Thoracoabdominal aortic aneurysm repair after frozen elephant trunk procedure†

OBJECTIVES To evaluate the feasibility and the outcomes of second-stage thoracoabdominal (TA) repair after previous frozen elephant trunk (FET) implantation. METHODS Between 2005 and 2013, 41 patients underwent open TA aortic repair in our institution. Of these, 9 patients (78% male) underwent second-stage TA repair after previous FET implantation. Feasibility and outcomes were evaluated. RESULTS The mean interval between FET implantation and second-stage TA repair was 423 days (19-1979 days). Indications for second-stage TA repair were progression in aortic diameter of atherosclerotic aneurysms in the downstream segments in 6 patients, diameter progression in post-dissection aneurysms in 2 patients and giant cell aortitis with aneurysm formation in another patient. There were no in-hospital deaths. The median intensive care unit stay was 3.5 days (range: 1-12 days) and median hospital stay was 22 days (range: 14-132 days). We did not observe symptomatic spinal cord ischaemia or stroke. One patient (11%) developed acute renal failure requiring haemodialysis. CONCLUSION Second-stage TA aortic repair after previous frozen elephant implantation is a feasible and effective treatment modality for patients with various pathologies of downstream aortic segments. This approach adds additional value to the conventional elephant trunk technique by providing an excellent landing zone not only for additional stent graft procedures but also for subsequent open TA repai

A very rare case of late diagnosis of cor triatriatum sinistrum

L

Repair of stent graft-induced retrograde type A aortic dissection using the E-vita open prosthesis†

OBJECTIVES Stent graft-induced retrograde type A dissection is a life-threatening complication after endovascular treatment of acute aortic type B dissections. METHODS From August 2005 to February 2011, retrograde aortic dissection occurred in 4 of 29 patients (13.8%) undergoing thoracic endovascular aortic repair (TEVAR) for acute complicated aortic type B dissection. Three patients underwent emergent surgical conversion immediately after TEVAR. The operative strategy was a combined surgical and endovascular approach (frozen elephant trunk technique) using a specially designed hybrid prosthesis (Jotec E-vita open). All operations were performed under moderate hypothermia (25-28°C) and selective bilateral antegrade cerebral perfusion. The mean duration of circulatory arrest was 56±7min. Operative data and the outcome of surgery were analysed retrospectively. Data were analysed retrospectively in the limited number of patients. RESULTS All patients survived the surgical procedure. No stroke, paraplegia, renal failure or other major complications occurred. Postoperative CT scans revealed perigraft thrombus formation and stable aortic dimensions in all patients after 6 months. In one patient, the retrograde dissection remained primarily undetected and untreated. The patient died suddenly, with no clinical signs, within 7 days after stent graft implantation. Autopsy revealed cardiac tamponade due to retrograde type A aortic dissection. CONCLUSIONS Retrograde aortic dissection type A is a serious complication of thoracic endovascular repair of acute aortic type B dissection. Despite the small number of patients investigated in this study, the frozen elephant trunk technique appears to be a feasible bail-out strategy for the treatment of these acute aortic event

Acute type A aortic dissection and pregnancy: a population-based study

Objective: Pregnancy has been reported to be an independent risk factor for 50% of acute aortic dissections recorded in women younger than 45 years of age. The present epidemiologic study aimed to identify whether this putative association of pregnancy and acute type A dissection could be an artifact of selective reporting. Methods: This population-based study was conducted in the City of Vienna, Austria, Europe, in an average female population of 341381 women in the age range of 15-45 years who were followed up between 1994 and 2004 (total of 3755.195 person-years of observation). During this study, the incidence, management, and outcome of acute type A dissection were determined. Results: Fifteen patients (mean age: 38.8 years, SD: 4.8) with acute aortic dissection were identified, and an overall incidence of 0.4 case per 100000 person-years was estimated. The prehospital mortality rate was recorded to be 53%. Six patients, including two women in late pregnancy (incidence: 0.05 cases per 100000 person-years), were treated successfully by surgical repair during deep hypothermic circulatory arrest (in-hospital mortality rate: 6.6%). Pregnancy and aortic dissection were identified as events that were not related (RR: 3.27; 95% confidence interval (CI): 0.82-12.95; P=0.14). Observation during long-term follow-up was uneventful. Conclusions: Acute aortic dissection represents a rare pathology in women younger than 45 years of age; however, it is associated with a high rate of sudden death. Pregnancy may not be a risk factor for this life-threatening vascular emergency. Immediate referral to surgery, even during pregnancy, will result in a prognosis of favorable outcom

The influence of gender on mortality in patients after thoracic endovascular aortic repair

Objectives: The aim of this study was to determine if gender affects mortality in patients after thoracic endovascular aortic repair (TEVAR). Methods: We retrospectively analyzed 286 consecutive patients undergoing TEVAR at our institution during a 12-year period (female 29%, median age 69 years). Chronic health conditions, risk factors, as well as early and long-term outcome were assessed. Follow-up data were available in all patients. Results: For female gender, 1-year survival and 5-year survival was 84% and 56% versus 83% and 60% for male gender. No significant gender influence was observed (odds ratio (OR) 0.96, 95% confidence interval (CI) 0.59-1.56). Furthermore, no significant gender influence could be observed according to the individual indication - atherosclerotic aneurysms (OR 0.78 95%CI 0.41-1.47), acute type B dissections (OR 0.78 95%CI 0.21-2.83), penetrating atherosclerotic ulcers/intramural hematoma (OR 1.48 95%CI 0.53-4.19), and traumatic aortic lesions (OR 1.48 95%CI 0.53-4.19). Age (OR 3.6 95%CI 1.24-10.45) and chronic obstructive pulmonary disease (COPD; OR 3.09 95%CI 0.98-9.73) were independent predictors of mortality in females. Conclusions: Gender does not affect mortality in patients after TEVAR irrespective of the underlying indication, atherosclerotic aneurysms, acute type B dissections, penetrating ulcers/intramural hematoma, and traumatic aortic lesions. Classical risk factors such as age and the presence of COPD at the time of TEVAR remain the most important risk factors in female

The location of the primary entry tear in acute type B aortic dissection affects early outcome†

OBJECTIVES The goal of the retrospective study was to relate the site of the primary entry tear in acute type B aortic dissections to the presence or development of complications. METHODS A consecutive series of 52 patients referred with acute type B aortic dissection was analysed with regard to the location of the primary entry tear (convexity or concavity of the distal aortic arch) using the referral CT scans at the time of diagnosis. These findings were related to the clinical outcome as well as to the need for intervention. RESULTS Twenty-five patients (48%) had the primary entry tear located at the convexity of the distal aortic arch, whereas 27 patients (52%) had the primary entry tear located at the concavity of the distal aortic arch. Twenty per cent of patients with the primary entry tear at the convexity presented with or developed complications, whereas 89% had or developed complications with the primary entry tear at the concavity (P<0.001). Furthermore, in patients with complicated type B aortic dissection, the distance of the primary entry tear to the left subclavian artery was significantly shorter as in uncomplicated patients (8 vs. 21mm; P=0.002). In Cox regression analysis, a primary entry tear at the concavity of the distal aortic arch was identified as an independent predictor of the presence or the development of complicated type B aortic dissection. CONCLUSIONS A primary entry tear at the concavity of the aortic arch as well as a short distance between the primary entry tear and the left subclavian artery are frequently associated with the presence or the development of complicated acute type B aortic dissection. These findings shall help us to further differentiate acute type B aortic dissections in addition to the common categorization in complicated and uncomplicated. These findings may therefore also have an impact on primary treatmen

Symptomatic spinal cord malperfusion after stent-graft coverage of the entire descending aorta

Objective: The study aims to identify risk constellations for symptomatic spinal cord malperfusion in patients undergoing extensive stent-graft coverage of the thoracic aorta. Methods: From 1997 through 2009, 26 patients (mean age 70 years) underwent extensive stent-graft coverage of the thoracic aorta. Indications for stent-graft placement were atherosclerotic aneurysms (n=18) and penetrating atherosclerotic ulcers (PAUs) (n=8). In 16 patients, a re-routing procedure was required to gain sufficient proximal landing zone length. Cerebrospinal fluid (CSF) drainage was not routinely applied owing to the necessity of maintaining continuing anti-platelet therapy due to severe cardiovascular co-morbidities. Results: Technical success was 100%. Five patients developed symptomatic spinal cord malperfusion. All symptomatic patients had impaired spinal cord blood supply by acute or chronic occlusion of at least two major blood-supplying vascular territories of the spinal cord. Secondary CSF drainage improved neurologic symptoms in all patients without causing any anti-platelet therapy-related collateral injury. Conclusions: Extensive stent-graft coverage of the entire thoracic aorta can be performed with a high rate of success. If collateral blood supply to the spinal cord is maintained, occlusion of the intercostal arteries does not cause symptomatic malperfusion. However, if acute or chronic occlusion of the subclavian, lumbar or hypogastric arteries is present, likelihood of symptomatic malperfusion dramatically increase