Aortic Aneurysm Replacement Research Articles

Long-term outcomes of extensive thoracoabdominal aortic aneurysm repair utilizing normothermic iliac perfusion: A retrospective cohort study with 10-year single-center experience.

Normothermic iliac perfusion has been increasingly utilized for TAAA repair; however, the long-term outcomes in large samples are lacking. This study was designed to assesses the perioperative and long-term results of thoracoabdominal aortic repair using normothermic iliac perfusion. We retrospectively analyzed 156 patients having Crawford extent II or III thoracoabdominal aortic aneurysm replacement with normothermic iliac perfusion from 2012 to 2022. Primary endpoints were composite adverse events and long-term survival, which encompassed 30-day mortality, persistent stroke, persistent paraplegia, and acute renal failure needing continuous dialysis. The cohort was divided into two subgroups based on the use of selective visceral and cold renal perfusion techniques. The combined adverse event rate was 14.1%. Specific rates were: 30-day mortality (4.5%), persistent stroke (1.9%), persistent paraplegia (4.5%), and renal failure requiring persistent dialysis (3.2%). The median follow-up time was 67 months. Overall survival rates at 1, 3, 5, 7, and 10 years were 91.6%, 90.0%, 85.4%, 77.6%, and 69.7%, respectively. Subgroup analysis showed the visceral and renal perfusion group had a significantly reduced adverse event incidence compared to the nonperfusion group (6.5% vs. 19.1%, P=0.026). Multivariable logistic regression analysis confirmed selective visceral and cold renal perfusion techniques as protective factors against postoperative adverse events (OR 0.30, 95%CI 0.09-0.94; P=0.038). Multivariable Cox regression analysis identified age ≥50 years (HR 2.63, 95%CI 1.10-6.27; P=0.029) and NYHA grade ≥III (HR: 3.20, 95% CI: 1.04-9.87; P=0.043) as independent risk factors predicting overall survival. Normothermic iliac perfusion is a feasible option for thoracoabdominal aortic repair with cost benefits and simpler management, and selective visceral and cold renal perfusion techniques may further improve its safety and effectiveness. However, enhanced vigilance and meticulous care are essential, particularly for elderly patients and those with cardiac insufficiency.

Patterns of collateral arteries to the spinal cord after thoraco-abdominal aortic aneurysm repair.

Our goal was to evaluate postoperative patterns of collateral arteries to the spinal cord during occlusion of the segmental arteries supplying the artery of Adamkiewicz (AKA). Between April 2011 and December 2022, a total of 179 patients underwent thoraco-abdominal aortic aneurysm repair; 141 had an identifiable AKA on preoperative multidetector computed tomography scans, 40 underwent thoraco-abdominal aortic aneurysm replacement (TAAR) and 101 underwent thoracic endovascular aortic repair (TEVAR). New postoperative collateral blood pathways invisible on preoperative contrast-enhanced computed tomography scans were identified in 42 patients (10 patients who had TAAR vs 32 patients who had TEVAR) who underwent preoperative and postoperative multidetector computed tomography scanning for AKA identification. The thoracodorsal and segmental arteries were the main collateral pathways in both groups. Th9-initiated collaterals were the most common. Collaterals from the internal thoracic artery were observed in the TEVAR group but not in the TAAR group. One patient in the TEVAR group experienced postoperative paraparesis, which was not observed in the TAAR group. Postoperative paraplegia was more common in the non-Th9-origin group, but this difference was not significant. Thoracodorsal and segmental arteries may be important collateral pathways after TEVAR and TAAR. For thoracodorsal arteries, preserving the thoracodorsal muscle during the approach would be crucial; for segmental arteries, minimizing the area to be replaced or covered would be paramount. An AKA not initiated at the Th9 level poses a high risk of postoperative paraplegia.

Safety and efficacy of ketorolac in improving the prognosis of acute type A aortic dissection patients: a protocol of a randomized, double-blinded, and placebo-controlled study

BackgroundAcute type A aortic dissection (aTAAD) is a critical and life-threatening condition. Previous research has demonstrated that the use of ketorolac not only reduces the progression, incidence, and severity of aortic aneurysms in animal models, but also decreases postoperative mortality and complications in patients undergoing open abdominal aortic aneurysm replacement. However, there is a lack of studies investigating the efficacy of ketorolac in treating aTAAD in humans. Therefore, we conducted a study to evaluate the safety and efficacy of ketorolac in patients with aTAAD. Our hypothesis was that ketorolac treatment for aTAAD patients would meet safety indicators and effectively improve patient prognosis.Methods/designThis study is a single-center, randomized, double-blinded, and placebo-controlled study. A total of 120 patients with aTAAD will be recruited and will be randomized into the ketorolac group and placebo group with a ratio of 1:1. Ketorolac tromethamine 60 mg per 2 ml will be intramuscularly injected within 2 h before surgery, followed by intramuscular injections of 30 mg per 1 ml BID. on the first and second postoperative days in the Ketorolac group, while 0.9% saline will be administered at the same dose, dosage form, and time in the placebo group. This study aims to evaluate the safety and efficacy of ketorolac in improving the prognosis of aTAAD. The primary endpoint is the composite endpoint event concerning drug-related adverse events. Secondary endpoints include drug-related adverse events, laboratory examination of blood, diagnostic imaging tests, clinical biomarkers, etc.DiscussionThis study has been approved by the Medical Ethics Committee of Affiliated Nanjing Drum Tower Hospital, Nanjing University Medical College (approval number: 2023–197-02). This study is designed to evaluate the safety and efficacy of ketorolac in patients with aTAAD. All participating patients will sign an informed consent form, and the trial results will be published in international peer-reviewed journals.Trial registrationThe Chinese Clinical Trial Registry (http://www.chictr.org.cn) ChiCTR2300074394. Registered on 4 October 2023.

Current understanding of the genetics of thoracic aortic disease

Thoracic aortic dissection is a feared, highly lethal condition most commonly developing from aneurysmal dilation of the thoracic aorta. Elective prophylactic replacement of thoracic aortic aneurysms dramatically mitigates this risk. However, diagnosis of a thoracic aortic aneurysm can be challenging. Thoracic aortic disease - horacic aortic aneurysm and dissection (TAAD) - can be sporadic or heritable. Patients with syndromic heritable TAAD present with classic phenotype and clinical features correlating to their disease. In contrast, patients with non-syndromic heritable disease are harder to diagnose due to their lack of defining uniform phenotypes. Recent advances in genomics have begun to elucidate the genetic underpinnings of non-syndromic TAAD (ns-TAAD) for better understanding this complex disease and improve diagnosis and management. Herein, we review the foundation of knowledge in ns-TAAD heritability and key research studies identifying gene mutations in vascular smooth muscle cells, the extracellular matrix, and TGF-beta signaling present in ns-TAAD. We summarize the current guidelines for the diagnosis, screening, and surgical management of ns-TAAD including recommendations for genetic testing of high-risk individuals. Finally, we highlight areas of future research that will continue to advance our understanding of the complex genetic and epigenetic factors in TAAD.

POS0804 OUTCOMES OF SURGICALLY RESECTED THORACIC AORTITIS: RESULTS FROM A PROSPECTIVE MULTI-CENTRE REGISTRY

Background:Inflammatory thoracic aortitis is a cause of aneurysm and is often diagnosed incidentally following aortic replacement surgery. It may be due to systemic diseases such as giant cell arteritis (GCA) and Takayasu arteritis (TAK) or a topographically isolated variant termed clinically isolated aortitis (CIA). While CIA is identified in 2-12% of thoracic aortic surgical pathology,1 its short-term post-operative outcome is unknown.Objectives:This study was undertaken to examine the short-term post-operative mortality and morbidity of patients with surgically resected thoracic aortitis compared to those with non-inflammatory thoracic aortic aneurysms and assess if outcomes varied based on post-operative corticosteroid therapy.Methods:The study was based at three tertiary referral hospitals in Sydney, Australia, for the years 2004-2018. Prospectively collected data was accessed from a national surgical registry for all patients who underwent thoracic aortic aneurysm replacement. Aortitis patients were identified from histopathology records.Inpatient medical records were reviewed to categorise aortitis cases as CIA, GCA, TAK or other aortitis and to audit the use of corticosteroids. Outcomes were compared between aortitis cases and the non-inflammatory cohort using logistic regressions, controlling for age, sex, year of procedure, and hospital.Results:41 aortitis cases were identified from the cohort of 1119 surgical patients (3.7%). 27 (66%) met criteria for CIA, 11 (27%) for GCA, 2 (5%) for TAK, and 1 (2%) for Other. 8 (20%) received corticosteroid therapy for aortitis.Compared with non-inflammatory patients, the aortitis cohort was predominantly female (54% vs 28%, p < 0.01), older (mean 70 vs 62 years, p < 0.01), and had higher rates of hypertension (83% vs 67%, p = 0.03) and pre-operative immunosuppression (10% vs 1%, p < 0.01).There was no difference (p > 0.05) between the aortitis and the non-aortitis groups for 30-day mortality (7% vs 7%), composite significant morbidity (15% vs 22%), composite infection (10% vs 6%), return to theatre for bleeding (7% vs 13%), stroke (5% vs 5%) or readmission (12% vs 10%). Similar results were also seen for CIA and the aortitis subgroup who did not receive corticoid steroid therapy when compared to the non-aortitis group (table 1).Table 1.30-day mortality and morbidityNon-aortitisAll aortitisAortitis, not treated for aortitisCIAn=1078n=41n=33n=27%n%n%n%nMortality770736241Stroke557526241Return to theatre bleed13137736241Composite morbidity22241156155113Composite infection66910493113Readmission10108125124113Note: Differences in outcomes between the aortitis groups and the no aortitis group were modelled using logistic regression, controlling for age, sex, year of procedure, and hospital. There were no statistically significant differences in outcomes (p > 0.05).CIA; clinically isolated aortitis. Composite morbidity; an outcome comprised of return to theatre for bleeding, stroke, new renal failure, acute myocardial infarction or aortic dissection. Composite infection; an outcome comprised of 30-day pneumonia, septicaemia, deep sternal wound infection or deep thoracotomy infection.Conclusion:The finding of thoracic aortitis following aortic replacement surgery does not affect short-term post-operative mortality or morbidity. Corticosteroid therapy in the immediate post-operative period did not impact upon short-term outcomes.

Relationship between indexed aortic area and aortic diameter in bicuspid aortic valve aortopathy: A retrospective cohort study

BackgroundAortic dissection is a life-threatening complication of bicuspid aortic valve (BAV)-associated aortopathy. In these populations, whilst prophylactic replacement of proximal thoracic aortic aneurysms (TAAs) is generally recommended at threshold diameters ≥5.5 cm, dissection may occur in smaller aortas. An alternative size-based parameter, the cross-sectional aortic area/patient height ratio (indexed aortic area, IAA), correlates with increased dissection risk at abnormal values > 10 cm2/m. We sought to assess the utility of the IAA in identifying at-risk BAV-associated TAAs with abnormal IAA, albeit with sub-threshold aortic diameter. Materials and methodsWe retrospectively identified 69 patients with BAV-associated TAAs who underwent surgical repair between 2010 and 2016. Aortic diameter was measured on pre-operative imaging, and IAA calculated, at the mid-sinus of Valsalva, sino-tubular junction and mid-ascending aorta for each patient. We determined proportions of aneurysms with IAA >10 cm2/m, median IAAs corresponding to aortic diameters <4.0 cm, 4.0–4.5 cm, 4.5–5.0 cm, 5.0–5.5 cm and >5.5 cm, and median aortic diameters corresponding to an abnormal IAA. Results50.9%, 12.5% and 64.6% of aneurysms at the sinus of Valsalva, sino-tubular junction and mid-ascending aorta, respectively, had an abnormal IAA. 51.9% and 88.9% of patients with aortic diameter 4.5–5.0 cm and 5.0–5.5 cm, respectively, had an abnormal IAA. In aneurysms with abnormal IAA involving the sinus of Valsalva, sino-tubular junction, and mid-ascending aorta, median aortic diameters were 4.98 cm, 5.04 cm and 5.11 cm, respectively. Overall, 57/72 (79.2%) at-risk aneurysms with IAA >10 cm2/m had diameters smaller than the 5.5 cm guideline cut-off for surgical intervention. ConclusionSignificant proportions of BAV-associated TAAs are at increased risk of aortic dissection attending an IAA >10 cm2/m, whilst not fulfilling the size criteria indicating aortic surgery in contemporary guidelines. Further analysis of IAA in larger BAV cohorts is necessary to clarify its role in patient selection and optimal timing for prophylactic aortic replacement.

EARLY LEFT VENTRICULAR GLOBAL LONGITUDINAL STRAIN DETERIORATION AFTER AORTIC ANEURYSM REPAIR IN HYPERTENSIVE PATIENTS: IMPACT OF AORTIC STIFFNESS

Objective: Invasive abdominal aortic aneurysm (AAA) replacement with an endograft interposes between the normal arterial tree which may acutely reduce overall systemic compliance. As a result, the input impedance is significantly increased, as are central systolic and pulse pressures. We evaluated changes in left ventricular global longitudinal peak strain (GLPS) in hypertensive patients undergoing repair of AAA in relation with the changes in arterial stiffness. Design and method: This was a single-center, nonrandomized, prospective, observational cohort study. Consecutive AAA hypertensive patients who underwent open or endovascular repair (EVAR) were enrolled. All patients were asymptomatic from their AAA and were admitted for elective treatment; there were no planned adjunctive procedures at the time of repair. A standard M-mode and 2-dimensional (2D) echocardiographic study was performed in all participants Left ventricular global longitudinal strain (GLS), and carotid-femoral pulse wave velocity (cf-PWV) were estimated 1 week preoperatively, as well as 1 and 6 months postoperatively. Left ventricular global longitudinal strain (GLS), and carotid-femoral pulse wave velocity (cf-PWV) were estimated 1 week preoperatively, as well as 1 and 6 months postoperatively. Results: A total of 70 men, mean age 70 ± 7 years, were evaluated. Of these, 58 underwent EVAR and 12 open repair. A significant time effect was found on cf-PWV, which showed an increase at 1 month and remained thereafter (p = 0.006). Additionally, a deterioration in GLS values was revealed, with a significant increase at 1 month that persisted 5 months later (p &lt; 0.001). No significant group effect was observed between EVAR and open repair (p = 0.98) and there was no significant interaction (p = 0.96). Notably, the difference of global longitudinal strain (DGLS) between baseline and 6 months significantly correlated with the corresponding changes in cf-PWV (r = 0.494, p &lt; 0.0001). Conclusions: AAA repair may have detrimental effects in cardiac systolic function. Our findings highlight the need a more intense cardiac surveillance program after aortic reconstruction. Further studies are needed to investigate how this may translate into long-term manifestations of cardiovascular complications and symptomatology.

Left ventricular global longitudinal peak strain deterioration in patients undergoing endovascular repair of abdominal aortic aneurysms: the effect of arterial stiffness

Abstract Purpose Invasive abdominal aortic aneurysm (AAA) replacement with an endograft interposes between the normal arterial tree which may acutely reduce overall systemic compliance and increase the input impedance. We evaluated the impact of aortic reconstruction, using currently available grafts and endografts, on pulse wave velocity (pwv) and its effect on early cardiac systolic function indices in these patients. Methods A total of 73 men, mean age 70±8 years, were evaluated. Of these, 61 underwent endovascular repair (EVAR) and 12 open repair (OS). All patients underwent an assessment with a standard conventional transthoracic and a two-dimensional speckle tracking echocardiography at baseline, at 1 and 6 months after the intervention. Carotid - femoral (c-f) artery waveforms were measured and pwv was determined in all participants on each follow up visit. Results No significant changes in blood pressure were observed during the study period. Notably, our findings revealed a significant reduction in global longitudinal peak strain (GLPS) during the 6 months follow-up (from −19.7±−5.9% at baseline to −17.1±−5.9% at 6 months, p=0.03). C-r pwv showed a significant increase 6 months after the procedure (from 10.7±−2.9 m/sec at baseline to 13.9±3.3 m/sec at 6 months, p&amp;lt;0.001). A significant time effect was found on cf-pwv, which showed an increase at 1 month and remained thereafter (p=0.007). Additionally, a deterioration in GLS values was revealed, with a significant increase at 1 month that persisted 5 months later (p&amp;lt;0.001). No significant group effect was observed between EVAR and open repair (p=0.98) and there was no significant interaction (p=0.96). Notably, the difference of global longitudinal strain (ΔGLS) between baseline and 6 months significantly correlated with the corresponding changes in cf-pwv (r=0.494, p&amp;lt;0.0001). Conclusions AAA repair not only leads to an increase in aortic stiffness, as measured by the increase in pwv, but also reduces cardiac systolic function. Our findings highlight the need a more intense cardiac surveillance program after aortic reconstruction. Further studies are needed to investigate how this may translate into long-term manifestations of cardiovascular complications and symptomatology. Funding Acknowledgement Type of funding source: None

Debunking the July Effect in Cardiac Surgery: A National Analysis of More Than 470,000 Procedures

Recent studies in noncardiac surgery have described worse outcomes in the first month of training. However, the "July effect" in the context of cardiac surgery outcomes is not well understood. We examined whether patient outcomes after cardiac surgery were affected by procedure month or academic year quartile. Using the National Inpatient Sample, we isolated all coronary artery bypass grafting (CABG), surgical aortic valve replacement (AVR), mitral valve repair or replacement (MV), and isolated thoracic aortic aneurysm (TAA) replacement procedures between 2012 and 2014. For each procedure, overall trends in in-hospital mortality and hospital complications were compared by academic year quartiles (ie, between the first academic year quartile vs the fourth quartile) and by procedure month. Outcomes between teaching and nonteaching hospitals were also compared. Overall, 301,105 CABG, 111,260 AVR, 54,985 MV, and 2,655 TAA procedures met inclusion criteria. In-hospital mortality for each procedure did not vary by procedure month or academic year quartile, even after risk adjustment (all P > .05). Teaching status did not influence risk-adjusted mortality for CABG and isolated TAA replacement (both P > .05). However, teaching hospitals had significantly lower adjusted mortality thannonteaching hospitals for AVR and MV surgery (both P < .01). The July effect is not evident for cardiac surgery despite preexisting notions. Teaching hospitals performed at least equivalent, if not better, for major cardiac surgery procedures. These findings highlight the pivotal role of hospital support systems to ensure the safe transition of resident classes without compromising on patient outcomes.

Surgical Outcome of Abdominal Aortic Aneurysm Replacement in Patients with Connective Tissue Disorders under 30 Years of Age.

Objectives: Abdominal aortic aneurysm (AAA) in patients <30 years old is relatively rare. We retrospectively analyzed patients <30 years who received an AAA replacement.Materials: Among 3,003 patients who received an AAA replacement during the last 40 years, 10 patients <30 years old were retrospectively reviewed. All patients suffered from a connective tissue disease: eight from Marfan syndrome and two from Loeys–Dietz syndrome. Five patients had a history of cardiovascular surgery. Aortic pathologies were a dissection type in eight patients and a non-dissection type in two. All patients received a graft replacement of infrarenal AAA, with a bifurcated graft in six patients and a straight graft in four.Results: Except for cases that were urgent and emergent, rapid aneurysm expansion was noted in all cases. Mean AAA diameter at surgery was 46.7±9.2 mm. No hospital mortality was recorded. Eight patients required 10 additional cardiovascular surgeries: two root replacements, two total arch replacements, two descending aortic replacements, and four thoracoabdominal replacements.Conclusion: AAA replacement in patients <30 years is safe. In younger patients with a connective tissue disease, AAA should be included in the routine medical check-up, and earlier surgical indication should be considered for its rapid expansion.

A Trial Early Mobilization Program for Abdominal Aortic Aneurysm Replacement Surgery: Retrospective Study of Independent Ambulation, Complications and Hospital Days after Early Ambulation

A Trial Early Mobilization Program for Abdominal Aortic Aneurysm Replacement Surgery: Retrospective Study of Independent Ambulation, Complications and Hospital Days after Early Ambulation

The use of intraoperative epiaortic ultrasonography in monitoring patients over 75 years old treated with aortic valve replacement.

IntroductionEpiaortic ultrasound scanning (EAS) extended the use of ultrasound to the intraoperative diagnosis of aortic pathology. Surgical palpation of the ascending aorta underestimates the presence and severity of atherosclerotic plaques. Epiaortic ultrasound scanning has been used as an adjunct to transesophageal echocardiography (TEE) or as a primary direct diagnostic tool for imaging the ascending aorta as well as the aortic arch, which gained prominence as part of a multipronged intraoperative strategy to reduce atherosclerotic emboli.AimTo compare the epiaortic examination with transthoracic and transesophageal echo (transthoracic echocardiography (TTE) and TEE), X-ray, surgical intraoperative palpation, and postoperative neurological status.Material and methodsThe analyzed group consisted of 35 patients (mean age: 81.3 years) treated with aortic valve replacement (AVR), either alone (60%) or combined with coronary artery bypass grafting (CABG; 22.8%) or aortic aneurysm replacement (11.42%). In 2 patients, only CABG was performed because intraoperatively reevaluated strategy. Thierteen patients have got a history of diabetes, 10 chronic renal failure and 3 of cerebral stroke.ResultsIn more than 80% of patients, positive EAS results had an influence on the choice of aortic clamping site and in 50% of patients on the site of cannulation. Female sex, peripheral vascular disease, history of previous stroke, and calcifications in the ascending aorta in TTE have significant predictive value for recognizing atherosclerotic changes in EAS and the risk of postoperative neurological complications in octogenarians treated with AVR.ConclusionsEpiaortic ultrasound scanning imaging is superior to TTE and manual palpation in the detection and localization of ascending atherosclerosis. This technique should be introduced as a standard perioperative examination in older patients at risk of neurological complications.

2F13 人工血管置換術用ナビゲーションにおける骨格の点を用いたレジストレーション法の開発と臨床データを用いた誤差評価

We have developed a navigation system for the blood vessel prosthesis replacement of aortic aneurysms, and have used it in clinical practice. This system supports surgeons to identify a target intercostal artery by using patient image. The patient image and real body are matched by registration. Reference points of registration are anatomical landmarks of skeleton such as jugular notch, sternal angle, left anterior superior iliac spine, pubis, and spinous process. However, identification of spinous process was hard to doctors in operation. We developed a new registration method which X, Y and Z axis correspond to the Head-Foot, Right-Left and Anterior-Posterior directions. The specific feature is that identification of spinous process is not necessary. We evaluated errors with the new registration method using the retrospective 6 clinical data. We calculated fiducial localization error. As a result, errors of anterior points in the Head-Foot direction were less than 10 mm. We aimed to reduce the Head-Foot error as less than 20 mm because the ribs exist at intervals of approximately 40 mm in the Head-Foot direction. The new registration method was confirmed to be effective in the decision of approach to the target artery. Moreover, even when the point of the spinous process changed to the next spinous process of the set spinous processes, error was equivalent to the original point, therefore, using the present system, the identification of the spinous process can be unnecessary. It was concluded that newly-developed registration algorism is effective for doctors in identification of intercostal artery.

Effect of aortic aneurysm replacement on outcomes after bicuspid aortic valve surgery: Validation of contemporary guidelines

Bicuspid aortic valve (BAV) disease is associated with aortic dilatation and aneurysm (AN) formation. The American College of Cardiology/American Heart Association (ACC/AHA) 2006 guidelines recommend replacement of the ascending aorta for an aortic diameter (AD)> 45 mm in patients undergoing aortic valve replacement (AVR). We evaluated the outcomes of AVR and AVR with aortic replacement (AVR/AN). We retrospectively reviewed (2004-2011) the data from 456 patients with BAV and compared the morbidity and mortality between the AVR and AVR/AN groups and 3 subgroups: AVR with an AD<45 mm; AVR/AN with an AD of 45 to 49 mm; and AVR/AN with an AD of ≥50 mm. Propensity score matching was used to reduce bias. Of the 456 patients, 250 (55%) underwent AVR and 206 (45%) AVR/AN, with 98% compliance with the current guidelines. The overall 30-day mortality was 0.9%. The AVR AD<45-mm group had adjusted short- and medium-term survival similar to that of the AVR/AN AD 45- to 49-mm and AVR/AN AD≥50-mm groups, with a 30-day mortality of 0.8%, 0%, and 1.9%, respectively (P=.41). The propensity score-matched AVR/AN AD≥50-mm group had significantly greater rates of reintubation than either the AVR AD<45-mm (P=.012) or AVR/AN AD 45- to 49-mm (P=.04) group and greater rates of prolonged ventilation (P=.022) than the AVR AD<45-mm group. No significant differences were found in reoperation or myocardial infarction among the subgroups. In patients with undergoing AVR, no increase was seen in morbidity or mortality when adding aortic replacement with an AD of 45 to 49 mm, in accordance with the 2006 ACC/AHA guidelines, although the AVR/AN AD≥50-mm group had a greater risk of respiratory complications. Our findings indicate that compliance with the ACC/AHA guidelines is safe in select centers.

Arterial Allografts in Treating Aortic Graft Infections: Something Old, Something New

Surgical treatment of major aortic infection remains the most demanding challenge in aortic surgery. Excellent results with cryopreserved allograft heart valves in the treatment of acute infectious endocarditis prompted the use of allografts for in situ replacement of mycotic aortic aneurysms and prosthetic aortic graft infection. This review summarizes the indications for use of allografts in the management of major aortic infection, describes technical pitfalls at the time of implantation, presents clinical results, and analyzes the findings in explanted segments of failed allografts. In addition, the current status of the use of allografts will be compared with competitive techniques for treatment of vascular infections.

Management of infrarenal abdominal aortic aneurysms in the elderly: “The geriatric abdominal aortic aneurysm”

Infrarenal abdominal aortic aneurysm (AAA) replacement was performed in 97 patients aged 79 or greater over a 14-year period. Sixty-eight patients had intact aneurysms and 29 had ruptured aneurysms. In the intact aneurysm group, the 30-day mortality rate from 1980 to 1986 was 11.5% and decreased to 2.3% from 1987 to 1994. In the ruptured aneurysm group, the 30-day mortality rate was 73% in the earlier period from 1980 to 1986 and 43% in the later period from 1987 to 1994. In the intact aneurysm group, the median hospital stay was 11 days for the transabdominal approach and 8 days with a retroperitoneal approach. In the ruptured aneurysm group, the median hospital stay was 26 days. The occurrence of a ruptured AAA in a patient over 79 years of age is still associated with a high mortality rate, despite the many advances in aneurysm surgery during the past few decades. Hence, in appropriately selected elderly patients, infrarenal aortic aneurysm replacement should be performed electively as the perioperative mortality is low and late survival is similar to that of agematched controls. Age alone should not be a contraindication for infrarenal aortic aneurysm replacement.

Cerebral oximetry monitoring during aortic arch aneurysm replacement surgery in Jehovah's Witness patient -A case report-.

Anesthetic management for aortic arch aneurysm (AAA) surgery employing deep hypothermic circulatory arrest in a Jehovah's Witness (JW) patient is a challenge to anesthesiologist due to its complexity of procedures and their refusal of allogeneic transfusion. Even in the strict application of intraoperative acute normovolemic hemodilution (ANH) and intraopertive cell salvage (ICS) technique, prompt timing of re-administration of salvaged blood is essential for successful operation without allogeneic transfusion or ischemic complication of major organs. Cerebral oximetery (rSO2) monitoring using near infrared spectroscopy is a useful modality for detecting cerebral ischemia during the AAA surgery requiring direct interruption of cerebral flow. The present case showed that rSO2 can be used as a trigger facilitating to find a better timing for the re-administration of salvaged blood acquired during the AAA surgery for JW patient.

Efficacy of TachoSil® patches in controlling Dacron suture-hole bleeding after abdominal aortic aneurysm open repair

PurposeThe aim of this study is evaluate the efficacy of TachoSil® patches in controlling suture-hole bleeding after elective infrarenal abdominal aortic aneurysm (AAA) replacement with Dacron graft.Materials and methodsPatients undergoing elective replacement of infrarenal AAA with Dacron grafts were prospectively randomized to TachoSil® patches (Group I) or standard compression with surgical swabs (Group II).We evaluated time to haemostasis, blood loss during the operation, blood loss after cross-clamp removal, duration of operation, drain volume, requirement for blood transfusion and surgeons rating of efficacy.ResultsTwenty patients were randomized (10 patients in each treatment Group). The mean time to haemostasis was 264 ± 127.1 s (range: 180-600 s) in Group I and 408 ± 159.5 s (range: 120-720 s) in Group II (p = 0.026); mean blood loss during the operation was 503.5 ± 20.7 cc (range: 474-545 cc) in Group I and 615.7 ± 60.3 cc (range: 530-720 cc) in Group II (p < 0.001); mean blood loss after cross-clamp removal was 26.5 ± 4 g (range: 22-34 g) in Group I and 45.4 ± 4.6 (range: 38-52 g) in Group II (p < 0.001) and mean drain volume was 116.7 ± 41.4 cc (range: 79-230 cc) in Group I and 134.5 ± 42.8 cc (range: 101-250 cc) in Group II (p = 0.034). There were no serious adverse events associated with use of TachoSil® patches.ConclusionFor patients undergoing aortic reconstruction with Dacron grafts, TachoSil® patches were found to be safe and effective for the control of suture-hole bleeding.

Adjustment of Sinotubular Junction for Aortic Insufficiency Secondary to Ascending Aortic Aneurysm

Dilatation of the sinotubular junction (STJ) causes aortic regurgitation (AR) in patients with ascending aneurysm. These patients can regain valve competence by simple reduction of the diameter of STJ. Results of this technique were investigated clinically and echocardiographically. Replacement of the ascending aorta with reduction of the diameter of the STJ to correct AR (mean grade, 2.7 +/- 0.7) was performed in 29 consecutive patients (mean age, 73.2 +/- 6.2). Two required repair of cusp prolapse. All underwent ascending aortic aneurysm replacement. Echocardiographic studies were performed at discharge and during latest clinical follow-up (mean follow-up, 3.8 +/- 2.5 years). No hospital deaths occurred. The AR grade at discharge was 0.7 +/- 0.5. No valve related-deaths occurred. Actual survival at 8 years was 91% +/- 9%. Failure occurred 4.1 years postoperatively in a patient with bicuspid valve. Three patients had late recurrence of AR that was caused by aortic root dilatation in bicuspid valves in 2. Multivariate analysis showed bicuspid aortic valve was the predictor of late progression of AR. The freedom from more than grade II AR at 8 years was 79.5% +/- 10.7%. Adjustment of the diameter of STJ could treat AR secondary to ascending aortic aneurysm with nearly normal aortic cusps. Midterm results of this procedure were acceptable. Although bicuspid aortic valve is the risk factor for late AR due to dilation of remaining aortic root, this procedure provides satisfactory long-term outcomes among the patients with tricuspid valve.

Extended replacement of aortic arch aneurysms through left posterolateral thoracotomy

To present our experience of total aortic arch replacement through a left posterolateral thoracotomy. Sixteen patients (13 males; mean age 62.1+/-11.3 years) with extended thoracic aortic aneurysms, including those in the thoracoabdominal aorta, underwent replacement through a left posterolateral thoracotomy. The pathology of the diseased aorta was non-dissecting aneurysm due to aortitis in 1 patient and aortic dissection in 15 patients (acute type A: 1, chronic type A: 12, chronic type B: 2). In a prior operation, the patient with aortitis had undergone the Bentall procedure with endovascular stenting of the brachiocephalic artery, and among the other 15 patients, one previously had endovascular stenting for the aortic arch and 12 had hemi-arch replacement for acute type A dissection. Extension of arch replacement was the aortic arch and descending aorta in eight patients, the ascending arch and descending aorta in five patients and the descending arch, and thoracoabdominal aorta in three patients. Additional retroperitoneal dissection was required for the repair of a thoracoabdominal aortic aneurysm. One patient died of traumatic cerebral hemorrhage on day 145 (hospital mortality 6.3%). Average duration of ventilation support was 19.4+/-17.0h and length of ICU stay was 3.6+/-1.6 days. Actuarial survival at 2 years after the operations was 67.7%. However, no aortic-related mortality was observed during follow-up. Early results of extended aortic arch replacement through a left posterolateral thoracotomy were satisfactory in selected patients.