Thoracoabdominal Aortic Repair Research Articles

Open and endovascular reinterventions after Candy Plug false lumen embolization of type B aortic dissection

ObjectiveIn the majority of patients with chronic type B aortic dissection, there is persistent retrograde flow in the false lumen (FL) through distal re-entry tears. Among several endovascular techniques proposed for FL management, the “Candy Plug” (CP) technique has gained acceptance with good early results. The aim of this study is to report the types and outcomes of open and endovascular reinterventions and identify mechanisms of procedure failure as well as other causes for reinterventions. MethodsAll patients with type B aortic dissection submitted to thoracic endovascular aneurysm repair and CP implantation for FL embolization from January 2016 to December 2022 at our institution were included in this study. The preoperative, intraoperative, and postoperative data of the primary intervention and secondary reinterventions, when performed, were prospectively collected and retrospectively analyzed. Preoperative and postoperative computed tomography angiography were also analyzed. ResultsDuring the study period, 33 patients were submitted to thoracic endovascular aneurysm repair and CP implantation. Twenty-three patients (69.7%) showed thoracic FL complete thrombosis with aortic stability or positive remodeling at a mean follow-up of 45 ± 23.1 months. Ten patients (30.3%) underwent aortic reinterventions (male, n = 9; mean age, 60.5 ± 7.6 years). Of these 10 patients, in four patients, complete thrombosis of the FL was never achieved, leading to ongoing perfusion of the FL, defined as “primary failure.” The other six patients underwent reinterventions for different causes: two patients, after initial sealing, showed a progressive enlargement of the abdominal FL leading to distal degeneration. One patient showed proximal degeneration, two patients showed a type II thoracoabdominal aortic aneurysm and CP implantation was used as a planned procedure to reduce the extent of the surgical procedure, and one patient had recurrent, intractable back pain despite complete thrombosis of the FL. Reinterventions were open in five cases and endovascular in five. One in-hospital death (postoperative day 27) after a type II thoracoabdominal aortic aneurysm open repair was recorded. In addition, two cases of delayed spinal cord ischemia after open reintervention were recorded: one resulting in permanent paraplegia and one transitory with complete recovery. ConclusionsThe CP technique was safe and effective; however, a significant rate of aortic-related reintervention was observed. Several mechanisms led to reinterventions either in terms of “primary failure” of the CP or subsequent aneurysmal degeneration. Complex reinterventions were often necessary, with a high rate of major complications in case of open repair. Life-long and closer surveillance might be required in these patients.

The result of prospective evaluation of 3-dimensional printing-aided extensive thoracoabdominal aorta repair.

Paraplegia is a distressing complication after open thoracoabdominal aortic aneurysm (TAAA) repair, and revascularization of T8-L2-level segmental arteries is considered pivotal to prevent paraplegia. We employed 3-dimensional (3D) printing to efficiently revascularize segmental/visceral arteries and prospectively evaluated its safety and efficacy. From January 1, 2020, to June 30, 2022, we prospectively enrolled patients of extent I, II, or III TAAA repair. Guidance models were 3D-printed based on preoperative computed tomography, and multibranched aortic grafts were manually constructed upon this model before surgery. The composite outcome of operative mortality, permanent stroke, and permanent spinal cord deficit (SCD) was compared with the historical control group (n=77, in 2015-2020), subjected to similar TAAA repair without 3D printing. A total of 38 patients (58.6± 13.2years) underwent open TAAA repair with the aid of 3D printing. Extent I, II, and III repairs were performed in 14 (36.8%), 17 (44.7%), and 7 (18.4%), respectively. Concomitant arch repair and bi-iliac reconstruction were performed in 7 (18.4%) and 6 patients (15.8%), respectively. Mean pump time was 107.7± 55.5minutes. Operative mortality, permanent stroke, and permanent SCD each occurred in 1 patient (2.6%), and the incidence of the composite outcome was 7.9% (3/38). In the control group, mean pump time was 166.0± 83.9minutes, significantly longer than the 3D-printing group (P<.001), and operative mortality, permanent stroke, permanent SCD, and the composite outcome occurred in 7 (9.1%), 9 (11.7%), 8 (10.4%), and 19 (24.7%), respectively. Open repairs of extensive TAAA with 3D printing showed favorable safety and efficacy, which need further validation by larger studies.

Computational fluid dynamics simulate optimal design of segmental arteries reattachment: Influence of blood flow stagnation

ObjectivesThis study aimed to simulate blood flow stagnation using computational fluid dynamics and to clarify the optimal design of segmental artery reattachment for thoracoabdominal aortic repair. MethodsBlood flow stagnation, defined by low-velocity volume or area of the segmental artery, was simulated by a 3-dimensional model emulating the systolic phase. Four groups were evaluated: direct anastomosis, graft interposition, loop-graft, and end graft. Based on contemporary clinical studies, direct anastomosis can provide a superior patency rate than other reattachment methods. We hypothesized that stagnation of the blood flow is negatively associated with patency rates. Over time, velocity changes were evaluated. ResultsThe direct anastomosis method led to the least blood flow stagnation, whilst the end-graft reattachment method resulted in worse blood flow stagnation. The loop-graft method was comparatively during late systole, which was also influenced by configuration of the side branch. Graft interposition using 20 mm showed a low-velocity area in the distal part of the side graft. When comparing length and diameter of an interposed graft, shorter and smaller branches resulted in less blood flow stagnation. ConclusionsIn our simulation, direct anastomosis of the segmental artery resulted in the most efficient design in terms of blood flow stagnation. A shorter (<20 mm) and smaller (<10 mm) branch should be used for graft interposition. Loop-graft is an attractive alternative to direct anastomosis; however, its blood flow pattern can be influenced.

The NephroCheck bedside system for detecting stage 3 acute kidney injury after open thoracoabdominal aortic repair

Acute kidney injury (AKI) is a common complication after complex aortic procedures and it is associated with relevant mortality and morbidity. Biomarkers for early and specific AKI detection are lacking. The aim of this work is to investigate the reliability of the NephroCheck bedside system for diagnosing stage 3 AKI following open aortic surgery. In this prospective, multicenter, observational study,—https://clinicaltrials.gov/ct2/show/NCT04087161—we included 45 patients undergoing open thoracoabdominal aortic repair. AKI risk (AKIRisk-Index) was calculated from urine samples at 5 timepoints: baseline, immediately postoperatively and at 12, 24, 48, and 72 h post-surgery. AKIs were classified according to the KDIGO criteria. Contributing factors were identified in univariable and multivariable logistic regression. Predictive ability was assessed with the area under the receiver operator curve (ROCAUC). Among 31 patients (68.8%) that developed AKIs, 21 (44.9%) developed stage-3 AKIs, which required dialysis. AKIs were correlated with increased in-hospital mortality (p = .006), respiratory complications (p < .001), sepsis (p < .001), and multi-organ dysfunction syndrome (p < .001). The AKIRisk-Index showed reliable diagnostic accuracy starting at 24 h post-surgery (ROCAUC: .8056, p = .001). In conclusion, starting at 24 h after open aortic repair, the NephroCheck system showed adequate diagnostic accuracy for detecting the patients at risk for stage 3 AKIs.

Discussion to: The result of prospective evaluation of 3-dimensional printing-aided extensive thoracoabdominal aorta repair.

Discussion to: The result of prospective evaluation of 3-dimensional printing-aided extensive thoracoabdominal aorta repair.

IFABP levels predict visceral malperfusion in the first hours after open thoracoabdominal aortic repair.

Intestinal ischemia after open thoracoabdominal aortic repairs, is a rare but devastating complication, associated with high mortality. Notoriously challenging to diagnose, visceral malperfusion necessitates immediate surgical attention. Intestinal fatty acid-binding protein (IFABP) has been proposed as a biomarker for the diagnosis of intestinal wall damage. In this prospectively conducted, observational study we evaluated the diagnostic capacity of IFABP levels in patients' serum and their correlation with visceral malperfusion. 23 patients undergoing open thoracoabdominal aortic repairs were included in this study and 8 of them were diagnosed postoperatively with visceral malperfusion-defined as a partial or complete thrombotic occlusion of the superior mesenteric artery and/or the coeliac trunk. IFABP levels and laboratory parameters often associated with intestinal ischemia (leucocytes, CRP, PCT and lactate) were measured at baseline, directly postoperatively, and at 12, 24 and 48 h after surgery. Postoperative visceral malperfusion-as revealed in CT angiography-was assessed and the predictive ability of IFABP levels to detect visceral malperfusion was evaluated with receiver-operator curve analysis. Patients with visceral malperfusion had a relevant risk for a fatal outcome (p = .001). IFABP levels were significantly elevated directly postoperatively and at 12 h after surgery in cases of visceral malperfusion. High IFABP concentrations in serum detected visceral malperfusion accurately during the first 12 h after surgery, with the maximum diagnostic ability achieved immediately after surgery (AUC 1, Sensitivity 100%, Specificity 100%, p < .001). We conclude, that IFABP measurements during the first postoperative hours after open thoracoabdominal aortic surgery can be a valuable tool for reliable and timely detection of visceral malperfusion.

Total Transfemoral Branched Endovascular Thoracoabdominal Aortic Repair (TORCH2): Short-term and 1-Year Outcomes From a National Multicenter Registry.

The use of steerable sheaths to allow total transfemoral access (TFA) of branched endovascular repair (BEVAR) of thoracoabdominal aortic aneurysms has been proposed as an alternative to upper extremity access (UEA); however, multicenter results from high-volume aortic centers are lacking. The Total Transfemoral Branched Endovascular Thoracoabdominal Aortic Repair (TORCH2) study is a physician-initiated, national, multicenter, retrospective, observational registry (Clinicaltrials.gov identifier: NCT04930172) of patients undergoing BEVAR with a TFA for the cannulation of reno-visceral target vessels (TV). The study endpoints, classified according to Society for Vascular Surgery reporting standards, were (1) technical success; (2) 30-day peri-operative major adverse events; (3) 30-day and midterm clinical success; (4) 30-day and midterm branch instability and TV-related adverse events (reinterventions, type I/III endoleaks). Sixty-eight patients (42 males; median age: 72 years) were treated through a TFA. All the centers included their entire experience with TFA: 18 (26%) used a homemade steerable sheath, and in 28 cases (41%), a stabilizing guidewire was employed. Steerable technical success was achieved in 66 patients (97%) with an overall in-hospital mortality of 6 patients (9%, 3 elective cases [3/58, 5%] and 3 urgent/emergent cases [3/12, 25%]) and major adverse event rate of 18% (12 patients). Overall, 257 bridging stents were implanted; of these, 225 (88%) were balloon-expandable and 32 (12%) were self-expanding. No strokes were observed among the patient completing the procedure from a TFA. One patient (2%) who failed to be treated completely from a TFA and needed a bailout UEA suffered an ischemic stroke on postoperative day 2. There were 10 (15%) major access-site complications. At 1-year follow-up, overall survival was 80%, and the rate of branch instability was 6%. A TFA for TV cannulation is a safe and feasible option with high technical success preventing the stroke risk of UEA. Primary patency at midterm seems comparable to historical controls, and future larger studies will be needed to assess potential differences with alternative options. Using a transfemoral approach for retrograde cannulation of reno-visceral branches is feasiable, safe and effective, thereby representing a reliable alternative for BEVAR interventions.

Mid-Term Outcomes of "Complete Aortic Repair": Surgical or Endovascular Total Arch Replacement With Thoracoabdominal Fenestrated-Branched Endovascular Aortic Repair.

To describe a single-center experience of "complete aortic repair" consisting of surgical or endovascular total arch replacement/repair (TAR) followed by thoracoabdominal fenestrated-branched endovascular aortic repair (FB-EVAR). We reviewed 480 consecutive patients who underwent FB-EVAR with physician-modified endografts (PMEGs) or manufactured stent-grafts between 2013 and 2022. From those, we selected only patients treated with open or endovascular arch repair and distal FB-EVAR for aneurysms involving the ascending, arch and thoracoabdominal aortic segments (zones 0-9). Manufactured devices were used under an investigational device exemption protocol. Endpoints included early/in-hospital mortality, mid-term survival, freedom from secondary intervention, and target artery instability. There were 22 patients, 14 men and 8 women with a median age of 72±7 years. Thirteen postdissection and 9 degenerative aortic aneurysms were repaired with a mean maximum diameter of 67±11 mm. Time from index aortic procedure to aneurysm exclusion was 169 and 270 days in those undergoing 2- and 3-stage repair strategies, respectively. The ascending aorta and aortic arch were treated with 19 surgical and 3 endovascular TAR procedures. Three (16%) surgical arch procedures were performed elsewhere, and perioperative details were unavailable. Mean bypass, cross-clamp, and circulatory arrest times were 295±57, 216±63, and 46±11 minutes, respectively. There were 4 major adverse events (MAEs) in 2 patients: both required postoperative hemodialysis, 1 had postbypass cardiogenic shock necessitating extracorporeal membrane oxygenation, and the other required evacuation of an acute-on-chronic subdural hematoma. Thoracoabdominal aortic aneurysm repair was performed with 17 manufactured endografts and 5 PMEGs. There was no early mortality. Six (27%) patients experienced MAEs. There were 4 (18%) cases of spinal cord injury with 3 (75%) experiencing complete symptom resolution before discharge. Mean follow-up was 30±17 months in which there were 5 patient deaths-0 aortic related. Eight patients required ≥1 secondary intervention, and 6 target arteries demonstrated instability (3 IC, 1 IIIC endoleaks; 2 TA stenoses). Kaplan-Meier 3-year estimates of patient survival, freedom from secondary intervention, and target artery instability were 78±8%, 56±11%, and 68±11%, respectively. Complete aortic repair with staged surgical or endovascular TAR and distal FB-EVAR is safe and effective with satisfactory morbidity, mid-term survival, and target artery outcomes. The presented study demonstrates that repair of the entirety of the aorta - via total endovascular or hybrid means- is safe and effective with low rates of spinal cord ischemia. Cardiovascular specialists within comprehensive aortic teams at should feel confident that staged repair of the most complex degenerative and post-dissection thoracoabdominal aortic aneurysms can be safely performed in their patients with complication profile similar to that of less extensive repairs. Meticulous and intentional case planning is imperative for immediate and long-term success.

Comparison of Landmark-Guided Versus Fluoroscopy-Guided Cerebrospinal Fluid Drain-Related Complications After Aortic Repairs

Cerebrospinal fluid drains (CSFDs) are efficacious in preventing spinal cord injury after thoracic or thoracoabdominal aortic repair with extensive coverage. Increasingly, fluoroscopy is used to guide placement instead of the traditional landmark-based approach, but it is unknown which approach is associated with fewer complications. A retrospective cohort study. In the operating room. Patients having undergone thoracic or thoracoabdominal aortic repair with a CSFD over a 7-year period at a single center. No intervention. Groups were reviewed and statistically compared with respect to baseline characteristics, ease of CSFD placement, and major and minor complications directly related to placement. A total of 150 CSFDs were placed with landmark guidance as opposed to 95 with fluoroscopy guidance. Compared to the landmark group, patients with fluoroscopy-guided CSFDs were older (p < 0.008), had lower American Society of Anesthesiologists physical status scores (p=0.008), required fewer CSFD placement attempts (p=0.011), had the CSFD in place for longer duration (p < 0.001), and had a similar incidence of CSFD-related complications (p > 0.999). Composites of both major (4.5% of cases) and minor CSFD-related complications (6.1% of cases), the primary outcomes of the study, occurred with similar incidences between the 2 groups (p > 0.999 for both comparisons) after adjusting potential confounders. In patients undergoing thoracic or thoracoabdominal aortic repairs, there were no significant differences in the risk of major and minor CSFD-related complications between fluoroscopic guidance and the landmark approach. Although the authors' institution is a high-volume center for this type of procedure, the study was limited by a small sample size. Hence, regardless of the technique used for the placement of CSFD, the risks related to the placement should be balanced carefully against the potential benefits resulting from spinal cord injury prevention. Fluoroscopy-aided insertion of CSFD requires fewer attempts and, hence, may be better tolerated by patients.

Atrial Fibrillation after Descending Aorta Repair: Occurrence, Risk Factors, and Impact on Outcomes.

As risks of repairing the descending thoracic and thoracoabdominal aorta diminish, common complications that may prolong hospital stay, or actually increase risk, require attention. One such complication is postoperative atrial fibrillation (AF). Therefore, we characterized prevalence of, risk factors for, and effects of postoperative atrial fibrillation (PoAF) after descending and thoracoabdominal aorta repair. From January 2000 to January 2011, 696 patients underwent open descending or thoracoabdominal aorta repair at Cleveland Clinic. Operations approached via median sternotomy (n = 178) and patients treated preoperatively for arrhythmias (32 amiodarone, 9 paced) or in AF on preoperative electrocardiogram (n = 14) were excluded, leaving 463. Logistic regression analysis identified risk factors for PoAF. Temporal relation of PoAF with postoperative morbidities was determined, and outcomes following PoAF were compared between propensity-matched pairs. New-onset PoAF occurred in 101 patients (22%) at a median 68 hours of postincision. Risk factors included older age (p = 0.002) and history of remote AF (p = 0.0004) but not operative details, such as pericardiotomy for cardiac cannulation. Hypoperfusion and neurologic complications tended to precede PoAF, whereas sepsis, respiratory failure, and dialysis followed. Among 94 propensity-matched patient pairs, those developing PoAF were more likely to experience hypoperfusion (p = 0.006), respiratory failure (p = 0.009), dialysis (p = 0.04), paralysis (p < 0.0001), longer intensive care unit stay (median 7 vs. 5 d, p = 0.02), and longer postoperative hospital stay (median 15 vs. 13 d, p = 0.004). However, hospital death was similar (6/94 PoAF [6.4%] vs. 7/94 no PoAF [7.4%], p = 0.8). PoAF after descending thoracic aorta surgery is relatively common and a part of a constellation of other serious complications prolonging postoperative recovery. While PoAF was associated with adverse events, it did not impact postoperative cost and mortality. Descending thoracic aorta surgery is by itself comorbid enough, which is likely why PoAF does not have a more significant effect on postoperative recovery and cost.

Feasibility of Direct Intercostal and Lumbar Artery Revascularization to Prevent Spinal Cord Ischemia Associated with Endovascular Thoracoabdominal Aortic Repair

Despite advances in complex endovascular aortic repair techniques, spinal cord ischemia (SCI) is still a devastating complication following endovascular thoracoabdominal aortic repairs. Current preventive strategies such as staged repair, temporary sac perfusion, hemodynamic management, and spinal drainage, focus on augmentation of spinal perfusion through collateral networks. Novel strategies to preserve key intercostal/lumbar arteries have been described including endovascular incorporation of fenestrations/branches and extra-anatomic bypass. We report our early results of patients who underwent direct intercostal/lumbar artery revascularization using endovascular or extra-anatomic approaches for fenestrated-branched endovascular aortic repairs (FBEVAR). A retrospective review of consecutive patients who underwent FBEVAR with intercostal/lumbar artery revascularization from 2018 to 2022 was performed. Patient characteristics, intraoperative details, and outcomes including SCI and branch occlusions were evaluated. Among 318 patients who underwent FBEVAR during the study period, 12 patients were included in the study. Aortic pathologies consisted of degenerative aneurysms (33%), postdissection aneurysms (33%), extensive penetrating aortic ulcers with intramural hematoma (25%), and visceral patch pseudoaneurysm (8%). Full thoracoabdominal coverage was required in eight patients and supraceliac coverage >10 cm was required in four. Nine patients received endovascular incorporation (Fig 1), including directional branches (5/9), unstented fenestrations (2/9), and stented fenestration (1/9). Three patients received extra-anatomic subcutaneous femoral-to-radicular artery bypass using a composite graft of polytetrafluoroethylene and saphenous vein (Fig 2). Our institutional SCI prevention protocol, consisting of prophylactic cerebral spinal fluid drain for high-risk patients, hemodynamic augmentation, and oxygen supplementation, was followed. Prophylactic cerebral spinal fluid drain was placed in nine patients. One patient had unsuccessful drain placement attempts. Two patients who had selective angiography identifying the great anterior radiculomedullary artery, did not undergo drain placement. Total number of target vessels for FBEVAR was 4.2 with a fluoroscopy time 66 ± 31 minutes, and contrast usage of 109 ± 51 mL. There were no in-hospital mortalities. One patient died of intracranial hemorrhage after sustaining a fall from a ladder 32 days after discharge. Tarlov grade II SCI were seen in two patients (one endovascular, one extra-anatomic bypass), which resolved before discharge. At median follow-up of 13 months (range, 13 days to 37 months), three patients had thrombosed intercostal/lumbar branches (one extra-anatomic bypass, two endovascular branches) with no new SCI symptoms. In patients at high risk for SCI undergoing FBEVAR, direct revascularization of an intercostal or lumbar artery is feasible using endovascular or extra-anatomic bypass approach. Further studies are planned to identify key contributing intercostal and lumbar arteries and optimization of revascularization strategies.Fig 2Extra-anatomic, profunda femoris to L1 radicular artery bypass using a composite polytetrafluoroethylene-saphenous vein conduit.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Integrative respiratory support during thoracoabdominal aortic aneurysm repair in a patient with severe lung disease: a case report

BackgroundThoracoabdominal aneurysm repair is a highly complicated procedure, especially among patients with severe lung disease, resulting in respiratory problems during and after the surgery. Herein, we designed a novel intraoperative respiratory support to address this.Case presentationAn open thoracoabdominal aortic aneurysm repair was performed on a 65-year-old man who had severe chronic obstructive pulmonary disease with a giant right lung bulla. One-and-a-half lung ventilation by left lower lobe blockade was maintained during the operation to avoid right barotrauma. Cardiopulmonary bypass (CPB) was established with venous cannulas in the right internal jugular vein and left femoral vein for elective venovenous extracorporeal membrane oxygenation (VV-ECMO). After aortic repair and withdrawal from CPB, the VV-ECMO was consecutively initiated using the same circuit by connecting the arterial cannula to the right internal jugular venous cannula. The patient maintained adequate oxygenation during hemostasis under the support of VV-ECMO after protamine was administered. He was weaned from VV-ECMO in the operating room and discharged without any complications.ConclusionPartial bronchial blockage and intraoperative VV-ECMO using the same circuit of CPB were useful methods for severe lung disease during a thoracoabdominal aortic repair.

Effect of cerebrospinal fluid drainage pressure in descending and thoracoabdominal aortic repair: a prospective multicenter observational study.

Cerebrospinal fluid drainage (CSFD) is recommended during open or endovascular thoracic aortic repair. However, the incidence of CSFD complications is still high. Recently, CSF pressure has been kept high to avoid complications, but the efficacy of CSFD at higher pressures has not been confirmed. We hypothesize that CSFD at higher pressures is effective for preventing motor deficits. This prospective observational study included 14 hospitals that are members of the Japanese Society of Cardiovascular Anesthesiologists. Patients who underwent thoracic and thoracoabdominal aortic repair were divided into four groups: Group 1, CSF pressure around 10mmHg; Group 2, CSF pressure around 15mmHg; Group 3, CSFD initiated when motor evoked potential amplitudes decreased; and Group 4, no CSFD. We assessed the association between the CSFD group and motor deficits using mixed-effects logistic regression with a random intercept for the institution. Of 1072 patients in the study, 84 patients (open surgery, 51; thoracic endovascular aortic repair, 33) had motor deficits at discharge. Groups 1 and 2 were not associated with motor deficits (Group 1, odds ratio (OR): 1.53, 95% confidence interval (95% CI): 0.71-3.29, p = 0.276; Group 2, OR: 1.73, 95% CI: 0.62-4.82) when compared with Group 4. Group 3 was significantly more prone to motor deficits than Group 4 (OR: 2.56, 95% CI: 1.27-5.17, p = 0.009). CSFD is not associated with motor deficits in thoracic and thoracoabdominal aortic repair with CSF pressure around 10 or 15mmHg.

Mid-Term Outcomes of Complete Aortic Repair: Surgical or Endovascular Total Arch Replacement Followed by Thoracoabdominal Fenestrated-Branched Endovascular Aortic Repair

Mid-Term Outcomes of Complete Aortic Repair: Surgical or Endovascular Total Arch Replacement Followed by Thoracoabdominal Fenestrated-Branched Endovascular Aortic Repair

Multicentre International Registry of Open Surgical Versus Percutaneous Upper Extremity Access During Endovascular Aortic Procedures

To investigate access failure (AF) and stroke rates of aortic procedures performed with upper extremity access (UEA), and compare results of open surgical vs. percutaneous UEA techniques with closure devices. A physician initiated, multicentre, ambispective, observational registry (SUPERAXA - NCT04589962) was carried out of patients undergoing aortic procedures requiring UEA, including transcatheter aortic valve replacement, aortic arch, and thoraco-abdominal aortic endovascular repair, pararenal parallel grafts, renovisceral and iliac vessels repair. Only vascular procedures performed with an open surgical or percutaneous (with a suture mediated vessel closure device) UEA were analysed. Risk factors and endpoints were classified according to the Society for Vascular Surgery and VARC-3 (Valve Academic Research Consortium) reporting standards. A logistic regression model was used to identify AF and stroke risk predictors, and propensity matching was employed to compare the UEA closure techniques. Sixteen centres registered 1 098 patients (806 men [73.4%]; median age 74 years, interquartile range 69 - 79 years) undergoing vascular procedures using open surgical (76%) or percutaneous (24%) UEA. Overall AF and stroke rates were 6.8% and 3.0%, respectively. Independent predictors of AF by multivariable analysis included pacemaker ipsilateral to the access (odds ratio [OR] 3.8, 95% confidence interval [CI] 1.2 - 12.1; p = .026), branched/fenestrated procedure (OR 3.4, 95% CI 1.2 - 9.6; p = .019) and introducer internal diameter ≥ 14 F (OR 6.6, 95% CI 2.1 - 20.7; p = .001). Stroke was associated with female sex (OR 3.4, 95% CI 1.3 - 9.0; p = .013), vessel diameter > 7 mm (OR 3.9, 95% CI 1.1 - 13.8; p = .037), and aortic arch procedure (OR 7.3, 95% CI 1.7 - 31.1; p = .007). After 1:1 propensity matching, there was no difference between open surgical and percutaneous cohorts. However, a statistically significantly higher number of endovascular adjunctive procedures were recorded in the percutaneous cohort (p < .001). AF and stroke rates during complex aortic procedures employing UEA are non-negligible. Therefore, selective use of UEA is warranted. Percutaneous access with vessel closure devices is associated with similar complication rates, but more adjunctive endovascular procedures are required to avoid surgical exposure.

Intraoperative Hemoadsorption (Cytosorb™) during Open Thoracoabdominal Aortic Repair: A Pilot Randomized Controlled Trial.

The efficacy of cytokine adsorption in controlling the early inflammation cascade after open thoracoabdominal aortic (TAAA) repair has not been investigated. The aim of this pilot randomized controlled trial was to assess the feasibility and effect of perioperative hemoadsorption during open TAAA repair. Patients scheduled for open TAAA repair with the use of cardiopulmonary bypass (CPB) were included. The patients were randomized the day before surgery to either intraoperative hemoadsorption during CPB or standard of care. A total of 10 patients were randomly assigned to the intervention group, whereas the control group consisted of 17 patients (mean age of the total cohort, 51.1 ± 11.2 years, 67% male, 3 patients not randomized). The majority of baseline and perioperative characteristics were similar, and no device-related adverse events were reported. A trend to shorter ventilation times in the intervention group was observed (median 88 h vs. 510 h, p = 0.08, Δ422). Severe acute respiratory distress syndrome was significantly less in the intervention patients (p = 0.02). This is the first pilot study showing that the intraoperative use of hemoadsorption in open TAAA repair patients may be feasible and safe, yet larger trials are needed to evaluate whether intraoperative hemoadsorption is associated with improved clinical outcomes.

Impact of frozen elephant trunk on the outcomes of thoracoabdominal aortic repair with normothermic iliac perfusion.

Frozen elephant trunk technique (FET) has been proven to provide an excellent landing zone for second-stage thoracoabdominal (TA) aortic repair. The aim of this study was to evaluate the impact of FET in TA aortic repair with normothermic iliac perfusion. From January 2008 to December 2019, 144 patients undergoing TA repair with normothermic iliac perfusion were enrolled in this study. Early and mid-term outcomes of patients with previous FET implantation (group A, n = 62) were compared with patients without previous FET implantation (group B, n = 82). The logistic regression analysis was performed to investigate the risk factors for adverse events, which were defined as early death, permanent stroke, permanent paraplegia, or permanent renal failure necessitating dialysis. The proximal aortic clamp time and operating time was 14.26 ± 5.57 min and 357.40 ± 94.51 respectively in group A, which were both significantly shorter than that in group B (18.67 ± 5.24 min and 18.67 ± 5.24 min). The incidence of adverse event was significantly lower in group A than that in group B (9.7% vs. 25.6%, P = 0.027). There was no significant difference between two groups with regard to other complications or late outcomes. In addition, age >50 years, a Ccr < 90 ml/min/1.73 m2 and the operating time were identified as significant risk factors through logistic regression analysis for adverse events of TA repair. The FET technique simplifies the operative technique of proximal anastomosis, decreases the operating time and improves the early outcomes in TA repair, whereas does not provide a significant benefit with regard to late outcomes. Long-term follow-up and studies with larger sample sizes are necessary for further confirmation.

First in Human Implantation of the Thoracoflo Graft: A New Hybrid Device for Thoraco-Abdominal Aortic Repair

Despite a high rate of success when performed in specialised centres, current techniques for thoraco-abdominal aortic repair are associated with serious complications. The problem of spinal cord ischaemia remains unsolved. The new hybrid graft for thoraco-abdominal aortic repair was developed based on the frozen elephant trunk principle. The device consists of a proximal stent graft for transabdominal retrograde delivery to the descending thoracic aorta, combined with a distal six branched abdominal device for open aortic repair. An additional seventh branch is provided for possible lumbar artery re-implantation. Because the stent graft is implanted via a transabdominal approach, it avoids the need for thoracotomy and extracorporeal circulation. A 56 year old patient with Loeys-Dietz syndrome was placed in a supine position. The aorto-iliac axis was exposed via a midline transperitoneal approach. Following an end to side anastomosis of the iliac branch to the left common iliac artery, the stent graft portion was inserted into the thoracic aorta via the coeliac trunk ostium. After stent implantation and graft de-airing by needle puncture, retrograde blood flow to the abdominal aortic segment, and the lumbar and visceral arteries was established via the end to side iliac anastomosis creating an extra-anatomic bypass. Subsequently, the visceral and renal arteries were anastomosed to the branches. Finally, the aorta was opened and surgical graft attached via the collar. The reconstruction ended with end to end anastomoses of both common iliac arteries to the graft branches. The first and successful implantation of the new Thoracoflo hybrid device via a novel surgical technique is reported, eliminating the need for thoracotomy and extracorporeal circulation for thoraco-abdominal aortic repair.

Arch vessels' switch in frozen elephant trunk: a new technique to facilitate the second-stage endovascular thoraco-abdominal aorta repair.

In patients with extensive thoraco-abdominal aortic disease, staged hybrid repair involving open total aortic arch replacement and endovascular thoraco-abdominal aorta repair with branched stent graft has emerged as a valuable treatment option. However, total arch replacement with the available branched vascular grafts often results in acute angulation between the reimplanted vessels and the aortic arch hampering antegrade catheterization of the thoraco-abdominal aorta during the second endovascular stage. Here, we present our 'switch technique' for arch vessels' reimplantation to facilitate antegrade aortic catheterization of the thoraco-abdominal aorta and visceral vessels.

A comparison of thoracoabdominal aortic aneurysms open repair in patients with or without “shaggy aorta”

ObjectiveIn the field of thoracoabdominal aortic aneurysm (TAAA) open surgical repair (OSR), some preoperative characteristics are established risk factors for adverse outcomes, whereas others are supposed to be relevant, but their role still need to be defined; among them, the presence of “shaggy aorta” (SA), an extensive and irregular atheroma within the aorta. The aim of this study is to report the results of a single-center large cohort of patients treated with OSR for TAAA with SA, comparing the outcomes with patients affected by TAAA without SA, and analyzing the impact of the scores for SA on the outcomes. MethodsAll consecutive patients receiving OSR for TAAA between 2012 and 2021 were retrospectively analyzed. Clinical data from patients with degenerative TAAA were included and analyzed for preoperative characteristics and postoperative outcomes; patients with ruptured TAAA, and patients with aortic dissection were excluded from the analysis. Patients with degenerative aortic aneurysm, thrombus measurement in non-aneurysmal aortic segments (≤40 mm), atheroma thickness ≥5 mm, and finger-like thrombus projection were included in the SA group, whereas the others were included in the non-shaggy aorta group (NSA group). The SA group and NSA group were compared using a propensity-matched comparison. Preoperative computed tomography scans of patients in the SA group were also stratified according to SA grading scores. ResultsA total of 58 patients with SA were identified (male, n = 43 [74.1%], mean age 70.1 ± 7.8 years) among 497 patients with TAAA treated with open surgical repair. After propensity matching, there were 57 patients in the SA group and 57 in the NSA group with correction of all differences in baseline characteristics. Patients in the SA group presented significantly higher in-hospital mortality (SA group, 14.0% vs NSA group, 3.5%; P = .047), postoperative acute renal failure (Risk, Injury, Failure, Loss of kidney function, and End-stage kidney disease [RIFLE], 3-5) (SA group, 21.1% vs NSA group, 5.3%; P = .013), and postoperative embolization (SA group, 28.1% vs NSA group, 8.8%; P = .008). Spinal cord ischemia and stroke rate were not significantly influenced by the presence of SA. In the SA group, 16 patients (27.6%) with end-organ embolization were compared with 42 patients (72.4%) without a documented embolization considering the grade of aortic “shagginess” and no significant difference was identified (P = .546). ConclusionsDespite a better knowledge of the SA disease, new classifications, and intraoperative adjuncts, TAAA patients with SA treated with OSR have worse postoperative outcomes if compared with patients without SA. The presence of SA is a risk factor itself, whereas the grade of “shagginess” seems not to impact on postoperative outcomes.