Endovascular treatment of thoracoabdominal aortic aneurysms

ObjectiveThis study assessed the role of multibranched stent grafts for thoracoabdominal aortic aneurysm (TAAA) repair.MethodsSelf-expanding covered stents were used to connect the caudally directed cuffs of an aortic stent graft with the visceral branches of a TAAA in 22 patients (16 men, 6 women) with a mean age of 76 ± 7 years. All patients were unfit for open repair, and nine had undergone prior aortic surgery. Customized aortic stent grafts were inserted through surgically exposed femoral (n = 16) or iliac (n = 6) arteries. Covered stents were inserted through surgically exposed brachial arteries. Spinal catheters were used for cerebrospinal fluid pressure drainage in 22 patients and for and spinal anesthesia in 11.ResultsAll 22 stent grafts and all 81 branches were deployed successfully. Aortic coverage as a percentage of subclavian-to-bifurcation distance was 69% ± 20%. Mean contrast volume was 203 mL, mean blood loss was 714 mL, and mean hospital stay was 10.9 days. Two patients (9.1%) died perioperatively: one from guidewire injury to a renal arterial branch and the other from a medication error. Serious or potentially serious complications occurred in 9 of 22 patients (41%). There was no paraplegia, renal failure, stroke, or myocardial infarction among the 20 surviving patients. Two patients (9.1%) underwent successful reintervention: one for localized intimal disruption and the other for aortic dissection, type I endoleak, and stenosis of the superior mesenteric artery. One patient has a type II endoleak. Follow-up is >1 month in 19 patients, >6 months in 12, and >12 months in 8. One branch (renal artery) occluded for a 98.75% branch patency rate at 1 month. The other 80 branches remain patent. There are no signs of stent graft migration, component separation, or fracture.ConclusionsMultibranched stent graft implantation eliminates aneurysm flow, preserves visceral perfusion, and avoids many of the physiologic stresses associated with other forms of repair. The results support an expanded role for this technique in the treatment of TAAA

Systemic inflammation, coagulopathy, and acute renal insufficiency following endovascular thoracoabdominal aortic aneurysm repair

ObjectiveTo characterize the inflammatory and coagulopathic response after endovascular thoracoabdominal aortic aneurysm (TAAA) repair and to evaluate the effect of the response on postoperative renal function.MethodsFrom July 2005 to June 2008, 42 patients underwent elective endovascular repair of a TAAA using custom designed multi-branched stent-grafts at a single academic institution. Four patients were excluded from the analysis. White blood cell count (WBC), platelet count, prothrombin time (PT), and creatinine were measured in all patients. In the last nine patients, interleukin-6 (IL-6), protein C, Factor V, d-dimers, cystatin C, and neutrophil gelatinase-associated lipocalin (NGAL) levels were also measured. Change in lab values were expressed as a percentage of baseline values.ResultsThe 30-day mortality rate was 5% (2/38). All patients (n = 38) had a higher WBC (mean ± SD: 139 ± 80%, P < .0001), lower platelet count (56 ± 15%, P < .0001), and higher PT (median: 17%, Interquartile range (IQR) 12%-22%, P < .0001) after stent-graft insertion. Twelve of 38 patients (32%) developed postoperative acute renal insufficiency (>50% rise in creatinine). Patients with renal insufficiency had significantly larger changes in WBC (178 ± 100% vs 121 ± 64%, P = .04) and platelet count (64 ± 17% vs 52 ± 12%, P = .02) compared with those without renal insufficiency. All patients (n = 9) had significant increases in NGAL (182 ± 115%, P = .008) after stent-graft insertion. Six of nine patients (67%) had increased cystatin C (35 ± 43%, P = .04) after stent-graft insertion, with a greater rise in those with postoperative renal insufficiency (87 ± 32% vs 8 ± 13%, P = .02). IL-6 levels were markedly increased in all patients (n = 9) after repair (9840 ± 6160%, P = .008). Protein C (35 ± 10%, P = .008) and Factor V levels (28 ± 20%, P = .008) were uniformly decreased, while d-dimers were elevated after repair in all patients (310 ± 213%, P = .008).ConclusionsLeukocytosis and thrombocytopenia were uniform following endovascular TAAA repair, and the severity of the response correlated with post-operative renal dysfunction. Elevation of a sensitive marker of renal injury (NGAL) suggests that renal injury may occur in all patients after stent-graft insertion

SS25. Cryopreserved Venous Allograft: An Alternative Conduit for Reconstruction of Infected Prosthetic Aortic Grafts

Olivé Milián, ArmandPla general picat del mosaic format per tres cercles: el central, amb un sol de color ocre sobre un cel blau. El sol, somrient, està encarat cap al sud. Aquest està envoltat d'un primer anell dentat i un segon on s'hi representen les fases d

Development of Risk Prediction Equations for Incident Chronic Kidney Disease

IMPORTANCE ‐ Early identification of individuals at elevated risk of developing chronic kidney disease  could improve clinical care through enhanced surveillance and better management of underlying health  conditions.  OBJECTIVE – To develop assessment tools to identify individuals at increased risk of chronic kidney  disease, defined by reduced estimated glomerular filtration rate (eGFR).  DESIGN, SETTING, AND PARTICIPANTS – Individual level data analysis of 34 multinational cohorts from  the CKD Prognosis Consortium including 5,222,711 individuals from 28 countries. Data were collected  from April, 1970 through January, 2017. A two‐stage analysis was performed, with each study first  analyzed individually and summarized overall using a weighted average. Since clinical variables were  often differentially available by diabetes status, models were developed separately within participants  with diabetes and without diabetes. Discrimination and calibration were also tested in 9 external  cohorts (N=2,253,540). EXPOSURE Demographic and clinical factors.  MAIN OUTCOMES AND MEASURES – Incident eGFR <60 ml/min/1.73 m2.  RESULTS – In 4,441,084 participants without diabetes (mean age, 54 years, 38% female), there were  660,856 incident cases of reduced eGFR during a mean follow‐up of 4.2 years. In 781,627 participants  with diabetes (mean age, 62 years, 13% female), there were 313,646 incident cases during a mean follow‐up of 3.9 years. Equations for the 5‐year risk of reduced eGFR included age, sex, ethnicity, eGFR, history of cardiovascular disease, ever smoker, hypertension, BMI, and albuminuria. For participants  with diabetes, the models also included diabetes medications, hemoglobin A1c, and the interaction  between the two. The risk equations had a median C statistic for the 5‐year predicted probability of  0.845 (25th – 75th percentile, 0.789‐0.890) in the cohorts without diabetes and 0.801 (25th – 75th percentile, 0.750‐0.819) in the cohorts with diabetes. Calibration analysis showed that 9 out of 13 (69%) study populations had a slope of observed to predicted risk between 0.80 and 1.25. Discrimination was  similar in 18 study populations in 9 external validation cohorts; calibration showed that 16 out of 18 (89%) had a slope of observed to predicted risk between 0.80 and 1.25. CONCLUSIONS AND RELEVANCE – Equations for predicting risk of incident chronic kidney disease developed in over 5 million people from 34 multinational cohorts demonstrated high discrimination and  variable calibration in diverse populations

Gender-specific risk factors for peripheral artery disease in a voluntary screening population.

Women have high rates of peripheral artery disease (PAD) despite fewer cardiovascular disease (CVD) risk factors, compared to men. We sought to determine the gender-specific prevalence of low ankle brachial index (ABI) and the relationship to C-reactive p