Total vs hemi-aortic arch transposition for hybrid aortic arch repair

ObjectiveTo compare the outcomes of total aortic arch transposition (TAAT) vs hemi-aortic arch transposition (HAAT) for hybrid aortic arch repair.MethodsA systematic search was performed using PubMed between November 1998 and May 2010 by two independent observers. Studies included reporting on patients treated by TAAT or HAAT and stent grafting in a proximal landing zone 0 or 1 by Ishimaru, respectively. Further articles were identified by following MEDLINE links, by cross-referencing from the reference lists, and by following citations for these studies. Case reports and case series of less than five patients were excluded. Primary technical and initial clinical success, perioperative, and late morbidity and mortality were extracted per study and were meta-analyzed.ResultsFourteen studies were included in the statistical analysis. The number of reported patients totaled 130 for TAAT/zone 0 and 131 for HAAT/zone 1. The primary technical success rate was significantly higher in zone 0 than 1 (95% vs 83%; odds ratio [OR], 4.0; 95% confidence interval [CI], 1.47-10.88; P = .0069), due to significantly higher primary type I or III endoleak rates in zone 1 (15.48% vs 3.97%; P = .0050). Reintervention rates were significantly higher in zone 1 (25.81% vs 12.00%; P = .0321). Initial clinical success rates were comparable between zone 0 and 1 (88% vs 85%; OR, 1.35; 95% CI, 0.61-3.02; P = .5354). In-hospital mortality was higher in zone 0 than 1 (8.46% vs 4.58%; P = .2212).ConclusionThe more invasive TAAT allows a better landing zone at the cost of higher perioperative mortality, therefore, patient selection is crucial

Treatment of blunt thoracic aortic injury in Germany—Assessment of the TraumaRegister DGU®

Purpose Using the data delivered by the German Trauma Register DGU® from 2002 till 2013, the value of different therapies of blunt thoracic aortic injury (BTAI) in Germany was analyzed. Methods Prospectively collected data of patients suffering from BTAI were retrospectively analyzed with focus on the different treatment modalities for grade I–IV injuries. Results 821 patients suffering from BTAI were identified: 51.6% (424) grade I injury, 35.4% (291) grade II or III injury and 12.9% (106) grade IV injury (77.5% men [44.94 ± 20.6 years]). The main patterns of injury were high- speed accidents and falls (78.0% [n = 640], 21.8% [n = 171] respectively). Significant differences between grade I and grade II/III as well as IV injuries could be assessed for the incidence of cardiopulmonary resuscitation, a Glasgow Coma Scale score below 8 and a systolic blood pressure below 90 mmHg (p-value: <0.001). In the primary admission subgroup, 44.1% (197/447) of the patients received best medical treatment, 55.9% received surgical intervention (250/447): Thereof 37.2% (93/250) received open surgery and 62.8% (147/250) had been treated by endovascular means. Significantly lower 24-h- and in-hospital-mortality rates were encountered after endovascular treatment for all gradings of BTAI (p-value: <0.001). Yet this subgroup of patients showed the lowest incidence of further severe injuries and cardiac arrest. Conclusion Endovascular therapy became the treatment of choice for BTAI in Germany. Patients who have been treated by surgical means showed the highest survival rate, especially endovascular therapy showed a favorable low mortality rate

Fenestrated Physician-Modified Endografts for Preservation of Main and Accessory Renal Arteries in Juxtarenal Aortic Aneurysms.

BACKGROUND There is a paucity of reporting outcomes of complex aortic aneurysm treatment such as juxtarenal abdominal aortic aneurysms, where additional techniques to preserve renal artery perfusion are required. METHODS Retrospective analysis of consecutive patients who underwent emergent and elective aortic repair with fenestrated PMEGs between March 2019 and January 2023. Endpoints were technical success, reinterventions, secondary reinterventions and target vessel patency. RESULTS Forty-seven target vessels in 37 patients (23 male, median age 75 years) were targeted, of which 44 were renal arteries (RAs) with a mean diameter of 5.4 ± 1.0 mm. Thirteen were accessory RAs and six had a diameter ≤ 4 mm. Technical success rate was 87% overall; 97% for main and 62% for accessory RAs respectively. Target vessel patency and freedom from secondary reintervention was 100% and 97% at 30 days and 96% and 91% at one year, respectively. There was no 30-day mortality. CONCLUSION Fenestrated physician-modified endografts are safe and effective for the treatment of patients with juxtarenal abdominal aortic aneurysms when incorporating main renal arteries. Limited technical success may be expected when targeting accessory renal arteries, especially when small in diameter. Long-term follow-up is needed to confirm durability of PMEGs for renal artery preservation

Prognostic Factors for Mortality in Acute Mesenteric Ischemia.

Postoperative mortality in patients undergoing surgical and/or interventional treatment for acute mesenteric ischemia (AMI) has remained an unsolved problem in recent decades. Here, we investigated clinical predictors of postoperative mortality in a large European cohort of patients undergoing treatment for AMI. In total, 179 patients who underwent surgical and/or interventional treatment for AMI between 2009 and 2021 at our institution were included in this analysis. Associations between postoperative mortality and various clinical variables were assessed using univariate and multivariable binary logistic regression analysis. Most of the patients were diagnosed with arterial ischemia (AI; n = 104), while venous ischemia (VI; n = 21) and non-occlusive mesenteric ischemia (NOMI; n = 54) were present in a subset of patients. Overall inhouse mortality was 55.9% (100/179). Multivariable analyses identified leukocytes (HR = 1.08; p = 0.008), lactate (HR = 1.25; p = 0.01), bilirubin (HR = 2.05; p = 0.045), creatinine (HR = 1.48; p = 0.039), etiology (AI, VI or NOMI; p = 0.038) and portomesenteric vein gas (PMVG; HR = 23.02; p = 0.012) as independent predictors of postoperative mortality. In a subanalysis excluding patients with fatal prognosis at the first surgical exploration (n = 24), leukocytes (HR = 1.09; p = 0.004), lactate (HR = 1.27; p = 0.003), etiology (AI, VI or NOMI; p = 0.006), PMVG (HR = 17.02; p = 0.018) and intraoperative FFP transfusion (HR = 4.4; p = 0.025) were determined as independent predictors of postoperative mortality. Further, the risk of fatal outcome changed disproportionally with increased preoperative lactate values. The clinical outcome of patients with AMI was determined using a combination of pre- and intraoperative clinical and radiological characteristics. Serum lactate appears to be of major clinical importance as the risk of fatal outcome increases significantly with higher lactate values

The Safety and Outcome of Minimally Invasive Staged Segmental Artery Coil Embolization (MIS2ACE) Prior Thoracoabdominal Aortic Aneurysm Repair: A Single-Center Study, Systematic Review, and Meta-Analysis.

BACKGROUND Minimally Invasive Staged Segmental Artery Coil Embolization (MIS2ACE) is a novel technique of spinal cord preconditioning used to reduce the risk of paraplegia in thoracoabdominal aortic aneurysm (TAAA) repair. In this study, we report our experience with MIS2ACE, including both degenerative and post-dissection TAAA, while we attempt to systematically summarize relevant data available in the literature. DESIGN single-center observational study with systematic review of the literature and meta-analysis. METHODS Initial retrospective analysis of 7 patients undergoing MIS2ACE over 12 sessions with a subsequent systematic review of the literature and meta-analysis of the available published data (PROSPERO protocol number: CRD42023477411). Baseline patient and aneurysm characteristics, along with procedural technique and outcomes, were analyzed. One-arm pooling of proportions was used to summarize available published data. RESULTS We treated seven patients (5 males, 71%) with a median age of 69 years (IQR 55,69). According to the Crawford classification, five patients (1%) had extent II TAAA, and two (29%) had extent III TAAA. Five patients (71%) had post-dissection -TAAA; four of them were after Stanford type A dissection, and one had a chronic type B dissection. Three patients (43%) had connective tissue disease. Of the seven patients, six (86%) underwent previous aortic surgery, while the median aneurysm diameter was 58 mm (IQR 55,58). MIS2ACE was successful in 11 sessions (92%). The median number of embolized arteries was 4 (IQR 1,4). There were no periprocedural complications in any embolization. The median embolization-operation time interval was 37.0 days (IQR 31,78). Two patients had open and five endovascular treatment. There were no events of spinal cord ischemia either after MIS2ACE or after the aortic repair. Out of the 432 initially retrieved articles, we included two studies in the meta-analysis, including patients with MIS2ACE for spinal cord preconditioning in addition to our cohort. The prevalence of pooled postoperative spinal cord ischemia among MIS2ACE patients is 1.9% (95% CI -0.028 to 0.066, p = 0.279; 3 studies; 81 patients, 127 coiling sessions). CONCLUSIONS While the current published data is limited, our study further confirms that MIS2ACE is a technically feasible and safe option for spinal cord preconditioning

Reinterventions during midterm follow-up after endovascular treatment of thoracic aortic disease

ObjectivesTo report incidence, indication, and timing of reinterventions after thoracic endovascular aortic repair (TEVAR) and identify subgroups most prone to reinterventions.MethodsBetween January 1997 and March 2010, a total of 264 patients received TEVAR in our institution. During follow-up, 58 patients (39 men, median age 63 years, range 28-87 years) required a total of 68 reinterventions, which represent the study population of this retrospective, single center analysis. The mean follow-up of all 264 patients was 31.2 months (range 0-141 months).ResultsThe overall reintervention rate was 22%: 1-, 3-, and 5-year free reintervention rates were 82% ± 3%, 74% ± 3%, and 70% ± 4%, respectively. Indications for reintervention were predominately endoleaks (41%) and progression of the underlying aortic disease (29%). Reinterventions were performed by endovascular means in 44%, by open repair in 35% (including 11 conversions), and by hybrid procedures in 21%. Multiple logistic regression analysis revealed patients with chronic expanding aortic dissections (odds ratio [OR]: 2.35), hybrid aortic procedures (OR: 2.11), and connective tissue diseases (OR: 7.54) at an increased risk for reintervention. The necessity for reintervention did not influence survival in this cohort (log-rank test P = .1706).ConclusionsTEVAR is associated with a relevant reintervention rate, predominately caused by endoleaks and progression of the aortic pathology. Patients with chronic expanding aortic dissections, hybrid aortic procedures, and connective tissue diseases are at an increased risk for reintervention and should therefore undergo close follow-up