Mid-term Outcomes of Endovascular and Hybrid Procedures to Treat Complex Aortic Arch Pathologies.

PURPOSE: To compare the mid-term outcomes of endovascular and hybrid procedures in treating aortic arch pathologies with an unfavorable proximal landing zone, and analyze the different indications of the 2 methods. METHODS: We collected the clinical data from 59 patients with complex aortic arch pathologies who underwent endovascular or hybrid surgery from March 2018 to April 2020 at a single center. Among the patients, 45 were treated by branched or fenestrated surgery and 14 by hybrid surgery. The clinical data of preoperative, perioperative, and postoperative results were retrospectively analyzed and compared. The main study indexes were the branch patency rate and endoleakage rate during the follow-up period. The secondary study indexes included the operation success rate, operative time, hospital expenses, complication incidence, freedom from reintervention rate, mortality, etc. RESULTS: The operation success rate of all the groups was 100%. The hospital expenses of the hybrid group were lower than those of the endovascular group (p<0.05). The operative time of the hybrid group was longer than that of the endovascular group (p<0.05). The incidence of anatomic variants in the hybrid group was 28.6%, which was significantly higher than that in the endovascular group (2.2%, p=0.011). However, there were no significant differences in operative bleeding, ventilator use duration, and treatment time in intensive care units between the 2 groups (p>0.05). Follow-up was conducted for a period of 12 to 34 months. Four patients of the hybrid group experienced numbness of the upper limb (28.57%); the proportion was higher than the endovascular group (0%, p=0.002). There were no significant differences in the occurrence of endoleaks, retrograde aortic dissection, target lesion, secondary operation, branch patency rate, paraplegia, cerebral apoplexy, renal failure, or other complications in either group (p>0.05). The mortality of the endovascular group was 6.67% (3/45). Overall cumulative survival at 1 year was 100% in the hybrid group and 93.3% in the endovascular group. There was no statistical difference in the increase of the true lumen between the 2 groups for vascular remodeling (p>0.05). CONCLUSION: The hybrid surgery costs less and proves more suitable for treating variants of the aortic arch. The endovascular treatment still has limitations due to anatomical conditions.

Primary Aortoduodenal Fistula in a Patient With Multiple Duodenal Diverticula.

A 67-year-old man with massive hematemesis was transferred to the emergency unit of our hospital. The patient was diagnosed with primary aortoduodenal fistula (PADF) based on the CT findings. Upon emergent exploration, multiple duodenal diverticula were found and in situ abdominal aortic aneurysm (AAA) repair using polytetrafluoroethylene (PTFE) graft was performed. The third and fourth parts of the duodenum with multiple duodenal diverticula and the origin of jejunum were excised, and end-to-side duodenojejunostomy was performed. The patient was discharged on the 38th postoperative day with another 6 month oral antibiotic treatment. The duodenal diverticula may be the cause for PADF.

Fenestrated Thoracic Endovascular Aortic Repair Using Physician Modified Stent Grafts for Acute Type B Aortic Dissection with Unfavourable Landing Zone.

OBJECTIVES: The aim was to evaluate the early results of fenestrated thoracic endovascular aortic repair (fTEVAR) using physician modified stent grafts (PMSGs) to revascularise aortic branches for acute type B aortic dissection (ABAD) with unfavourable proximal landing zone. METHODS: Twenty consecutive patients who underwent fenestrated TEVAR using PMSGs between November 2015 and December 2016 were retrospectively reviewed. Pre-, intra-, and post-operative clinical data were recorded. RESULTS: The median patient age was 53 years (range, 18-83 years), and 16 of the 20 (80%) patients were men. Indications were complicated ABAD with unfavourable proximal landing zones, including inadequate proximal landing zone (n = 4), retrograde dissection extending to the left subclavian artery (LSA) (n = 13), and retrograde haematoma involving the LSA (n = 3). Twenty PMSGs (Medtronic Valiant stent grafts, n = 4; Relay thoracic stent grafts, n = 10; Ankura thoracic stent grafts, n = 6) were deployed. One LSA fenestration was created in 19 patients, and one LSA fenestration combined with a left common carotid artery (LCCA) scallop was created in one patient. Branch stents consist of a covered stent for the LSA (n = 7), an uncovered stent for the LSA (n = 14), and an uncovered stent for the LCCA (n = 1). The median duration for stent graft modifications was 40 min (range 30-60 min). The mean interval between symptom onset and treatment was 5 ± 3 days (range, 1-10 days). The initial technical success rate was 90% (18 of 20). Partial coverage of the LCCA in one patient resolved after uncovered chimney stent implantation in the LCCA. Type III endoleak between the LSA covered stent and the PMSG occurred in this patient 1 week post fTEVAR and resolved after re-intervention with deployment of an Amplatzer occluder device across the site of the leak. A chimney stent was deployed to solve the misalignment of the LSA in another patient. The mean operation time was 101 ± 48 min, and fluoroscopy time was 24 ± 16 min. There were no in hospital deaths and no peri-operative neurological complications. The median length of stay was 9 ± 6 days (range, 5-26 days). One patient had a left brachial artery (LBA) pseudoaneurysm at the puncture site that required open repair. One patient presented renal deterioration post-operatively and recovered uneventfully after conservative therapy. All patients survived at a mean follow-up of 6.95 months (range, 2-14 months). During follow-up, no post-operative complications occurred and all target vessels remained patent. No fenestration related Type I or III endoleaks were observed. CONCLUSIONS: fTEVAR using PMSGs may be a viable alternative for patients who present with ABAD without healthy proximal landing zones and who are unable to wait for a custom made fenestrated device.

One-stage supraclavicular hybrid procedure for type B aortic dissection involving three rare anatomical anomalies: a case report and literature review.

Managing type B aortic dissection (TBAD) involving Kommerell's diverticulum (KD), aberrant right subclavian artery (ARSA), and isolated left vertebral artery (ILVA), is extremely challenging. As treatment, we described a one-stage hybrid technique combined with thoracic endovascular aortic repair (TEVAR) with open surgery through a supraclavicular incision. A 57-year-old man with TBAD and the three anomalies successfully underwent hybrid TEVAR. A side-to-side artificial bypass between the ARSA and the right common carotid artery was established through a right supraclavicular incision before TEVAR. The release of the stent-graft was designed from the distal aortic ostium to the left common carotid artery (LCCA) to cover the ILVA, ARSA, and left subclavian artery (LSA). Then, the ILVA and LSA were transposed to the LCCA through a left supraclavicular incision. Intraoperative angiography confirmed complete false lumen exclusion and KD, with all branches patent and without endoleaks. Computed tomography angiography 7 days and 1 year postoperatively demonstrated well-perfused ARSA, LSA, and ILVA, and a fully expanded stent-graft with no endoleaks, migration, disconnection, or stenosis. TBAD involving KD, ARSA, and ILVA in one case is rare. This is the first report to treat this pathology with a one-stage supraclavicular hybrid procedure.

Outcomes of single physician-modified fenestrated stent grafts for endovascular repair of thoracic aortic lesions involving the distal aortic arch.

OBJECTIVES: Our goal was to evaluate the outcomes of fenestrated thoracic endovascular aortic repair of thoracic aortic lesions involving the distal aortic arch using single physician-modified stent grafts. METHODS: This single-centre, retrospective study included 58 consecutive patients (mean age, 57 ± 14 years; 11 women) who underwent fenestrated thoracic endovascular aortic repair for thoracic aortic pathologies involving the distal aortic arch using single physician-modified stent grafts between November 2015 and December 2018. Indications included complicated acute type B dissection or intramural haematoma with an unfavourable proximal landing zone (n = 49), type Ia endoleak subsequent to thoracic endovascular aortic repair due to acute type B dissection (n = 1) and distal arch degenerative aneurysms <15 mm from the left subclavian artery (n = 8). RESULTS: The technical success rate was 94.8%. The 30-day mortality was 1.7%, and the perioperative ischaemic stroke rate was 1.7%. The incidence of perioperative complications was 10.3%. At a mean follow-up of 26.3 months (range, 7-44), all target vessels were patent. All-cause mortality was 5.2%. Estimated 1-, 2- and 3-year survival was 98.3 ± 1.7%, 96.4 ± 2.5% and 93.2 ± 3.9%, respectively. CONCLUSION: The single fenestrated stent graft technique is feasible and effective for endovascular repair of thoracic aortic pathologies involving the distal aortic arch.

Treatment of aortic dissecting aneurysm involving visceral arteries with multi-layer bare stents.

OBJECTIVE: Aortic dissecting aneurysms involving visceral arteries are difficult for clinical treatment. This study aimed to explore the clinical efficacy and safety of multi-layer bare stents technique in the treatment of aortic dissecting aneurysms involving visceral arteries. METHOD: The clinical data of 16 patients of aortic dissecting aneurysm involving visceral artery treated with multi-layer bare stents technique from March 2013 to March 2017 in Tianjin Medical University General Hospital were retrospectively analyzed. To explore the clinical efficacy, the number of stents applied, postoperative aortic dissecting thrombosis and postoperative cumulative branch arterial patency of the16 patients. RESULTS: The operations of the 16 patients were successfully completed without peri-operative death cases. The 16 patients were implanted with 39 bare stents with an average of 2.44 per person. There were 2 cases with 1 stent, 8 cases with 2 stents and 7 cases with 3 stents. One month after the operation, CTA showed complete thrombosis in the arterial dissection in 4 cases (25.0%), partial thrombosis in 12 cases (75.0%); CTA showed that celiac artery, left and right renal arteries, and superior mesenteric artery were all unobstructed. There were 4 cases (25.0%) of dissecting artery with reduced diameter, 12 patients (75.0%) without changes in the diameter, and no diameter expanding cases. CONCLUSION: The treatment for aortic dissecting aneurysm involving the visceral arteries using multi-layer bare stents technique is safe and reliable with a higher patency rate of postoperative accumulated branch arteries.

Fenestrated Thoracic Endovascular Aortic Repair Using Physician-Modified Stent Grafts (PMSGs) in Zone 0 and Zone 1 for Aortic Arch Diseases.

PURPOSE: To evaluate the outcomes of fenestrated thoracic endovascular aortic repair (f-TEVAR) using physician-modified stent grafts (PMSGs) in zone 0 and zone 1 for aortic arch diseases. METHODS: f-TEVAR using PMSGs in Z0 and Z1 was performed on ten high-risk patients for open surgery from November 2015 to September 2017. Indications were complicated acute type B dissection (ABAD) with retrograde dissection involving the mid-arch (n = 1), distal arch aneurysms (n = 3), mid-arch aneurysms of the inner arch curvature (n = 3) and penetrating aortic ulcer located in the mid- or proximal arch (n = 3). Pre-, intra- and postoperative clinical data were recorded. RESULTS: The median patient age was 61 (range 45-81) years, and 9 (90%) patients were men. Ten PMSGs (Medtronic Valiant stent grafts, n = 1; Relay thoracic stent grafts, n = 4; Cook TX2 device, n = 5) were deployed. PMSGs were deployed from Z0 and Z1 in 5 and 5 patients, respectively. Double small fenestrations for the left subclavian artery (LSA) and the left common carotid artery (LCCA), respectively, were created in 3 patients. Triple small fenestrations for the innominate artery (IA), the LCCA and the LSA, respectively, were created in 2 patients. One large fenestration for both the IA and the LCCA combined with one small fenestration for the LSA was created in 3 patients. One large fenestration for the LCCA combined with one small fenestration for the LSA was created in 2 patients. Posterior diameter-reducing ties were added to all the devices except to one Valiant stent graft. All but 2 patients underwent elective procedure. Median duration for stent graft modifications was 105 (range 90-125) min. The technical success rate was 90%. Overall mortality was 10% (1/10). One patient died of sudden cardiac arrest intraoperatively after the deployment of the PMSG and all the supra-aortic branch stents. Mean operative time was 106.0 ± 43.0 min, and fluoroscopy time was 30.6 ± 22.9 min. There were no type I or type III endoleaks, perioperative neurological complications or spinal cord ischemia. Median length of stay was 8 (range 4-35) days. Nine patients survived at mean 13.3 (range 6.0-19.0) months follow-up. Retrograde dissection occurred in one patient of Z0 group 40 days post-f-TEVAR and resolved after open repair. During follow-up, all target vessels remained patent without fenestration-related type I or III endoleaks. CONCLUSIONS: f-TEVAR using PMSGs in Z0 and Z1 for the treatment of aortic arch diseases in high-risk patients is feasible in the hands of experienced operators.

Endovascular treatment of primary mycotic aortic aneurysms: a 7-year single-center experience.

Objective This study was performed to assess the efficacy and outcome of endovascular aneurysm repair (EVAR) for treatment of primary mycotic aortic aneurysms (PMAAs). Methods Fourteen consecutive patients who presented with PMAA from April 2010 to July 2017 were retrospectively reviewed. Preoperative, intraoperative, and postoperative clinical data were recorded, and late infection-related complications and long-term survival were assessed. Results The aneurysms were located in the abdominal aorta in 10 patients and in the left common iliac artery in 4 patients. Positive microbial cultures were found in 12 patients, including Salmonella species in 11 and Streptococcus in 1. The remaining two patients had negative culture results. Ten patients received preoperative antibiotics before elective EVAR for 7 ± 9 days after admission. Four patients who underwent emergent EVAR due to ruptured aneurysms were given their first dose of antibiotics before EVAR. Three patients underwent surgical drainage, and six underwent percutaneous drainage within 30 days after EVAR. No death occurred within 30 days of the initial procedure. The mean follow-up was 34.8 (range, 3-84 months). One patient underwent re-intervention to resolve obstruction of the iliac/femoral artery 5 months postoperatively. Relapse of infection occurred in six patients (42.8%) during follow-up; infection-related death occurred in three of these patients. The other patients recovered with either conversion to open radical surgery or medical therapy. The actuarial 7-year survival after EVAR was 75.7%. Conclusions EVAR and aggressive antibiotic therapy might be suitable for PMAAs. Favorable results may be typical for infection caused by Salmonella.

Treatment for thoracoabdominal aortic aneurysm by fenestrated endovascular aortic repair with physician-modified stent graft.

Despite being widely used for several years, the endovascular aortic repair (EVAR) of a thoracoabdominal aneurysm (TAAA) remains challenging, particularly the revascularization of the abdominal aortic visceral branches. A 66-year-old male was admitted to hospital with abdominal bloating and pain. Computed tomographic angiography (CTA) confirmed a Crawford type III TAAA from the distal descending aorta to the suprarenal abdominal aorta that involved the celiac axis, accompanied with an occlusion of the left subclavian artery. Fenestrated-EVAR was performed successfully and 1 week later CTA showed a type III endoleak, which had resolved 3 months later, without stent migration or visceral artery occlusion. In this present case, the surgeons preferred to perform the procedure in three surgical stages, postponing the deployment of a covered stent in the CA fenestration to provide additional time for the development of collateral circulation to the spinal cord as a possible means of preventing postoperative paraplegia.

Inhibition of myeloid differentiation factor 88 signaling mediated by histidine-grafted poly(ß-amino ester) ester nanovector induces donor-specific liver allograft tolerance.

Toll-like receptors (TLRs) activate biochemical pathways that evoke activation of innate immunity, which leads to dendritic cell maturation and initiation of adaptive immune responses that provoke allograft rejection. We aimed to prolong allograft survival by selectively inhibiting expression of myeloid differentiation factor 88 (MyD88), which is an essential adaptor in TLR signaling. We designed and synthesized a novel histidine-grafted poly(ß-amino ester) (HGPAE) nanovector, which was shown to be safe and efficient both in vitro and in vivo for the delivery of a plasmid containing shRNA targeting MyD88 (pMyD88). We also demonstrated that the pMyD88/HGPAE complex mediated remarkable inhibition of MyD88 expression in rat liver in vivo. We transplanted Dark Agouti rat livers lacking MyD88 as result of transfection with the pMyD88/HGPAE complex into Lewis rats. The recipients survived longer and graft rejection of the donor liver as well as serum levels of IL-2 and IFN-γ in the recipient were significantly reduced.

Obstructive jaundice due to von Hippel-Lindau disease-associated pancreatic lesions: A case report.

von Hippel-Lindau (VHL) disease is an autosomal dominantly inherited neoplastic syndrome that may lead to pancreatic masses and obstructive jaundice. The present study describes the case of a 20-year-old male who suffered from obstructive jaundice due to VHL disease-associated pancreatic lesions whose primary symptom was dizziness, followed by the appearance of jaundice. Since the excision of the renal cell carcinomas was not possible, the patient also refused surgery to resect the pancreatic head mass. A metallic stent was placed at the stenosis site of the common bile duct. Percutaneous transhepatic cholangiography (PTCD) surgery was later performed following complete blockage of the stent, however, to date, the patient continues to rely on PTCD. VHL disease-associated pancreatic lesions are rarely the direct cause of mortality, however, obstructive jaundice due to these lesions may be lethal. Therefore, the treatment of patients with incurable renal or central nervous system tumors and obstructive jaundice presents a problem.

Treatment of aortic dissecting aneurysm involving visceral arteries with multi-layer bare stents

SUMMARY OBJECTIVE: Aortic dissecting aneurysms involving visceral arteries are difficult for clinical treatment. This study aimed to explore the clinical efficacy and safety of multi-layer bare stents technique in the treatment of aortic dissecting aneurysms involving visceral arteries. METHOD: The clinical data of 16 patients of aortic dissecting aneurysm involving visceral artery treated with multi-layer bare stents technique from March 2013 to March 2017 in Tianjin Medical University General Hospital were retrospectively analyzed. To explore the clinical efficacy, the number of stents applied, postoperative aortic dissecting thrombosis and postoperative cumulative branch arterial patency of the16 patients. RESULTS: The operations of the 16 patients were successfully completed without peri-operative death cases. The 16 patients were implanted with 39 bare stents with an average of 2.44 per person. There were 2 cases with 1 stent, 8 cases with 2 stents and 7 cases with 3 stents. One month after the operation, CTA showed complete thrombosis in the arterial dissection in 4 cases (25.0%), partial thrombosis in 12 cases (75.0%); CTA showed that celiac artery, left and right renal arteries, and superior mesenteric artery were all unobstructed. There were 4 cases (25.0%) of dissecting artery with reduced diameter, 12 patients (75.0%) without changes in the diameter, and no diameter expanding cases. CONCLUSION: The treatment for aortic dissecting aneurysm involving the visceral arteries using multi-layer bare stents technique is safe and reliable with a higher patency rate of postoperative accumulated branch arteries.

RESUMO Objetivo: Aneurismas dissecantes da aorta envolvendo artérias viscerais são de difícil tratamento clínico. O objetivo deste estudo foi explorar a eficácia e segurança clínica da técnica de stents multicamadas não farmacológicos para o tratamento de aneurismas dissecantes da aorta envolvendo artérias viscerais. Métodos: Foi feito um estudo retrospectivo usando os dados de 16 pacientes com aneurisma dissecante da aorta envolvendo artérias viscerais e tratados com stents multicamadas não farmacológicos de março de 2013 a março de 2017, do Hospital da Escola de Medicina da Universidade de Tianjin. Foram analisados nos 167 pacientes: a eficácia clínica, o número de stents aplicados, trombose dissecante da aorta no pós-operatório e patência cumulativa pós-operatória do ramo arterial. Resultados: As operações dos 16 pacientes foram concluídas com sucesso sem nenhum óbito perioperatório. Os 16 pacientes receberam 39 stents não farmacológicos, com uma média de 2,44 por indivíduo. Houve 2 casos com 1 stent, 8 com 2 stents, e 7 com 3. Um mês após a operação, a ATC mostrou trombose completa da dissecção arterial em 4 casos (25,0%) e trombose parcial em 12 casos (75%). Também mostrou que a artéria celíaca, as artérias renais direita e esquerda e a artéria mesentérica superior estavam todas desobstruídas. Houve 4 casos (25,0%) de artéria dissecante com diâmetro reduzido, 12 (75,0%) pacientes sem alteração no diâmetro, e nenhum caso de aumento de diâmetro. Conclusão: O tratamento para aneurisma dissecante da aorta envolvendo artérias viscerais com a técnica de stents não farmacológicos multicamadas é seguro e confiável, com uma taxa mais alta de patência de ramos arteriais acumulados no pós-operatório.