Endovascular stenting of the ascending aorta for type A aortic dissections in patients at high risk for open surgery

Background: Open repair is the gold standard for type A aortic dissection (TAAD). Endovascular option has been proposed in very limited and selected TAAD patients. We report our experience with endovascular TAAD repair. Methods: Inclusion criteria were: (1) entry tear in the ascending aorta; (2) proximal landing zone of at least 2 cm; (3) distance between entry tear and brachio-cephalic trunk of at least 0.5 cm; (4) no signs of cardiac tamponade or severe aortic regurgitation and (5) no signs of aortic branches ischaemia. Patients with cardiac revascularisation from ascending aorta were excluded. Results: From April 2009 to June 2012, 37 patients with TAAD were admitted to our hospital. As many as 28 underwent surgical repair and 9 were considered at high surgical risk in a multidisciplinary meeting. Four met our inclusion criteria for an endovascular approach. Two of them had previous ascending aortic repair for TAAD and one had aortic valve replacement. Technical success was achieved in 100% of the patients. No mortality was registered during a median follow-up of 15 months (range 4-39 months), no migration of the graft and complete false lumen thrombosis of the ascending aorta in three patients. Conclusion: Endovascular treatment of TAAD is challenging but feasible in a selected subset of patients. Further research remains mandatory. © 2013 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved

A ruptured aneurysm after stent graft puncture during computed tomography-guided thrombin injection

Type II endoleaks occur in 5% to 10% of patients who are treated by endovascular aneurysm repair. A persistent type II endoleak combined with documented aneurysm expansion is generally considered an indication for intervention. Thrombin injection directly into the aneurysm sac is described as a safe and efficient treatment option. We present a patient with a ruptured aneurysm caused by a puncture of the stent graft during computed tomography-guided thrombin injection. This case highlights a possible harmful complication of thrombin injection and emphasizes the need for caution while performing such a procedure

Season of Sampling and Season of Birth Influence Serotonin Metabolite Levels in Human Cerebrospinal Fluid

BACKGROUND: Animal studies have revealed seasonal patterns in cerebrospinal fluid (CSF) monoamine (MA) turnover. In humans, no study had systematically assessed seasonal patterns in CSF MA turnover in a large set of healthy adults. METHODOLOGY/PRINCIPAL FINDINGS: Standardized amounts of CSF were prospectively collected from 223 healthy individuals undergoing spinal anesthesia for minor surgical procedures. The metabolites of serotonin (5-hydroxyindoleacetic acid, 5-HIAA), dopamine (homovanillic acid, HVA) and norepinephrine (3-methoxy-4-hydroxyphenylglycol, MPHG) were measured using high performance liquid chromatography (HPLC). Concentration measurements by sampling and birth dates were modeled using a non-linear quantile cosine function and locally weighted scatterplot smoothing (LOESS, span = 0.75). The cosine model showed a unimodal season of sampling 5-HIAA zenith in April and a nadir in October (p-value of the amplitude of the cosine = 0.00050), with predicted maximum (PC(max)) and minimum (PC(min)) concentrations of 173 and 108 nmol/L, respectively, implying a 60% increase from trough to peak. Season of birth showed a unimodal 5-HIAA zenith in May and a nadir in November (p = 0.00339; PC(max) = 172 and PC(min) = 126). The non-parametric LOESS showed a similar pattern to the cosine in both season of sampling and season of birth models, validating the cosine model. A final model including both sampling and birth months demonstrated that both sampling and birth seasons were independent predictors of 5-HIAA concentrations. CONCLUSION: In subjects without mental illness, 5-HT turnover shows circannual variation by season of sampling as well as season of birth, with peaks in spring and troughs in fall

Effect of remote ischemic conditioning on atrial fibrillation and outcome after coronary artery bypass grafting (RICO-trial)

Background: Pre- and postconditioning describe mechanisms whereby short ischemic periods protect an organ against a longer period of ischemia. Interestingly, short ischemic periods of a limb, in itself harmless, may increase the ischemia tolerance of remote organs, e.g. the heart (remote conditioning, RC). Although several studies have shown reduced biomarker release by RC, a reduction of complications and improvement of patient outcome still has to be demonstrated. Atrial fibrillation (AF) is one of the most common complications after coronary artery bypass graft surgery (CABG), affecting 27-46% of patients. It is associated with increased mortality, adverse cardiovascular events, and prolonged in-hospital stay. We hypothesize that remote ischemic pre- and/or post-conditioning reduce the incidence of AF following CABG, and improve patient outcome.Methods/design: This study is a randomized, controlled, patient and investigator blinded multicenter trial. Elective CABG patients are randomized to one of the following four groups: 1) control, 2) remote ischemic preconditioning, 3) remote ischemic postconditioning, or 4) remote ischemic pre- and postconditioning. Remote conditio

Contemporary Management of Locally Advanced and Recurrent Rectal Cancer: Views from the PelvEx Collaborative

Pelvic exenteration is a complex operation performed for locally advanced and recurrent pelvic cancers. The goal of surgery is to achieve clear margins, therefore identifying adjacent or involved organs, bone, muscle, nerves and/or vascular structures that may need resection. While these extensive resections are potentially curative, they can be associated with substantial morbidity. Recently, there has been a move to centralize care to specialized units, as this facilitates better multi-disciplinary care input. Advancements in pelvic oncology and surgical innovation have redefined the boundaries of pelvic exenterative surgery. Combined with improved neoadjuvant therapies, advances in diagnostics, and better reconstructive techniques have provided quicker recovery and better quality of life outcomes, with improved survival This article provides highlights of the current management of advanced pelvic cancers in terms of surgical strategy and potential future developments

Global patient outcomes after elective surgery: prospective cohort study in 27 low-, middle- and high-income countries.

BACKGROUND: As global initiatives increase patient access to surgical treatments, there remains a need to understand the adverse effects of surgery and define appropriate levels of perioperative care. METHODS: We designed a prospective international 7-day cohort study of outcomes following elective adult inpatient surgery in 27 countries. The primary outcome was in-hospital complications. Secondary outcomes were death following a complication (failure to rescue) and death in hospital. Process measures were admission to critical care immediately after surgery or to treat a complication and duration of hospital stay. A single definition of critical care was used for all countries. RESULTS: A total of 474 hospitals in 19 high-, 7 middle- and 1 low-income country were included in the primary analysis. Data included 44 814 patients with a median hospital stay of 4 (range 2-7) days. A total of 7508 patients (16.8%) developed one or more postoperative complication and 207 died (0.5%). The overall mortality among patients who developed complications was 2.8%. Mortality following complications ranged from 2.4% for pulmonary embolism to 43.9% for cardiac arrest. A total of 4360 (9.7%) patients were admitted to a critical care unit as routine immediately after surgery, of whom 2198 (50.4%) developed a complication, with 105 (2.4%) deaths. A total of 1233 patients (16.4%) were admitted to a critical care unit to treat complications, with 119 (9.7%) deaths. Despite lower baseline risk, outcomes were similar in low- and middle-income compared with high-income countries. CONCLUSIONS: Poor patient outcomes are common after inpatient surgery. Global initiatives to increase access to surgical treatments should also address the need for safe perioperative care. STUDY REGISTRATION: ISRCTN5181700

Value of risk scores in the decision to palliate patients with ruptured abdominal aortic aneurysm

Background: The aim of this study was to develop a 48-h mortality risk score, which included morphology data, for patients with ruptured abdominal aortic aneurysm presenting to an emergency department, and to assess its predictive accuracy and clinical effectiveness in triaging patients to immediate aneurysm repair, transfer or palliative care. Methods: Data from patients in the IMPROVE (Immediate Management of the Patient With Ruptured Aneurysm: Open Versus Endovascular Repair) randomized trial were used to develop the risk score. Variables considered included age, sex, haemodynamic markers and aortic morphology. Backwards selection was used to identify relevant predictors. Predictive performance was assessed using calibration plots and the C-statistic. Validation of the newly developed and other previously published scores was conducted in four external populations. The net benefit of treating patients based on a risk threshold compared with treating none was quantified. Results: Data from 536 patients in the IMPROVE trial were included. The final variables retained were age, sex, haemoglobin level, serum creatinine level, systolic BP, aortic neck length and angle, and acute myocardial ischaemia. The discrimination of the score for 48-h mortality in the IMPROVE data was reasonable (C-statistic 0·710, 95 per cent c.i. 0·659 to 0·760), but varied in external populations (from 0·652 to 0·761). The new score outperformed other published risk scores in some, but not all, populations. An 8 (95 per cent c.i. 5 to 11) per cent improvement in the C-statistic was estimated compared with using age alone. Conclusion: The assessed risk scores did not have sufficient accuracy to enable potentially life-saving decisions to be made regarding intervention. Focus should therefore shift to offering repair to more patients and reducing non-intervention rates, while respecting the wishes of the patient and family

Predictors of Outcome in Acute Type B Aortic Dissection

Acute aortic dissection is a life-threatening cardiovascular event which occurs in 2.9-4 per 100.000 people a year. Aortic dissection originates from a laceration of the intimal layer of the aorta, defined as entry tear, allowing blood inflow along the medial layer, which will separate both layers of the aorta. The Stanford classification is most commonly used and divides dissections into type A and type B. Type B aortic dissection (TBAD) typically involve the descending aorta. The primary objective of this thesis is to provide predictors, both clinical as radiologic, for the outcome in TBAD, in order to have a patient specific approach to decide on whom to intervene and whom to treat conservatively. Medical treatment is still the therapy of choice in these patients, but several subset of patients have been identified in the first part of this book that warrant additional attention. TBAD patients presenting with aortic arch involvement and those with intramural hematoma type B have proven to have comparable outcomes to “classic” TBAD, and medical therapy should be considered the best therapy available. Predictors of aortic growth and complications during follow-up remain a debated topic in aortic dissections, because of the high late mortality rates associated with this disease. Due to periprocedural complications, routine stent graft placement has failed to show to be beneficial in the short term and a more patient specific approach is warranted. Partial thrombosis of the false lumen, reduced number of entry tears and the involvement of branch vessels have shown to be predictors of aortic dilatation and these patients might benefit from preemptive stent graft placement. In addition we looked at predictors for outcome in patients treated with thoracic endovascular aneurysm repair of the descending thoracic aorta (TEVAR). TEVAR is widely adopted as it has proven to be a superior treatment option in patients with TBAD compared to open surgical repair. Patients with a patent false lumen status and branch vessel involvement are less likely to develop false lumen thrombosis and physicians should consider a more extensive procedure with extensive aortic coverage and more stent placement of the affected organ vessels. Development of new low-profile and more reliable devices will lead to a further increased use of TEVAR in TBAD. Especially, since a recent study showed that TEVAR in addition to optimal medical treatment is associated with improved 5-year aorta-specific survival and delayed disease progression in uncomplicated TBAD. Although these findings might suggest that preemptive TEVAR should be considered in all stable type B dissection patients, our studies showed that medical therapy alone can be sufficient in many patient, which is important for both the morbidity and mortality as for the related costs. To further stratify patients that benefit from these procedures, dynamic imaging and specific biomarkers will play a key-roll. Future studies using dynamic CT and 4D PC-MRI, which can both visualize and quantify flow characteristics in relationship to aortic expansion, will allow us to better understand the dynamics of this disease and the influence of endovascular therapies on this proces

Influence of oversizing on outcome in thoracic endovascular aortic repair

Purpose: To investigate the influence of stent-graft oversizing on device-related complications after thoracic endovascular aortic repair (TEVAR) for thoracic aortic aneurysm (TAA). Methods: The study cohort was composed of patients enrolled in 4 clinical trials of the TAG thoracic stent-graft. A total of 337 TAA patients (222 men; mean age 72 years) treated in these trials had sufficient data for analysis of oversizing and post-procedure mortality and complications, such as endoleak, migration, rupture, and reinterventions. Mean oversizing at the proximal landing zone was 14.6% (range -3.4% to 39.7%). Patients were stratified based on the percentage of oversizing: 20% (n=64, group 3). Results: Patients in group 1 had significantly larger preoperative proximal aortic diameters (32.6 vs. 31.3 vs. 28.2 mm, respectively; p<0.001) and neck lengths (6.9 vs. 5.8 vs. 5.2 cm (p=0.035). Overall, type I endoleak was the most frequent complication during the first 30 days of follow-up (35, 10.4%), but the incidences did not differ among the 3 groups (10.6% vs. 11.2% vs. 7.8%, respectively; p=0.809). Over a mean follow-up of 41.8\ub120.7 months, there were no significant differences in the occurrence of device-related complications among the groups, though the incidence of type I endoleaks was lower in group 2 (9.4% vs. 3.2% vs. 7.8%, respectively; p=0.073). Cox proportional hazards modeling showed no difference in the time to type I endoleak among oversizing groups [group 1 vs. 2: HR 1.24, 95% CI 0.65 to 2.36 (p=0.509) and group 3 vs. 2: HR 1.24, 95% CI 0.60 to 2.60 (p=0.562)]. Conclusion: The percentage of oversizing did not significantly affect the incidence of devicerelated complications after TEVAR for TAA. Although oversizing may enhance the radial force and help maintain a good proximal seal, additional oversizing seemed not to improve the overall outcome in this analysis. The current guidelines regarding stent-graft oversizing for TAA seem appropriate, though the correct percentage remains to be determined