Suitable Anatomy Research Articles

Patient selection and anatomical considerations for zone 0 endovascular aneurysm arch repair

Endovascular aortic arch repair has been widely used in select patients who are considered high risk for open surgical repair and have suitable anatomy. The anatomical challenges of placement of stent-grafts in the ascending aorta are many, including the curved configuration, short landing zone, proximity to the aortic valve and coronary arteries and need to incorporate the supra-aortic trunks. Stent-graft designs with fenestrations and/or directional branches are applicable to patients who have suitable landing zones in the aorta and supra-aortic trunks, adequate access and absence of significant atheromatous debris. These devices include single and multibranch concepts, which are used in combination or not with cervical debranching procedures. This article summarizes the most commonly used anatomical criterion with currently utilized arch branch stent-grafts.

Physician preferences for revascularization in patients with ischemic cardiomyopathy: Defining equipoise from web-based surveys

BackgroundThe optimal revascularization approach in patients with heart failure with reduced ejection fraction (HFrEF) and ischemic heart disease (“ischemic cardiomyopathy”) is unknown. Physician preferences regarding clinical equipoise for mode of revascularization and their willingness to consider offering enrollment in a randomized trial to patients with ischemic cardiomyopathy have not been characterized. MethodsWe conducted two anonymous online surveys: 1) a clinical case scenario-based survey to assess willingness to offer clinical trial enrollment for a patient with ischemic cardiomyopathy (overall response rate to email invitation 0.45 %), and 2) a Delphi consensus-building survey to identify specific areas of clinical equipoise (overall response rate to email invitation 37 %). ResultsAmong 304 physicians responding to the clinical case scenario-based survey, the majority were willing to offer the opportunity for clinical trial enrollment to a prototypical patient with ischemic cardiomyopathy (92 %), and felt that a finding of non-inferiority for PCI vs. CABG would influence their clinical practice (78 %). Among 53 physicians responding to the Delphi consensus-building survey, the median appropriateness rating for CABG was significantly higher than that of PCI (p < 0.0001). In 17 scenarios (11.8 %), there was no difference in CABG or PCI appropriateness ratings, suggesting clinical equipoise in these settings. ConclusionsOur findings demonstrate willingness to consider offering enrollment in a randomized clinical trial and areas of clinical equipoise, two factors that support the feasibility of a randomized trial to compare clinical outcomes after revascularization with CABG vs. PCI in selected patients with ischemic cardiomyopathy, suitable coronary anatomy and co-morbidity profile.

Assessment of Safety of a Fully Implanted Endovascular Brain-Computer Interface for Severe Paralysis in 4 Patients

Brain-computer interface (BCI) implants have previously required craniotomy to deliver penetrating or surface electrodes to the brain. Whether a minimally invasive endovascular technique to deliver recording electrodes through the jugular vein to superior sagittal sinus is safe and feasible is unknown. To assess the safety of an endovascular BCI and feasibility of using the system to control a computer by thought. The Stentrode With Thought-Controlled Digital Switch (SWITCH) study, a single-center, prospective, first in-human study, evaluated 5 patients with severe bilateral upper-limb paralysis, with a follow-up of 12 months. From a referred sample, 4 patients with amyotrophic lateral sclerosis and 1 with primary lateral sclerosis met inclusion criteria and were enrolled in the study. Surgical procedures and follow-up visits were performed at the Royal Melbourne Hospital, Parkville, Australia. Training sessions were performed at patients' homes and at a university clinic. The study start date was May 27, 2019, and final follow-up was completed January 9, 2022. Recording devices were delivered via catheter and connected to subcutaneous electronic units. Devices communicated wirelessly to an external device for personal computer control. The primary safety end point was device-related serious adverse events resulting in death or permanent increased disability. Secondary end points were blood vessel occlusion and device migration. Exploratory end points were signal fidelity and stability over 12 months, number of distinct commands created by neuronal activity, and use of system for digital device control. Of 4 patients included in analyses, all were male, and the mean (SD) age was 61 (17) years. Patients with preserved motor cortex activity and suitable venous anatomy were implanted. Each completed 12-month follow-up with no serious adverse events and no vessel occlusion or device migration. Mean (SD) signal bandwidth was 233 (16) Hz and was stable throughout study in all 4 patients (SD range across all sessions, 7-32 Hz). At least 5 attempted movement types were decoded offline, and each patient successfully controlled a computer with the BCI. Endovascular access to the sensorimotor cortex is an alternative to placing BCI electrodes in or on the dura by open-brain surgery. These final safety and feasibility data from the first in-human SWITCH study indicate that it is possible to record neural signals from a blood vessel. The favorable safety profile could promote wider and more rapid translation of BCI to people with paralysis. ClinicalTrials.gov Identifier: NCT03834857.

Treatment selection for thoracoabdominal aortic aneurysm repair: open or endovascular?

Despite advancements in operative techniques and perioperative management, early mortality and morbidity from open thoracoabdominal aortic aneurysm (TAAA) repair remain significant. Endovascular aortic repair (EVAR), with visceral parallel grafts or branched/fenestrated stent grafts, is the less invasive treatment option. However, off-the-shelf, branched/fenestrated stent grafts are currently not readily available on the market. The anatomical complexities of TAAAs, which make open repair difficult, such as the involvement of visceral branches and spinal cord blood supplies, are also challenges to endovascular repair. Open surgical TAAA repair should be considered in patients with connective tissue disorders, younger age (less than 50 years old), and ruptured hemodynamically unstable TAAA. Endovascular TAAA repair should be considered in patients with sarcopenia, advanced age, renal dysfunction, and lung dysfunction, if patients have suitable anatomy. The two approaches should remain complementary. Overall, few data exist on which TAAA patient population would benefit from open vs. endovascular approaches. Therefore, this manuscript discusses patient selection for open and endovascular repair of TAAA from a literature review and our institutional experience.

Postoperative Sigmoidoscopy and Biopsy After Elective Endovascular and Open Aortic Surgery for Preventing Mortality by Colonic Ischemia (PSB-Aorta-CI): Protocol for a Prospective Study.

Endovascular aortic repair is considered the standard procedure in treating patients diagnosed with pathologies of the abdominal aorta with suitable anatomy. Open surgery remains an option mostly for patients not suitable for endovascular surgery. Colonic ischemia is an important and life-threatening postoperative complication of these procedures. The aim of this study is to evaluate the clinical value and safety of performing a planned sigmoidoscopy and biopsy for detection of colonic ischemia in patients undergoing elective aortic surgery. We also aim to develop prediction scores which could identify patients at risk for colonic ischemia and facilitate their timely treatment. The trial is designed as a prospective study. The decision for aortic surgery and eligibility for these procedures will be ascertained according to current guidelines. Afterward, screening of the patient for the remaining inclusion and exclusion criteria will occur. If eligibility for study inclusion is confirmed, the patient will be informed about the aims of the study and all study-specific procedures (sigmoidoscopy and biopsy) and asked to provide informed consent. The primary end point is the proportion of patients diagnosed endoscopically with subclinical and clinically relevant colonic ischemia among all patients undergoing aortic surgery. Patient recruitment started on June 2021. The final patient is expected to be treated by the end of June 2023. Institutional Review Board review has been completed at the University of Halle (Saale; reference #052-2021). this shows that sigmoidoscopy can be performed safely and is effective for the timely diagnosis of colonic ischemia in these patients, this could result in its routine implementation in both elective and emergency settings. German Clinical Trials Register DRKS00025587; https://www.drks.de/drks_web/navigate.do?navigationId =trial.HTML&TRIAL_ID=DRKS00025587. DERR1-10.2196/39071.

Novel classification of proximal forearm perforator vein in the planning and creation of percutaneous and surgical Gracz-type arteriovenous fistulae.

The perforator vein determines whether it is feasible to create a percutaneous (pAVF) or surgical "Gracz-type" arteriovenous fistula (sAVF). Creating a standard anatomic classification of the antecubital region is beneficial to both the selection of the appropriate device and/or procedure and technical outcomes. Accordingly, an analysis of a large cohort of patients undergoing pAVF/sAVF was performed, focusing on perforator vein anatomical suitability, and a novel anatomical classification of the antecubital region was developed and proposed. Between August 2018 and July 2022, chronic or end-stage kidney disease patients as well as patients anticipated an initiation of apheresis, who were referred for vascular access planning, underwent a standardized evaluation of upper extremities. A vessel mapping summary detailing the vasculature and the access creation plan was completed, indicating the anatomical suitability for sAVF and pAVF (Ellipsys and WavelinQ) techniques. Of 524 patients, 36.5% were female (average age 65 years). 53.2% were on dialysis, 41.6% had diabetes, and 13.2% had a previously failed permanent dialysis access. The anatomy for successful pAVF creation was judged to be suitable in 54% of patients for an Ellipsys-pAVF, and 29.8% for WavelinQ-pAVF. Of the WavelinQ group, 54.4% had suitable anatomy for ulnar, 26.9% for radial, and 18.6% for both ulnar/radial anastomoses. Additionally, 60.7% had suitable anatomy for pAVF creation with at least one of the systems, while 22.5% were suited for both types of pAVF-systems. 80.3% were candidates for creation of a Gracz-AVF. Overall, we found that about 60% of patients are likely candidates for a pAVF, with 80% being candidates for creation of a Gracz-AVF. Male patients have significantly higher suitability for most types of AVF creation, and younger patients are more suitable for Ellipsys-pAVF and RCAVFs. Most importantly, a universal classification of perforator vein was developed, which is indispensable in modern vascular access planning.

Total aortic arch repair between endo and hybrid-the Nexus single-branched endograft.

Minimally invasive zone 0 arch procedures have experienced a great evolution from the total zone 0 debranching techniques towards the total endovascular aortic arch procedures in the last decade. This evolution followed the aim of improved perioperative outcomes for patients with substantial comorbidities, who are not candidates for open aortic arch repair. Nowadays, branched endografts are the main endovascular alternative to the frozen elephant trunk technique. In the case of anatomical suitability, branched endovascular repair of the aortic arch offers an excellent treatment option for patients with severe risk profiles for open surgery [1]. The repair is predominantly based on the custom-made inner branch platforms, with 2 or 3 tunnels located in the main graft, which allow for a safe overlap with the bridging stent grafts to the supra-aortic vessels [2]. From the technical point of view, the Nexus single-branched endograft is different. It is bimodular and consists of a branched arch and an anatomically preshaped ascending aorta module. The branch to the brachiocephalic trunk (BCT) is located at the proximal end of the arch module and allows for precise deployment of the BCT branch from the bifurcation to the BCT origin prior to the complete deployment of the aortic arch and descending aorta portion. The implantation is accomplished by the deployment of the ascending module, which lands distally with its locking latches into the docking sleeve of the arch module.

Technical tips and clinical experience with the Gore Thoracic Branch Endoprosthesis®.

Thoracic endovascular aortic repair (TEVAR) has been widely accepted as a treatment option in patients with thoracic aortic aneurysms and dissections who have suitable anatomy. It is estimated that up to 60% of patients treated by TEVAR require extension of the repair into the distal aortic arch across Ishimaru zone 2. In these patients, coverage of the left subclavian artery (LSA) without revascularization has been associated with increased risk of arm ischemia, stroke, and spinal cord injury. The Gore Thoracic Branch Endoprosthesis (TBE, WL Gore, Flagstaff, AZ, USA) is the first off-the-shelf thoracic branch stent-graft approved by the Federal Drug Administration for treatment of distal aortic arch lesions requiring extension of the proximal seal into zone 2. This article summarizes the technical pitfalls and clinical outcomes of the TBE® device in zone 2.

Pretreatment with a P2Y12 receptor inhibitor and delay to coronary artery bypass surgery in patients with non-ST segment elevation acute coronary syndrome.

2020 ESC guidelines for non-ST elevation acute coronary syndromes (NSTE-ACS) recommend against the pretreatment with P2Y12 receptor inhibitors (P2Y12i) in patients undergoing early invasive management (<24 h). The rationale is, in part, to prevent bleeding complications and the delay of coronary artery bypass graft surgery (CABG) in patients with suitable coronary anatomy. This study aimed to analyze the theoretical impact of pretreatment with a P2Y12i on delay to CABG surgery in a real-world population with NSTE-ACS. Single-center retrospective cohort of consecutive patients with NSTE-ACS undergoing invasive evaluation in 2019. Those with previous CABG or nonobstructive coronary disease were excluded. The total cohort included 262 patients (mean age 68±12 years, 69% male, 15% with unstable angina and mean GRACE score 134±35). Median time from FMC to angiography was 2 (1-4) days. Overall, 168 (64%) patients underwent percutaneous coronary intervention, 47 (18%) were proposed for CABG and the remainder received conservative management. All patients considered for CABG received pretreatment with P2Y12i (clopidogrel or ticagrelor). The median time from angiography to CABG was 12 (7-15) days. Six patients experienced recurrent angina (13%) and 2 (4%) died before surgery due to refractory ventricular fibrillation. Those who underwent CABG under P2Y12i effect were more likely to receive blood and platelets transfusions (64.7% vs. 28.6%, P=0.017 and 82.4% vs. 21.4%, P<0.001, respectively), although there were no differences regarding major bleeding. Pretreatment with P2Y12i was a potential but not the sole driver of CABG delay in our cohort. Adopting the new recommendations of withholding pretreatment might decrease this delay, but other factors must be considered.

Comparative clinical study of short-term outcomes between table fenestrated and chimney endovascular aneurysm repair for hostile neck aneurysms.

Hostile neck abdominal aortic aneurysm (AAA) is challenging for standard endovascular aneurysm repair (EVAR). We sought to compare fenestrated endovascular aneurysm repair (fEVAR) and chimney endovascular aneurysm repair (chEVAR) for hostile neck AAA. Patients were identified retrospectively. Hostile neck anatomy was defined as a proximal neck length of <15mm or angulation >60°. The choice of fEVAR or chEVAR was based on neck anatomy and physician preference. Type I endoleak (T1EL) was the primary outcome. Other outcomes included type III endoleak (T3EL), visceral stent occlusion, renal insufficiency, reintervention, and mortality. A total of 84 patients were included from April 2012 to December 2021. fEVAR and chEVAR patients were 48 and 36 cases, respectively. Both groups showed similar rate of T1EL, T3EL, visceral stent occlusion, renal insufficiency, reintervention, and mortality. However, chEVAR patients had a more tortuous neck (61.1% vs. 16.7%, p < 0.001), while fEVAR patients had a greater neck size (29.5 ± 6.3mm vs. 24.5 ± 4.8mm, p < 0.001) and more reconstructing target arteries (2.2 ± 1.1 vs 1.3 ± 0.6, p < 0.001). fEVAR and chEVAR show similar safe and effective outcomes in well-selected hostile neck. fEVAR might be able to reconstruct multiple visceral arteries, and chEVAR seems justified in patients with poor anatomical suitability for fEVAR.

Delayed Surgical Repair of Ventricular Septal Rupture with CABG following Acute Myocardial Infraction- A Case Report

Ventricular septal rupture (VSR) is a rare but often life-threatening mechanical complication after acute myocardial infarction. Although surgical intervention is challenging and associated with high mortality and morbidity, but it is still now the gold standard treatment. Percutaneous device closure of VSR is an option in selected patients with suitable anatomy and when surgery is contraindicated. Optimally medically managed patients who survive at least 4 weeks before elective surgery to generate scar formation at the edges of the defect in a viable infarcted tissue have the greatest outcomes. Here we report a case of VSR following acute myocardial infarction. About 3 weeks after the occurrence of ventricular septal rupture following acute myocardial infraction, surgery was successfully performed with good outcome. Cardiovasc j 2022; 15(1): 100-105

Numerical simulation of transcatheter mitral valve replacement: The dynamic implication of LVOT obstruction in the valve-in-ring case

Transcatheter mitral valve replacement (TMVR) has been used for “off-label” treatment when annuloplasty band ring for mitral repair fails. However, the complex anatomy and function of the mitral valve may lead to fatal complications as a result of the left ventricular outflow tract (LVOT) obstruction in TMVR. We report the structural and hemodynamic response of LVOT obstruction resulting from TMVR with the Edwards SAPIEN 3 Ultra (S3) device. We modified the original Living Heart Human Model (LHHM) to account for a failed mitral valve with an annuloplasty band ring and simulated the cardiac beating condition in the setting of S3 device implantation. Findings demonstrated a high dynamic behavior of the newly formed LVOT (neoLVOT) as confined by the displaced mitral valve and the interventricular septum. During the cardiac beat, the neoLVOT area oscillated from a maximum of 472.1 mm2 at early systole to the minimum of 183 mm2 at end-systole. The profile of both anchoring force and contact pressure revealed that the band ring serves as the anchoring zone while mitral valve is primally displaced by the deployed device. At early systole, computational flow dynamics highlighted hemodynamic disturbances associated with the LVOT obstruction, with a skewed flow towards the septum and a pressured drop of 4.5 mmHg between the left ventricular apex and the neoLVOT region. This study can lead to a more accurate assessment of the risk induced by the LVOT obstruction when stratifying patient anatomic suitability for TMVR.

Severe rheumatic mitral stenosis – analysis of clinical and echocardiographic very long-term outcomes after percutaneous mitral balloon valvuloplasty

Abstract Introduction Mitral balloon valvuloplasty (MBV) is the guideline recommended treatment for symptomatic severe mitral stenosis (MS) with suitable anatomy, but is often deemed transitory. However, data on very-long term echocardiographic follow-up is scarce. The aim of our study was to describe clinical and echocardiographic outcomes in patients previously submitted to MBV for rheumatic MS. Methods We conducted a single-centre retrospective study enrolling patients previously submitted to MBV for rheumatic MS from 1990 until 2021. Follow-up was considered until last registered echocardiographic re-evaluation. Patients without electronic health records available were excluded. The primary endpoint was a composite of all-cause death or need of surgery. Results A total of 193 patients were included (15.5% male, with a mean age of 52±15 years at the time of MBV, 60.6% with permanent atrial fibrillation). During a mean follow-up of 11±8 years, 87 (45.1%) patients implanted a mitral valve prosthesis, 4 (2.1%) were submitted to surgical mitral valvuloplasty and 30 (15.5%) died without being reinterventioned. Moreover, a total of 23 (11.9%) embolic events were registered – 21 strokes, 1 pulmonary embolism and 1 acute lower limb embolism. Overall, 133 patients (68.9%) survived more than 5 years, 95 (49.2%) more than 10 years and 56 (26.9%) more than 15 years since MBV without meeting the primary endpoint. The maximum follow-up without intervention was 32 years. Concerning patients submitted to surgery, the mean time from MBV until operation was 9.4±7.3 years (minimum 8 days; maximum 29.3 years). In regard to echocardiographic long-term outcomes on alive non-operated patients (mean follow-up of 12±9 years), 52.8% remain with mild MS, 91.6% with mild or no mitral regurgitation and 77.6% with mild or no tricuspid regurgitation. Furthermore, only 20.4% have right ventricle dysfunction (defined as a TAPSE &amp;lt;17 mm), 18.3% have pulmonary hypertension (pulmonary artery systolic pressure &amp;gt;45 mmHg), and 6.8% have residual interatrial communication. Conclusion MBV is a minimally invasive procedure that has an important benefit in a very significant proportion of patients with rheumatic mitral stenosis, with potential benefit that may last more than three decades without need for another invasive intervention. Funding Acknowledgement Type of funding sources: None.

Novel Multiportal Approach to the Internal Auditory Canal for Hearing-Preserving Surgery: Feasibility Assessment in Dissections

State-of-the-art, minimally invasive endoscopic transcanal surgery of the internal auditory canal (IAC) sacrifices the cochlea with complete hearing loss. With a combination of the transcanal infracochlear and transmastoid retrolabyrinthine approaches, we aim to preserve hearing and enable minimally invasive surgical treatment of vestibular schwannoma. In this study, we investigate the anatomical indications and the feasibility of both approaches in dissections, in human whole head specimens. We operated whole head anatomical specimens with a four-handed technique, using the retrolabyrinthine approach as the main surgical corridor and the infracochlear approach for endoscopic visualization. We tested 4 different powered surgical systems. We collected intraoperative data on the size of the access windows, the surgical freedom, and the exposed area of the IAC. Finally, we evaluated the outcome in postoperative computed tomography scans. Six out of 14 sides were anatomically suitable and qualified for the surgery based on preoperative computed tomography. In all attempted sides, the IAC could be reached and opened, leaving the ossicular chain and the labyrinth intact. 51%-75% of the length and 22%-40% of the circumference of the IAC could be exposed. All tested instruments were beneficial at different stages of the surgery. The four-handed technique enabled good maneuverability of the instruments. The combined multiportal approach to the IAC is feasible with a good surgical exposure and full anatomical preservation of hearing. State-of-the-art surgical instruments in specimens with suitable anatomy are sufficient to perform this approach.

Severe pediatric pulmonary arterial hypertension: Long-term outcomes of reverse Potts shunt and transplantation

Reverse Potts shunt (RPS) and lung or heart-lung transplantation are life extending surgical interventions for pediatric patients with severe pulmonary arterial hypertension (PAH). Robust criteria for identifying patients who will benefit from these procedures remain elusive. Based on our 30 years of experience, we sought to refine the surgical indications of RPS. This single-center retrospective cohort study included 61 consecutive pediatric patients with PAH managed by RPS (2004–2020) or transplantation (1988–2020). Their long-term outcomes were assessed. Compared to the 20 patients managed by RPS, the 41 transplant waitlist patients, of whom 28 were transplanted, were older (14.9 versus 8.0 years, P = 0.0001) and had worse right-ventricular impairment (tricuspid annular plane systolic excursion, 12.5 mm versus 18.0 mm, P = 0.03). After implementation of a high-priority allocation program in 2007, waitlist mortality decreased from 52.6% to 13.6% ( P = 0.02) and survival raised from 57.1% to 74.7% after RPS and 55.6% to 77.2 after transplantation. At a median follow-up of 8.6 years after RPS and 5.9 years after transplantation, functional capacity had improved significantly, and PAH specific drug requirements had diminished markedly. The cumulative transplantation incidence after RPS was 0% and 25.3% at 5 and 10 years, respectively ( Fig. 1 ). RPS was associated with functional capacity improvements, decreased pharmacotherapy needs, and delayed need for transplantation over the long-term in selected children with suprasystemic PAH, preserved right ventricular function, and suitable anatomy.

Cancer and Infection Screening in Potential Living Donors

Living donor transplant is a safe practice but is not completely risk free. Although both infection and malignancy transmissions have occurred through living organ donation, in the global view, the number of these events is negligible in contrast to the successful lifesaving transplants performed each year; however, an event can be devastating for the recipient, donor, and treatment team if it occurs. Each living donor is unique, and the donor evaluation is multifactorial, taking into the account the medical, social, and family history of individual donors, needs of the recipient, and determination of the anatomic and functional suitability of the donor organ. These considerations can be further complicated by geographical and temporal components. Although the balancing of all practical considerations can be complex, a thorough medical assessment for infection and malignancy of a potential living donor is central in protecting the donor and the intended transplant recipient. Good medical practice requires consistent donor evaluation and reasonable followup.

Percutaneous Transvenous Balloon Mitral Commissurotomy: A Single-Center Experience.

Rheumatic heart disease and its impact on cardiac health is still a concern in developing countries. Percutaneous trans-mitral commissurotomy (PTMC) is the standard of care in managing severe rheumatic mitral stenosis (MS). This article reports a single-center, 10-year real-world experience in Qatar. In this retrospective study, we reviewed all the patients who underwent PTMC in Qatar between January 1, 2012, and January 1, 2022. Periprocedural data were collected at baseline, postprocedural, 1 year, and during the last follow-up. The primary outcome was procedural success (improvement in valve area by 50%, final valve area >1.5 cm2, and freedom from > moderate mitral regurgitation, stroke, or pericardial effusion). Safety endpoints were freedom from death, periprocedural cardiogenic shock and cardiac arrest, stroke urgent mitral valve replacement (MVR), or pericardiocentesis. Long-term outcomes included the requirement of redo PTMC or MVR, in addition to rehospitalization due to arrhythmias, heart failure, or stroke. Sixty-five patients were included in the review (age 42 ± 10, female 38 [58.5%]). Sixty-two patients (95.4%) had a successful procedure. One patient developed a hemorrhagic pericardial tamponade and cardiogenic shock, for which he underwent pericardiocentesis and emergency aortic root repair. One patient developed acute stroke 8 h after the procedure, and one patient had tamponade resolved with emergency pericardiocentesis. Two patients required MVR after 1 and 4 years, respectively. PTMC is the mainstay of rheumatic MS management in patients with suitable anatomy as most patients have excellent outcomes with long-term freedom from surgery, which has been the case in our single-center experience.

Women with thoracoabdominal aortic aneurysms have increased frailty and more complex aortic anatomy compared with men: Presented at the plenary session of the Thirty-sixth Western Vascular Society Annual Meeting, Jackson Hole, WY, October 16-19, 2021.

Objective: Operative repair of thoracoabdominal aortic aneurysms (TAAAs) is high risk, and many patients will be unfit for intervention. Prior studies have noted lower rates of repair for women than for men. The reasons for this disparity have remained unknown but could include a greater burden of co-morbid illness or anatomic barriers. Frailty could also contribute to the lower intervention rates but has rarely been reported in preoperative risk assessments. The aim of the present study was to assess the sex-related differences in clinical comorbidities, anatomic suitability, and frailty among an unselected cohort of patients who had presented with TAAAs.

Trends in annual open abdominal aortic surgical volumes for vascular trainees compared with annual national volumes in the endovascular era

ObjectiveA prior analysis predicted a shortfall in open abdominal aortic repair (OAR) experience for vascular trainees resulting from the rapid adoption, and increased anatomic suitability, of endovascular aortic aneurysm repair (EVAR) technology. We explored how EVAR has transformed contemporary open aortic surgical education for vascular trainees. MethodsWe examined the Accreditation Council for Graduate Medical Education case volumes of open abdominal aortic aneurysm (AAA) repair and reconstruction for aortoiliac occlusive disease via aortoiliac or femoral bypass (AFB) from integrated vascular surgery residents (VSRs) and fellows (VSFs) graduating from 2006 to 2017 and compared them to the national estimates of total OAR (open AAA repair plus AFB) in the Agency for Healthcare Research and Quality National Inpatient Sample using the International Classification of Diseases, 9th and 10th revision, procedural codes. Changes over time were assessed using the χ2 test, Student’s t test, and linear regression. ResultsDuring the 12-year study period, the national annual total OAR and open AAA repair estimates had decreased: total OAR by 72.5% (estimate ± standard error: 2006, 24,255 ± 1185; vs 2017, 6690 ± 274; P < .001) and open AAA repair by 84.7% (estimate ± standard error: 2006, 18,619 ± 924; vs 2017, 2850 ± 168; P < .001). The AFB estimates had decreased by 33.0% (P < .001). The percentage of total OAR, open AAA repair, and AFB performed at teaching hospitals had significantly increased, from ∼55% to 80% (P < .001 for all). A 40.9% decrease was found for open AAA repairs performed by graduating VSFs (mean, 18.6 vs 11) but only a 6.9% decrease in total OAR cases (mean, 27.6 vs 25.7) owing to increasing AFB volumes (mean, 9.0 vs 14.7). The VSR graduates had consistently logged an average of ∼10 open AAA repairs, with a 31.0% increase in total OARs (mean, 23.2 vs 30.4), again secondary to increasing AFB volumes (mean, 11.4 vs 17.5). Although an absolute decrease was found in open aortic experience for VSFs, the rate of decline for the total OAR case volumes was not significantly different after VSR programs had been established (P = .40). ConclusionsAs the incidence has decreased nationally, the use of OAR has been shifting toward teaching hospitals. Although open AAA procedures for trainees have been declining with the increased use of EVAR, open aortic reconstruction for aortoiliac occlusive disease has been increasing, playing an important role in ensuring that vascular trainees continue to have satisfactory OAR experience sufficient for meeting minimum graduation requirements. Strategies to maintain and maximize the education and experience from these cases should be the top priority for vascular surgery program directors.

Outcomes Following Urgent Fenestrated-Branched Endovascular Repair for Pararenal and Thoracoabdominal Aortic Aneurysms

To evaluate outcomes following urgent or emergent fenestrated-branched endovascular aortic repair (F-BEVAR) for pararenal (PRA) and thoracoabdominal aortic aneurysms (TAAA) in patients who are considered high-risk for open repair. A retrospective, single institution evaluation of outcomes following F-BEVAR of symptomatic, rapidly enlarging, or ruptured PRA or TAAA treated with physician modified endograft (PMEG) and company manufactured devices (CMD). Outcomes were technical success, 30-day morbidity and mortality, and 1 year aortic related outcomes. Thirty-two patients (23 male, mean age, 74±9years) underwent F-BEVAR using PMEG or CMD over a 12-year period. Fourteen patients underwent emergent repair for contained rupture and 18 patients underwent urgent repair for symptomatic, mycotic, or rapidly growing aneurysms. Aneurysm classification was PRA in 10 patients and TAAA in 22 (9 extent IV and 13 extent I-III). Twenty-three patients (72%) were repaired with PMEG and 8 patients (26%) with CMD. Technical success was 97% with a total of 98 renal-mesenteric arteries incorporated using 67 fenestrations (68%), 29 directional branches (29%), and 2 double-wide scallops (2%). A 30-day mortality was 6%, with 1 patient expiring from unclear causes after hospital discharge and the other from mesenteric ischemia. Mortality and major adverse events MAEs otherwise occurred in 16 patients (50%), including minor stroke in 3 patients, transient paraparesis and heart failure in 1 patient each, and early return to the operating room in 6 patients. Mean follow-up was 24±22months. At 1-year, overall survival, freedom from aortic-related mortality and freedom from secondary intervention were 70%±8%, 94%±3 and 83%±7, respectively. Urgent F-BEVAR of selected patients with PRA and TAAA is a feasible and potentially safe treatment in patients with suitable anatomy, with low rates of early mortality and spinal cord complications. Long-term follow-up is needed to assess the durability of repair and device-related complications.