Visceral Ischemia Research Articles

Pathophysiology of intraabdominal hypertension and abdominal compartment syndrome and relevance to veterinary critical care.

Increased intraabdominal pressure, termed intraabdominal hypertension (IAH), is reported as an independent cause of morbidity and mortality in the human ICU but, until recently, has been rarely described in veterinary species outside of experimental models. Failure to identify severe IAH leads to organ dysfunction, termed abdominal compartment syndrome, and rapidly becomes fatal without therapeutic intervention. Although the veterinary community has been slow to address the concept of IAH and associated comorbidities, recent companion and large animal case series and experimental studies suggest IAH may also be common in veterinary species and correlates well with risk factors and grading systems already described in the human literature. Increasing abdominal pressures exert deleterious local effects through visceral ischemia and reperfusion injury as well as systemic effects on the cardiovascular, pulmonary, renal, and central nervous systems. Even mild grades of IAH increase systemic vascular resistance, impede venous return, increase pulmonary wedge pressure, and decrease pulmonary function. More severe grades cause azotemia, oliguria, decreased coronary blood flow, hypoxia, increased intracranial pressure, and death. Many of the common diseases in veterinary patients are associated with IAH, including gastric dilatation-volvulus, colon volvulus, closed pyometra, hemoperitoneum, ascites, uroperitoneum, and hydrops. Monitoring of the veterinary patient is difficult, but several experimental studies validate both the presence of IAH and the ability to monitor abdominal pressures in large and small animal species. Moreover, prompt recognition of IAH and subsequent treatment is feasible in the veterinary ICU. Increasing abdominal pressures exert deleterious local effects through visceral ischemia and reperfusion injury as well as systemic effects on the cardiovascular, pulmonary, renal, and central nervous systems. Increases in central venous pressure, systemic vascular resistance, pulmonary wedge pressure, and a decreased cardiac output by way of both decreased preload and increased afterload have been documented as a result of intraabdominal hypertension (IAH). Direct diagnosis of IAH is achieved by blind or ultrasound-guided abdominal needle puncture attached to a water manometer or direct pressure monitoring transducer. Transvesicular measurement of intraabdominal pressure (IAP) is relatively noninvasive, and many patients that would benefit from rapid diagnosis of IAH and abdominal compartment syndrome already have indwelling bladder catheters. Recommendations for interventions are based on the assigned grade of IAH (mild, moderate, severe). If IAH is strongly suspected or diagnosed, abdominal wall compliance may be improved through judicious use of neuromuscular blockers and sedation. Decompression, either minimally invasive or surgical, is absolutely recommended for IAPs consistently above 20mm Hg, especially in the presence of signs attributed to secondary organ dysfunction.

Fate of the Dissected Thoraco-Abdominal Aorta Distal to TEVAR (Thoracic Endovascular Aortic Repair) for Complicated Acute and Subacute Type B Aortic Dissection

Purpose: This study assessed morphological changes in the aortic true and false lumens during follow-up of patients undergoing TEVAR (Thoracic Endovascular Aortic Repair) for complicated acute and subacute type B dissection. The study analyzes the effectiveness of TEVAR in preventing distal aneurysmal progression. Materials and Methods: All patients between 2009 and 2019 undergoing TEVAR for complicated acute and subacute type B dissection at the study institution were retrospectively reviewed. Maximal diameters were measured on the proximal descending aorta right below the left subclavian artery, thoraco-abdominal junction right above the celiac trunk, and infrarenal aortic right above the inferior mesenteric artery, pre-operatively and during follow-up, analyzing either expansion or shrinkage of true and false lumens at these 3 sites. Results: Forty-one patients were included. Thirty-day incidence of death, stroke, paraplegia, and visceral ischemia was, respectively, 8% (n = 4), 6% (n = 3), 2% (n = 1), and 2% (n = 1). Three patients (6%) died from intervention-related cause. Mortality was 17% (n = 8) during a mean follow-up of 54 months. One patient had aneurysmal dilation of the descending aorta needing additional coverage and only 2 (4%) developed thoraco-abdominal aneurysms requiring re-intervention. In the remaining patients, both significant expansion of the true lumen and shrinkage of false lumen were observed at all 3 sites. Conclusion: Proximal coverage of the main entry tear appears to prevent aneurysmal progression in most patients (96%). With such promising results, TEVAR should be considered as a first-line treatment in acute and subacute type B dissection.

Endovascular versus open surgical repair for complicated chronic Type B aortic dissection.

Type B aortic dissection can lead to serious and life-threatening complications such as aortic rupture, stroke, renal failure, and paraplegia, all of which require intervention. Traditionally, these complications have been treated with open surgery. Recently however, endovascular repair has been proposed as an alternative. To assess the effectiveness and safety of thoracic aortic endovascular repair versus open surgical repair for treatment of complicated chronic Type B aortic dissection (CBAD). The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, and AMED databases, as well as the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers, to 2 August 2021. We searched references of relevant articles retrieved through the electronic search for additional citations. We considered all randomised controlled trials (RCTs) and controlled clinical trials (CCTs) assessing the effects of thoracic aortic endovascular repair (TEVAR) versus open surgical repair (OSR) for treatment of complicated chronic Type B aortic dissection (CBAD). Outcomes of interest were mortality (all-cause, dissection-related), neurological sequelae (stroke, spinal cord ischaemia/paresis-paralysis, vertebral insufficiency), morphological outcomes (false lumen thrombosis, progression of dissection, aortic diameters), acute renal failure, ischaemic symptoms (visceral ischaemia, limb ischaemia), re-intervention, and health-related quality of life. Two review authors independently screened all titles and abstracts identified by the searches to identify those that met the inclusion criteria. From title and abstract screening, we did not identify any trials (RCTs or CCTs) that required full-text assessment. We planned to undertake data collection and analysis in accordance with recommendations described in the Cochrane Handbook for Systematic Reviews of Interventions. We planned to assess the certainty of evidence using GRADE. We did not identify any trials (RCTs or CCTs) that met the inclusion criteria for this review. Due to lack of RCTs or CCTs investigating the effectiveness and safety of TEVAR compared to OSR for patients with complicated CBAD, we are unable to provide any evidence to inform decision-making on the optimal intervention for these patients. High-quality RCTs or CCTs addressing this objective are necessary. However, conducting such studies will be challenging for this life-threatening disease.

Efficacy and safety of carboplatin with nab-paclitaxel versus docetaxel in older patients with squamous non-small-cell lung cancer (CAPITAL): a randomised, multicentre, open-label, phase 3 trial

In Japan, docetaxel, a cytotoxic monotherapy, is the standard drug administered to older patients with advanced non-small-cell lung cancer (NSCLC). Carboplatin plus nab-paclitaxel has shown a high objective response rate in patients with squamous histology and was suggested to improve overall survival in patients aged 70 years and older. The CAPITAL trial aimed to assess the safety and efficacy of carboplatin plus nab-paclitaxel versus docetaxel as first-line therapy for patients aged 70 years and older with advanced squamous NSCLC. This multicentre, open-label, randomised, phase 3 trial was carried out at 92 medical institutions in Japan. Eligible patients were aged 70 years and older, had advanced squamous NSCLC with no previous systemic chemotherapy, and had an Eastern Cooperative Oncology Group (ECOG) performance status of 0 or 1. Using an electronic data capture system, patients were randomly assigned (1:1) to intravenous carboplatin (area under the concentration-time curve of 6 mg/mL per min for 30 min) on day 1 of a 21-day cycle and intravenous nab-paclitaxel (100 mg/m2 for 60 min) on days 1, 8, and 15 every 3 weeks or intravenous docetaxel (60 mg/m2 for 60 min) on day 1 every 3 weeks. Randomisation was computer-generated per participant and stratified by ECOG performance status, clinical stage, sex, age, and institution. The primary endpoint was overall survival, measured in the full analysis set and defined as the time from registration to the date of death due to any cause. Safety was assessed in all patients who received at least one dose of the trial treatment. This trial is registered with the UMIN Clinical Trials Registry, UMIN000019843, and the Japan Registry of Clinical Trials, jRCTs041180110. After the planned interim analysis in Aug 3, 2020, the independent data monitoring committee recommended that the trial be stopped early. This report represents the final analysis. Between Feb 24, 2016, and Aug 11, 2020, 196 patients were enrolled and were randomly assigned to the carboplatin plus nab-paclitaxel group (n=98) or the docetaxel group (n=98). Of these patients, four (carboplatin plus nab-paclitaxel group, n=3; docetaxel group, n=1) did not receive any treatment and two patients in the docetaxel group were excluded from the full analysis set. Median overall survival in the full analysis set was 16·9 months (95% CI 12·6-25·4) in the carboplatin plus nab-paclitaxel group and 10·9 months (8·5-12·4) in the docetaxel group (hazard ratio 0·52 [90% CI 0·38-0·70]; p=0·0003). Grade 3-4 adverse events occurred in 79 (83%) patients in the carboplatin plus nab-paclitaxel group and 77 (79%) patients in the docetaxel group (p=0·63). The most common grade 3-4 adverse events in the carboplatin plus nab-paclitaxel group and the docetaxel group were leukopenia (44 [46%] vs 55 [57%]; p=0·20), neutropenia (60 [63%] vs 75 [77%]; p=0·046), febrile neutropenia (nine [10%] vs 19 [20%]; p=0·073), and anaemia (37 [39%] vs two [2%]; p<0·0001). Serious treatment-related adverse events of all grades occurred in 13 (14%) patients in the carboplatin plus nab-paclitaxel group and 11 (11%) patients in the docetaxel group. Treatment-related deaths occurred in two (2%; respiratory failure n=1, visceral arterial ischaemia n=1) patients in the carboplatin plus nab-paclitaxel group and one (1%; sepsis) patient in the docetaxel group. Our study showed that overall survival was longer with carboplatin plus nab-paclitaxel than with docetaxel, suggesting that carboplatin plus nab-paclitaxel can be used as standard first-line treatment for patients aged 70 years and older with advanced squamous NSCLC. Taiho Pharmaceutical.

Surgical Fenestration for Acute Type A Aortic Dissection with Visceral and Lower Limb Ischemia and Paraplegia

Surgical Fenestration for Acute Type A Aortic Dissection with Visceral and Lower Limb Ischemia and Paraplegia

Chronic thoracoabdominal aortic dissection: endovascular options to obliterate the false lumen.

Persistent false lumen patency in chronic thoracoabdominal aortic dissections after thoracic endovascular aortic repair (TEVAR) contributes to negative aortic remodeling. We have previously described the evolution of various endovascular techniques to treat persistent false lumen perfusion including false lumen embolization. Objectives of this study are to describe endovascular techniques to obliterate the false lumen and present updated outcomes in a recent series of patients undergoing false lumen embolization for chronic aortic dissection. From January 2018 to May 2021, 17 patients with chronic dissection underwent false lumen embolization with coils, iliac plugs, and nitinol plugs. This was often in conjunction with or following TEVAR and balloon fracture fenestration. Mean follow-up 354±324 days. After false lumen embolization there was no mortality, stroke, spinal cord ischemia, or visceral and limb ischemia. No patients required dialysis, though 1 (5.9%) did experience acute kidney injury. There was 1 (5.9%) patient that required endovascular re-intervention on the thoracoabdominal aorta. No patients underwent subsequent open surgical repair. TEVAR with adjunctive false lumen embolization and balloon fracture fenestration are techniques to obliterate retrograde flow into the false lumen of chronic thoracoabdominal aortic dissections in appropriately selected patients.

Clinical Characteristics Associated with Visceral Ischemia in Acute Aortic Occlusion: Retrospective Analysis of Single-Institution Data

Clinical Characteristics Associated with Visceral Ischemia in Acute Aortic Occlusion: Retrospective Analysis of Single-Institution Data

Coronary angiography in patients with native or prosthetic aortic-valve endocarditis: outcomes and implications for myocardial revascularisation

Abstract Background Coronary angiography (CA) remains the cornerstone of the preoperative assessments before open-heart surgery to detect or rule out coronary artery disease (CAD). Preoperative CA is currently not recommended in patients with active infective aortic valve endocarditis, but may help to reduce the risk of perioperative myocardial infarction. Purpose This study aimed to evaluate the risks and benefits of preoperative CA in selected patients before aortic valve replacement to treat active infective endocarditis of the aortic valve and to assess the incidence and relevance of CAD. Methods Sixty-five patients with native or prosthetic aortic-valve endocarditis underwent preoperative diagnostic CA between 03/2008 and 09/2020. We collected their baseline characteristics, including the neurological status, previous cardiac surgical procedures, and reviewed the preoperative echocardiograms and the CA data. We evaluated the intraoperative data, and clinical outcomes after CA and after surgery. Patients were selected according to the site, size and mobility of vegetations of the underlying active infective process. Results CA revealed CAD in the majority of patients (n=34; 52%): one-vessel disease n=17 (26%), two-vessel disease n=6 (9%), and three-vessel disease n=11 (17%). Coronary sclerosis without hemodynamic significance were detected in 23 patients (35%). Sixteen patients had a previous history of CAD. We observed no adverse events following preoperative diagnostic CA, particularly no thromboembolic complications, including stroke, visceral, or lower body ischaemia. Surgery was performed 3 [IQR 1; 5] days after CA. During surgical aortic-valve replacement, concomitant coronary artery bypass grafting was performed in 19 patients (29%). Postoperative in-hospital mortality was 12% (n=8) and the new-onset disabling-stroke incidence was 2% (n=1). Neither stroke nor visceral or lower body ischemia due to embolism were observed in any patient after surgery. Conclusions By weighing risks and benefits of CA together as a team, no adverse clinical outcomes but significant clinical implications could be identified in patients with active infective aortic valve endocarditis. Concomitant surgical myocardial revascularization was frequent and may well have contributed to favorable clinical outcome. Therefore, active infective endocarditis of the aortic valve per se should not be regarded as an absolute contraindication for CA. Funding Acknowledgement Type of funding sources: None.

444 Acute Surgical Admissions at the End of Life: An Analysis of Deaths in Non-operatively Managed Patients

Abstract Aim Patients with advanced illnesses are often admitted with acute surgical emergencies. There is currently no evidence characterising such admissions. We aimed to evaluate emergency patients, managed non-operatively, who died during the same admission. Method This single-centre retrospective, observational study collected data points for a 12-month period including age, prior documented do not resuscitate order (DNAR), existing cancer, Charlson Comorbidity Index, frailty, surgical diagnosis, interval from admission to death and care given. Patients who underwent surgical intervention were excluded. Non-parametric tests were used for statistical analysis. Results 72 patients were included. 68.1% of patients died within 6 days of admission (median 4.0 days). Patients with visceral perforation, obstruction, bowel ischaemia or known malignancy were more likely to die within 6 days than those with pancreatitis, sepsis, or new malignancy (median 2 vs 7 days, p &amp;lt; 0.001). Patients with frailty (2 vs 4 days, p = 0.017) and existing DNAR (3 vs 4 days, p = 0.048) died more rapidly than those without. Age and comorbidity index did not impact time to death. Conclusions Frailty, surgical diagnosis and existing DNAR were predictors of shorter admission to death interval, while age and comorbidity index were not. This has implications on inpatient palliative care service planning.

Application of the VORTEC Technique in Creating a Proximal Inflow Conduit in the Circumferentially-Calcified or “Lead-Pipe” Aorta

A heavily calcified or "lead-pipe" aorta can present many challenges to any surgeon. There is higher risk of vessel wall rupture or disruption, distal embolization, and prolonged ischemia time of visceral organs due to longer clamp times. Hybrid revascularization techniques, which were originally described in visceral revascularization during complex aortic procedures, can be potentially utilized for lower extremity bypasses. These techniques, such as "VORTEC," are well-studied and have been shown to have similar patency rates as traditional bypass grafts with the added benefit of decreased ischemia time and lower levels of acute kidney injury and visceral organ ischemia. This allows VORTEC and other similar hybrid techniques to be utilized as options when traditional vessel control cannot be safely achieved during distal revascularization procedures, as we describe in our patient.

Monocentric case-series of mesenteric vascular disease occurred in the first month of the COVID-19 pandemic

Objectiveswe describe Coronavirus Disease (COVID-19) patients also manifesting gastro-intestinal symptoms. Methodsfive women, between the ages of 32 and 82 years old, were admitted for acute abdomen, and received a nasopharyngeal swab for COVID-19 screening, lab test analysis, and contrast thoraco-abdominal CT-scan. All presented leukocytosis, different localizations of visceral vessels thrombosis and ischemia, and COVID-19. Resultsemergency laparotomy was accepted by all but 1, who died after 5 days. Postoperatively, 1 died of multi-organ failure, 3 were discharged home after 14, 8 and 10 days respectively, under anti-platelet and anticoagulation treatment. Conclusionsin COVID-19 patients with acute abdomen, abdominal contrast CT-scans should be systematically extended to the thorax to detect visceral COVID-19 initial pulmonary signs. Emergency laparotomy and visceral arteries thrombectomy could be necessary.

Intestinal Autotransplantation and In-Situ Resection of Recurrent Pancreatic Head Intraductal Tubulopapillary Neoplasm with Portal Cavernoma: A Case Report

Intraductal tubulopapillary neoplasm (ITPN) is a new entity of a rare premalignant pancreatic neoplasia, and a radical curative resection is indicated. As with other tumors of the root of the mesentery, the proximity of the lesion to large splanchnic vessels, abdominal aorta, and inferior vena cava poses major risks of a massive hemorrhage and visceral ischemia using conventional surgical techniques. At times, these lesions are amenable for resection using novel techniques developed from organ transplantation. Multivisceral (allo-) transplantation should be considered when radical resection of a benign tumor is likely to compromise portal flow and possibly precipitate acute liver failure, but it may be associated with a long waitlist time and tumor progression. Autotransplantation offers a safe and curative resection of otherwise inoperable tumors in a bloodless field, an excellent exposure, and prevention of warm ischemic injury to the affected viscera, which are then autotransplanted. We describe the en bloc resection of a large and recurrent ITPN of the pancreas, distal stomach, proximal duodenum, transverse colon, superior mesenteric vein, and portal cavernoma, followed by intestinal autotransplantation. A complete tumor resection was achieved with negative margins, adequate cold preservation of the reimplanted intestine, and without significant hemorrhage. The patient was discharged from the hospital 10 days later. The histopathologic examination revealed free-margin resection of ITPN with an associated invasive carcinoma. The patient received adjuvant chemotherapy with folinic acid, fluorouracil, and oxaliplatin and remains disease-free 20 months after surgery. Autotransplantation offers curative resection of otherwise unresectable lesions of the root of the mesentery.

Who would benefit from open abdomen in severe acute pancreatitis?\u2014a matched case-control study

BackgroundSelection of patients for open abdomen (OA) treatment in severe acute pancreatitis (SAP) is challenging. Treatment related morbidity and risk of adverse events are high; however, refractory abdominal compartment syndrome (ACS) is potentially lethal. Factors influencing the decision to initiate OA treatment are clinically important. We aimed to study these factors to help understand what influences the selection of patients for OA treatment in SAP.MethodsA single center study of patients with SAP that underwent OA treatment compared with conservatively treated matched controls.ResultsWithin study period, 47 patients treated with OA were matched in a 1:1 fashion with conservatively treated control patients. Urinary output under 20 ml/h (OR 5.0 95% CI 1.8-13.7) and ACS (OR 4.6 95% CI 1.4-15.2) independently associated with OA treatment. Patients with OA treatment had significantly more often visceral ischemia (34%) than controls (6%), P = 0.002. Mortality among patients with visceral ischemia was 63%. Clinically meaningful parameters predicting developing ischemia were not found. OA treatment associated with higher overall 90-day mortality rate (43% vs 17%, P = 0.012) and increased need for necrosectomy (55% vs 21%, P = 0.001). Delayed primary fascial closure was achieved in 33 (97%) patients that survived past OA treatment.ConclusionDecreased urine output and ACS were independently associated with the choice of OA treatment in patients with SAP. Underlying visceral ischemia was strikingly common in patients undergoing OA treatment, but predicting ischemia in these patients seems difficult.

Mid-Term Results of Thoracic Endovascular Aortic Repair for Complicated Acute Type B Aortic Dissection at a Single Center.

BackgroundComplicated acute type B aortic dissection is a life-threatening condition with high morbidity and mortality. The aim of this study was to report a single-center experience with endovascular stent-graft repair of acute type B dissection of the thoracic aorta and to evaluate the mid-term outcomes.MethodsWe reviewed 18 patients treated for complicated acute type B aortic dissection by thoracic endovascular aortic repair (TEVAR) from September 2011 to July 2017. The indications for surgery included rupture, impending rupture, limb ischemia, visceral malperfusion, and paraplegia. The median follow-up was 34.50 months (range, 12–80 months).ResultsThe median interval from aortic dissection to TEVAR was 5.50 days (range, 0–32 days). There was no in-hospital mortality. All cases of malperfusion improved except for 1 patient. The morbidities included endoleak in 2 patients (11.1%), stroke in 3 patients (16.7%), pneumonia in 2 patients (11.1%), transient ischemia of the left arm in 1 patient (5.6%), and temporary visceral ischemia in 1 patient (5.6%). Postoperative computed tomography angiography at 1 year showed complete thrombosis of the false lumen in 15 patients (83.3%).ConclusionTEVAR of complicated type B aortic dissection with a stent-graft was effective, with a low morbidity and mortality rate.

Decreased transfusion requirements with use of acute normovolemic hemodilution in open aortic aneurysm repair

ObjectiveAcute normovolemic hemodilution (ANH) is an operative blood conservation technique involving the removal and storage of patient blood after the induction of anesthesia, with maintenance of normovolemia by crystalloid and/or colloid replacement. Developed and used predominately in cardiac surgery, ANH has been applied to the vascular surgery population. However, data regarding the effects on transfusion requirements in this population are limited. The objective of the present study was to compare the transfusion requirements and coagulopathy for patients who had undergone open abdominal aortic aneurysm repair (oAAAR) using ANH to those for patients who had received only product replacements, as clinically indicated. MethodsWe performed a retrospective review of patients who had undergone elective oAAAR at a quaternary aortic referral center from 2017 to 2019. Those eligible for ANH, with no active cardiac ischemia, no valvular disease, normal left ventricular and right ventricular function, chronic kidney disease stage <3, hematocrit >38%, and a normal coagulation profile were included in the present study. Patient demographics and characteristics and operative variables, including aneurysm extent, clamp site, visceral and renal ischemia time, operative time, and transfusion requirements, were collected. Postoperative morbidity, mortality, and length of stay were analyzed. The patients with and without ANH were matched and compared. Continuous measures were analyzed using Wilcoxon rank sum tests and t tests. ResultsDuring the study period, 209 oAAARs had been performed. Of the 209 patients, 76 had met the inclusion criteria. Of these 76 patients, 27 had undergone ANH and 49 had not. The patients with ANH had required fewer PRBC transfusions intraoperatively (median, 0 U; interquartile range [IQR], 0-1 U; median, 1 U; IQR, 0-2 U; P = .02), at 24 hours (median, 0 U; IQR, 0-1 U; vs median, 1 U; IQR, 0-2 U; P = .008), at 48 hours (median, 0 U; IQR, 0-1 U; vs median, 1 U; IQR, 0-2; P = .007), and throughout the admission (median, 0 U; IQR, 0-1 U; vs median, 2 U; IQR, 0-2 U; P = .011). No difference was found in the number of intraoperative platelet or cryoprecipitate transfusions. At 48 hours, the ANH group had had significantly greater platelet counts (142 ± 35.8 × 103/μL vs 124 ± 37.6 × 103/μL; P = .044), lower partial thromboplastin time, and lower international normalized ratio. No difference in myocardial infarction, return to the operating room, or mortality (one death overall). The ANH patients had a shorter length of stay (7.0 ± 2.7 vs 8.8 ± 4.8 days; P = .041). ConclusionsThe use of ANH during oAAAR resulted in fewer intraoperative and postoperative PRBC transfusions with improved coagulation parameters and a shorter hospital length of stay.

A Hybrid Solution to Manage a Thoraco-Abdominal Aortic Aneurysm: the “Simplified Technique” Associated with Endografting of the Proximal Aortic Anastomosis

Introduction: Thoraco-abdominal aortic aneurysms (TAAA) remain a therapeutic challenge for vascular surgeons. This is the report of a Crawford type III TAAA managed by the “simplified technique” to approach TAAA associated with endograft implantation in the proximal aortic anastomosis to minimise the risk of aortic stump blowout. Report: A 43 year old female patient was evacuated from Mozambique with a history of TAAA and admitted to the emergency department with recent chest and abdominal pain. She had history of HIV infection and pulmonary tuberculosis. Examination revealed a painful, pulsatile abdominal mass, and computed tomographic angiography (CTA) an 8 cm type III TAAA without signs of rupture. The aneurysm morphology was not suitable for endovascular treatment and because of the immediate non-availability of the usual adjuncts for the Crawford technique (ECC and selective visceral perfusion), this symptomatic patient was submitted to a thoraco-phreno-laparotomy with left medial visceral rotation. A bifurcated Dacron 18 × 9 mm graft was anastomosed distally in an end to side fashion to both external iliac arteries and proximally to a 22 mm polyester four branched graft (Jotec). This latter graft was anastomosed proximally to the descending thoracic aorta (end to side) with no visceral or renal ischaemia. The aorta distal to the anastomosis and the infrarenal segment were then cross clamped, the aneurysm opened, and no patent intercostal arteries were visible. Lower limb perfusion was maintained by the lateral shunt. Both kidneys were cooled with lactated Ringer’s solution through Pruitt catheters and the visceral arteries were temporarily occluded with Fogarty catheters. The four anastomoses were performed sequentially to the right renal artery, superior mesenteric artery, coeliac trunk and left renal artery. After completing all the reconstructions, a Zenith Alpha 32 × 155 mm endograft was implanted from the descending thoracic aorta to the pre-branch segment of the lateral shunt. The operation was uneventful, and the patient remained haemodynamically stable. The post-operative period was complicated by pulmonary infection and the post-operative CTA (Fig. 1) revealed the occlusion of the left renal artery graft (without clinical or laboratory repercussions). The patient was discharged 50 days after the operation. Discussion: The adjunct of an endograft to the “simplified technique” has been described previously and overcomes the risk of aortic stump blowout, one of the major limitations of the technique. This strategy was a successful alternative to manage a TAAA as organ protection adjuncts to the Crawford technique were not available. Keywords: Endograft, Open surgery, Simplified technique, Thoracoabdominal aortic aneurysms

Management strategy for lower extremity malperfusion due to acute aortic dissection

ObjectiveAortic dissection can result in devastating cerebral, visceral, renal, spinal, and extremity ischemia. We describe the management and outcomes of patients presenting with aortic dissection and lower extremity malperfusion (LEM). MethodsA single-center institutional aortic database was queried for patients with aortic dissection and LEM from 2011 to 2019. The primary end point was resolution of LEM after aortic repair. Secondary end points were amputation, in-hospital mortality, time to intervention, and postoperative complications. ResultsOf 769 patients with aortic dissection, 42 (5.5%) presented acutely with LEM: 16 with Stanford type A and 26 Stanford type B aortic dissection (age 55 ± 13 years; 90% men). Most presented as Rutherford IIB symptoms, but patients with type A had Rutherford III more often, compared with those with type B. Aortic repair was performed before limb interventions in 36 patients (86%; 19 TEVAR, 16 open arch and ascending repair, and 1 open descending aortic repair with fenestration). Seven (19%) had immediate failure with persistent malperfusion recognized in the operating room and underwent additional limb intervention, including extra-anatomic revascularization (n = 4), iliac stenting (n = 2), and femoral patch with septal fenestration or tacking (n = 2). Three patients (8%) had early delayed failure requiring extra-anatomic bypass in two and amputation in one. In contrast, six patients had limb-first intervention with extra-anatomic revascularization. None had immediate failure, but one-half had early delayed failure requiring proximal aortic intervention: two TEVAR and one open aortic fenestration. Limb-first patients were more likely to have early delayed failure compared with aortic dissection treated first patients (50% vs 8%; P = .029). The amputation rate was 2%, occurring in one type A patient. The overall in-hospital mortality was 7% (n = 3), with no difference between type A and type B aortic dissection. There was no difference in surgical site infection, postoperative dialysis need, stroke, and myocardial infarction. ConclusionsIn patients presenting with acute aortic dissection with limb ischemia, resolution of the malperfusion occurs in the majority of cases after primary aortic dissection intervention, emphasizing the usefulness of urgent TEVAR for complicated type B and open repair of type A before lower extremity intervention. Limb-first interventions have a higher early delayed failure rate and thus require more frequent reoperation. However, the overall amputation rate in LEM owing to aortic dissection remains low.

Sex Differences of Clinical Presentation and Outcomes in Propensity-Matched Patients with Acute Type A Aortic Dissection.

To assess sex differences of clinical presentation and outcomes in propensity-matched patients with acute type A aortic dissection (AAAD). We collected the clinical data of patients with AAAD from a single heart center between January 2009 and July 2014. After propensity score matching, we compared differences in clinical presentation and outcomes of patients with AAAD between men and women. There were 590 patients (295 men and 295 women) with AAAD through propensity matching on demographics and patients' history. We found that the presentation and diagnosis of AAAD often were more delayed in women. Severe signs of congestive heart failure (9.8% vs. 5.1%, P = 0.017), cardiac tamponade/shock (9.1% vs. 4.1%, P < 0.001), and periaortic hematoma (26.4% vs. 21.7%, P < 0.001) were more commonly presented in women. Surgery was more commonly performed in men than in women (95.4% (281/295) vs. 91.5% (270/295), P = 0.045), indicating the association of sex with surgical decision. To investigate the association of sex with outcomes after surgery, patients who underwent surgical treatment were re-matched (262 men and 262 women) by propensity score. Women suffered from greater in-hospital mortality than men (8.4% vs. 3.4%, P < 0.001). Postoperative complications of congestive heart failure (9.1% vs. 3.8%, P < 0.001), visceral ischemia (6.8% vs. 1.1%, P < 0.001), and limb ischemia (7.6% vs. 1.5%, P < 0.001) were more frequent in women. For women, prolonged operative time may increase in-hospital mortality, especially after 12 hours from the start of surgery (30.0% vs. 14.3%, P < 0.001). Kaplan-Meier survival analysis indicated worse late outcomes in women in the matched surgery group (log-rank P = 0.012). Our analysis provides new insights into sex differences in clinical presentation and outcomes of AAAD.

"Proximalization is Advancement"-Zone 3 Frozen Elephant Trunk vs Zone 2 Frozen Elephant Trunk: A Literature Review.

Over the decades, the Frozen Elephant Trunk (FET) technique has gained immense popularity allowing simplified treatment of complex aortic pathologies. FET is frequently used to treat aortic conditions involving the distal aortic arch and the proximal descending aorta in a single stage. Surgical preference has recently changed from FET procedures being performed at Zone 3 to Zone 2. There are several advantages of Zone 2 FET over Zone 3 FET including reduction in spinal cord injury, visceral ischemia, neurological and cardiovascular sequelae. In addition, Zone 2 FET is a technically less complicated procedure. Literature on the comparison between Zone 3 and Zone 2 FET is scarce and primarily observational and anecdotal. Therefore, further research is warranted in this paradigm to substantiate current surgical treatment options for complex aortic pathologies. In this review, we explore literature surrounding FET and the reasons for the shift in surgical preference from Zone 3 to Zone 2.

Impact of standardized computed tomographic angiography for minimally invasive mitral and tricuspid valve surgery

BackgroundFemoral cannulation for extracorporeal circulation (ECC) is a standard procedure for minimally invasive cardiac surgery (MICS) of the atrio-ventricular valves. Vascular pathologies may cause serious complications. Preoperative computed tomography-angiography (CT-A) of the aorta, axillary and iliac arteries was implemented at our department.MethodsBetween July 2017 and December 2018 all MICS were retrospectively reviewed (n = 143), and divided into 3 groups.ResultsIn patients without CT (n = 45, 31.5%) ECC was applied via femoral arteries (91.1% right, 8.9% left). Vascular related complications (dissection, stroke, coronary and visceral ischemia, related in-hospital death) occurred in 3 patients (6.7%). In patients with non-contrast CT (n = 35, 24.5%) only femoral cannulation was applied (94.3% right) with complications in 4 patients (11.4%). CT-angiography (n = 63, 44.1%) identified 12 patients (19.0%) with vulnerable plaques, 7 patients (11.1%) with kinking of iliac vessels, 41 patients (65.1%) with multiple calcified plaques and 5 patients (7.9%) with small femoral artery diameter (d ≤ 6 mm). In 7 patients (11.1%) pathologic findings led to alternative cannulation via right axillary artery, additional 4 patients (6.3%) were cannulated via left femoral artery. Only 2 patients (3.2%) suffered from complications.ConclusionsCT-A identifies vascular pathologies otherwise undetectable in routine preoperative preparation. A standardized imaging protocol may help to customize the operative strategy.