Treatment Of Aortic Pathologies Research Articles

Coaxial electrospun Ag-NPs-loaded endograft membrane with long-term antibacterial function treating mycotic aortic aneurysm

The use of endovascular stent-graft has become an important option in the treatment of aortic pathologies. However, the currently used endograft membranes have limited ability to prevent bacterial colonization. This makes them unsuitable for the treatment of mycotic aneurysms, as the infection is prone to progress after endograft implantation. Moreover, even in non-mycotic aortic pathologies, endograft infections can occur in the short or long term, especially for patients with diabetes mellitus or in immune insufficiency conditions. So, this study aimed to develop a kind of Ag-NPs-loaded endograft membrane by coaxial electrospinning technique, and a series of physical and chemical properties and biological properties of the Ag-NPs-loaded membrane were characterized. Animal experiments conducted in pigs confirmed that the Ag-NPs-loaded membrane was basically non-toxic, exhibited good biocompatibility, and effectively prevented bacterial growth in a mycotic aortic aneurysm model. In conclusion, the Ag-NPs-loaded membrane exhibited good biocompatibility, good anti-infection function and slow-release of Ag-NPs for long-term bacteriostasis. Thus, the Ag-NPs-loaded membrane might hold potential for preventing infection progression and treating mycotic aortic aneurysms in an endovascular way.

Systematic review of surgical procedures used in the treatment of aortic pathology in Mexico

Systematic review of surgical procedures used in the treatment of aortic pathology in Mexico

Editor's Choice – Early Outcomes of a Novel Off the Shelf Preloaded Inner Branch Endograft for the Treatment of Complex Aortic Pathologies in the ItaliaN Branched Registry of E-nside EnDograft (INBREED)

The aim of this study was to investigate the early outcomes of a novel off the shelf pre-loaded inner branched thoraco-abdominal endograft (E-nside) in the treatment of aortic pathologies. Data from a physician initiated national multicentre registry on patients treated with the E-nside endograft, were prospectively collected and analysed. Pre-operative clinical and anatomical characteristics, procedural data, and early outcomes (90 days) were recorded in a dedicated electronic data capture system. The primary endpoint was technical success. Secondary endpoints were early mortality (90 days), procedural metrics, target vessel patency, endoleak rate, and major adverse events (MAEs) at 90 days. In total, 116 patients from 31 Italian centres were included. Mean ± standard deviation (SD) patient age was 73 ± 8 years and 76 (65.5%) were male. Aortic pathologies included degenerative aneurysm in 98 (84.5%), post-dissection aneurysm in five (4.3%), pseudoaneurysm in six (5.2%), penetrating aortic ulcer or intramural haematoma in four (3.4%), and subacute dissection in three (2.6%). Mean ± SD aneurysm diameter was 66 ± 17 mm; aneurysm extent was Crawford I - III in 55 (50.4%), IV in 21 (19.2%), pararenal in 29 (26.7%), and juxtarenal in four (3.7%). The procedure setting was urgent in 25 (21.5%) patients. Median procedural time was 240 minutes (interquartile range [IQR] 195, 303), with a median contrast volume of 175 mL (IQR 120, 235). The endograft's technical success rate was 98.2% and the 90 day mortality rate was 5.2% (n= 6; 2.1% for elective repair and 16% for urgent repair). The 90-days cumulative MAE rate was 24.1% (n= 28). At 90 days, there were 10 (2.3%) target vessel related events (nine occlusions and one type IC endoleak) and one type 1A endoleak requiring re-intervention. In this real life, non-sponsored registry, the E-nside endograft was used for the treatment of a broad spectrum of aortic pathologies, including urgent cases and different anatomies. The results showed excellent technical implantation safety and efficacy, as well as early outcomes. Longer term follow up is needed to better define the clinical role of this novel endograft.

3D printing in aortic endovascular therapies.

Endovascular treatment of aortic disease, including aneurysm or dissection, is expanding at a rapid pace. Often, the specific patient anatomy in these cases is complex. Additive manufacturing, also known as three-dimensional (3D) printing, is especially useful in the treatment of aortic disease, due to its ability to manufacture physical models of complex patient anatomy. Compared to other surgical procedures, endovascular aortic repair can readily exploit the advantages of 3D printing with regard to operative planning and preoperative training. To date, there have been numerous uses of 3D printing in the treatment of aortic pathology as an adjunct in presurgical planning and as a basis for training modules for fellows and residents. In this review, we summarize the current uses of 3D printing in the endovascular management of aortic disease. We also review the process of producing these models, the limitations of their applications, and future directions of 3D printing in this field.

P45 OUTCOME AFTER ACUTE TYPE A AORTIC DISSECTION: THE ROLE OF AN AORTIC TEAM AND AN AORTIC REGIONAL NETWORK

Abstract Background The outcome of acute type–A aortic dissection (A–AAD) repair is strictly related both to surgical factors and patient conditions. Improvement in surgical experience and in diagnosis and treatment protocols could significantly increase survival for patients affected by A–AAD. The aim of this study was to assess the impact on patients outcomes of a standardized integrated surgical approach and of a regional aortic hub and spokes network. Materials and Methods From 2004 to 2021, a total of 258 patients underwent repair of A–AAD. In 2010 in our Institution was created the Aortic Team, with cardiac surgeons dedicated on the treatment of aortic pathologies, while in 2017 was created a regional aortic network between hub and spokes in order to standardize the diagnosis and treatment algorithm. Thus, patients were distributed among three periods: 2004–2010 (Era 1, n = 90), 2011–2016 (Era 2, n = 87), and 2017–2021 (Era 3, n = 81). Results Baseline demographic characteristics of the groups were similar. Compared to Era1 and Era2, clinical status at time of operation was better in Era3, because of less rates of malperfusion (16% vs 11% vs 4%, p = 0.01) and hemodynamic compromise (34% vs 38% vs 22%, p = 0.07). Patients of Era 3 were less likely to Axillary artery cannulation was almost routinely used in Eras 2 (86%) and 3 (91%) while femoral artery was mainly cannulated in Era 1 (91%) (p < 0.01). Retrograde cerebral perfusion was predominantly used in Era 1 (60%) while antegrade cerebral perfusion was preferred in Eras 2 (94%,) and 3 (100%); (p < 0.01). There was a significant increase of arch replacement procedures from Era 1 (11%) to Eras 2 (33%) and 3 (48%) (p < 0.01). Frozen elephant trunk was mainly performed in Era 3. Operative mortality was 13% in Era 1, 11% in Era 2, and 4% in Era 3 (p = 0.07, p = 0.03 between Era 1 and Era3). Actuarial survival at 3 years is 74%, in Era 1, 78% in Era 2, and 89% in Era 3 (p = 0.05). Patients of Era 3 received less re–exploration for bleeding (p = 0.02) and less high inotropic support (p = 0.04). Conclusions With increasing experience and a more aggressive approach, including total arch replacement, repair of A–AAD can be more tailored to patients conditions, being performed with low operative mortality in many patients. Moreover, patient care and treatment by a multidisciplinary regional organization allows faster diagnosis and effective clinical stabilization allowing to further improve early and late outcomes.

Anaesthetic-surgical guide in the treatment of ascending aorta and surgery of the ascending aorta and aortic arch. Consensus document of the Spanish Society of Cardiovascular and Endovascular Surgery and the Sociedad of Anaesthesiology, Resuscitation and Pain Therapy.

Aortic pathology is always a challenge for the clinician, and must be diagnosed and treated by a multidisciplinary team due to the technical and technological complexity of the resources used. Ongoing efforts to implement a systematic, protocolized approach involving "Aortic teams" made up of cardiologists, cardiac surgeons, vascular surgeons, anaesthesiologists and radiologists, among others are now leading to improved outcomes. The aim of this consensus document drawn up by the Aortic working groups of the Spanish Society of Anaesthesiology, Resuscitation and Pain Therapy (SEDAR) and the Spanish Society of Thoracic and Cardiovascular Surgery (SECTCV) is to disseminate a set of working protocols. The latest consensus document of the European Association for Cardio-Thoracic Surgery (EACTS) and the European Society for Vascular Surgery (ESVS) define the concept of "AORTIC TEAM"(1). The aortic team should be closely involved from diagnosis to treatment and finally follow-up, and should be formed of cardiac and vascular surgeons working together with anaesthesiologists, cardiologists, radiologists and geneticists. Treatment of aortic pathologies should be centralised in large centres, because this is the only way to effectively understand the natural course of the disease, provide the entire range of treatment options under one umbrella and treat potential complications. A streamlined emergent care pathway (24/7 availability), adequate transportation and transfer capabilities, as well as rapid activation of the multidisciplinary team must be available. In light of the complexity and constant evolution of therapeutic options, we present this first version of the Anaesthesiology and surgical guidelines for surgery of the ascending aorta and aortic arch. Some questions will no doubt remain unanswered, and future versions will include new techniques that, though implemented in some centres, are still not widely recommended.

HYBRID AORTIC ARCH SURGERY TO CREATE A LANDING ZONE IN THE ASCENDING AORTA.

Thoracic Endovascular Aortic Repair (TEVAR) has enabled the treatment of aortic pathology that previously required open surgery, with higher morbidity and mortality. The need for a favorable landing zone (Lz), without compromising the patency of the supra-aortic vessels meant that Ishimaru Lz 2 was the most proximal technically feasible Lz. We developed a hybrid technique for the creation of a more proximal Lz in high risk patients - in the first stage, debranching/ rerouting of the supra-aortic vessels, with or without ascending aorta replacement, was performed; a few weeks later, a TEVAR with a LZ in the distal ascending aorta was performed. This technique allowed the avoidance of the more aggressive total arch and proximal descending aorta replacement (Elephant Trunk or Frozen Elephant Trunk - FET) in high risk patients. We reviewed all patients who underwent hybrid arch surgery in our Department to create a more proximal Lz that allowed safe TEVAR stent placement. From November 2007 to October 2019, 15 patients required hybrid surgery to achieve treatment - 9 by replacing the ascending aorta and debranching supra-aortic vessels and 6 by debranching and re-routing supra-aortic vessels to the native ascending aorta. All underwent computed tomography angiography within 30 days of surgery and had follow-up with annual appointments and imaging control. Patients average age was 65.5 (+/- 11.5) years, 73.3% being male. Average follow-up was 54.7 (+/- 46.2) months. The most common diagnosis was thoracic aortic aneurysm (66.7%), followed by chronic type B aortic dissection (20.0%), pen- etrating atherosclerotic ulcer (6.7%) and reintervention due to endoleak (EL, 6.7%). No in-hospital mortality was registered. ICU and hospital stay was 1.3 (0.8) days and 9.8 (10.3) days, respectively. Survival at 1- and 5- years was 84.6% and 65.8%, respectively. No EL was detected in 66.7% (n=10) of patients. Incidence of early EL was 20.0% (n=3), of which two-thirds had spontaneous resolution, and late EL was 13.3% (n=2). Endovascular reintervention was required in one patient. TEVAR in the context of hybrid surgery is associated with low morbidity and mortality, with a low incidence of EL and good early and long term survival.

Guía anestésico-quirúrgica en el tratamiento de la cirugía de aorta ascendente y del arco aórtico. Documento de consenso de la Sociedad Española de Cirugía Cardiovascular y Endovascular y la Sociedad Española de Anestesiología, Reanimación y Terapeútica del Dolor

Aortic pathology is always a challenge for the clinician, and must be diagnosed and treated by a multidisciplinary team due to the technical and technological complexity of the resources used. Ongoing efforts to implement a systematic, protocolized approach involving “Aortic teams” made up of cardiologists, cardiac surgeons, vascular surgeons, anaesthesiologists and radiologists, among others are now leading to improved outcomes. The aim of this consensus document drawn up by the Aortic working groups of the Spanish Society of Anaesthesiology, Resuscitation and Pain Therapy (SEDAR) and the Spanish Society of Thoracic and Cardiovascular Surgery (SECTCV) is to disseminate a set of working protocols. The latest consensus document of the European Association for Cardio-Thoracic Surgery (EACTS) and the European Society for Vascular Surgery (ESVS) define the concept of “AORTIC TEAM”(1). The aortic team should be closely involved from diagnosis to treatment and finally follow-up, and should be formed of cardiac and vascular surgeons working together with anaesthesiologists, cardiologists, radiologists and geneticists. Treatment of aortic pathologies should be centralised in large centres, because this is the only way to effectively understand the natural course of the disease, provide the entire range of treatment options under one umbrella and treat potential complications. A streamlined emergent care pathway (24/7 availability), adequate transportation and transfer capabilities, as well as rapid activation of the multidisciplinary team must be available. In light of the complexity and constant evolution of therapeutic options, we present this first version of the Anaesthesiology and surgical guidelines for surgery of the ascending aorta and aortic arch. Some questions will no doubt remain unanswered, and future versions will include new techniques that, though implemented in some centres, are still not widely recommended.

Treatment reality of aortic diseases in Switzerland

HintergrundDurch das föderalistisch organisierte Gesundheitssystem in der Schweiz werden Aorteneingriffe an vielen verschiedenen Krankenhäusern, mutmaßlich mit teils sehr kleiner Fallzahl, durchgeführt. In dieser Arbeit soll anhand der erfassten Aorteneingriffe im schweizerischen Gefäßregister Swissvasc die Versorgungsrealität von Aortenerkrankungen dargestellt werden.MethodeFür diese Übersichtsarbeit wurden sämtliche Eingriffe an der Aorta, welche zwischen Januar 2018 und Dezember 2020 in der Schweiz durchgeführt und in das Swissvasc-Register eingegeben wurden, eingeschlossen. Nicht berücksichtigt wurden Eingriffe zur Behandlung von isolierten Pathologien an den Beckengefäßen sowie Eingriffe an der Aorta ascendens und dem proximalen Aortenbogen.ResultateOffene Aorteneingriffe wurden an 28 und endovaskuläre an 33 Krankenhäusern durchgeführt. Nur knapp die Hälfte dieser Krankenhäuser erreicht dabei die empfohlene Mindestfallzahl für abdominale Aortenaneurysmen von 30 offenen und endovaskulären Eingriffen pro Jahr, die in der Literatur aktuell diskutiert werden. Von den abdominalen Aneurysmen waren im Dreijahreszeitraum der Literatur entsprechend 11 % rupturiert, diese wurden aber entgegen den Richtlinien zu knapp 60 % offen versorgt. Die elektive Behandlung der abdominalen Aneurysmen war den Richtlinien entsprechend zu 67 % endovaskulär. Bei der Versorgung der thorakalen Aortenpathologien zeigt sich eine Zentralisierung. Hier wurden 87 % der Eingriffe an lediglich 5 Krankenhäusern durchgeführt.ZusammenfassungDiese Untersuchung zeigt, dass viele Kliniken in der Schweiz, teils mit sehr kleinen Fallzahlen, Aortenpathologien behandeln. Weitere Untersuchungen zur Versorgungsqualität bei der Behandlung dieser Pathologien sind dringend notwendig.

Clinical case of successful staged treatment of patients with aneurysms of the thoracic and abdominal aorta and adenocarcinoma of the stomach

А clinical case of treatment of a patient with isolated saccular aneurysm of the aortic arch and aneurysm of the infrarenal aorta of large size is presented. As a сoncomitant pathology, gastric adenocarcinoma was revealed. Multi-stage surgical treatment was performed. The first stage included left-sided carotid-subclavian bypass, the second –TEVAR, the third — EVAR. The final stage was an extended gastrectomy with lymphodissection. No complications were found during the treatment. The technique of operations is described, explanations on the chosen tactics of treatment are given. The conclusion is made about the advantage of endovascular techniques in the treatment of aortic pathology in patients with oncological pathology.

Long-term failure of Amplatzer plugs in the treatment of aortic pathology.

We present two cases of Amplatzer® device deployment that exhibited long-term failure necessitating surgical correction. The first case illustrates recanalization of a ruptured Valsalva aneurysm with worsening aortic insufficiency after percutaneous repair with the Amplatzer Vascular Plugs and Amplatzer duct occluder, while the second case illustrates recanalization after deployment of the Amplatzer septal occluder in a patient with a pseudoaneursym in a bovine aorta after type I aortic dissection repair. These two cases illustrate the potential long-term complications and limitations in durability with these devices.

Hybridoperation eines thorakoabdominellen Aortenaneurysmas

The treatment of thoracoabdominal aortic aneurysms remains an ongoing challenge in vascular surgery and has been associated with high periprocedural mortality. Since the introduction of endovascular procedures in the treatment of aortic pathologies during the last decade, new therapeutic options have arisen. We report here some technical aspects of a 2-step hybrid-procedure that consists of an initial debranching of all visceral arteries by perfusing them through a special vascular prosthesis, which is anastomosed to the healthy common iliac artery. The second step is performed after recovery of the patient from the debranching procedure and stentgraft prostheses are implanted to fully exclude the aneurysm. Thoracoabdominal aortic aneurysm. Two-step hybrid-procedure for treatment of thoracoabdominal aneurysms. In our opinion, this procedure is, although technically demanding, safely performable with a tolerable periprocedural morbidity and mortality. Major advantages are the restriction to one visceral cavity and a sequential debranching that allows us to avoid use of a temporary bypass. This procedure appears to be a promising alternative to conventional thoracoabdominal aortic repair in centres with expertise in visceral artery revascularisation.

Chimney technique in the endovascular management of complex aortic disease

The objective of this study was to systematically review the literature reporting on the chimney technique and perform an analysis of the outcomes. A search of electronic databases was undertaken to identify all studies reporting on the outcome of the chimney technique. The selected articles were divided into those reporting on the treatment of aortic pathology involving the visceral and those involving the supra-aortic branches. Twenty-one articles reporting on the treatment of juxta/supra-renal aorta and aortic arch disease in 102 and 37 patients, respectively, were identified. In the visceral group, an overall technical success rate of 91% was achieved, the perioperative major morbidity and mortality rates were 17 and 5%, respectively, and an early type I endoleak developed in 13 patients (13%). During follow-up, one patient died of intestinal ischemia. In the supra-aortic group, the technical success rate was recorded in 95%, and three patients (8%) developed an early type I endoleak. Three patients (13%) required conversion to open surgery during follow-up. In conclusion, this technique may be viewed as a complementary technique in high-surgical-risk patients.

Laparoskopische Aortenchirurgie

Outside Germany, laparoscopic techniques are more commonly used in aortic surgery than in Germany, but some German centres have now adopted this technique as well. Particularly in high qualified centres laparoscopic surgery offers additional options in treatment of aortic pathologies. This sophisticated technique is very advantageous for a strictly defined group of patients. Indications, preparations and complications of laparoscopy correspond to those of open aortic surgery. Extensive calcifications are considered as contraindications. An evaluation of calcifications is done by CT-scan. The correct positioning of the patient is vital for the success of the operation. Compared to open surgery patients recover faster after laparoscopy.

Incidence of neurological complications following overstenting of the left subclavian artery

Aortic endovascular stent-graft implantation is associated with low morbidity and mortality rates. Overstenting of the left subclavian artery may be necessary to create a satisfactory proximal 'landing zone' for the stent-graft. Few cases have been published reporting adverse neurological events after overstenting of the left subclavian artery. We thus evaluated whether this procedure is associated with a higher rate of neurological complications by focusing on the management of the supra-aortic vessels. Twenty patients suffering from aortic arch aneurysms (n=3), descending aortic aneurysms (n=7), acute (n=6) and chronic (n=4) type-B aortic dissections underwent stent-graft repair with complete (n=14) or partial (n=6) overstenting of the left subclavian artery. Three patients underwent overstenting of the entire aortic arch with ascending aortic-bi-carotid bypass grafting. One patient with right carotid and vertebral artery occlusion underwent initial carotid-to-subclavian bypass. All patients subsequently underwent neurological examination and Doppler ultrasound for detection of neurological and peripheral vascular complications. Aortic stent-graft repair was successful in all patients without acute neurologic complications. Two patients developed late central adverse neurological events: right-sided vertebral artery occlusion with brainstem infarction (n=1) and impaired binocular vision combined with dizziness (n=1), necessitating secondary subclavian transposition in one patient. Peripheral symptoms related to occlusion of the left subclavian artery were observed in five patients as sensory and motoric deficits of the left hand and arm. Overstenting of the left subclavian artery as treatment of aortic pathologies in high-risk patients is feasible but associated with the risk of neurological complications and peripheral symptoms. Side effects were mild or transient in most of our patients. Detailed preoperative exploration of vascular anatomy and pathology via Doppler ultrasound, CT- or MRI scan is mandatory to avoid adverse neurological events. Prior surgical revascularization of the left subclavian artery is essential in patients with high-grade stenoses, occlusions, or anatomic variants of the supra-aortic branches. Delayed surgical revascularization is necessary only in patients with relevant subclavian steal syndrome or severe peripheral vascular symptoms.

The Hybrid Procedure For Surgical Repair Of Thoracoabdominal Aneurysms

INTRODUCTION Cardiovascular surgeons at the Methodist DeBakey Heart Center have a long history of leadership in the treatment of aortic pathology, and nowhere is this leadership more apparent than with thoracoabdominal aneurysms (TAAs). The Methodist DeBakey Heart Center has more experience in treating TAAs than any other institution in the world. Yet despite our expertise and concentration of surgical experts, TAA repair remains complex and carries significant morbidity and mortality. The center's success with endograft repair of infrarenal abdominal aortic aneurysm has led our team to extend these techniques to thoracoabdominal aneurysm repair in an effort to decrease the magnitude of this surgery.

The Hybrid Procedure for Surgical Repair of Thoracoabdominal Aneurysms

Cardiovascular surgeons at the Methodist DeBakey Heart Center have a long history of leadership in the treatment of aortic pathology, and nowhere is this leadership more apparent than with thoracoabdominal aneurysms (TAAs). The Methodist DeBakey Heart Center has more experience in treating TAAs than any other institution in the world. Yet despite our expertise and concentration of surgical experts, TAA repair remains complex and carries significant morbidity and mortality. The center’s success with endograft repair of infrarenal abdominal aortic aneurysm has led our team to extend these techniques to thoracoabdominal aneurysm repair in an effort to decrease the magnitude of this surgery.

How to avoid and manage nerve injuries associated with aortic surgery: ischemic neuropathy, traction injuries, and sexual derangements.

Both open and endovascular surgery of the infrarenal aorta are attended by risks of neurologic complications. Injury to the periaortic autonomic plexi frequently results in ejaculatory and erectile dysfunction. Traction injuries to lumbosacral nerve roots can cause peripheral nerve injury, most commonly exhibited as a femoral nerve deficit. The least common but most feared neurologic complication that can occur with infrarenal aortic surgery is ischemic injury to the spinal cord, or conus medullaris. The risk of this complication is increased with emergent or complicated aortic reconstructions. The importance of internal iliac artery perfusion to the development of ischemic cord and nerve root injury has been recognized. Although some neurologic complications may be avoidable by technical modifications, there is a small and probably irreducible neurologic risk to aortic surgery that should be considered when weighing options for treatment of aortic pathology.

Clinical Results of Retrograde Cerebral Perfusion in Treatment of Aortic Disease

Between 1993 and 1998, 106 adults underwent ascending aorta or aortic arch operations using deep-hypothermic circulatory arrest and retrograde cerebral perfusion via the superior vena cava. Aortic lesions were acute type I dissection in 44 (41.5%), chronic type I dissection in 12 (11.3%), acute type II dissection in 6 (5.7%), chronic type II dissection in 9 (8.5%), ascending aorta or aortic arch aneurysms in 34 (32.1%), and an aneurysm of the sinus of Valsalva with aortic arch aneurysm in 1 (0.9%). The overall neurologic dysfunction rate was 6.6%. Early mortality was 18.8%. By multivariate analysis, circulatory arrest longer than 60 minutes and chronic renal failure were significant predictors of neurological dysfunction. Female gender, preoperative hemodynamic instability, circulatory arrest longer than 60 minutes, preoperative neurological dysfunction, and preoperative organ malperfusion were significant predictors of early mortality. We concluded that retrograde cerebral perfusion minimized neurological complications by preventing debris and air emboli and by providing adequate metabolic support in patients who needed circulatory arrest for surgical treatment of aortic pathology.