Hemodynamic Implications of STABILISE Technique for Aortic Dissection Repair.

BACKGROUND: The stent-assisted balloon-induced intimal disruption and relamination (STABILISE) technique for treatment of type B dissection has shown promising clinical results at mid-term. Computational modeling is a way of noninvasively obtaining hemodynamic effects, such as pressure and wall shear stress, leading to a better understanding of potential benefits. Particular areas of interest are (1) the effect of intimal disruption and re-lamination and (2) the effect of the bare metal stent in the visceral aortic segment. METHODS: Single-center prospective case series. Data from 5 consecutive locally performed cases of STABILISE technique were analyzed. Included cases were type B aortic dissection with or without prior de-branching. The STABILISE procedure had to be performed without 30-day major complications. Preoperative and postoperative imaging data for each patient were transferred to the biomedical engineering team. Each case was reconstructed, meshed, and simulated with computational fluid dynamics using patient-specific data (heart rate, blood pressure, height, and weight). Hemodynamic parameters were then extracted from the simulations. RESULTS: In all cases, computational analysis showed for postoperative patients: (1) a drop in pressure difference between lumina and (2) lower wall shear stress effects, compared to their preoperative status. These observations were most pronounced in the visceral aortic segment. CONCLUSIONS: Computational modeling shows favourable changes in the flow dynamics of type B dissection treated using the STABILISE technique. This may suggest protective effects of this technique for long-term aortic healing and cicatrization.

Trends in the incidence, surgical management and outcomes of type B aortic dissections in Australia over the last decade.

OBJECTIVES: This study aims to investigate the incidence and in-hospital outcomes of surgical repair for type B aortic dissection (TBAD) in Australia. METHODS: Data were obtained from the Australasian Vascular Audit (AVA) and the Australian Institute of Health and Welfare (AIHW). The former is a total practice audit mandated for all members of the Australian and New Zealand Society for Vascular Surgery (ANZSVS) while the latter is an independent government agency which records all healthcare data in Australia. All cases of TBAD which underwent surgical intervention (endovascular or open repair) between 2010 and 2019 were identified using prospectively recorded data from the AVA (New Zealand data was excluded). The primary outcomes were temporal trends in procedures and hospital mortality; secondary outcomes were complications and risk factors for mortality. All admissions and procedures for, and hospital deaths from, TBAD in Australia were identified in AIHW datasets using the relevant diagnosis and procedure codes, with age-standardized rates calculated for the period 2000-01 to 2018-19. RESULTS: A total of 567 cases of TBAD underwent vascular surgical intervention (AVA data, Australia). Of these, 96.3% were treated by endovascular repair. There was an increase in the annual procedure number from 45 in 2010 to 88 in 2019. In-hospital mortality was 4.8% for endovascular repair and 19% for open repair (p = 0.021). From 2000-01 to 201819, the age-standardized procedure rates for TBAD (Australia) doubled, the proportion of admitted patients undergoing a procedure rose from 28% to 43%, and in-hospital deaths fell by 25%. CONCLUSION: There has been an increasing incidence of vascular surgical intervention for TBAD in Australia. The majority of patients received endovascular therapy while the mortality from surgically managed TBAD appears to be falling.

Surgical Decision Making in Uncomplicated Type B Aortic Dissection: A Survey of Australian/New Zealand and European Surgeons.

OBJECTIVE: There is controversy about the role of pre-emptive thoracic endovascular aortic repair (TEVAR) in uncomplicated type B aortic dissection (TBAD). The aim was to understand expert opinions and the factors influencing decision making. METHODS: In 2018, surgeons from Australia/New Zealand (ANZ) and Europe (EUR) were contacted to participate in an online survey which comprised questions about preferences for pre-emptive TEVAR, followed by five case scenarios, and two ranking questions for anatomical and technical risk factors respectively. Case 1 was designed to favour TEVAR in a hypertensive patient with partial false lumen thrombosis and large diameter (aortic ≥ 40 mm, false lumen ≥ 22 mm). Case 2 had no risk factors mandating TEVAR, according to current evidence. Cases 3, 4, and 5 were designed to test one risk factor respectively, large entry tear on the inner aortic curvature (≥10 mm), partial false lumen thrombosis, and large diameter alone. RESULTS: There were 75 responses, 42 from EUR and 33 from ANZ. Almost half of surgeons (49.3%) endorsed pre-emptive TEVAR with 82.3% preferring to perform TEVAR in the subacute phase. In Case 1 and 5, 58.3% and 52.8% of surgeons respectively chose TEVAR, the highest rates obtained in the survey. Cases 1 and 5 included large diameters ≥40 mm, which were ranked the highest in importance when surgeons considered anatomical risk factors. Surgeons who recommend pre-emptive TEVAR were more likely to choose TEVAR in both Case 1 (83.3% vs. 33.3%, p < .001, 95% CI 27.6%-65.8%) and Case 5 (69.4% vs. 38.2%, p = .008, 95% CI 8.2%-50.0%). CONCLUSION: In this survey about uncomplicated TBAD, about half of surgeons recommended pre-emptive TEVAR in selected cases. The surgeon's predisposition towards intervention and large diameters appear to be the most influential factors in decision making. These findings underline the uncertainty in today's practice and emphasise the need for better predictive tools.

Antimicrobial stewardship opportunities among inpatients with diabetic foot infections: microbiology results from a tertiary hospital multidisciplinary unit.

Among 125 inpatients with diabetic foot infections managed by a multidisciplinary foot ulcer unit, knowledge of methicillin-resistant Staphylococcus aureus colonisation status assisted decision-making to prescribe appropriately or with-hold empiric anti-methicillin-resistant Staphylococcus aureus therapy. Despite adherence to national guidelines, apparent overuse of anti-pseudomonal therapy was frequent, providing potential antimicrobial stewardship opportunities.

The "fenestrated inside fenestrated" stent graft solution for therapy-resistant type Ia endoleak after fenestrated endovascular aortic aneurysm repair.

Endoleaks combined with increasing sac size following endovascular aneurysm repair require reintervention to prevent secondary aneurysm rupture. For standard infrarenal stent grafts, there are multiple treatment strategies available. However, in the presence of a fenestrated or branched stent graft, options are limited. We describe a novel challenging approach to treat a persistent type Ia endoleak by placing a second fenestrated stent graft into the pre-existing one, thus, realigning the graft and extending the proximal sealing zone.

Hard to diagnose and potentially fatal: slow aortic erosion post spinal fusion.

BACKGROUND: Delayed aortic injuries are a rare, but well-recognized complication of spinal surgery. They are a result of slow erosion of osteosynthesis material into the aorta. Although this is a life-threatening complication, patients might present years later with nonspecific symptoms. OBJECTIVE: A complex case of slow aortic injury after thoracic spinal surgery is presented, which highlights the challenges involved in diagnosis and treatment. CASE REPORT: A 62-year-old man had a T6 vertebrectomy and T5-7 anterior spinal fusion for multiple myeloma 5 years earlier. Two years postoperatively, the patient developed intermittent hemoptysis that triggered several presentations to the emergency department and consecutive hospital admissions during a 3-year period. All investigations, including endoscopy, bronchoscopy, and repeated chest computed tomography (CT) scans, were unremarkable. Eventually, the patient presented with frank hemoptysis associated with severe left-sided chest pain. Urgent CT angiography revealed a pseudoaneurysm measuring 34 × 20 mm at the level of the vertebrectomy. The patient underwent emergency surgery and an endoluminal stent graft was successfully placed. The patient remains well after 6 months. CONCLUSIONS: The close proximity of the aorta and spine entertains the risk of aortic injury associated with vertebral osteosynthesis. Long-term complications of slow aortic erosion are extremely difficult to diagnose. The presented patient suffered from an undetected bronchio-aortic fistula with consecutive pseudoaneurysm formation and rupture. Awareness of slow aortic erosion is important for correct diagnostic pathways and subsequent early diagnosis to ensure a positive outcome for the patient.

Carotid endarterectomy: where do we stand at present?

PURPOSE OF REVIEW: The introduction of endovascular techniques and improvements in the medical management of atherosclerotic carotid lesions have led to changes in the modern management of stroke. The purpose of this review is to summarize the latest developments in surgical carotid intervention and highlight the current controversies. RECENT FINDINGS: The predominant controversies that dominate the correct surgical management of carotid atherosclerotic disease are: Notwithstanding the results of the Carotid Revascularisation Endarterectomy versus Stenting Trial, does carotid artery stenting produce equivalent outcomes to surgical carotid endarterectomy? Should recent developments in best medical management of these lesions and changing socioeconomic factors restrict the indication for surgical intervention for asymptomatic lesions? What is the ideal time frame for carotid interventions in symptomatic patients? SUMMARY: There is insufficient current or historic evidence to resolve these controversies and further large randomized controlled trials are therefore required. The current knowledge limits are explored.

Chimney stent technique for treatment of severe abdominal aortic atherosclerotic stenosis.

Application of the "chimney" stent technique is described in a case of complex multilevel atherosclerotic disease involving the juxtarenal aorta. A patient with significant comorbidities was unsuitable for major open reconstructive surgery. He was treated with a combined procedure consisting of chimney stent placement in the juxtarenal aorta, iliac "kissing" stent placement, and right-sided common femoral artery (CFA) replacement. This case shows that the chimney stent technique can be a feasible alternative to leaving a safety wire in the renal arteries and observation during primary angioplasty in complex atherosclerotic lesions of the abdominal aorta.

Clinical Outcomes of Ambulatory Endovascular Treatment Using 4-French and 6-French Femoral Access Strategies: The Bio4amb Multicentre Trial.

PURPOSE: Ambulatory peripheral vascular interventions have been steadily increasing. In ambulatory procedures, 4F devices might be particularly useful having the potential to reduce access-site complications; however, further evidence on their safety and efficacy is needed. MATERIALS AND METHODS: BIO4AMB is a prospective, non-randomized mulitcentre, non-inferiority trial conducted in 35 centres in Europe and Australia comparing the use of 4F- and 6F-compatible devices. The main exclusion criteria included an American Society of Anaesthesiologists class ≥ 4, coagulation disorders, or social isolation. The primary endpoint was access-site complications within 30 days. RESULTS: The 4F group enrolled 390 patients and the 6F group 404 patients. Baseline characteristics were similar between the groups. Vascular closure devices were used in 7.7% (4F group) and 87.6% (6F group) of patients. Patients with vascular closure device use in the 4F group were subsequently excluded from the primary analysis, resulting in 361 patients in the 4F group. Time to haemostasis was longer for the 4F group, but the total procedure time was shorter (13.2 ± 18.8 vs. 6.4 ± 8.9 min, p < 0.0001, and 39.1 ± 25.2 vs. 46.4 ± 27.6 min, p < 0.0001). Discharge on the day of the procedure was possible in 95.0% (4F group) and 94.6% (6F group) of patients. Access-site complications were similar between the groups (2.8% and 3.2%) and included predominantly groin haematomas and pseudoaneurysms. Major adverse events through 30 days occurred in 1.7% and 2.0%, respectively. CONCLUSIONS: Ambulatory peripheral vascular interventions are feasible and safe. The use of 4F devices resulted in similar outcomes compared to that of 6F devices.

Covered Stenting as Bail-Out Technique for Central Venous Catheter Malposition Within the Brachiocephalic Trunk.

Central venous catheter (CVC) insertion with ultrasound guidance is routine clinical practice in the critically ill patient. Arterial malposition is serious and may lead to severe complications such as hemorrhage, stroke, or death. We describe a bail-out technique for removal of right-sided CVC that was mispositioned into the brachiocephalic trunk (BCT) at the origin of the right common carotid artery (CCA). Covered stenting of the BCT extending into the CCA in combination with plug embolization of the right subclavian artery was utilized.

Management of acute type B aortic dissection.

BACKGROUND: The best management of acute uncomplicated type B aortic dissection is currently a controversial area. Recent advances in endovascular intervention have begun to establish pre-emptive thoracic endovascular aortic repair as a potential strategy. A review about the management for type B aortic dissection has been conducted. METHODS: A narrative review consisting of 157 original articles, meta-analyses and guidelines was conducted. The findings were synthesized and summarized using 70 articles. RESULTS: There are clear guidelines directing surgical management of acute complicated type B aortic dissection. However, the best management of acute uncomplicated disease is more ambiguous, which is especially concerning in a condition which is associated with significant morbidity and mortality. Medical management alone is generally favoured. Endovascular intervention is now being considered by some surgeons, but it can be technically difficult, while exposing the patient to potential surgical risks. CONCLUSIONS: Clinical and anatomical risk factors have been identified to help vascular surgeons make decisions about treatment in acute uncomplicated type B aortic dissection. New endovascular strategies are being developed to reduce surgical risk and address technical challenges. Registry data should be used to support future best management.

Spray on skin for diabetic foot ulcers: an open label randomised controlled trial.

BACKGROUND: One Australian loses a limb every 3 h as a result of infected diabetic foot ulcers (DFU). This common condition accounts for substantial morbidity and mortality for affected individuals and heavy economic costs for the health sector and the community. There is an urgent need to test interventions that improve wound healing time, prevent amputations and recurrent ulceration in patients presenting with DFU whilst improving quality of life and reducing health care costs. METHODS: One hundred and fifty eligible participants will be randomised to receive an autologous skin cell suspension, also termed 'spray-on' skin (ReCell®) or standard care interventions for their DFU. The primary outcome is complete wound healing at 6 months, but participants will be followed up for a total of 12 months to enable secondary outcomes including total overall costs, ulcer free days at 12 months and quality of life to be assessed. DISCUSSION: Outpatient costs for dressings, home nursing visits and outpatient appointments are key cost drivers for DFU. If spray-on skin is effective, large cost savings to WA Health will be realised immediately through a shortened time to healing, and through a higher proportion of patients achieving complete healing. Shortened healing times may enable participants to return to work earlier. Any economic benefits are likely to be amplified across Australia and other similar demographic settings where aging populations with increased diabetes rates are considered major future challenges. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12618000511235. Registered on 9 April 2018.

The current management of carotid atherosclerotic disease: who, when and how?

Ischaemic stroke represents a major health hazard in the western world, which has a severe impact on society and the health-care system. Roughly, 10% of all first ischaemic strokes can be attributed to significant atherosclerotic disease of the carotid arteries. Correct management of these lesions is essential in the prevention and treatment of carotid disease-related ischaemic events. The close relationship between diagnosis and medical and surgical management makes it necessary that all involved physicians and surgeons have profound knowledge of management strategies beyond their specific speciality. Continuous improvement in pharmacological therapy and operative techniques as well as frequently changing guidelines represent a constant challenge for the individual health-care professional. This review gives a thorough outline of the up-to-date evidence-based management of carotid artery disease and discusses its current controversies.

Aorto-gastroduodenal bypass grafting for an inferior pancreaticoduodenal aneurysm and celiac trunk thrombosis.

We present a case of a male patient diagnosed with a large inferior pancreaticoduodenal artery (IPDA) aneurysm, associated with a fresh thrombotic occlusion of the celiac trunk. Given the risk of splanchnic ischaemia, radiologic embolisation of the aneurysm combined with celiac axis stenting was deemed unsafe. Management was therefore modified to elective revascularisation of the celiac axis prior to surgical resection of the aneurysm. A retropancreatic aorto-gastroduodenal artery bypass graft was performed prior to exposing and resecting the pancreaticoduodenal artery aneurysm. This ensured near uninterrupted retrograde supply to the celiac axis during the procedure. This is an effective, efficient and expeditious patient pathway for these rare and complex aneurysms complicated by celiac trunk involvement.