Repair of aortic root in patients with aneurysm or dissection: comparing the outcomes of valvesparing root replacement with those from the Bentall procedure

INTRODUCTION: Management of aortic root aneurysm or dissection has been the subject of much discussion that has led to some modifications. The current trend is a valve-sparing root replacement. We compared the outcome following valve sparing root repair with Bentall procedure. METHODS: We retrospectively evaluated 70 patients who underwent root replacement for aneurysm or dissection and compared the outcomes of valve-sparing root replacement with those of the Bentall procedure from January 2007 to December 2011 at our institution. RESULTS: Twenty-five patients had valve-sparing aortic root replacement (VSR, including reimplantation or remodeling) (23 males and 2 females), and 45 patients had the Bentall procedure (34 males and 11 females). Patients who underwent a VSR were younger with a mean age of 55.4 ± 14.8 years compared to those who underwent the Bentall procedure with a mean age of 60.6 ± 12.7 (P=ns). The preoperative aortic insufficiency (AI) in the VSR group was moderate in 8 (32%) patients, and severe in 6 (24%). Preoperative creatinine was 1 ± 0.35 mg/dl in the VSR group and 1.1 ± 0.87 mg/dl in the Bentall group. In the VSR group, 3 (12%) patients had emergency surgery; by contrast, in the Bentall group, 8 (17%) patients had emergent surgery. Concomitant coronary artery bypass grafting (excluding coronary reimplantation) was performed in 8 (32%) patients in the VSR group and in 12 (26.6%) patients in the Bentall group (P=0.78); additional valve procedures were performed in 2 (8%) patients in the VSR group and in 11 (24.4%) patients in the Bentall group. The perioperative mortality was 8% (n=2) and 13.3% (n=6), for the VSR and Bentall procedures, respectively (P=0.7, ns). The total duration of intensive care unit stay was 116.6 ± 106 hours for VSR patients and 152.5 ± 218.2 hours for Bentall patients (P=0.5). The overall length of stay in the hospital was 10 ± 8.1 days for VSR and 11 ± 9.52 days for Bentall (P=0.89). The one-year survival was 92% for the VSR group and 79.0% for the Bentall group. The seven-year survival for the VSR group was 92% and 79% for the Bentall group (95% CI [1.215 to 0.1275], P=0.1). CONCLUSION: Aortic valve-sparing root replacement can be performed with acceptable morbidity and mortality with a comparable long-term survival to the Bentall procedure

Delayed migration of a thrombosed aortic endograft within a thrombosed aneurysm sac resulting in continued sac expansion and rupture

We present the case of delayed migration of a thrombosed aortic endograft within a thrombosed aneurysm sac that expanded and ruptured. Dilation of the aortic neck likely led to endograft migration and exposure of the occluded endograft and aneurysm sac to systemic pressure. Although no endoleak was identified, a key finding on ultrasound showed mobility of the sac thrombus. This may be an indicator of flow within the sac that may predict potential for rupture. Despite thrombosis of the aortic sac and endograft, the risk of rupture still lingers, and thus continued surveillance of occluded endografts may be prudent

Use of three-dimensional–three-dimensional digital subtraction angiography spin fusion protocol for complex aortoiliac endovascular interventions

Complex endovascular aortic interventions in patients with excessive tortuosity or difficult gantry angles can be challenging. Although fusion imaging can help navigate these issues, it is based on preoperative imaging studies, which becomes skewed after introduction of stiff wires and large devices into the aorta. The subtraction spin protocol performs two cone-beam computed tomography scans to create a subtracted image of the contrast-filled vessels after wire and device placement to accommodate vessel distortion. We have reported a complex fenestrated endovascular aneurysm repair case with a highly angulated neck to highlight the advantages of the subtraction spin protocol in anatomically hostile endovascular repairs

Inguinal pain and fullness due to an intravascular leiomyoma in the external iliac vein

Intravascular leiomyomatosis (IVL) is a benign smooth muscle tumor that evolves from the pelvic veins and can spread to the central veins and heart. Cardiac involvement is the most commonly reported presentation. Initial diagnosis is difficult, and IVL is commonly misdiagnosed as thrombus or atrial myxoma. Appropriate imaging and a high clinical suspicion are required for accurate diagnosis. We report a rare case of IVL in the external iliac vein that recurred 4 years after hysterectomy. Only four cases have been reported in the literature to involve the external iliac vein as it has no direct connection to pelvic venous drainage

Comparison of anticoagulation versus mechanical thrombectomy for the treatment of iliofemoral deep vein thrombosis

Objective:To compare the comparative effects of treatment with contemporary mechanical thrombectomy or anticoagulation on Villalta scores and post thrombotic syndrome incidence through 12 months in iliofemoral deep vein thrombosis. Methods:Patients with deep vein thrombosis in the Acute Venous Thrombosis: Thrombus Removal with Adjunctive Catheter-Directed Thrombolysis (ATTRACT) randomized trial and the ClotTriever Outcomes (CLOUT) registry were included in this analysis. Both studies evaluated the effects of thrombus removal on the incidence of post thrombotic syndrome. Patients with bilateral deep vein thrombosis, isolated femoral-popliteal deep vein thrombosis, symptom duration \u3e4 weeks, or incomplete case data for matching covariates were excluded. Propensity scores were used to match patients 1:1 that received anticoagulation (from ATTRACT) to those treated with mechanical thrombectomy (from CLOUT) using nearest neighbor matching on 9 baseline covariates, including age, body mass index, leg treated, provoked deep vein thrombosis, prior venous thromboembolism, race, sex, Villalta score, and symptom duration. Clinical outcomes, including Villalta score and post thrombotic syndrome, were assessed. Logistic regression was used to estimate the likelihood of developing post thrombotic syndrome at 12 months. Results:A total of 164 pairs were matched, with no significant differences in baseline characteristics after matching. There were fewer patients with any post thrombotic syndrome at 6 months (19% vs 46%, p\u3c.001) and 12 months (17% vs 38%, p\u3c.001) in the mechanical thrombectomy treatment group. Modeling revealed that after adjusting for baseline Villalta scores, patients treated with anticoagulation had significantly higher odds of developing any post thrombotic syndrome (OR=3.1, 95% CI [1.5 to 6.2], p=.002) or moderate to severe post thrombotic syndrome (OR=3.1, 95% CI [1.1 to 8.4], p=.027) at 12 months compared with those treated with mechanical thrombectomy. Mean Villalta scores were lower through 12 months among those receiving mechanical thrombectomy vs anticoagulation (3.3 vs 6.3 at 30 days, 2.5 vs 5.5 at 6 months, and 2.6 vs 4.9 at 12 months, p\u3c.001 for all). Conclusions:Mechanical thrombectomy treatment of iliofemoral deep vein thrombosis was associated with significantly lower Villalta scores and reduced incidence of post thrombotic syndrome through 12 months compared with treatment using anticoagulation. Results from currently enrolling clinical trials will further clarify the role of these therapies in the prevention of post thrombotic syndrome following an acute deep vein thrombosis event

Six-month outcomes of mechanical thrombectomy for treating deep vein thrombosis: Analysis from the 500-patient CLOUT registry

Purpose:Mechanical thrombectomy for the treatment of deep vein thrombosis (DVT) is being increasingly utilized to reduce symptoms and prevent postthrombotic syndrome (PTS), but more data on clinical outcomes are needed. Mechanical thrombectomy was studied in the ClotTriever Outcomes (CLOUT) registry with 6-month full analysis outcomes reported herein. Materials and methods:The CLOUT registry is a prospective, all-comer study that enrolled 500 lower extremity DVT patients across 43 US sites treated with mechanical thrombectomy using the ClotTriever System. Core-lab assessed Marder scores and physician-assessed venous patency by duplex ultrasound, PTS assessment using Villalta score, venous symptom severity, pain, and quality of life scores through 6 months were analyzed. Adverse events were identified and independently adjudicated. Results:All-cause mortality at 30 days was 0.9%, and 8.6% of subjects experienced a serious adverse event (SAE) within the first 30 days, 1 of which (0.2%) was device related. SAE rethrombosis/residual thrombus incidence was 4.8% at 30 days and 8.0% at 6 months. Between baseline and 6 months, venous flow increased from 27.2% to 92.5% of limbs (P \u3c 0.0001), and venous compressibility improved from 28.0% to 91.8% (P \u3c 0.0001), while median Villalta scores improved from 9.0 at baseline to 1.0 at 6 months (P \u3c 0.0001). Significant improvements in venous symptom severity, pain, and quality of life were also demonstrated. Outcomes from iliofemoral and isolated femoral-popliteal segments showed similar improvements. Conclusion:Outcomes from the CLOUT study, a large prospective registry for DVT, indicate that mechanical thrombectomy is safe and demonstrates significant improvement in symptoms and health status through 6 months. Level of Evidence 3: Non-randomized controlled cohort/follow-up study