Aneurysm Surgery Research Articles

Aorto-pulmonary artery fistula with Laubry-Pezzi syndrome: A diagnostic enigma

Usually diagnosed post-mortem, aortopulmonary artery fistula is an exceptionally rare and often highly lethal condition. Here, we present a unique case of a 29-year-old woman with no history of aortic aneurysm or previous aortic surgery, referred for surgical management of Laubry-Pezzi syndrome in whom an aorto-pulmonary artery fistula bridging the ascending aorta and the main pulmonary artery was discovered intra operatively. The patient was successfully managed with an uneventful postoperative recovery. Our case outlines the inaugural reported occurrence of an aortopulmonary artery fistula coinciding with Laubry-Pezzi syndrome. Unique features include subtle onset of heart failure over months due to occult left ventricular volume overload, challenging diagnosis alongside known intracardiac shunts, emphasizing the need for vigilance, and demonstration of successful surgical outcomes despite high morbidity and mortality.

Current state of endovascular treatment of anterior cerebral artery aneurysms.

The locations of anterior cerebral artery (ACA) aneurysms vary, and various aneurysms can occur along the course of the ACA. Ruptured and some unruptured ACA aneurysms may require aggressive treatment to avoid bleeding or rebleeding. Although open surgery is an effective treatment for ACA aneurysms, endovascular treatment (EVT) is becoming an alternative treatment in select cases. EVT techniques for ACA aneurysms often vary and are performed on a case-by-case basis according to the nature and location of the aneurysm. To better understand the EVT strategy for ACA aneurysms, it is necessary to review EVT for ACA aneurysms. In this review, the following topics are discussed: ACA anatomy and anomalies, classifications of ACA aneurysms, the natural history of ACA aneurysms, open surgery and EVT statuses for ACA aneurysms, EVT techniques for various ACA aneurysms, and the prognosis and complications of EVT for ACA aneurysms. According to our review and experience, traditional coiling EVT is still the preferred therapy for most ACA aneurysms. For A1 aneurysms, EVT is challenging. After the selection of appropriate cases, deployment of a flow diverter and Woven EndoBridge device can result in a good prognosis for patients with ACA aneurysms. In addition, parent artery occlusion can be used to treat A1 aneurysms with good collateral circulation and some distal ACA aneurysms. In general, EVT is gaining popularity as an alternative treatment option for ACA aneurysms.

Reverse cannulation method as a strategy for aortic aneurysm surgery: A computational fluid dynamics study on minimizing neurological risks

ObjectivesTo evaluate the blood flow velocity and wall shear stress in total arch replacement with a “shaggy” aorta, using computational fluid dynamics, and determine the optimal cannulation method. MethodsA patient-specific aortic arch aneurysm model was constructed by using computed tomography scans. Three cannulas were assessed, as follows: dispersive with a steep angle, dispersive with a gentle angle, and the endo-hole type. The cannula tips were oriented toward the aortic arch (standard direction) and aortic root (reversed direction), with an ideal angle (base orientation: 0°), tip orientations rotated 20° clockwise and counterclockwise from the base orientation. The variables of interest included the blood flow velocity, streamlines, wall shear stress, and flow distribution. ResultsThe standard direction resulted in variable accelerated flow and wall shear stress locations based on cannula tip orientation, leading to unstable cerebral branch flow. Minor deviation in the cannula tip angle and cannula type led to significant alterations in flow distribution. Conversely, in the reverse direction for all cannulas, no accelerated blood flow was observed in the proximal aortic arch or cerebral vessel ostia even with angular adjustments, helping maintain a stable cerebral branch flow. Minimal variation in blood flow distribution was observed across all cannula types and angles. ConclusionsOur simulations indicate that, irrespective of the cannula type or orientation, directing the cannula tip toward the aortic root (reversed direction) prevents accelerated blood flow in critical areas, suggesting its potential as an optimal approach for aortic arch surgery in “shaggy” aorta cases.

Giant Morgagni hernia and aorto-pulmonary collaterals in a Loeys-Dietz patient undergoing surgery for aortic root aneurysm and mitral valve prolapse.

The case of a Loeys-Dietz syndrome patient undergoing mitral valve repair and composite aortic root and valve replacement is here described: preoperative CT scan unravelled a previously misdiagnosed Morgagni hernia (anterior diaphragmatic), containing omentum only, compressing the right ventricle. Intraoperatively, an abnormal oxygenated blood backflow into the left ventricle was observed, postoperatively found to be caused by major aorto-pulmonary collateral arteries. This is the 1st case of Morgagni hernia and systemic-pulmonary shunt ever reported associated with Loeys-Dietz syndrome. These congenital features may be important in both phenotyping and surgical management.

Minimally Invasive Lateral Transorbital Approach for Clipping of Right Middle Cerebral Artery Aneurysm: 2-Dimensional Operative Video.

The lateral transorbital approach is a minimally invasive approach that was first described for accessing the cavernous sinus.1 Although other minimally invasive approaches have been broadly applied to aneurysm surgery,2 the use of transorbital keyholes for this is still quite rare.3,4 We present a 72-year-old man with an incidentally discovered 5-mm middle cerebral artery aneurysm. Despite a low rupture risk,5 the patient himself opted for treatment, and because of the complex shape of the aneurysm, he chose surgical clipping as the treatment of choice. Two unique aspects of the patient's anatomy brought forth transorbital approach for consideration. He had a wide fissure, which opened to the orbital wall, and a giant frontal sinus made its avoidance difficult with any anterolateral transcranial approach. The lateral transorbital approach was started with a transpalpebral incision.4,6,7 Both wings of the sphenoid bone were drilled until the frontal and temporal dura was exposed. Opening this through the orbit gained direct access to the large Sylvian fissure. Two specific challenges were specific to this opening: the aneurysm dome pointed straight at the surgeon, and the M1 segment, needed for proximal control, was directly behind the aneurysm. Despite these, the aneurysm was successfully eliminated through the transorbital approach with no residual or normal branch compromise. Given the specific anatomical provisions, the lateral transorbital approach was an effective and safety alternative to the pterional approach for middle cerebral artery aneurysms. No Institutional Review Board approval was sought or necessary as the patient provided consent for the procedure, publication of his image, and this submission.

Acute Intraoperative Conversion from Endovascular to Open vs Planned Open Operation for Abdominal Aortic Aneurysm: A Propensity-Score Matched Study from the American College of Surgeons NSQIP-Targeted Database.

Evaluating outcomes for acute intraoperative conversion to open surgery during endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA) was difficult due to low incidence. This study aimed to compare 30-day outcomes between patients with acute intraoperative conversion during EVAR and planned open surgery, and to identify risk factors associated with acute conversion. Patients who underwent EVAR or planned open AAA repair were identified in American College of Surgeons NSQIP-targeted databases from 2012 to 2021. Patients with acute intraoperative conversion during EVAR were selected. A 1:3 propensity-score matching was used to match demographics, baseline characteristics, surgical indications, aneurysm size and extent, and emergency cases between the conversion open and planned open groups. Thirty-day postoperative outcomes were assessed. Of 20,566 EVAR cases, 177 (0.86%) had acute intraoperative conversion to open surgery. The conversion open group was matched to 504 of 5,249 planned open patients. Conversion open and planned open groups had comparable 30-day mortality (23.43% vs 17.46%, p = 0.09) and organ system complications, including major adverse cardiovascular event (14.86% vs 10.71%, p = 0.17), pulmonary complications (17.71% vs 24.01%, p = 0.09), and renal complications (8.57% vs 11.11%, p = 0.39). The conversion open group had lower bleeding requiring transfusion (48.57% vs 75.60%, p < 0.01), shorter operation time (p < 0.01), and shorter length of stay (p < 0.01). Other postoperative outcomes did not differ. Risk factors associated with acute intraoperative conversion included ruptured aneurysm with or without hypotension. Protective factors included hypertension and aortic distal aneurysm extent. Although this study does not endorse a universal "EVAR first" strategy for all patients with AAA, EVAR can be attempted first in eligible patients with AAA. Even when EVAR is unsuccessful, intraoperative conversion to open surgery still appears to be safe compared with planned open repair.

A Comprehensive Training Model for Simulation of Intracranial Aneurysm Surgery Using a Human Placenta and a Cadaveric Head.

Aneurysmal surgery is technically complex, and surgeon experience is an important factor in therapeutic success, but training young vascular neurosurgeons has become a complex paradigm. Despite new technologies and simulation models, cadaveric studies still offer an incomparable training tool with perfect anatomic accuracy, especially in neurosurgery. The use of human placenta for learning and improving microsurgical skills has been previously described. In this article, we present a comprehensive simulation model with both realistic craniotomy exposure and vascular handling consisting of a previously prepared and perfused human placenta encased in a human cadaveric specimen. Humans' placentas from the maternity and cadaveric heads from the body donation program of the anatomy laboratory were used. Placentas were prepared according to the established protocol, and aneurysms were created by catheterization of a placental artery. Ten participants, including senior residents or young attendees, completed an evaluation questionnaire after completing the simulation of conventional unruptured middle artery aneurysm clipping surgery from opening to closure. The skin incision, muscle dissection, and craniotomy were assessed as very similar to reality. Brain tissue emulation and dissection of the lateral fissure were judged to be less realistic. Vascular management was evaluated as similar to reality as closure. Participants uniformly agreed that this method could be implemented as a standard part of their training. This model could provide a good model for unruptured aneurysm clipping training.

A secondary abdominal aorta-duodenal fistula accompanied with acquired Immune Deficiency Syndrome presented with recurrent sepsis: a case report

BackgroundAbdominal aorta-duodenal fistulas are rare abnormal communications between the abdominal aorta and duodenum. Secondary abdominal aorta-duodenal fistulas often result from endovascular surgery for aneurysms and can present as severe late complications.Case presentationA 50-year-old male patient underwent endovascular reconstruction for an infrarenal abdominal aortic pseudoaneurysm. Prior to the operation, he was diagnosed with Acquired Immune Deficiency Syndrome and Syphilis. Two years later, he was readmitted with lower extremity pain and fever. Blood cultures grew Enterococcus faecium, Salmonella, and Streptococcus anginosus. Sepsis was successfully treated with comprehensive anti-infective therapy. He was readmitted 6 months later, with blood cultures growing Enterococcus faecium and Escherichia coli. Although computed tomography did not show contrast agent leakage, we suspected an abdominal aorta-duodenal fistula. Esophagogastroduodenoscopy confirmed this suspicion. The patient underwent in situ abdominal aortic repair and received long-term antibiotic therapy. He remained symptom-free during a year and a half of follow-up.ConclusionsThis case suggests that recurrent infections with non-typhoidal Salmonella and gut bacteria may be an initial clue to secondary abdominal aorta-duodenal fistula.

Comparison of intraoperative sodium fluorescein and indocyanine green videoangiography during intracranial aneurysm and arteriovenous malformation surgery

ObjectiveIndocyanine green (ICG) and sodium fluorescein (Na-Fl) are two fluorophores, which are used for videoangiography purposes. This prospective study reports our experience by using surgical microscopes equipped with two special filters. We compared the imaging efficacy of Na-FL and ICG videoangiography techniques during aneurysm and arteriovenous malformations (AVM) surgeries.Patient and methods:Fourtynine consecutive patients were operated between September 2015 and December 2022. Patients with ruptured/unruptured aneurysms or with AVMs presented with/without hemorrhage were included to the current study. ResultsThere were a total of 48 aneurysms and 11 AVMs in 49 patients in the current study. Na-Fl enables the surgeon to manipulate vessels and aneurysms real-time. ICG provides the ability to watch the videoangiography repeatedly and understand the angioarchitecture. The use of FLOW-800 module allows the surgeon to make concrete judgements about the flow dynamics of AVMs and therefore ICG videoangiography found useful in AVM surgery. Na-Fl has been found more useful for the evalution of the low caliber perforating arteries and anatomical features of the aneursym dome in aneurysm surgery. ConclusionThe results of our series demonstrated the safety and efficacy of Na-Fl use in the surgery of aneurysms and AVMs. Both the ICG and Na-Fl videoangiographies are easy to perform and complimentary to each other. Combined use of these two mediums may provide better surgical results, considering the separate advantages and disadvantages of these both techniques.

Microsurgical clipping of unruptured intracranial aneurysms: Clinical and radiological outcomes

Background and objectivesThe prevalence of unruptured intracranial aneurysms is 1–3%. The annual rupture rate increases in patients with multiple aneurysms that presented a previous hemorrhage from another aneurysm. ObjectivesTo evaluate outcomes of clipping unruptured aneurysms, comparing patients with single or multiple aneurysms clipped, describe the complications related to surgery and to identify risk factors predicting an unfavorable outcome. Materials and methodsRetrospective study including patients who underwent clipping of unruptured aneurysms between 2020–2023 at our center. Occlusion rate, complications, and functional outcome were analyzed. Risk factors for poor prognosis are identified using univariate model. Results82 patients with 114 aneurysms were treated with microsurgery. Multiple aneurysms were clipped in 22 patients. A mini-open approach was used in 86,5% of cases. Complete occlusion in angio3D was found in 78.6% of clipped aneurysms. Complication rate was 12.2%, including asymptomatic cases. Mortality was 0%. The probability of 1 point mRS worsening was 7.3% and 2 or more points was 1.2%, with a good functional outcome in 98.9%. Clipping multiple aneurysms, miniopen approaches, or surgery in patients with previous subarachnoid hemorrhage did not increase the risk of complications. Posterior circulation aneurysms surgery increased the risk of ischemia. ConclusionsThe management for unruptured intracranial aneurysms should be multimodal and based on clinical and radiological outcomes. Microsurgery is a valid and safe technique, with 0% mortality and bleeding rates and 1,2% rate of severe morbidity in our series.

Lessons Learned with Enhanced Recovery for Open Abdominal Aortic Aneurysm Surgery: A Long Term Regional Network Experience

This enhanced recovery programme (ERP) aimed to achieve early recovery for patients undergoing major surgery. Results of a standardised ERP protocol for open infrarenal abdominal aortic aneurysm (AAA) repair within a hub and spoke regional network are presented. In this monocentric prospective study (January 2004 - December 2021), consecutive AAAs (≥ 55 mm) were included in the ERP (patient discharge on post-operative day [POD] 4). The four phases of the ERP were pre-admission, pre-operative, intra-operative, and post-operative. Exclusion criteria were BMI > 35 kg/m2, functional capacity < 4 MET, previous aortic or abdominal surgery, and life expectancy < 5 years. Transperitoneal surgery was undertaken with routine AAA resection, graft interposition, and closure. Consecutive patients (n = 778) were enrolled into the study (mean age 72.3 ± 3.2 years; n = 712 men); 160 (20.5%) were treated in spoke hospitals. Median follow up was 78 (IQR 28, 128) months; median length of stay, procedure time, and blood loss were 4 days (IQR 3, 5), 190 min (IQR 170, 225), and 564 mL (IQR 300, 600). Infrarenal clamping and tube graft configuration were used in 96.5% (n = 751) and 72.5% (n = 564) of patients; 30 day mortality and complication rates were 0.4% (n = 3) and 9.2% (n = 72). Discharge after POD 4 occurred in 15.0%, and most significant predictors for discharge after POD 4 were haemotransfusion, re-intervention, and ileus over 3 days. Overall survival was: 98.2% at 1 year, 85.0% at 5 years, and 59.9% at 10 years. Freedom from re-intervention was 97.9% at 1 year, 94.1% at 5 years, and 86.8% at 10 years. Short and long term outcomes were comparable between hub and spoke hospitals. The ERP protocol was associated with low short and long term mortality and complication rates. Future studies should apply the ERP protocol to other vascular centres.

ROSES: The most Complete System for Endovascular Surgery

ROSES, an innovative Robotic System for Endovascular Surgery, features a unique mechanism that continuously measures the resistance encountered by catheters and guide wires as they advance within the body. This feature operates seamlessly without the need for additional specialized components. The system is comprised of a series of robotic actuators (up to three) arranged linearly on slides running along a rail, inclined toward the patient. Another slide, housing a pair of step motors, facilitates the adjustment of relative positions between the actuators, with the proximal actuator affixed to the motor slide by a lateral bar. A force transducer, linked to the motor slide via a wire, is responsive to the gravitational component of any object on the rail. Importantly, this force remains constant even as the actuators move. However, the force dynamically changes if an external obstruction hinders the progress of catheters and guide wires, serving as an alert to the attending physician. The system, uniquely, is also capable of guiding the introduction of the first catheter, even if it is pre-curved. This capability facilitates the complete separation of the doctor from the patient throughout the entire surgical procedure. The system employs compact, purely mechanical disposables designed for a wide range of interventions utilizing commercially available catheters and guide wires, including angioplasty, brain and carotid surgery (for aneurysms or thrombi), TAVI, and various lower and upper limb procedures. Future developments include the incorporation of animated catheters capable of altering their shape configuration under console control. As the system also records the penetration length of each device and transmits this data to a workstation along with X-ray images, it effectively becomes the "black box" of endovascular surgeries. This functionality allows for a complete separation between physicians and patients throughout the entire surgical procedure. The system is safeguarded by multiple pending international patent applications.

Intrasylvian Retraction Technique to Facilitate the Sylvian Fissure Dissection: A Clinical Study of 125 Cases.

Although many authors have recommended the retractorless technique to avoid retractor-induced brain injury, others usually use brain retractors with a meticulous technique to facilitate the surgery, especially for sylvian fissure dissection. The intrasylvian retraction technique was described for sylvian fissure opening, but no clinical evidence was found. We evaluate the efficacy and safety of this technique for the distal transsylvian approach. We reviewed the video records of clinical cases where the distal transsylvian approach was performed using the intrasylvian retraction technique for aneurysm treatment and middle cerebral artery (MCA) bypass between September 2018 and August 2022. Operative techniques are described. The efficacy and safety of the technique were assessed by full exposure of the sylvian fissure and new postoperative perisylvian hematoma, respectively. One hundred twenty-five cases were included and had an average age of 53.5 (range 16-85) years. Women comprised 73.6%. Aneurysm surgery, pure MCA revascularization, and aneurysm surgery with MCA revascularization were 106 (84.8%), 12 (9.6%), and 7 cases (5.6%), respectively. The most common aneurysm location was the internal carotid artery-posterior communicating artery junction in 37 cases (34.9%), followed by the anterior communicating artery in 27 (25.5%). Full exposure of the Sylvian fissure was achieved in all cases. No perisylvian hematoma was detected by immediate postoperative computed tomography in any patient. Using an appropriate technique for brain retractor application, sylvian fissure dissection was safely performed. The intrasylvian retraction technique effectively facilitated sylvian fissure dissection and provided wide exposure for the distal transsylvian approach.

Temporal evolution of ascending aortic aneurysm wall stress predicts all-cause mortality.

Diameter-based risk stratification for elective repair of ascending aortic aneurysm fails to prevent type A dissection in many patients. Aneurysm wall stresses may contribute to risk prediction; however, rates of wall stress change over time are poorly understood. Our objective was to examine aneurysm wall stress changes over 3-5 years and subsequent all-cause mortality. Male veterans with <5.5 cm ascending aortic aneurysms and computed tomography at baseline and 3- to 5-year follow-up underwent three-dimensional aneurysm model construction. Peak circumferential and longitudinal wall stresses at systole were calculated using finite element analysis. Temporal trends were assessed by mixed-effects modelling. Changes in aortic wall stresses, diameter and length over time were evaluated as predictors of subsequent 3-year all-cause mortality by Cox proportional hazards modelling. Sixty-two male veterans were included in the study. Yearly changes in geometric and biomechanical measures were 0.12 mm/year (95% confidence interval, 0.04-0.20) for aortic diameter, 0.41 mm/year (0.12-0.71) for aortic length, 1.19 kPa/year -5.94 to 8.33) for peak circumferential stress, and 0.48 kPa/year (-3.89 to 4.84) for peak longitudinal stress. Yearly change in peak circumferential stress was significantly associated with hazard of death-hazard ratio for peak circumferential stress growth per 10 kPa/year, 1.27 (95% CI, 1.02-1.60; P = 0.037); hazard ratio for peak circumferential stress growth ≥ 32 kPa/year, 8.47 (95% CI, 2.42-30; P < 0.001). In this population of nonsurgical aneurysm patients, large temporal changes in peak circumferential stress, but not aortic diameter or length, was associated with all-cause mortality. Biomechanical stress and stress changes over time may be beneficial as additional risk factors for elective surgery in small aneurysms.

Airway Management of Intracranial Aneurysms Associated with Nasopharyngolaryngeal Hemangioma: A Case Report

Intracranial aneurysm is a very common disease, which is an abnormal bulge on the wall of intracranial artery. It is the first cause of subarachnoid hemorrhage. With the development of imaging, the disease is easily diagnosed. A 60-year-old man was diagnosed with anterior communicating artery aneurysm and underwent aneurysm clipping. During routine induction of anesthesia, a nasopharyngolaryngeal hemangioma was visualized under a video laryngoscope. This poses a serious challenge for tracheal intubation. With the assistance of a video laryngoscope and local anesthesia with lidocaine, a 6.5# reinforced endotracheal tube was inserted. Nasopharyngolaryngeal hemangioma is a congenital vascular anomaly characterized by proliferation of endothelial cells. The incidence of infantile and childhood hemangiomas is low, and most spontaneously resolve by the age of 4 to 6 years. Adult nasopharyngolaryngeal hemangioma are extremely rare and are residual lesions from infancy and childhood. Although nasopharyngolaryngeal hemangioma does not clearly affect the quality of life of patients, intracranial hemangioma has caused blurred vision and decreased vision. Therefore, surgery for intracranial aneurysm was necessary for this patient. This case emphasizes the management of unplanned difficult airway of pharyngeal hemangioma and the emergency plan for hemangioma rupture and bleeding. Provide guidance and risk management procedures for nasopharyngotracheal intubation.

Assessment of Damage in Takayasu's Arteritis.

To evaluate damage and clinical characteristics associated with damage in Takayasu's arteritis (TAK). Patients with TAK enrolled in a multicentre, prospective, observational study underwent standardized damage assessment every 6 months using the Vasculitis Damage Index (VDI) and the Large-Vessel Vasculitis Index of Damage (LVVID). The study included 236 patients with TAK: 92% female, 81% Caucasian; median (25th, 75th percentile) disease duration = 2.6 (0.12, 6.9) years. Eighty-four percent had follow-up: median (25th, 75th) duration 4.1 (1.9, 7.5) years.Items of damage were present in 89% on VDI, 87% on LVVID, in the peripheral vascular (76% VDI, 74% LVVID), cardiac (40% VDI, 45% LVVID) systems. During follow-up, 42% patients had new damage;, including major vessel stenosis/arterial occlusion (8%), limb claudication (6%), hypertension (7%), aortic aneurysm (4%), and bypass surgery (4%). Disease-specific damage accounted for >90% new items. Older age, relapse, and longer duration of follow-up were associated with new damage items; a higher proportion of patients without new damage were on methotrexate (p< 0.05). Among 48 patients diagnosed with TAK within 180 days of enrolment, new damage occurred in 31% on VDI and 52% on LVVID. History of relapse was associated with new damage in the entire cohort while in patients with a recent diagnosis, older age at diagnosis was associated with new damage. Damage is present in > 80% of patients with TAK even with recent diagnosis and >40% of patients accrue new, mainly disease-specific damage. Therapies for TAK that better control disease activity and prevent damage should be prioritized.

Exploring how military culture shapes veterans' perception of aortic aneurysm repair: A qualitative study.

Veterans represent a distinct cultural group whose perceptions of illness and treatment are influenced by military culture. The study explores how prior military service shapes Veterans' assumptions and behaviors in the setting of aneurysm repair surgery. We conducted content and thematic analysis of a case series of 10 transcripts from telephone interviews with older (76.7 ± 4.3 years) African American and White male Veterans now residing in the Southern U.S. who underwent open or endovascular aneurysm surgery at Veterans Affairs Medical Centers or university affiliates between 2004 and2019. Throughout the continuum of care, Veterans described deferring to authority and not questioning provider's decisions ["I just can't make a judgment on that, because I'm not a doctor"]. Veterans valued commitment and articulated pride in keeping logistically challenging surveillance appointments [I always took them very seriously. . . If I'm scheduled for something by the doctor, I always make it."]. The routine structure of VA care aligned with Veterans military experiences, facilitating compliance with doctor's orders. However, procedural deviations in VA care were disconcerting for patients ["They haven't reached out to me in at least three years, since my surgery; I was being seen once a year and then all of a sudden, they just quit."]. While Veterans praised VA care, they exhibited sensitivity to signs of untoward treatment from clinical and support staff "…my surgeon, he never talked to me before, nor after, no anytime…I thought that maybe that wasn't right". Military culture embodies rank, order, and respect, and remains a source of strength and stability for Veterans in their medical care late in life. Cultural competency about how military service has shaped Veterans' expectations can enhance providers' awareness of patients' military mindsets and inform surgeons' efforts to engage Veterans in shared decision making.

Sex-based disparities in ascending aortic aneurysm surgery outcomes: a comprehensive analysis of 1148 consecutive patients with propensity-score matching

BackgroundWomen undergoing cardiac surgery have been historically recognized to carry higher periprocedural mortality risk. We aimed to investigate the influence of sex on clinical presentation, perioperative, and long-term outcomes in patients who undergo surgery for ascending aortic aneurysm.MethodsWe conducted a retrospective review of 1148 consecutive patients (380 [33.1%] female) who underwent thoracic aortic surgery under moderate hypothermic circulatory arrest for ascending aortic aneurysms between 2001 and 2021. Baseline and operative characteristics, in-hospital mortality, and survival were compared between male and female patients before and after propensity-score-matched (PSM) analysis.ResultsWomen were significantly older (median age: 69 [IQR: 63–75] vs. 67 [IQR: 58–73]; P < 0.001), while men had a higher prevalence of aortic valve stenosis, bicuspid valve and coronary artery disease at the time of surgery (P < 0.05). After PSM, EuroSCORE II (4.36 [2.68; 6.87] vs. 3.22 [1.85; 5.31]; p < 0.001), and indexed aortic diameter were significantly higher in female patients (2.94 [2.68; 3.30] vs. 2.58 [2.38; 2.81] cm/m2, p < 0.001). In the matched cohort, men were more likely to experience postoperative delirium (18.1% vs. 11.5%; P = 0.002), and postoperative neurological deficits (6.7% vs. 3.0%, P = 0.044),. Female patients were more likely to receive postoperative packed red blood cells (p = 0.036) and fresh frozen plasma (p = 0.049). In-hospital and 30-day mortality was similar between both groups. Long-term survival was comparable between both groups with 88% vs. 88% at 5 years, 76% vs. 71% at 10 years, and 59% vs. 47% at 15 years.ConclusionFemale patients required more transfusions, while males had a higher incidence of postoperative delirium and neurological deficits. Differences in preoperative age and timing of surgery between the sexes could be attributed to variations in comorbidity profiles and the greater prevalence of concomitant surgery indications in males.

Cool-Shot Technique to Protect Spinal Cord during Thoracoabdominal Aortic Replacement.

Deep hypothermia helps protect the spinal cord, but is invasive. Here, we present a method to avoid reperfusion injury by selectively circulating cold blood under high pressure to the intercostal artery during reperfusion after intercostal artery reconstruction. Of the 23 patients who underwent thoracoabdominal aortic aneurysm open repair, one died. The motor evoked potential disappeared during aortic clamping in nine patients. Six patients recovered completely from aortic clamping release, two showed recovery >50% and one achieved full recovery 3 months later. Permanent motor impairment did not occur. This method could prevent reperfusion injury and paraplegia following thoracoabdominal aortic aneurysm surgery.

Improved rates of postoperative ischemia, completeness of aneurysm occlusion and neurological deficits in elective clipping of anterior circulation aneurysms over the past 20 years – association with technical improvements

Background/PurposeSeveral periprocedural adjuncts for elective surgical aneurysm treatment have been introduced over the last 20 years to increase safety and efficacy. Besides the introduction of IONM in the late-1990s, ICG-videoangiography (ICG-VAG) since the mid-2000s and intraoperative CT-angiography/-perfusion (iCT-A/-P) since the mid-2010s are available. We aimed to clarify whether the introduction of ICG-VAG and iCT-A/-P resulted in our department in a stepwise improvement in the rate of radiologically detected postoperative ischemia, complete aneurysm occlusion and postoperative new deficits.MethodsPatients undergoing microsurgical clip occlusion for unruptured anterior circulation aneurysms between 2000 and 2019 were included, with ICG-VAG since 2009 and iCT-A/-P (for selected cases) since 2016. Baseline characteristics and treatment-related morbidity/outcome focusing on differences between the three distinct cohorts (cohort-I: pre-ICG-VAG-era, cohort-II: ICG-VAG-era, cohort-III: ICG-VAG&iCT-A/-P-era) were analyzed.Results1391 patients were enrolled (n = 74 were excluded), 779 patients were interventionally treated, 538 patients were surgically clipped by a specialized vascular team (cohort-I n = 167, cohort-II n = 284, cohort-III n = 87). Aneurysm size was larger in cohort-I (8.9 vs. 7.5/6.8 mm; p < 0.01) without differences concerning age (mean:55years), gender distribution (m: f = 1:2.6) and aneurysm location (MCA:61%, ICA:18%, ACA/AcomA:21%). There was a stepwise improvement in the rate of radiologically detected postoperative ischemia (16.2vs.12.0vs.8.0%; p = 0.161), complete aneurysm occlusion (68.3vs.83.6vs.91.0%; p < 0.01) and postoperative new deficits (10.8vs.7.7vs.5.7%; p = 0.335) from cohort-I to -III. After a mean follow-up of 12months, a median modified Rankin scale of 0 was achieved in all cohorts.DiscussionAssociated with periprocedural technical achievements, surgical outcome in elective anterior circulation aneurysm surgery has improved in our service during the past 20 years.