Experience Over 25 Years

Aortic disease is a lifelong, progressive illness that may require repeated intervention over time. We reviewed our 25-year experience with open redo thoracoabdominal aortic aneurysm (TAAA) and descending thoracic aortic aneurysm (DTAA) repair. Our objectives were to determine patient outcomes after redo repair of DTAA/TAAA and compare them with nonredo repair. We also attempted to identify the risk factors for poor outcome. We reviewed all open redo TAAA and DTAA repairs between 1991 and 2014. Patient characteristics, preoperative, intraoperative variables, and postoperative outcomes were gathered. Data were analyzed by contingency table and by multiple logistic regression. We performed 1,900 open DTAA/TAAA repairs, with 266 (14%) being redos. Redos were associated with younger age (62 ± 16.4 years vs 64.5 ± 13.4 years, p < 0.02). Reasons for redo DTAA/TAAA were extension of the disease (86.8%), intercostal patch expansion (6.8%), visceral patch expansion (10.9%), infection (4.5%), anastomotic pseudoaneurysm (8.3%), and previous endovascular aortic repair complications (6.4%). Extent IV TAAA was predominantly involved in redos (42.8% redo vs 14.6% nonredo, p < 0.0001). The early mortality rate was significantly higher in redo (61 of 266 [23%]). Long-term survival was significantly lower among redo compared with nonredo DTAA/TAAAs. A multivariable analysis using the significant risk factors for early death from the risk factors on univariate analysis found four preoperative variables were significant (age >70 years, glomerular filtration rate <48 mL/min per 1.73m2, extent III TAAA, and emergency presentation) for predicting early death. In the presence of all four risk factors in a redo patient, a maximal risk of 82% for early death was predicted. The need for a redo operation in DTAA/TAAA repair is common and most often presents as an extension of the disease into an adjacent segment. A hybrid or completely endovascular treatment should be considered in high-risk patients.

Is volume important in aneurysm treatment outcome?

Several studies have suggested that surgical procedures performed at high-volume centers may result in superior outcome. Technically more demanding procedures such as aortic aneurysm repair appear to demonstrate a stronger relationship with volume. The present chapter reviewed the literature using the MEDLINE database to identify studies investigating the effect of volume in aortic aneurysm repair outcomes. The great majority of studies identified shows an advantage for high-volume hospitals with regard to perioperative mortality of abdominal (AAA), thoracic (TAA) and thoracoabdominal (TAAA) aortic aneurysm repair. A similar advantage is shown for high-volume surgeons. The volume advantage appears to be less evident for simple endovascular procedures (EVAR & TEVAR), compared to more complex endovascular (F/BEVAR) and open surgical procedures. Superior outcomes observed in high-volume hospitals are not only explained by increased surgeons' experience, but importantly also by a more effective management of intra- and postoperative complications. Confounding factors to be taken into account are the timing of the studies in relation to positive evolution of outcomes in several high-risk procedures, and patient cohorts selected in regions with very low- and very high-volume hospitals only.

Type II endoleak after endoluminal repair of thoracic aortic aneurysm associated with native coarctation.

Aneurysm formation and recurrent coarctation are common complications of coarctation repair, and various types of treatment have been described. Native aortic coarctation during adult life is rarer and can be responsible for severe complications. We report an original case of thoracic aortic aneurysm associated with native coarctation successfully treated by a hybrid approach, comprising retrograde implantation of a thoracic stent graft and carotid-axillary bypass graft. A large intercostal collateral was embolized with coils.

Development of Collaterals to the Spinal Cord after Endovascular Stent Graft Repair of Thoracic Aneurysms

In thoracic and thoraco-abdominal aortic aneurysm repair, spinal cord injury (SCI) is devastating. Detection of the Adamkiewicz artery might be important for preventing SCI. Although thoracic endovascular stent grafts often occlude the segmental artery, the incidence of SCI in thoracic endovascular aortic repair is thought to be low compared with open repair. This study aimed to evaluate how the Adamkiewicz artery is supplied after segmental arteries are occluded by stent grafts. From March 2007 to August 2015, 32 patients were enrolled whose segmental arteries that were connected to the Adamkiewicz arteries were occluded by stent grafts. Segmental arteries, Adamkiewicz arteries, collateral circulation into the Adamkiewicz arteries, and anterior spinal arteries were pre- and post-operatively evaluated by computed tomography angiography. Post-operatively, Adamkiewicz arteries were detected in 24 (75%) patients, except for two patients with paraplegia and six without paraplegia. Post-operative Adamkiewicz arteries were the same as pre-operative Adamkiewicz arteries, except for one Adamkiewicz artery that was located at two vertebral levels below the pre-operative level. SCI occurred in two (6.3%) patients. The distribution of feeding arteries into the Adamkiewicz artery post-operatively was divided into three patterns as follows: a segmental artery below the distal landing zone of the stent graft (53%), branches of the left subclavian artery (33%), and a branch of the left external iliac artery (13%). The length of the stent graft should be as short as possible. Blood supply to the left subclavian artery should be maintained because segmental arteries below the segmental artery occluded by the stent graft and branches of the left subclavian artery can become collaterals post-operatively.

Exploring Spinal Cord Protection by Remote Ischemic Preconditioning: An Experimental Study

Paraplegia is one of the most severe complications occurring after the repair of thoracic and thoracoabdominal aortic aneurysms. Remote ischemic preconditioning (RIPC) has been shown to mitigate neurologic damage, and this study assessed its efficacy in preventing spinal cord ischemia. The study randomized 16 female pigs into an RIPC group (n= 8) and a control group (n= 8). The RIPC group underwent four cycles of 5-minute ischemia-reperfusion episodes by intermittent occlusion of the left iliac artery. All animals underwent systematic closure of the left subclavian artery and segmental arteries of the descending thoracic aorta to the level of diaphragm. Motor-evoked potential monitoring was performed in both hind limbs. Continuous electrocardiogram and hemodynamics were monitored, and pulmonary artery blood samples were collected. A neurologic assessment was performed 6 hours after the procedure. The thoracic and lumbar portions of the spinal cord were collected for histologic and immunohistochemical analysis. The bilateral motor-evoked potential amplitude responses were higher in the RIPC group (p < 0.05) than in the control group; the difference was detected already before spinal cord ischemia. Paraplegia occurred in 1 control animal. Immunohistochemical total scores of antioxidant response regulator nuclear factor erythroid 2-related factor 2 were better in the RIPC group (11.0; range, 8.5 to 14.0) than in the control group (5.2; range, 1.0 to 9.0; p= 0.023). RIPC induces electrophysiologic changes in the central nervous system that may confer spinal cord protection extending the resistance to ischemia. The significantly higher nuclear factor erythroid 2-related factor 2 scores suggest better neuronal cell protection against oxidative stress in the RIPC group.

Endovascular management of acute thoracic aortic emergencies

Acute emergencies involving the descending thoracic aorta, such as traumatic aortic disruption (TAD), ruptured descending thoracic aneurysm (RDTA), complicated type B dissection (cTBD), have been particularly challenging for aortic surgeons. Many patients do not survive the initial event, and are never afforded the opportunity to undergo surgical repair. Emergent open operative repair of the descending thoracic aorta, the traditional gold standard, is a formidable undertaking with significant operative mortality and morbidity. These are some of the most difficult and highest risk procedures performed by vascular surgeons. Since the approval of the first thoracic endograft in 2005, thoracic endovascular aortic repair (TEVAR) has quickly become the treatment of choice for elective thoracic aortic aneurysm repair. It was not long before the “off-label” use of TEVAR for a wide variety of conditions, both elective and emergent, was reported. The expanded use of TEVAR has resulted in a decrease in both operative mortality and morbidity for patients with a wide variety of aortic pathologies. In addition, hospital length of stay is usually less following TEVAR, especially if the procedure is done using a totally percutaneous technique.

Preoperative Morphology Influences Thoracic Aortic Aneurysm Sac Expansion After Endovascular Repair

Sac expansion is common in patients undergoing thoracic endovascular aortic repair (TEVAR) for thoracic aortic aneurysms (TAAs) and is particularly influenced by adverse morphologic of the aortic stent graft sealing zones.

Open aortic surgery after thoracic endovascular aortic repair.

In the last decade, thoracic endovascular aortic aneurysm repair (TEVAR) has emerged as an appealing alternative to the traditional open aortic aneurysm repair. This is largely due to generally improved early outcomes associated with TEVAR, including lower perioperative mortality and morbidity. However, it is relatively common for patients who undergo TEVAR to need a secondary intervention. In select circumstances, these secondary interventions are performed as an open procedure. Although it is difficult to assess the rate of open repairs after TEVAR, the rates in large series of TEVAR cases (>300) have ranged from 0.4 to 7.9%. Major complications of TEVAR that typically necessitates open distal aortic repair (i.e., repair of the descending thoracic or thoracoabdominal aorta) include endoleak (especially type I), aortic fistula, endograft infection, device collapse or migration, and continued expansion of the aneurysm sac. Conversion to open repair of the distal aorta may be either elective (as for many endoleaks) or emergent (as for rupture, retrograde complicated dissection, malperfusion, and endograft infection). In addition, in select patients (e.g., those with a chronic aortic dissection), unrepaired sections of the aorta may progressively dilate, resulting in the need for multiple distal aortic repairs. Open repairs after TEVAR can be broadly classified as full extraction, partial extraction, or full salvage of the stent-graft. Although full and partial stent-graft extraction imply failure of TEVAR, such failure is generally absent in cases where the stent-graft can be fully salvaged. We review the literature regarding open repair after TEVAR and highlight operative strategies.

Retraction of: Reversal of Spinal Cord Ischemia Following Endovascular Thoracic Aortic Aneurysm Repair with Hyperbaric Oxygen and Therapeutic Hypothermia, by Urquieta E, et al. Ther Hypothermia Temp Manag. DOI: 10.1089/ther.2015.0025.

Therapeutic Hypothermia and Temperature ManagementVol. 6, No. 2 RetractionFree AccessRetraction of: Reversal of Spinal Cord Ischemia Following Endovascular Thoracic Aortic Aneurysm Repair with Hyperbaric Oxygen and Therapeutic Hypothermia, by Urquieta E, et al. Ther Hypothermia Temp Manag. DOI: 10.1089/ther.2015.0025This article retracts the following:Retracted: Reversal of Spinal Cord Ischemia Following Endovascular Thoracic Aortic Aneurysm Repair with Hyperbaric Oxygen and Therapeutic HypothermiaPublished Online:10 Jun 2016https://doi.org/10.1089/ther.2015.0025.retractAboutSectionsPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail The senior author, Emmanuel Urquieta, of the article entitled, “Reversal of Spinal Cord Ischemia Following Endovascular Thoracic Aortic Aneurysm Repair with Hyperbaric Oxygen and Therapeutic Hypothermia,” has requested that the article, published online ahead of print (DOI: 10.1089/ther.2015.0025), be retracted because he discovered one of his coauthors mistakenly submitted the same article to the Journal of Vascular Surgery due to a miscommunication between them.The editorial leadership of Therapeutic Hypothermia and Temperature Management agree that the article must be retracted as a matter of proper scientific publishing protocol whereby an article may not be simultaneously submitted to two journals. The Editors commend Dr. Urquieta for willingly bringing this situation to their attention.Dr. Urquieta and his coauthors sincerely apologize to the Editors and the readership of Therapeutic Hypothermia and Temperature Management.FiguresReferencesRelatedDetailsRelated articlesRetracted: Reversal of Spinal Cord Ischemia Following Endovascular Thoracic Aortic Aneurysm Repair with Hyperbaric Oxygen and Therapeutic Hypothermia14 Dec 2015Therapeutic Hypothermia and Temperature Management Volume 6Issue 2Jun 2016 InformationCopyright 2016, Mary Ann Liebert, Inc.To cite this article:Retraction of: Reversal of Spinal Cord Ischemia Following Endovascular Thoracic Aortic Aneurysm Repair with Hyperbaric Oxygen and Therapeutic Hypothermia, by Urquieta E, et al. Ther Hypothermia Temp Manag. DOI: 10.1089/ther.2015.0025.Therapeutic Hypothermia and Temperature Management.Jun 2016.110-110.http://doi.org/10.1089/ther.2015.0025.retractPublished in Volume: 6 Issue 2: June 10, 2016PDF download

Aortic Dissection in Patients With Genetically Mediated Aneurysms: Incidence and Predictors in the GenTAC Registry

BackgroundAortic dissection (AoD) is a serious complication of thoracic aortic aneurysm (TAA). Relative risk for AoD in relation to TAA etiology, incidence, and pattern after prophylactic TAA surgery are poorly understood. ObjectivesThis study sought to determine the incidence, pattern, and relative risk for AoD among patients with genetically associated TAA. MethodsThe population included adult GenTAC participants without AoD at baseline. Standardized core laboratory tests classified TAA etiology and measured aortic size. Follow-up was performed for AoD. ResultsBicuspid aortic valve (BAV) (39%) and Marfan syndrome (MFS) (22%) were the leading diagnoses in the studied GenTAC participants (n = 1,991). AoD occurred in 1.6% over 3.6 ± 2.0 years; 61% of AoD occurred in patients with MFS. Cumulative AoD incidence was 6-fold higher among patients with MFS (4.5%) versus others (0.7%; p < 0.001). MFS event rates were similarly elevated versus those in patients with BAV (0.3%; p < 0.001). AoD originated in the distal arch or descending aorta in 71%; 52% of affected patients, including 68% with MFS, had previously undergone aortic grafting. In patients with proximal aortic surgery, distal aortic size (descending thoracic, abdominal aorta) was larger among patients with AoD versus those without AoD (both p < 0.05), whereas the ascending aorta size was similar. Conversely, in patients without previous surgery, aortic root size was greater in patients with subsequent AoD (p < 0.05), whereas distal aortic segments were of similar size. MFS (odds ratio: 7.42; 95% confidence interval: 3.43 to 16.82; p < 0.001) and maximal aortic size (1.86 per cm; 95% confidence interval: 1.26 to 2.67; p = 0.001) were independently associated with AoD. Only 4 of 31 (13%) patients with AoD had pre-dissection images that fulfilled size criteria for prophylactic TAA surgery at a subsequent AoD site. ConclusionsAmong patients with genetically associated TAA, MFS augments risk for AoD even after TAA grafting. Although increased aortic size is a risk factor for subsequent AoD, events typically occur below established thresholds for prophylactic TAA repair.

Simultaneous endovascular repairs of concomitant ruptured abdominal aortic aneurysm and huge silent thoracic aortic aneurysm

Ruptured abdominal aortic aneurysm (rAAA) is an emergent condition that carries higher mortality rate. Although there had been development of interventional and surgical technique besides improved critical care, mortality rates were still varied between 35 and 53% in the reported series. Preoperative shock was reported as a major factor predicting mortality rate. Feasibility of simultaneous endovascular repair of rAAA and silent thoracic aortic aneurysm (TAA) is not known. Herein, we aimed to demonstrate the advantage of simultaneous endovascular repair of rAAA and silent TAA in the settling of hemodynamic and neurologic instability. We proposed that simultaneous repair of silent aneurysm would eliminate second procedural risk and also further rupture risk, especially in high-risk patients.

Endovascular Aortic Aneurysm and Dissection Repair (EVAR) in Iran: Descriptive Midterm Follow-up Results.

Background:Endovascular repair of aorta in comparison to open surgery has a low early operative mortality rate, but its long-term results are uncertain.Objectives:The current study describes for the first time our initial four-year experience of elective endovascular aortic repair (EVAR) at Tehran heart center, the first and a major referral heart center in Iran, as a pioneer of EVAR in Iran.Patients and Methods:A total of 51 patients (46 men) who had the diagnosis of either an abdominal aortic aneurysm (AAA) (n = 36), thoracic aortic aneurysm (TAA) (n = 7), or thoracic aortic dissection (TAD) (n = 8) who had undergone EVAR by Medtronic stent grafts by our team between December 2006 and June 2009 were reviewed.Results:The rate of in-hospital aneurysm-related deaths in the group with AAA stood at 2.8% (one case), while there was no in-hospital mortality in the other groups. All patients were followed up for 13-18 months. The cumulative death rate in follow-up was nine cases from the total 51 cases (18%), out of which six cases were in the AAA group (four patients due to non-cardiac causes and two patients due to aneurysm-related causes), one case in the TAA group (following a severe hemoptysis), and two cases in the TAD group (following an expansion of dissection from re-entrance). The major event-free survival rate was 80.7% for endovascular repair of AAA, 85.7% for endovascular repair of TAA, and 65.6% for endovascular repair of TAD.Conclusion:The endovascular stent-graft repair of the abdominal and thoracic aortic aneurysm and aortic dissection had high technical success rates in tandem with low-rate early mortality and morbidity, short hospital stay, and acceptable mid-term free symptom survival among Iranian patients.