Endovascular repair of thoracic and thoraco-abdominal aortic lesions

BACKGROUND: We report our "real-world" experience of endovascular repair of thoracic/thoraco-abdominal aortic lesions in patients treated from May 2002 to May 2017. METHODS: Data of all consecutive treated patients were retrospectively collected in a database and analyzed. Patients were divided into 4 groups: atherosclerotic thoracic/thoraco-abdominal aneurysms (TAA/TAAA) and floating thrombus (group A); acute complicated type B dissection (TBD), penetrating aortic ulcers (PAU) and intra-mural hematomas (IMH) in group B; chronic TBD evolving in TAA (group C); traumatic injuries (group D). Mortality, reinterventions and occurrence of neurological complications, both at 30 days and in the long term, were analyzed as primary outcomes for each group. RESULTS: Ninety-four patients were treated complessively, most for a TAA (55.3%). Thirty-days deaths and neurological complications were observed in group A only (5 cases each, 5.3%). A reintervention was necessary in 6 patients (64%) of group A. At 5 years, in group A survival was 62.8%+/- 63% and freedom from neurological complication was 88.3%+/- 4.2%. Neither deaths nor neurological complications were recorded in the other groups. No late aortic ruptures were recorded. Freedom from reintervention in group A was 54.7%+/- 7.6% at 5 years and a reintervention was needed in all patients of group D. Overall, the main cause for reintervention was a type I endoleak. CONCLUSIONS: The endovascular repair of thoracic/thoraco-abdominal aortic lesions had acceptable mortality and neurological complication rates, both at 30 days and in the long term. Reinterventions in the long term occurred more frequently after TAA/TAAA and traumatic injuries, and were mainly required for a type I endoleak

Vitamin D deficiency isassociated with increased osteocalcin levels in acute aortic dissection : a pilot study on elderly patients

An imbalance between degradation and reconstruction of the aortic wall is one of the leading causes of acute aortic dissection (AAD). Vitamin D seems an intriguing molecule to explore in the field of AAD since it improves endothelial function and protects smooth muscle cells from inflammation-induced remodeling, calcification, and loss of function, all events which are strongly related to the aging process. We quantified 25-hydroxy vitamin D, calcium, parathormone, bone alkaline phosphatase, and osteocalcin levels in 24 elderly AAD patients to identify a potential pathological implication of these molecules in AAD. Median 25-hydroxy vitamin D (10.75\u2009ng/mL, 25th\u201375th percentiles: 6.86\u201319.23\u2009ng/mL) and calcium levels (8.70\u2009mg/dL, 25th\u201375th percentiles: 7.30\u20138.80\u2009mg/dL) suggested hypovitaminosis D and a moderate hypocalcemia. Thirty-eight percent of AAD patients had severe (<10\u2009ng/mL), 38% moderate (10\u201320\u2009ng/mL), and 24% mild 25-hydroxy vitamin D deficiency (20\u201330\u2009ng/mL). A significant inverse correlation was observed between 25OHD and osteocalcin levels. All the other molecules were unchanged. A condition of hypovitaminosis D associated to an increase in osteocalcin levels is present in AAD patients. The identification of these molecules as new factors involved in AAD may be helpful to identify individuals at high risk as well to study preventing strategies

Aorto-oesophageal and Aortobronchial Fistulae Following Thoracic Endovascular Aortic Repair: A National Survey

Objective: We evaluated the incidence of aorto-oesophageal (AEF) and aortobronchial (ABF) fistulae after thoracic endovascular aortic repair (TEVAR), and investigated their clinical features, determinants, therapeutic options and results. Methods: We conducted a voluntary national survey among Italian universities and hospital centres with a thoracic endovascular programme. Results: Thirty-nine centres were contacted, and 17 participated. Of the patients who underwent TEVAR between 1998 and 2008, 19/1113 (1.7%) developed AEF/ABF. Among indications to TEVAR, aortic pseudo-aneurysm was associated with the development of late AEF/ABF (P = 0.009). Further, emergent and complicated procedures resulted in increased risk of AEF/ABF (P = 0.008 and P < 0.001, respectively). Eight patients were treated conservatively, all of whom died within 30 days. Eleven patients underwent AEF/ABF surgical treatment, with a perioperative mortality of 64% (7/11). At a mean follow-up of 17.7 ± 12.5 months, overall survival was 16% (3/19). Conclusions: The incidence of AEF and ABF following TEVAR is not negligible, and is comparable to that following open repair. This finding warrants an ad hoc long-term follow-up after TEVAR, particularly in patients submitted to emergent and complicated procedures. Both surgical and endovascular treatment of AEF/ABF are associated with high mortality. However, conservative treatment does not appear to be a viable option. © 2009 European Society for Vascular Surgery

An unusual case of dysphagia after endovascular exclusion of thoracoabdominal aortic aneurysm

Purpose: To report an unusual case of dysphagia that developed immediately after stent-grafting of a thoracoabdominal aortic aneurysm. Case Report: A 79-year-old woman was submitted to a staged hybrid repair of a thoracoabdominal aortic aneurysm and developed new onset dysphagia and regurgitation early after stent-grafting of the thoracic aorta. Esophageal imaging showed a marked endoluminal stenosis, suggesting the development of secondary achalasia. The patient was submitted to endoscopic injections of botulinum toxin at the lower esophageal sphincter, which completely resolved the symptoms. Conclusion: Acute dysphagic syndrome after thoracic aorta endografting has been anecdotically reported, and its etiology remains undefined. In this report, we illustrate the clinical features of this rare condition, discuss etiological hypotheses, and suggest a noninvasive therapeutic approach. © 2009 by the International Society of Endovascular Specialists

The best treatment of juxtarenal aortic occlusion is and will be open surgery

Occlusion of the infrarenal aorta (IAO) represents from 3% to 8.5% of aortoiliac occlusive diseases, and is a variant of TransAtlantic Inter-Society Consensus (TASC) Type D lesions. Two different patterns of IAO can be identified: Distal and proximal, or iuxtarenal. The former typically spares the origin of the inferior mesenteric artery, and is associated with the classic Leriche clinical triad. The latter extends cephalad approaching the level of the renal arteries, and may also cause acute renal failure, intestinal infarction, and even paraplegia due to the proximal propagation of aortic thrombosis. Endovascular treatment for TASC Type C and D lesions as a whole provides impressive results in terms of periprocedural morbidity, secondary patency rates, and of course less invasivity in comparison to open surgery. However, when complete aortic occlusions, and particularly juxtarenal occlusion, are specifically addressed, the reported results are in fact sobering, both in terms of technical success rates, and perioperative complications. Surgery repair of juxtarenal aortic occlusion, namely aortic endarterectomy and bypass grafting, is a challenging procedure that requires almost invariably aortic cross-clamping above the level of the renal arteries, and may be associated with significant morbidity and mortality. Nevertheless, it currently provides unmatched perioperative and long-term results, and should be regarded as the treatment of choice

Remifentanil Conscious Sedation During Regional Anaesthesia for Carotid Endarterectomy: Rationale and Safety

AbstractObjectives to prospectively evaluate the safety and efficacy of remifentanil during regional anaesthesia for carotid endarterectomy. Methods twenty-eight consecutive patients underwent carotid endarterectomy with combined superficial and deep cervical plexus block supplemented with continuous intravenous 0.04 μg·kg−1·min−1remifentanil infusion. Depth of sedation was monitored using the Observer's Assessment of Alertness/Sedation Scale (OAA/S). The degree of pain, discomfort and anxiety was self-assessed by the patients using a horizontal visual analogue scale. Results all patients experienced adequate comfort and analgesia. No local anaesthetic supplementation was necessary. No patient had a OAA/S score lower than 4 (with 5=awake/alert to 1=asleep). Respiratory depression did not occur. Selective shunting was required in four cases. No patient was converted to general anaesthesia. There were no permanent neurological deficits, cardiopulmonary complications or deaths. Conclusion remifentanil as a supplement to regional aneasthesia for carotid endarterectomy, provides comfort and analgesia without hampering mental status evaluation

Geometric Pattern of Proximal Landing Zones for Thoracic Endovascular Aortic Repair in the Bovine Arch Variant

Objectives: The aim was to investigate whether the \u201cbovine\u201d aortic arch (i.e. arch variant with a common origin of the innominate and left carotid artery (CILCA)) is associated with a consistent geometric configuration of proximal landing zones for thoracic endovascular aortic repair (TEVAR). Methods: Anonymised thoracic computed tomography (CT) scans of healthy aortas were reviewed to retrieve 100 cases of CILCA. Suitable cases were stratified according to type 1 and 2 CILCA, and also based on type of arch (I, II, and III). Further processing allowed calculation of angulation and tortuosity of the proximal landing zones. Centre lumen line lengths of each proximal landing zone were measured in a view perpendicular to the centre line. All geometric features were compared with those measured in healthy patients with a standard arch configuration (n = 60). Two senior authors independently evaluated the CT scans, and intra- and interobserver repeatability were assessed. Results: The 100 selected patients (63% male) were 71.4 \ub1 7.7 years old. Type 1 CILCA (62/100) was more prevalent than type 2 CILCA (38/100), and the two groups were comparable in age (p = .11). Zone 3 presented a severe angulation (i.e. &gt; 60\ub0), which was greater than in Zone 2 (p &lt; .001), and a consistently greater tortuosity than Zone 2 (p = .003). This pattern did not differ between type 1 and type 2 CILCA. A greater tortuosity was also observed in Zone 0, which was related to increased elongation of the ascending aorta (i.e. Zone 0), than the standard configuration. The CILCA had an overall greater elongation, and Zone 2 also was specifically longer. When stratifying by type of arch, reversely from Type III to Type I, the CILCA presented a gradual flattening of its transverse tract, which entailed a consistent progressive elongation (p = .03) and kinking of the ascending aorta, with a significant increase of Zone 0 angulation to even a severe degree (p = .001). Also, from Type III to Type I, Zone 2 presented a progressively shorter length (p = .004), which was associated with increased tortuosity (p &lt; .05). Mean intra- and interobserver differences for angulation measurements were 1.4\ub0 \ub1 6.8\ub0 (p = .17) and 2.0\ub0 \ub1 10.1\ub0 (p = .19), respectively. Conclusions: CILCA presents a consistent and peculiar geometric pattern compared with standard arch configuration, which provides relevant information for TEVAR planning, and may have prognostic implications