Application of endograft to treat thoracic aortic pathologies: A single center experience

PurposeTo evaluate our experience of thoracic endoluminal graft (ELG) repair of various thoracic aortic pathologies using a commercially available device approved by the Food and Drug Administration. Our patient population includes patients eligible for open surgical repair and those with prohibitive surgical risk.MethodsFrom March 1998 to March 2006, endovascular stent repair of the thoracic aorta was performed on 406 patients with 324 patients (median age 72; 200 male) receiving the Gore Excluder endograft. Patient demographics, procedural characteristics, complications, including endoleak, spinal cord ischemia, and mortality, were retrospectively reviewed during follow-up. All patients were followed with chest computer tomography at 6 months and yearly. Statistical analysis was performed utilizing the SPSS Windows 11.0 program. Logistic regression (univariate) analysis used to identify risk factors for paraplegia; analysis of variance (ANOVA) for endoleak distribution; and χ2 used to analyze variables. Survival analysis was done using SAS version 9.1 (SAS Institute, Cary, NC).ResultsThree hundred twenty-four patients were treated with Gore Excluder graft between March 1998 and March 2006. One hundred fifty-seven patients (48.5%) had atherosclerotic aneurysms, 82 (25.3%) had dissections type B (DTB), 34 (10.5%) had penetrating ulcers (PU), 26 (8.0%) with pseudoaneurysms (PSA), 11 (3.4%) had transections (MVAT), 9 (2.8%) aorto-bronchial fistulas (AoBF), 4 (1.2%) embolization, and 1 (0.3%) aorto-esophageal fistula (AoEF). Preoperative aneurysm sac size in TAA ranged from 5 to 12 centimeters, average size 6.3 cm. Sac shrinkage occurred in 65% (102 of 157) of patients. Average postoperative sac size of 5.4 cm in a mean follow-up of 20.4 months. One hundred cases (31.5%) were nonelective; 49 (15.1%) were ruptures. Overall complication was 22.7%, 14.2% (46) in elective cases and 8.5% (28) in nonelective cases. Paraplegia occurred in five (1.5%) patients and paresis in three (0.9%); two of the latter improved and one resolved completely prior to discharge. Incidence of paraplegia was statistically significant (P value < .05) with retroperitoneal approach, perioperative blood loss greater than 1000 cc, and aortic coverage greater than 40 cm. Early endoleaks included 18 (5.5%) type I, four (1.2%) type II, and two (0.6%) type III. Thirty-day mortality was 5.5% (18 related deaths, including three intraoperative deaths). A log rank test did not find statistical differences in actuarial survival with 30-day related mortality between TAA and other pathologies (P = .29) or between DTB and other pathologies (P = .97). Late mortality was 9.6% with 31 unrelated deaths. Follow-up ranged between 1 month and 70 months, average 17 months.ConclusionsEndoluminal grafting is a feasible alternative to open surgical repair for thoracic aortic pathologies. After more than 300 cases, 30-day morbidity and mortality compares favorably with open repair. Paraplegia remains low as a complication and increases in incidence with retroperitoneal approach, increased perioperative blood loss, and increased aortic coverage

A Long Way to Tipperary: The Irish in the First World War

‘The Irish are out in force’: it was a rainy summer day on the fields of the Somme, and they were very young, in their early teens, in fact. However, this was not 1916, but 2016, when the centenary of one of the bloodiest battles in history attracted an international crowd, including large contingents of school children from the Republic. In contrast to the 50th anniversary, which, in 1966, had been a ‘Unionist’ commemoration – claimed by the Northern Irish loyalists as their own, while the survivors of the Southern veterans kept their heads down and suppressed this part of their past – in 2016, the conflict was widely construed as an inclusive experience, which saw men and women giving their lives ‘for Ireland’ even when fighting ‘for King and Empire’. A generation ago this would have shocked traditional nationalists, who regarded the Great War as an ‘English’ one, in contrast to the Easter Rising and the subsequent War of Independence. However, European integration and the Peace Process gradually brought about a different mindset. Among historians, it was the late Keith Jeffery who spearheaded the revision of our perception of Ireland's standing in the war. This reassessment was further developed in 2008, with John Horne's editing Our war, a volume jointly published by RTÉ (the Irish broadcasting company) and the Royal Irish Academy, in which ten of the leading historians of the period – including Keith Jeffery, Paul Bew, David Fitzpatrick, and Catriona Pennell – presented Ireland as a protagonist, rather than merely a victim of British imperialism. By 2016, this new understanding had largely reshaped both government and public perceptions, with ‘the emergence of a more tolerant and flexible sense of Irish identity’. This has been confirmed by the largely consensual nature of the war centenary commemorations. While Dublin took the initiative, Northern Ireland's Sinn Féin leaders were ready to follow suit with the then deputy first minister of Northern Ireland, Martin McGuinness, visiting the battlefield of the Western Front to honour the memory of the Irish dead, and the Speaker of the Belfast Assembly, Mitchel McLaughlin, and his party colleague, Elisha McCallion, the mayor of Derry and Strabane, laying wreaths at the local war memorials

Evolving Paradigms in Aortic Dissection Management

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