AORTA, June 2013, Volume 1, Issue 1:79-87
The Houston Aortic Symposium: Frontiers in Cardiovascular Diseases, the Sixth in the Series March 21–23, 2013
The Houston Aortic Symposium is pleased to partner with AORTA in their common goal of impacting worldwide patient care by fulfilling the educational needs and practice gaps of cardiovascular clinicians and scientists. The symposium is designed for vascular surgeons, cardiothoracic surgeons, interventional radiologists, cardiologists, anesthesiologists, physician assistants, nurse practitioners, perfusionists, and other health care professionals involved in the care and treatment of patients with aortic diseases. The resulting scientific program represents a worldwide overview and hybrid approach to important issues facing all practitioners in the field of cardiovascular medicine.
 Note from the Editors: The unedited abstracts from the renowned Houston Aortic Symposium are reproduced herein, as supplied by the organizers. AORTA is interested in publishing abstracts and/or full selected scientific papers from key aortic symposia worldwide. Full scientific papers will be peer reviewed.
SPONTANEOUS MEDIASTINAL HEMATOMA WITH RIGHT HEMOTHORAX CAUSED BY RUPTURE OF ECTOPIC BRONCHIAL ARTERY ANEURYSM (CASE REPORT AND MEDICAL LITERATURE REVIEW)
The patient is a male, 52 years old. Emergent admission for complaint of abrupt onset of right chest pain with headache for one day. T 37.2 degrees C. HR 106 bpm. R 20 bpm. BP 147/92 mm Hg. The patient was conscious with sanity, psychasthenic, deaf and dumb. The both side pupils were round and in equal size. The reaction to light was sensitive and delicate. No jugular vein distension. The trachea in the midline. The respiratory sound at the left lung and at the right upper lung was clear. The respiratory sound at the right middle and lower lung disappeared with dull percussion resonance. No dry or moist rales. Heart rhythm was regular, no cardiac murmur. The abdomen was flat and soft with no tenderness. No edema in the lower extremities. Denied the history of TB and bronchiectasis. Denied the history of allergy to medicine or food and denied any trauma or surgical operation history. Laboratory examination was made emergently. CBC: WBC 10.4 x 109/L Hgb. 13.58/DL; platelet count: 173 x 109/L neutrophil percentage: 86.5%. Biochemical tests suggested that the electrolyte, liver and kidney functions, myocardic enzyme spectrum were normal. Enhanced CT examination suggested: 1. The right lung with extensively exudative change; the lower portion of the lung present as consolidation; the lingual segment of the left lung had some inflammatory focuses. 2. Right thoracic pleural effusion with hemorrhage probability. 3. Beneath the tracheal septum the modular image intensified evidently. By the side of it there was a small vessel image, the probability of the pseudoaneurysm could not be excluded from it. The soft tissue mass image in the posterior mediastinum was considered the probability of the hematoma bursting and entering into the right thorax. Aortic angiography and ectopic bronchial artery (pseudoaneurym) embolotherapy were immediately proceeded. During the operation, the aortic angiography showed that an ectopic bronchial artery erupted from the left subclavian artery. The ectopic bronchial artery increased in size, at the level of the tracheal septum appeared in cystoids and pocket-like dilatation. Embolotherapy was carried out. During the surgery, 5F Cobra catheter and micro-catheter were used to pass and enter into the ectopic bronchial artery. At first, a piece of gelafoam was injected; the angiogram showed that the terminal branches of the ectopic brachial artery disappeared; but the pseudoaneurysm was still manifest. Then, through the micro-catheter, tower-fashioned spring steel rings, one in 2mm-6cm, one in 4mm-8cm were delivered. Postoperative angiogram showed that the ectopic bronchial artery was obliterated and the pseudoaneurysm was no more manifest. Chest tubes were placed for continuous drainage. Postoperatively, the patient recovered very well and discharged on 9th day. Follow-up examination was carried-out on the 22nd day after surgery. The enhanced CT showed that the chest appeared the post ectopic bronchial artery embolization changes, thrombogenesis. No intensified image.
The cause of bronchial artery aneurysm (BAA) is still unclear. The increased blood flow may be one of the causes of its formation
The diagnosis relies on instrumentalities such as CTA, DSA, MRA, etc.
Once BAA rupture occurs, the consequence is serious and threatens the patient's life. As soon as possible to treat is necessary. Surgical operation is generally thought to be more reliable and effective, especially in emergency, for the aneurysm close to the original site of the bronchial artery, and for the cases that have recurrence of the disease post interventional treatment or fail to the treatment. In recent years, with the advances in endovascular techniques, the trans-catheter arterial embolotherapy has made continuous progress. It has simple, micro-traumatic high effective and “one station” therapeutic modality advantages and becomes the treatment of choice for BAA.
Based on the reports from the domestic and foreign medical literatures, the interventional treatment chiefly uses 4 methods: spring ring filled in the aneurysm; gelfoam embolization in the efferent end; efferent end blocked with spring ring; acrylate (NBCA)-Lipiodol mixture and gelatin granules endovascular embolization; aortic occlusion with stent.
If the surgical operation were used for this case, because of the hematoma formation in the mediastinum and with active bleeding, the exposure of the topical anatomy would be difficult. At the same time, due to the involved vessel originating from the left subclavian artery. If left transthoracotomy were selected, it would be also quite difficult to find the involved ectopic vessel. The right transthoracotomy only exposes the right chest and the structures under the tracheal septum. The failure of the surgical operation would be quite probable.
Postoperative follow-up is necessary for the patients with TAE. So that the effectiveness of embolization could be accurately evaluated; and the possible recurrence, missed diagnosis and the complicated infection, etc. could be discovered in time.
PROCTORING TRANSAPICAL TRANSCATHERTER AORTIC VALVE IMPLANTATION (TAVI) REDUCES EARLY AND LATE MORTALITY AND MORBIDITY
Transapical TAVI is a safe, reproducible, and effective procedure for the treatment of critical aortic stenosis in a high-risk population that is not a candidate for a transfemoral procedure, Reported TAVI results suggests the presence of a learning period with a direct impact on patients' outcomes. In fact, the incremental improvements acquired during the TAVI program may have affected patient selection, as well as the implantation technique itself, and post-procedural management. Education provided by experienced proctor may have an impact on the outcome we have analyzed the international experiences of single proctor to establish the effectiveness of this educational policy when compared to the partner trial transapical arm patients.
From October 2007 to April 2012, 162 patients with severe symptomatic AS consecutively referred for TAVI by primary or tertiary hospitals from total of 40 centers (28 European, 7 UK, 1 Middle East 4 Australian) were assessed and selected applying the same partner protocol all data were reviewed by the proctor prior to inclusion. Data were prospectively collected and analyzed.
The Demographic of the proctored transapical group (PTA) were no different from Partner trial transapical group TA Both groups had more patients with peripheral artery disease (22.0% vs 10.9%), coronary artery disease (64.4% vs 58.3%), carotid stenosis (23.2% vs 15. 7%), redo-operation (25.7% vs 14.8%) and neurological dysfunction (14.8% vs 10.4%) than in TF (all p<0.05). The mean Euroscore I in TA was 24.2% and in PTA 25.3%. All cause 30 day mortality in the proctored cohort was 2.4 % versus 8.7% and 7.6% in both the partner transapical and surgical arms. Proctored TAVI had lower stroke 2% versus 7% lower major bleeding 9.3% versus 1.8% lower major vascular complication 3% versus 11% (P<0.05) all contributed to lower Mortality at three years in TA was 33.7%, PTA 22.5% and 27.3% in TF.
The close impact of the learning curve on patients' outcomes underlines the necessity of proper training, and the restriction of these procedures to high-volume centers education can lead to early results that are comparable transfemoral results in some cases somewhat better, Transapical aortic valve implantation can be performed with excellent outcome in high risk patients with aortic stenosis. Optimal imaging and a team approach are essential for success. Recent results indicate a persistently high-risk profile of the included patients and improved outcomes based on initial learning and technical refinements of the procedure.
GENE ANALYSIS IN PATIENTS WITH NON-SYNDROMIC AORTIC ANEURYSM AND DISSECTION
Aortic aneurysm and/or dissection (AAD) is life-threatening condition, and several syndromes, Marfan syndrome, Ehlers-Danlos syndrome, Loeys-Dietz syndrome, etc. are known to be related AAD. Several genes are known to be associated with syndromes presenting with hereditary AAD and vascular disruption: FBN1, TGFBR2, TGFBR1, COL3A1, PLOD1, MYH11, SLC2A10 and ACTA2. Most AAD patients who have been surgically treated are not affected by these syndromes. In this study, we analyzed the eight AAD-associated genes in the 70 patients with non-syndromic AAD.
70 patients (53 male, 17 femal with mean age 67.3±10.2; range: 39-83 years old) had operation for non-syndormic AAD. DNA was extracted from peripheral blood leukocytes. The eight genes (FBN1, TGFBR2, TGFBR1, COL3A1, PLOD1, MYH11, SLC2A10 and ACTA2) were analyzed by PCR method.
The genes were detected in 3 / 70 cases (4.3%). The all 3 cases were aortic dissection. (Case 1) c.1815+5G>A in COL3A1 (a 67 y.o. female, Type B aortic dissection). COL3A1 had been reported in a patient with Ehlers-Danlos syndrome type IV (Lee et al.1991). (Case 2) c.4963C>T in MYH11 (An 80 y.o. male, dissecting thracoabdominal aortic aneurysm). (Case 3) c.482T>C in ACTA2 (A 47 y.o. female, type A aortic dissection with familiar thoracic AAD).
RE-OPERATIVE AORTIC ARCH SURGERY. OUR EXPERIENCE IN 119 PATIENTS
Aim of this study was to assess early and late outcomes of patients undergoing aortic arch re-interventions.
Between 1986 and 2012, 119 consecutive re-operations on the aortic arch after previous aortic surgery were performed in our Institution. Patients' mean age was 59.7 years, and 93 (78.2%) were men. An urgent/emergent operation was performed in 15 (12.6%) patients. A chronic post-dissection arch aneurysm represented the most common (51.1%) indication for surgery. A complete arch replacement was performed in 81.2% of cases, and an associated root repair in 51.3%.
Hospital mortality was 13.4%. Post-operatively, 1.7% of patient suffered from coma, 4.2% from stroke, and 4.2% from paraplegia. On multivariate analysis, CPB time (OR: 1.017/min; p=0.018) emerged as the only independent predictor of hospital mortality. Follow up was 100% complete. The estimated 1, 5-, and 10-years survival was 79.5%, 71.4% and 48.4%, respectively. During follow up, 18 re-interventions were performed. Freedom from re-operation at 5-, and 10-years was 82.6%, 62.1%, respectively. On Cox regression analysis, chronic aortic dissection (OR=8.1; p=0.004) emerged as the only independent predictor of re-intervention at follow up.
SURGERY VS. ENDOVASCULAR THERAPY FOR BLUNT TRAUMATIC THORACIC AORTIC INJURY: OUR 20 YEARS EXPERIENCE WITH DELAYED MANAGEMENT
Since 1992, delayed aortic repair has represented our first-line management for all blunt traumatic thoracic aortic injury (BTTAI) patients, except for those who showed signs of impending aortic rupture at admission or during delay. These patients were converted to urgent primary aortic repair. Aim of the present study was to report our 20 years experience with delayed surgical and endovascular repair of BTTAI patients.
Between 1992 and 2012, 86 patients (mean age: 34.1 years; male: 74.4%) received delayed management of traumatic aortic injury. Of these patients, 31 (36%) underwent Surgical Repair (SR), 53 (61.6%) underwent Endovascular Repair (ER), and 2 died while awaiting aortic repair. Due to unpaired hemodynamics or imaging signs of impending aortic rupture, 21 patients required emergent repair, which was endovascular in 17 (32.1%) cases, and surgical in 4 (12.9%). The trauma-to-repair timespan (in days) was 200 (Q1-Q3: 27-340) and 5.5 (Q1-Q3: 1-54) for SR and ER patients, respectively (p=0.001).
Overall, hospital mortality was 3.5% (n=3), being 0% in SR patients, and 1.9% (n=1) in ER patients (p=0.442). No new post-operative paraplegia occurred, and a cerebellar stroke occurred in one (1.9%) ER patient. During follow up (95.2% complete) no late deaths occurred. At 15 years, estimates of survival and freedom from secondary aortic procedures were 96% and 100%, respectively.
Delayed management of BTTAI patients was associated with satisfactory long-term outcomes. Surgery was not inferior to endovascular repair. Nevertheless, the latter can optimize operative timing allowing earlier aortic repair, and provide a “bridging” therapy for patients severely injured from their non-aortic traumatic injuries.
SURGICAL TREATMENT OF ASCENDING AORTA‘S ANEURYSM BY ROBISCHEK‘S OPERATION AND WRAPPING TAPE OPERATION DURING AORTIC VALVE REPLACEMENT
To analyze possibilities of surgical treatment of aneurysm of ascending aorta (AAA) by Robischek‘s operation, wrapping tape operation (WTO) and other methods.
During 1996-2012 yy 821 patients (pts) with aortic valve disease (AVD) and AAA in average age 58,9±5,1 yy were operated in Institute. In all groups 11 (1,3%) pts were in II NYHA class, 358 (43,6%) in III, 452 (55,1%) in IV. The following operations were performed: aortic valve replacement (AVR) + WTO of ascending aorta (AA) - 248 (30,2%) pts (group A), AVR + Robischek‘s operation - 152 (18,5%) pts (group B), AVR without correction of AAA (AA's diameter 4,9 ± 0,5 cm) - 421 (51,3%) pts (group C). In all cases in group A after AVR nylon tape (diameter 1 cm) was wrapped on AA by 5-9 tours and fixated between them in proximal and distal part of AA.
Hospital mortality were 1,2%, 1,9% and 1,7% in group A,B,C accordingly (p > 0.05). During remote period (10,5±0,7 yy) we follow up 797 pts. Actuarial survival at 7 years after operation was 93,5% (n=243), 94.3% (n=145), 85.2% (n= 409) in group A,B,C accordingly (p < 0.05). Echo examination of diameter of AA (cm) (preoperative, postoperative, remote period) for group A: 4,7±0,4, 4,0±0,3, 4,1±0,3; for group B: 5,3±0,3, 3,1±0,2, 3,2±0,1, group C: 4,9±0,3,4,7±0,4, 5,2±0,2.
ONE-YEAR FOLLOW-UP OF THE EVITA OPEN PLUS HYBRID ENDOPROSTHESIS FOR THE TREATMENT OF COMPLEX AORTIC PATHOLOGY
We analyze the mid-term results of the Evita Open Plus hybrid endoprosthesis for the treatment of extensive thoracic aortic disease.
A prospective clinical and instrumental follow-up was performed at our Institution in 16 patients.
Indications to surgery were post-dissection aneurysm (50%), true aneurysm (31.2%), pseudoaneurysm (18.7%). Carotid-subclavian bypass was performed in 18.7% (previous cardiac surgery in 31.2%). Procedural success was 100% (arch replacement under selective perfusion). Concomitant procedures were performed in 50% of cases, including 3 endovascular repairs of descending aneurysm (distal prolongation of the Evita Open Plus). There were no cases of operative mortality. Neurological complications were 2 transient paraparesis and one Brown-Séquard syndrome. After 14 ± 7.6 months, no complications were evident (CT scan). During the follow-up no patient deceased; one was reoperated for completion of the aortic replacement at the distal thoracoabdominal level.
THORACIC ENDOVASCULAR AORTIC REPAIR USING PERCUTANEOUS TECHNIQUE VS OPEN EXPOSURE
Devices for percutaneous closure have been developed; however, due to larger sheath sizes this technology has lagged in TEVAR. We hypothesized that percutaneous techniques could be applied to TEVAR with improved early outcomes.
A retrospective review of patients from 2/2006 to 1/ 2013 was conducted. Forty patients that underwent TEVAR using percutaneous technique were compared to 29 patients that received open exposure of the CFA. Patients in percutaneous group received preoperative CTA or intraoperative pelvic angiogram to determine appropriateness of percutaneous closure.
Measured included successful percutaneous closure, technical success rate, early complication rates, and hospital course.
In the percutaneous group 10.0% required conversion to open exposure. Reason for conversion included hemostasis 7.5% and vessel occlusion 2.5%. There was no difference in ICU or hospital stay. Patients that received standard surgical cut down had a significantly higher incidence of wound complications when compared to the percutaneous approach (p<0.05).
Percutaneous TEVAR can be performed easily and with minimal risk to the patient when used in appropriate patients. Additionally, these approaches can minimize the risk of post-operative wound complications. With some consideration, percutaneous closure of large sheath access for TEVAR is safe and effective.
A NEW CLASSIFICATION SYSTEM FOR BRANCH ARTERY PERFUSION PATTERNS IN ACUTE AORTIC DISSECTION FOR EXAMINING THE EFFECTS OF CENTRAL AORTIC REPAIR
We developed a new classification system for branch perfusion patterns in acute aortic dissection and used it to retrospectively evaluate the perfusion status of whole aortic branches and examine the effects of central aortic repair.
Between August 2008 and December 2011, 34 consecutive patients with acute type A aortic dissection underwent emergent surgery at our institution. A retrospective review of pre- and postoperative computed tomographic angiography was performed. Branch perfusion patterns were categorized into three classes: class I, dissection involving but not extending into the branch; class II, dissection extending into the branch; and class III, dissection causing ostial avulsion.
In cervical branches (total 169 branches), 70 branches (41%) presented with class I patterns, 58 (34%) with class II, and none with class III. In abdominal branches (total 135 branches), 76 branches (56%) presented with class I patterns, 12 (9%) with class II, and 18 (13%) with class III. In common iliac arteries (total 68 arteries), 14 arteries (21%) presented with class I patterns, 24 (35%) with class II, and none with class III. After repair, among 21 high-risk cervical branches, 14 branches (67%) showed improvement, 3 (14%) preserved distal perfusion supplied through the patent branch false lumen, and 4 (19%) showed no improvement in high-risk perfusion pattern or worsened. Among 22 high-risk abdominal branches, 18 branches (82%) showed improvement, 3 (14%) preserved distal perfusion supplied through the patent branch or aortic false lumen, and one (5%) showed no improvement in high-risk perfusion pattern.
INNOMINATE ARTERY CANNULATION PREFERENTIAL ACCESS IN HYPOTHERMIC CIRCULATORY ARREST
Innominate artery cannulation for cardiopulmonary bypass and antegrade cerebral perfusion in hypothermic circulatory arrest has been utilized at our institution as an alternative to axillary artery cannulation in patients undergoing thoracic aortic procedures.
Data was collected on the 6 patients that underwent innominate artery cannulation for cardiopulmonary bypass and antegrade cerebral perfusion during hypothermic circulatory arrest. Patient demographics, indications for surgery, the type of procedure, cardiopulmonary bypass time, hypothermic circulatory arrest time, and post-operative complications were identified.
All 6 patients were male with a mean age of 64.8 (range 51-75). The indications for surgery were aortic aneurysms; including 2 ascending aneurysms, 3 root/ascending aneurysms, and 1 ascending/arch/descending aneurysm. None of the operations were emergent. Mean hypothermic circulatory arrest with antegrade cerebral perfusion time was 15.3 minutes (range 8-40). None of the patients died. One patient (16.6%) had a post-operative stroke.
MAGNETIC RESONANCE IMAGING FINDINGS OF SPINAL CORD INJURY IN AORTIC SURGERY
We reviewed magnetic resonance imaging (MRI) findings of spinal cord injury in patients undergoing aortic surgery.
Between 2000 and 2012, 746 patients underwent descending or thoracoabdominal aortic surgery (480 open repair and 266 endovascular repair). Twenty-six (3.5%) had spinal cord injury. Of them, 18 (15 open repair and 3 endovascular repair) had postoperative spinal cord MRI. Preoperative identification of Adamkiewicz artery (ARM) was obtained in all patients.
In endovascular repair, sporadic infarction distant from the covered lesion was observed in all. In open repair, sporadic infarction distant from the location of ARM was observed in 5, continuous infarction involving the location of ARM in 6, and conus infarction in 4.
TOTAL PERCUTANEOUS THORACIC ENDOVASCULAR AORTIC REPAIR USING THE PRECLOSURE TECHNIQUE
In recent years, percutaneous approaches have been applied to EVAR, but avoided in thoracic cases due to larger sheath size. We hypothesized that percutaneous techniques could be applied to TEVAR safely in appropriately selected patients.
Following an overview of appropriate patient selection and pre-procedural work-up, the percutaneous technique is demonstrated. Highlighted in this video are the technical considerations for device insertion and closure of arteriotomy using the preclosure technique.
Following pre-procedure ultrasound and intraoperative angiogram the patient was determined to be an adequate candidate for percutaneous technique. The preclosure technique for total percutaneous TEVAR is then demonstrated with successful closure of the arteriotomy following stent delivery with a 24Fr sheath.
MYOCARDIAL PROTECTION WITH CUSTODIAL HTK VS PLEGISOL: COMPARISON OF EARLY OUTCOMES FOLLOWING ELECTIVE ROOT AND ASCENDING REPAIRS
Custodial (HTK) solution has been shown to be an effective agent for protection of transplanted organs with ischemic times regularly over 3 hours. We hypothesize that HTK provides excellent myocardial protection with longer times between doses during elective root and ascending aortic surgery.
Retrospective review of 34 patients from 9/11 to 11/12 that presented for elective root or ascending aortic repair of aortic aneurysms was conducted. Patients given 2 liters of HTK initially with redosing of 0.5-1L at 1 hour (n=19) was compared to patients that received standard cold blood-plegisol at 20 minute intervals (n=15). Post-operative ionotropic requirements, ICU stay, hospital stay and duration intubation were compared.
Myocardial ischemia by cardiopulmonary bypass, cross-clamp and hypothermic circulatory arrest times did not significantly differ between the groups. Nor was there a significant difference in inotropic requirements, duration of ventilator support or hospital and ICU stay. Average time for cardioplegia delivery was significantly less in the HTK group compared to plegisol group.
NOVEL APPLICATION OF ACETAZOLAMIDE TO REDUCE CEREBROSPINAL FLUID PRODUCTION IN PATIENTS UNDERGOING THORACOABDOMINAL AORTIC SURGERY
To report acetazolamide (ACZ) application in thoracoabdominal surgery (TAS) aiming to improve cerebrospinal cord perfusion pressure and reducing risk of paraplegia.
1) In patients were a spinal drain couldn't be positioned; 2) Blood stained CSF; 3) CSF volume drained was outside guidelines; 4) Elevated CSF pressure 5) Excessive vasopressor usage 6) Postoperative neurological dysfunction as measured by MEP or clinical examination. All were given ACZ 500mg IV, not more than 8 hourly, for a response dependent duration.
In 6 patients, 2 received single dose of ACZ, with immediate drop in ICP. Among 4 with multiple doses, 1 had ICP immediate decline after each of the first 6 doses, while 3 had no discernable response.
AORTIC ARCH REPLACEMENT (AAR): CONTEMPORARY OUTCOMES AND 5 YEARS SURVIVAL - LIVERPOOL EXPERIENCE
To evaluate mortality and 5 years survival in patients undergoing AAR in the elective (EL) and non-elective (N-EL) setting.
Between (1999-2011), in-hospital outcomes and follow up survival were stratified by EL and N-EL for total (T-AAR) & hemiarch (H-AAR). Kaplan-Meier used for Actuarial survival (AS).
221 underwent AAR. 92 underwent T-AAR and 129 H-AAR. 27 (T-AAR) and 16 (H-AAR) were performed (N-EL). In-hospital mortality in the EL and N-EL TAAR and HAAR groups was 7.7% (5/65), 29.6% (8/27), 1.8% (2/113) and 25.0% (4/16) respectively. Stroke rate- 3.1% (2/65), 18.5% (5/27), 3.5% (4/113) and 12.5% (2/16) respectively. For the whole cohort the AS at 1 year was 87% and 72% at 5 years. 1 year AS in the EL and N-EL T-AAR and H-AAR groups were 88%, 70%, 92% and 75%, respectively. 5 year AS was 69%, 70%, 77% and 50%, respectively.
THE FATE OF THE ELEPHANT TRUNK (ET): A KEY QUALITY MARKER IN AORTIC SURGERY
Entire Aortic Aneurysms require 2 Stage operations. Failure to progress between stages is a failure of assessment, treatment and a quality marker of service.
Between (1999 - 2011), 221 patients underwent arch surgery, 92 total arch (TA), 129 hemiarch (HA). ET used: conventional (n=33), frozen (n=13) and reverse (n=5).
Our elective mortality-7.7% (TA) and 1.8% (HA). In conventional ET, 6 died in-hospital after stage 1, (elective: 4/20, non-elective: 2/13). All 4 elective mortalities had aneurysmal size (AS) viable for stage 2. From 27 survived, 11 proceeded to stage 2 based on AS >6.5cm. The median interval between stages was 8.9 months. In-hospital mortality at stage 2: (elective: 1/9, non-elective: 1/2). 16 patients are suspended between stages because no indication for advancement due to AS or died (3/16) in community. In frozen ET; 1 death & 2 endoleaks. No adverse outcomes in the reverse ET.
SURGERY FOR ACUTE TYPE A AORTIC DISSECTION (ATAD): HOW MUCH DOES QUALITY COST? A UK FIRST COST-ANALYSIS STUDY
We investigated whether a subspecialized on-call aortic rota (SOCAR) would impact the cost of ATAD repair (ATADR).
135 patients underwent ATADR (1999-2012). Since 2007, 55 had ATADR; 29 (53%) had concomitant aortic valve and root replacement (AVRR). Before 2007, 80 had ATADR, 39 (49%) had concomitant AVRR. Patient Level Information & Costing System (PLICS) was used to estimate the cost for 99 patients before 2010 & actual cost for 36 patients since 2010. The driving costs were hospital & ITU length of stay (LOS) and operating times (OT).
2 comparator groups were established, ATADR +/- AVRR. 68 underwent ATADR+AVRR and 67 without AVRR. The average relevant cost (ARC) for 39 ATADR+AVRR before SOCAR -£44,094 & for 29 since SBS -£40,388. ARC for 41 ATADR without AVRR before SBS was £28,220 & for 26 since SBS- £32,009. ATADR+AVRR- ARC decreased by £3,705, ATADR without AVRR- ARC increased by £3,788. Over all ARC- cost-neutral (CN).
BRIDGE-USE OF AORTIC STENT-GRAFT FOR BLUNT TRAUMATIC AORTIC INJURY IN THE YOUNGER PATIENTS
TEVAR has been rapidly adopted as an alternative to the traditional open aortic repair (OAR) for treatment of traumatic aortic injury (TAI). However, long-term efficiency of TEVAR for the younger patients remains unclear.
Between 9/03 and 12/12, 45 patients with TAI were arrived to our institute, including 10 required emergent room thoracotomy (ERT), 8 underwent OAR, and 25 underwent TEVAR as an initial treatment.
Mortality of ERT, OAR, TEVAR group was 100%, 25%, 8%, respectively (p<0.001). However, in TEVAR group, 8 patients required removal of the stent-graft and performed OAR due to migration. High incidence of graft migration was related to acute angulation of the aortic arch in the younger patient. Mean time interval from TEVAR to OAR was 39.5 days, and none of the patient died postoperatively. In younger patients (<40y.o.), 12 of 13 patients underwent OAR, including 5 as an initial treatment and 7 as a secondary treatment.
LONG-TERM OUTCOMES FOLLOWING IMMEDIATE AORTIC REPAIR FOR ACUTE TYPE A AORTIC DISSECTION COMPLICATED BY COMA
Management of acute type A aortic dissection complicated by coma remains controversial. We previously reported an excellent recovery of consciousness for patients with coma if aortic repair performed within 5 hours from onset of symptoms. This study evaluates the early and long-term outcomes with this approach.
Between 9/03 and 1/13, 179 patients with acute type A aortic dissection were treated surgically, including 28 (15.6%) presented with coma (Glasgow Coma Scale <11) on arrival. Twenty-three patients were repaired immediately; time from onset of symptoms to operating room was less than 5 hours in 22 pts. Neurological deficit, such as hemiplegia or concomitant deviation of eyes, coexisted in 74%. For brain protection, deep hypothermia with antegrade cerebral perfusion was utilized and postoperative induced hypothermia for 48 hours was performed.
Time from onset of symptoms to operating room was 204 (SD 60) minutes. Hospital mortality was 13.0%. Full recovery of consciousness was achieved in 83% in 30 days, and the incidence of coexisted neurological deficits was 52%. The mean follow-up periods were 48.7months. Cumulative survival rate was 69.6% in 8 years, and ADL independence was achieved in 63% (12/19).
IMMEDIATE POSTOPERATIVE NEURO-MONITORING FOLLOWING THORACOABDOMINAL ANEURYSM REPAIR - INITIAL EXPERIENCE
Intraoperative Motor Evoked Potential (MEP) monitoring is an accepted adjunct to reduce paraplegia during thoracoabdominal aortic repair. In addition to this we use MEP postoperatively in critical care for neurological assessment. We report of our experience. The effect of postoperative MEP monitoring on inotropes/vasoconstrictor usage was evaluated. A retrospective analysis of two groups; with and without MEP monitoring was conducted. The parameters studied for 96 hours post-operatively are described in Table 1.
|No post-op MEP (n=15)||Post-op MEP (n=15)||p-value|
|Noradrenaline (mg (w/v %))||0.74||0.39||0.48|
|BE (mmol L-1)||0.44||-1.20||0.07|
Six patients in the 'No post-op MEP' group had adrenaline infusion compared to 2 patients in the 'Post-op MEP' group. We observed a trend towards reduced inotrope/vasoconstrictor usage in the 'Post-op MEP' group. With further studies, this may have implications on postoperative management.
THE TRANSAPICAL APPROACH TO TRANSCATHER AORTIC VALVE IMPLANTATION IS SAFE AND ACCEPTABLE: LIVERPOOL EXPERIENCE
Recent trend with aggressive Transfemoral (TF) or a Transaortic (TAo) approach in Transcatheter Aortic Valve Implantation (TAVI) procedure is due to a perceived high risk with the Transapical (TA) approach. We evaluated our experience in this context.
We analyzed prospectively collected data on 68 consecutive patients undergoing TA-TAVI procedure at our hospital between September 2008 and October 2012.
68/118 patients (57.6%) underwent a TA-TAVI procedure. All procedures were carried out using Edwards Sapien™ or Sapien XT™ prosthesis. 50% were female. Mean age was 81.8 ± 6.49 years. The Mean Logistic Euroscores were 25.95 ± 13.3%. 29 patients (42.6%) had undergone previous cardiac surgery. Successful valve deployment was achieved in 94.1%. 30-day mortality was 8.8%. There were no left ventricular apex complications. Both stroke and new renal impairment requiring haemofiltration were 2.9% each. The median ITU and postoperative lengths of stay were 1 days and 8.5 days respectively. 69% of patients were discharged homes.
FIRST IN MAN TRIAL: GIOVANNI TRANSCATHERTER EDWARDS-SAPIENS AORTIC VALVE IMPLANTATION (GTAVI) FOR SEVERE, NON-CALCIFIED AORTIC REGURGITATION (AR) AND DILATED AORTIC ROOT
To date, feasibility for treating aortic incompetence With TAVI has only been demonstrated with the Medtronic Core Valve prosthesis (MCV) in a normal aortic root. We report 5 cases of Edward Sapien implantation for severe AR and dilated aortic root in high risk surgical patients using a novel delivery system (Giovanni delivery system) requiring simultaneous transfemoral and transapical approach All patients had a high perioperative risk for aortic valve replacement (mean logistic EuroSCORE of 36% +/- 12%; Society of Thoracic Surgeons [STS] score 16% +/- 3%) Giovanni Transcatheter aortic valve implantation (GTAVI) is an emerging alternative technique that has shown promise in the treatment of severe aortic regurgitation in patient populations at high risk with conventional surgery.
INITIAL EXPERIENCE OF ATRIAL SEPTAL DEFECT CLOSURE WITH HEARTR OCCLUDER DEVICE
To report the initial experience obtained with the new Heartr Occluder Device for percutaneous closure of the secundum atrial septal defect (ASD).
46 consecutive patients (32 females and 14 males) underwent attempted catheter closure of ASD in a prospective study between November 2005 and July 2008. Mean age was 35.8±15 years (range 9-71 years). The devices used for transcatheter closure were the Amplatzer septal occlude in 33 patients and the Heartr device in 13 patients.
The devices were successfully implanted in 40 patients (6 failure cases). A comparison between the success rates of the two devices revealed no statistically significant difference (P value > 0.05). In one patient, the Amplatzer device embolized to the left ventricle immediately following release due to floppy rims. This patient was successfully treated surgically. In other 5 patients, the devices (4 Amplatzer and 1 Heartr) could not be stabilized in an acceptable position due to the large size of ASD, inadequate rims of the atrial septal defect, or floppy rims. During follow-up (8.5±5.2 months), 2 patients had a small residual shunt and another 2 patients showed a mild compression effect on the aorta.
EARLY BODY REPERFUSION IN HYPOTHERMIC CIRCULATORY ARREST
Early body reperfusion through the side arm of the aortic graft prior to completion of the innominate anastomosis has been utilized at our institution in patients undergoing complex thoracic aortic arch procedures.
Data was collected on 5 patients that underwent early body reperfusion. Patient demographics, indications for surgery, the type of procedure, cardiopulmonary bypass time, hypothermic circulatory arrest time, and post-operative complications were identified.
Three patients were female and 2 were male with a mean age of 65.4 (range 51-73). The indications for surgery were a type A dissection, stenotic bovine trunk, and 3 with ascending/arch/descending aortic aneurysms. One operation was emergent and 1 was urgent. Mean hypothermic circulatory arrest with antegrade cerebral perfusion time was 42.2 minutes (range 28-50). None of the patients died. None of the patients had strokes or paraplegia. Two patients (40%) had acute kidney injury, which resolved.
A SURGICAL STAPLER DESIGNED AND TESTED TO ANASTOMOSE AORTA AND A DACRON TUBE GRAFT
An aortic stapler was developed to anastomose open end of aorta to Dacron tube graft. Its design and function were tested and compared to hand-sewn anastomosis. The basic design of the stapler is a central rod surrounded by ten stapling limbs, which can be closed over the anvil and staples extruded by turning a knob at the back. A tube graft was inserted in the middle of a length of bovine aorta. One side was staple-anastomosed and the other hand-sewn in each of ten experiments. Blood was infused under increasing pressure. It took considerably less time to complete stapled anastomosis compared to hand-sewn side (3 minutes 46 seconds versus 15 minutes 42 seconds). Initial leak occurred at low pressures in the hand-sewn side (mean pressure 40 mmHg) compared to stapled side (mean pressure 70 mmHg). The stapling device performed well in all cases except when the bovine aorta was uneven and too thick for the staples (two cases) or a missed branch at the anastomotic site (1 case). These experiments validate the concept and the design of this aortic stapler.
CAUSES OF DEATH IN SURGICALLY TREATED PATIENTS WITH TYPE A AORTIC DISSECTION - A TEN-YEAR REVIEW
We sought the causes of death in surgically treated patients with type A aortic dissection.
We retrospectively reviewed for the 211 consecutive patients who were admitted with aortic dissection to a large community hospital over a ten-year period. Type A dissection patients who underwent surgery were analyzed.
Of the 211 patients, 92 had type A dissections. 68 of the patients had aortic surgery, 35 have since then expired since the date of surgery. Average patient age was 63.07 years, and 48.6% of patients expired during the same admission (compared to 51.4% discharged patients). The top three causes of death for in-hospital patients were malperfusion (17), heart failure (2), and aortic rupture (2). For discharged patients the top three causes were unknown causes (12), malperfusion (3), and heart failure (3).
DE-BRANCHING OF THE AORTIC ARCH DURING THORACIC ENDOVASCULAR AORTIC REPAIR
Aortic arch diseases are difficult to treat with open surgical repair. We evaluated aortic arch de-branching with thoracic endovascular aortic repair (TEVAR) as an emerging alternative to treat this problem.
We retrospectively reviewed our seven consecutive TEVAR de-branching patients from January 2010 to June 2011 at our institution from electronic medical records and office charts.
All patients were male. The mean age was 72.6 years (range 57-83). Co-morbid conditions were HTN, PVD, COPD, CAD, history of tobacco use, and history of abdominal and thoracic aortic aneurysm. Postoperative complications included atrial fibrillation (n=5), acute renal failure without requiring dialysis (n=2), mental status changes (n=1), ventricular tachycardia in (n=1) and aortic rupture (n=1). Length of hospital stay ranged from 6-10 days. In-house post-operative mortality was 14.3% (n=1).
THE RECENT OUTCOME OF OPEN REPAIR FOR ABDOMINAL AORTIC ANEURYSM
The aim of this study is to analyze the recent surgical results of abdominal aortic aneurysm (AAA) open surgical repair at EVAR era. Since 2009, a total of 278 open repair for AAA were performed electively (mean age 69.9±11.0, range 23 to 93, male 239). Degenerative aneurysms were in 232 patients (83.5%), dissecting aneurysms in 26 (9.4%), and inflammatory aneurysms in 12 (4.3%). Reconstruction included interposition of straight graft in 76 patients (27.3%) and Y-graft in 202 (72.7%). Inferior mesenteric artery was reconstructed in 86 patients (30.9%), internal iliac artery in 40 (14.4%) and renal artery in 6 (2.2%). The operation time was 224±71 minutes (range, 82-440 minutes). Hospital mortality was 0%. Postoperative complications were respiratory failure in 5 patients (1.8%), transient renal failure in 10 (3.6%) and lower limbs ischemia in 3 (1.1%). The late complications needed surgery were abdominal incisional hernia in 5 patients (1.8%), anastomotic pseudoaneurysm in 1 (0.3%), obstruction of the graft in 1 (0.4%) and graft infection in 1 (0.4%). Although EVAR has emerged as a less invasive alternative, open repair for AAA still remains a robust strategy.
EASIER, QUICKER AND MORE EFFICIENT AORTIC-PROSTHESIS ANASTOMOSIS IN TOTAL ARCH REPLACEMENT WITH ELEPHANT TRUNK. “EX-VIVO” SWINE MODEL
Open thoracic aorta prosthetic substitution still carries significant mortality and serious complications risk, in particular to CNS. Risk is mostly correlated to the length of clamping/circulatory arrest time, i.e. essentially to the time required for vascular anastomosis construction. We developed devices for easier, quicker and more efficient aortic-prosthesis anastomosis based on a new working principle: i.e. compression of vascular stump between inner (nitinol wireframe) and outer structures (external ligature or nitinol wireframe) instead of sewing with full-thickness perforation of the vessel wall. The device consists of loops of nitinol wires, wrapped within a Dacron fabric, and connected to a prosthesis end (Type I and III). The nitinol wire loops can be expanded and tightened by activating a removable guide in such a way that device varies its diameter, while maintaining a regular cylindrical shape. This allows the easy and quick insertion of the retracted device into the vascular stump and then its expansion to perfectly fit with the vessel diameter. Hemostasis and permanent device fixation are provided by external ligature & suture. Three main models (Type I, II and III) applying the same working mechanism, but with different configurations, allow to fit with all aorta segments as well as special conditions of use. Device type I, previously connected with a tube graft end, is used for the first anastomosis, either proximal or distal; device type II is then used for the second anastomosis after having tailored the graft tube at its appropriate length. Device type III is ideally used for anastomosis in dissection cases, allowing in particular to include even the concavity of arch. Single graft layer type I devices for small diameters (6-14mm) can be used for supra-aortic trunks.
Purpose of this video is to show “ex-vivo” swine model simulation of full aortic arch replacement with a combinations of graft/devices assemblage that allows positioning of the elephant trunk, buttressing at once with anastomosis of tube graft to distal arch and supraortic trunks connections in a very simple, easy and quick way. In fact the regularly expandable configuration of the ring allows to solve all the insertion, positioning and stability problems of the 70ies intraluminal prosthesis. That makes performing anastomosis a very simple task, which can be carried out in seconds vs the 10-15 min per anastomosis at best required with hand suture. The aortic wall being not perforated by the suture, the coupling is immediately blood-thigh (“air-tight” in fact) and then independent by the integrity of the physiological coagulation mechanisms. The same technique can be advantageously applied in thoraco-abdominal aortic substitution In summary the favorable effects on complications rate, particularly in aortic arch substitution, related to circulatory arrest, hypothermia, CNS perfusion and dissection layers reconstructions can be expected due to: 1 - dramatic reduction of the time required for completing aortic prosthetic anastomosis because of a) great simplification of anastomosis technique which is performed at once with b) double strip graft vascular stump buttressing (video) and c)“air-tight” sealing dissection layers re-approximation 2 - easy and quick supraortic trunks anastomosis previously prepared on the main tube graft (video). Anastomosis immediate blood-tightness not dependent on coagulation integrity may predictably decrease intra- and postoperative blood losses. Use of these devices may also enhance mini-invasive access in prosthetic open substitution of any aortic segments. (Fig & video)
ENDOVASCULAR NET PROSTHESIS FOR PREVENTION OF ANEURYSM FORMATION IN MARFAN AND OTHER GENETIC DISORDERS OR FOR VERY EARLY STABILIZATION OF OTHER ANEURYSMS
The relative slowness of aneurysm formation and progression to rupture indicates that the decrease in the strength of the arterial wall under the aneurysm formation threshold may be very gradual and limited. Consequently one can imagine that measures to in- crease, even moderately, the mechanical strength of the arterial wall, for example by means of a Dacron fabric network, should be successful in preventing aneurysm formations and thus its complications (dissection and rupture), without necessarily requiring complete prosthetic substitution. The experimental hypothesis is based on the fact that the net prosthesis positioned and maintained in stable contact with the aortic walls (fig 1-A) is spontaneously, gradually covered by the neo-intima (fig 1-B) (as constantly happens with all tube graft currently in use), invaded by fibroblasts and thus stably associated to the aortic wall (fig 1-C).
A significant advantage of this approach is that, if the net mesh is appropriately dimensioned, it may be expected that the blood flow through the collateral branches is not significantly affected (B-arrows), thus allowing application in all aortic tracts overcoming limitations of cur- rent endovascular techniques; moreover this may be the only method theoretically able to fully prevent spinal cord ischemic injury.
The structural properties of the aortic wall associated to the intraluminal net prosthesis rely on three factors (fig 2): -1) the structural properties of the net prosthesis, -2) the structural properties of the aortic wall, -3) the strength of the bonds between the aortic wall and the net prosthesis, based substantially on fibroblastic invasion of the net fabric and its permanent integration with aortic wall.
Given the structural adequacy of the net prosthesis (1) (polypropylene thread diameter 0.5mm, mesh 5x5mm) and its mechanical effect of fractioning the aortic wall in the small area of the net mesh (2), crucial to this model is aorta-prosthesis bond (3). In fact if this link is sufficiently strong and stable in the time, it can be hypothesized of being able to stabilize aortic wall and prevent dilatation even independently from the true diameter of the “net” prosthesis, which could not be further distended after that their meshes have been firmly integrated into the aortic wall. The practical consequence is that the precise equivalence between diameter of the net prosthesis and aortic diameter would not be necessary; the prosthesis in fact could be significantly redundant in respect to the effective aortic diameter, thus allowing for its easier adaptability to geometrical irregularity of vascular wall, with- out consequences on its efficiency in keeping stable aortic diameter. Interestingly enough in this model the endovascular net prosthesis pro-vides aortic wall mechanical support just where the mechanical stress is higher, and thus just where it's most needed both to prevent further dilatation and to avoid partial (dissection) or total rupture, with the minimal amount of prosthetic material (approximately ≤1/6th of current endoprosthesis volume).
ENDOVASCULAR AORTIC REPAIR FOR SARCOMA INVASION OF THE AORTA
Secondary sarcoma invasion to arteries are known to lead to rupture and present technically challenging problems in lieu of definitive resection. We report our experience of EVAR in patients with sarcoma invasion of the aorta and iliac arteries.
Materials and Methods:
A retrospective case review was performed of patients undergoing EVAR for sarcoma involving the aorta and iliac arteries.
Patient 1 is a 54 year-old male with a paraspinal sarcoma invading the descending thoracic aorta with resultant pseudonaeurysm development; he underwent TEVAR and successful exclusion. Patient 2 is a 65 year-old male with chondrosarcoma encasing the left iliac artery; EVAR was undertaken prior to definitive tumor resection. Patient 3 is a 58 year-old male with a leiomyosarcoma invading the infrarenal aorta; EVAR was performed to prevent continued aortic erosion. All procedures were technically successful. There were no perioperative deaths or complications.
OUTCOMES OF MEDICALLY MANAGED CAROTID ARTERY DISSECTION AFTER ACUTE AORTIC DISSECTION
Aortic dissections can extend into branch vessels, including the common carotid arteries. Although several reports describe repair of carotid artery dissection after aortic repair, the natural history and risk of stroke is unclear. We examined our cases of common carotid artery dissection (CCAD) after acute aortic dissection repair to determine risk of postoperative stroke and need for carotid revascularization.
We queried our cases of type A aortic dissection over a ten-year period from January 2002 to December 2012. Imaging was reviewed to determine presence of CCAD. Analysis was performed to determine risk of stroke on initial presentation and on follow-up.
We repaired 288 cases of type A aortic dissection and identified 44 cases of CCAD (15.3%). Carotid artery dissection was associated with neurologic event on initial presentation (OR...). No patient with CCAD had additional stroke in hospital or on long-term follow-up. One elderly patient had transient ischemic attack nine years after aortic repair.
Cite this article as: Safi HJ, McPherson DD. The Houston Aortic Symposium: Frontiers in Cardiovascular Diseases, the Sixth in the Series March 21–23, 2013. AORTA (Stamford). 2013;1(1):79-87. DOI: NO_DOI
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