Open thoracic or thoracoabdominal aortic aneurysm repair after previous abdominal aortic aneurysm surgery

ObjectiveThe purpose of this study was to provide insight into the incidence of thoracic and thoracoabdominal aortic aneurysm repair following previous infrarenal abdominal aortic aneurysm (AAA) surgery and to determine whether thoracic or thoracoabdominal aortic aneurysm repair after prior infrarenal AAA surgery is associated with higher mortality and morbidity rates.MethodsMEDLINE, Cochrane Library CENTRAL, and EMBASE databases were searched for relevant articles. Selected articles were critically appraised and meta-analyses were performed.ResultsA total of 12.4% of patients with thoracic aortic aneurysms and 18.7% of patients with thoracoabdominal aortic aneurysms have had prior AAA surgery. The chance of developing a thoracic aortic aneurysm in patients with AAA is 2.2% and 2.5% for developing a thoracoabdominal aortic aneurysm. The mean time interval between prior AAA surgery and subsequent thoracoabdominal aortic aneurysm surgery or detection is 8.0 years with a wide variation between individuals. Surgery in these patients is technically feasible. The 30-day mortality of patients undergoing open thoracoabdominal aortic aneurysm repair does not significantly differ from patients without prior AAA surgery and the 30-day mortality is 11.8%. No data were available about mortality of patients with prior AAA repair undergoing thoracic aortic aneurysm surgery. Morbidity risks are higher in patients with thoracic or thoracoabdominal aortic aneurysms. Prior AAA repair was a significant risk factor for neurological deficit after thoracic or thoracoabdominal aortic aneurysms surgery with relative risks (RRs) of 11.1 (95% confidence interval [CI] 3.8-32.3, P value < .0001) and 2.90 (95% CI 1.26-6.65, P value = .008), respectively. Prior AAA repair was a significant risk factor for developing renal failure in patients undergoing thoracoabdominal aortic aneurysm repair (RR 3.47, 95% CI 1.74-6.91, P value = .0001). Determinants of the prognosis in these patients include distal aortic perfusion, distal extent of the landing zone of the graft, drainage of cerebrospinal fluid for thoracic aortic aneurysm repair and age, history of cardiac diseases, extent of the aneurysm, rupture, amount of estimated blood loss, aortic clamp time, and visceral ischemic times for thoracoabdominal aortic aneurysm repair.ConclusionsA considerable group of patients with thoracic or thoracoabdominal aortic aneurysms have had prior AAA repair. The risk of postoperative morbidity is increased in these patients. Mortality appears to be similar for patients with thoracoabdominal aortic aneurysms. Patients with prior AAA repair undergoing thoracic or thoracoabdominal aortic aneurysm repair should be provided maximum care to protect their spinal cord and renal function

Simultaneous proximal embolic protection and inferior vena cava mechanical thrombectomy using the FlowTriever system

Interventional radiologists have the unique ability to apply their imaging knowledge, wide scope of technical skills, and use of innovative technologies to comprehensively address the percutaneous management of the thromboembolic disease processes. This report illustrates successful management of a thrombosed IVC, while protecting against possible pulmonary embolism. Here, we present a 49-year-old female with stage IIIB ovarian cancer who presented with severe bilateral lower extremity edema and anasarca in setting of occlusive thrombus of IVC. The thrombus was the result of compressionfrom a large hepatic hematoma which gradually developed after radical hysterectomy. A new mechanical thrombectomy device approved for use in pulmonary embolism, Inari FlowTriever catheter, was used off-label to remove the clot. The self-expanding mesh discs in the Inari FlowTriever catheter were utilized to protect against pulmonary embolism while percutaneously draining the hepatic hematoma and alleviating the IVC compression. The IVC was largely patent at the end of the procedure, and the patient experienced complete resolution of her symptoms. This case report demonstrates the successful and safe off-label use of a new mechanical thrombectomy device approved for pulmonary embolism thrombectomy in the IVC and illustrates a novel application of the nitinol mesh discs in the device as proximal embolic protection

Use of a funneled sheath for embolic protection during removal of thrombosed Simon Nitinol filters

Inferior vena cava (IVC) filters should be removed when no longer needed, given their association with complications such as thrombosis of the IVC and lower extremities, fracture, migration, and growth into adjacent structures. While this is generally straightforward in the setting of retrievable filters, permanent filters present more of a challenge. In fact, many operators will not attempt to do so for fear of intraprocedural complications, among them, filter fracture and fragment embolization. Despite this, leaving the filters in situ places patients at risk of the complications described above. Here, the authors illustrate a novel technique for retrieving permanent filters using a funneled sheath to protect against embolization

Reverse sheathing technique for iliocaval thrombectomy in the setting of IVC filters

Abstract The Inari ClotTriever system (Inari Medical, Irvine, California) is safe and effective for the treatment of DVT. However, because it consists of a 31 cm coring device and collection bag that must be extended for use, application may be precluded by available intravascular “running room”, such as in the presence of an IVC filter. Here we present a technique for bypassing IVC filters via retrograde deployment of the ClotTriever within a sheath, as illustrated in three cases. This technique extends the applicability of the ClotTriever to locations in which its length would otherwise preclude use

T1-refBlochi: high resolution 3D post-contrast T1 myocardial mapping based on a single 3D late gadolinium enhancement volume, Bloch equations, and a reference T1

Abstract Background High resolution 3D T1 mapping is important for assessment of diffuse myocardial fibrosis in left atrium or other thin-walled structures. In this work, we investigated a fast single-TI 3D high resolution T1 mapping method that directly transforms a 3D late gadolinium enhancement (LGE) volume to a 3D T1 map. Methods The proposed method, T1-refBlochi, is based on Bloch equation modeling of the LGE signal, a single-point calibration, and assumptions that proton density and T2* are relatively uniform in the heart. Several sources of error of this method were analyzed mathematically and with simulations. Imaging was performed in phantoms, eight swine and five patients, comparing T1-refBlochi to a standard spin-echo T1 mapping, 3D multi-TI T1 mapping, and 2D ShMOLLI, respectively. Results The method has a good accuracy and adequate precision, even considering various sources of error. In phantoms, over a range of protocols, heart-rates and T1 s, the bias ±1SD was -3 ms ± 9 ms. The porcine studies showed excellent agreement between T1-refBlochi and the multi-TI method (bias ±1SD = −6 ± 22 ms). The proton density and T2* weightings yielded ratios for scar/blood of 0.94 ± 0.01 and for myocardium/blood of 1.03 ± 0.02 in the eight swine, confirming that sufficient uniformity of proton density and T2* weightings exists among heterogeneous tissues of the heart. In the patients, the mean T1 bias ±1SD in myocardium and blood between T1-refBlochi and ShMOLLI was -9 ms ± 21 ms. Conclusion T1-refBlochi provides a fast single-TI high resolution 3D T1 map of the heart with good accuracy and adequate precision