Orthotopic cardiac transplantation after minimally invasive direct coronary artery bypass

AbstractJ Thorac Cardiovasc Surg 1999;117:390-

Blunt traumatic aortic injury: Initial experience with endovascular repair

ObjectivesEndovascular treatment of traumatic aortic injury (TAI) is an alternative to open repair (OR) in patients with blunt trauma. We report our initial experience after integration of endovascular repair using thoracic devices.MethodsA retrospective review of a prospectively collected institutional trauma registry was performed. Between September 2005 and November 2008, 71 patients with TAI presented to our institution. Based on imaging, TAIs were classified into grade 1-4 in severity. These included: grade 1, intimal tear; grade 2, intramural hematoma; grade 3, aortic pseudoaneurysm; and grade 4, free rupture. Initial management included resuscitation, blood pressure control, and treatment of associated injuries. After stabilization, all patients were considered for thoracic endovascular aortic repair (TEVAR) using a thoracic device. If contraindicated, candidates underwent OR. Outcome measures were mortality, stroke, paraplegia, intensive care unit (ICU), and hospital stay.ResultsThe mean age was 39.8 years, with 50 males. The mean injury severity score (ISS) was 42.6. Nineteen (27%) patients with a mean ISS of 60 died shortly after arrival prior to any vascular intervention. Ten (14%) patients with grade 1 injuries were managed medically. The remaining 42 (59%) patients with grade 2 and 3 injuries underwent repair. Median interval between admission and repair was 4.3 days (range, 0-109 days). Fifteen (21%) patients with a mean ISS of 34.4 underwent OR with no mortality, stroke, or paraplegia. Twenty-seven (38%) patients with a mean ISS of 36.7 underwent TEVAR with no mortality or paraplegia. One TEVAR patient suffered a perioperative stroke. Twenty-two patients had a TAG (W.L. Gore & Associates, Flagstaff, Ariz) device. Four patients had a Talent Thoracic (Medtronic Vascular, Santa Rosa, Calif), and 1 patient had an Excluder (W.L. Gore) device. The left subclavian artery was covered in 13 (48%) patients. Patients who underwent TEVAR were older than those who had OR (47.8 vs 31.1 years, P < .006). The aortic diameter proximal to the injury was larger in the TEVAR group (24.4 vs 19.6 mm, P < .0001). There was no difference in the mean ICU or hospital length of stay between the two groups. Mortality correlated with the ISS score (P < .0001). Median follow-up time was 19.4 months (range, 0-27). Only 56% of the TEVAR patients were fully compliant with their surveillance imaging protocol.ConclusionIn this initial experience, the results of TEVAR did not differ from OR. Long-term follow-up is required to determine the effectiveness of this treatment strategy. Adherence to follow-up imaging protocols is challenging in this patient population. Next generation devices will make TEVAR applicable to a wider range of patients

Update on blunt thoracic aortic injury: Fifteen-year single-institution experience

ObjectivesDespite improvements in the management of blunt thoracic aortic injury, mortality remains high. We report our experience with blunt thoracic aortic injury at a level 1 trauma center over the past 15 years.MethodsBetween January 1, 1997, and January 1, 2012, data on 338 patients who presented with suspected blunt thoracic aortic injury were entered into the University of Texas Medical School at Houston Trauma Center Registry. A total of 175 patients (52%) underwent thoracic aortic repair; 29 (17%) had open repair with aortic crossclamping, 77 (44%) had open repair with distal aortic perfusion, and 69 (39%) had thoracic endovascular aortic repair. Outcomes were determined, including early mortality, morbidity, length of stay, and late survival. Multiple logistic regression analysis was used to compute adjusted estimates for the effects of the operative technique.ResultsThe early mortality for all patients with blunt thoracic aortic injury was 41% (139/338). Early mortality was 17% (27/175) for operative aortic interventions, 4% (3/69) for thoracic endovascular aortic repairs, 31% (11/29) for open repairs with aortic crossclamping, and 14% (11/77) for open repairs with distal aortic perfusion. Survival for thoracic endovascular aortic repair at 1 year and 5 years was 92% and 87%, respectively. Survival for open repair at 1, 5, 10, and 15 years was 76%, 75%, 72%, and 68%, respectively.ConclusionsBlunt thoracic aortic injury remains associated with significant early mortality. Delayed selective management, when applied with open repair with distal aortic perfusion and the use of thoracic endovascular aortic repair, has been associated with improved early outcomes. The long-term durability of thoracic endovascular aortic repair is unknown, necessitating close radiographic follow-up

Postoperative renal function preservation with nonischemic femoral arterial cannulation for thoracoabdominal aortic repair.

BACKGROUND: Renal failure after thoracoabdominal aortic repair is a significant clinical problem. Distal aortic perfusion for organ and spinal cord protection requires cannulation of the left femoral artery. In 2006, we reported the finding that direct cannulation led to leg ischemia in some patients and was associated with increased renal failure. After this finding, we modified our perfusion technique to eliminate leg ischemia from cannulation. In this article, we present the effects of this change on postoperative renal function. METHODS: Between February 1991 and July 2008, we repaired 1464 thoracoabdominal aortic aneurysms. Distal aortic perfusion was used in 1088, and these were studied. Median patient age was 68 years, and 378 (35%) were women. In September 2006, we began to adopt a sidearm femoral cannulation technique that provides distal aortic perfusion while maintaining downstream flow to the leg. This was used in 167 patients (15%). We measured the joint effects of preoperative glomerular filtration rate (GFR) and cannulation technique on the highest postoperative creatinine level, postoperative renal failure, and death. Analysis was by multiple linear or logistic regression with interaction. RESULTS: The preoperative GFR was the strongest predictor of postoperative renal dysfunction and death. No significant main effects of sidearm cannulation were noted. For peak creatinine level and postoperative renal failure, however, strong interactions between preoperative GFR and sidearm cannulation were present, resulting in reductions of postoperative renal complications of 15% to 20% when GFR was \u3c60 mL\u3e/min/1.73 m(2). For normal GFR, the effect was negated or even reversed at very high levels of GFR. Mortality, although not significantly affected by sidearm cannulation, showed a similar trend to the renal outcomes. CONCLUSION: Use of sidearm cannulation is associated with a clinically important and highly statistically significant reduction in postoperative renal complications in patients with a low GFR. Reduced renal effect of skeletal muscle ischemia is the proposed mechanism. Effects among patients with good preoperative renal function are less clear. A randomized trial is needed

Outcomes after endovascular repair of arterial trauma

BackgroundEndovascular repair of peripheral arterial trauma using covered stent grafts is a minimally invasive alternative to open surgery in selected patients. Although the technical feasibility of endovascular repair has been established, there are a paucity of data regarding outcomes. The purpose of this study was to evaluate the short-term outcomes of endovascular repair in patients with peripheral arterial trauma.MethodsA review of a prospectively collected institutional trauma registry captured all patients with peripheral arterial injury who underwent endovascular repair from August 2004 to June 2012. Data collected included demographics, Injury Severity Score (ISS), mechanism, location and type of injury, imaging modality, intervention type, complications and reintervention, length of stay, and follow-up. Descriptive statistics were used for analysis.ResultsDuring the study period, we performed endovascular repair in 28 patients with peripheral arterial injuries. There were 20 male patients (71%) with a median age of 39 years (range, 13-88 years). The mean ISS was 17.2 (range, 9-41). The mechanism of injury was penetrating in 21 (75%) and blunt in seven (25%). The anatomic locations of the 28 arterial injuries were carotid (3 [11%]), subclavian (7 [25%]), axillary (6 [22%]), iliac (3 [11%]), and femoral/popliteal (9 [32%]). Findings consistent with injury on imaging included pseudoaneurysms (9 [32%]), extravasations (9 [32%]), occlusions (6 [22%]), and arteriovenous fistulas (4 [14%]). Technical success was achieved in all patients. The overall complication rate was 21%, with six patients requiring a secondary procedure. Two patients underwent a planned, elective conversion to open repair during the initial hospitalization. Four patients required conversion secondary to stent graft thrombosis. Three conversions were early (<30 days) and one was late (>30 days). The mean length of stay was 18.4 ± 22.9 days (range, 1-93 days), with a median follow-up of 13 months (range, 1-60 months). The overall limb salvage rate was 92% at 45 days and 79% at 93 days.ConclusionsThe present study outlines our early experience with endovascular repair of peripheral arterial injuries in a variety of anatomic locations. Overall complication rates are appreciable but can be effectively detected and managed with additional intervention. The inclusion of endovascular modalities in algorithms of trauma care holds considerable promise. The need to better define optimal algorithms for utilization and determine long-term outcomes of intervention requires significant additional study

Cerebral monitoring with transcranial Doppler ultrasonography improves neurologic outcome during repairs of acute type A aortic dissection

ObjectiveNeurologic complications after repair of acute type A aortic dissection remain significant. The use of power M-mode transcranial Doppler monitoring to verify cerebral blood flow during these repairs might decrease cerebral ischemia by correcting malperfusion. The purpose of this study was to analyze the use of power M-mode transcranial Doppler monitoring during repairs of acute type A dissection with regard to neurologic outcome.MethodsWe performed a prospective study of patients undergoing repairs of acute type A aortic dissection. Repairs included profound hypothermic circulatory arrest and retrograde cerebral perfusion. Patients in whom transcranial Doppler monitoring was used to monitor cerebral blood flow and modify operative technique during repair (study group) were compared with those without monitoring and modification (control group).ResultsBetween September 2001 and October 2003, we repaired 56 cases of acute type A dissection. Power M-mode transcranial Doppler monitoring was used in 50% (28/56) of cases. Power M-mode transcranial Doppler monitoring altered operative cannulation and guided retrograde cerebral perfusion flow in 28.5% (8/28) and 78.6% (22/28) of cases, respectively. Two patients presented with preoperative stroke, one in each group. One operative death occurred in each group. In-hospital mortality and the occurrence of new stroke were not significantly different between the 2 groups. Temporary neurologic dysfunction occurred less often in the study group (14.8% [4/27] vs 51.8% [14/27], P = .008).ConclusionsIdentification of cerebral malperfusion requires cerebral monitoring. By ensuring cerebral blood flow by using power M-mode transcranial Doppler monitoring and correcting cerebral malperfusion by modifying operative technique, neurologic outcome was improved during repairs of acute type A aortic dissection

Intentional left subclavian artery coverage during thoracic endovascular aortic repair for traumatic aortic injury

BackgroundThoracic endovascular aortic repair (TEVAR) is widely used for treatment of traumatic aortic injury (TAI). Stent graft coverage of the left subclavian artery (LSA) may be required in up to 40% of patients. We evaluated the long-term effects of intentional LSA coverage (LSAC) on symptoms and return to normal activity in TAI patients compared with a similarly treated group whose LSA was uncovered (LSAU).MethodsPatients were identified from a prospective institutional trauma registry between September 2005 and July 2012. TAI was confirmed using computed tomography angiography. The electronic medical records, angiograms, and computed tomography angiograms were reviewed in a retrospective fashion. In-person or telephone interviews were conducted using the SF-12v2 (Quality Metrics, Lincoln, RI) to assess quality of life. An additional questionnaire was used to assess specific LSA symptoms and the ability to return to normal activities. Data were analyzed by Spearman rank correlation and multiple linear and logistic regression analysis with appropriate transformations using SAS software (SAS Institute, Cary, NC).ResultsDuring the study period, 82 patients (57 men; mean age 40.5 ± 20 years, mean Injury Severity Score, 34 ± 10.0) underwent TEVAR for treatment of TAI. Among them, LSAC was used in 32 (39.5%) and LSAU in 50. A group of the LSAU patients (n = 22) served as matched controls in the analysis. We found no statistically significant difference in SF-12v2 physical health scores (ρ = −0.08; P = .62) between LSAC and LSAU patients. LSAC patients had slightly better mental health scores (ρ = 0.62; P = .037) than LSAU patients. LSAC patients did not have an increased likelihood of experiencing pain (ρ = −0.0056; P = .97), numbness (ρ = −0.12; P = .45), paresthesia (ρ = −0.11; P = .48), fatigue (ρ = −0.066; P = .69), or cramping (ρ = −0.12; P = .45). We found no difference between groups in the ability to return to activities. The mean follow-up time was 3.35 years. Six LSAC patients (19%) died during the follow-up period of unrelated causes.ConclusionsIntentional LSAC during TEVAR for TAI appears safe, without compromising mental or physical health outcomes. Furthermore, LSAC does not increase the long-term risk of upper extremity symptoms or impairment of normal activities

Glomerular filtration rate is superior to serum creatinine for prediction of mortality after thoracoabdominal aortic surgery

BackgroundClinically evident renal disease (dialysis, history of renal insufficiency, or serum creatinine >2.0 mg/dL) is a known risk factor for mortality after thoracoabdominal aortic aneurysm repair. We extended this concept to the questions of whether subclinical renal disease is also a risk factor and how best to identify subclinical disease. We hypothesized that the glomerular filtration rate (GFR) would be a more sensitive determinant of renal function than serum creatinine alone.MethodsBetween 1991 and 2004, we repaired 1106 thoracoabdominal aortic aneurysms and descending thoracic aortic aneurysms. The median age was 67 years. There were 400 (36%) women and 706 (64%) men. We estimated GFR by using the Cockcroft-Gault equation. We divided baseline serum creatinine and baseline GFR into quartiles and estimated the association of the quartiles with 30-day postoperative mortality by χ2 testing. We further subdivided the population into patients with and without clinically evident renal disease and repeated the analysis in the patients without clinically apparent disease (n = 869).ResultsClinically apparent renal disease was highly associated with 30-day mortality (odds ratio, 3.2; P < .0001). In all patients, serum creatinine quartile and GFR quartile were also both highly significantly associated with 30-day mortality (P < .0001). In patients without clinically apparent renal disease, both creatinine and GFR predicted additional mortality, but GFR was a much stronger predictor (P < .02 for creatinine vs <.0001 for GFR). In these patients, mortality ranged from 5% in the best GFR quartile to 27% in the worst. Taken as continuous variables in logistic regression equations, serum creatinine had no discrimination in patients without clinical disease (P = .73), whereas GFR remained strong (P <.0001).ConclusionsPreoperative renal function is an important determinant of early mortality even in patients without clinically evident disease. Estimated GFR is a much more powerful determinant of mortality risk than serum creatinine alone