Prospective Single-Arm Trial of Endovascular Mechanical Debulking as Initial Therapy in Patients With Acute and Subacute Lower Limb Ischemia: One-Year Outcomes.

PURPOSE: To report the results of a prospective, single-arm study to establish whether the initial treatment of acute or subacute limb ischemia (ALI and SLI, respectively) can be accomplished successfully using endovascular mechanical debulking of the target vessels to avoid the risks associated with thrombolysis and/or open surgery. MATERIALS AND METHODS: From April 2009 to April 2015, 316 consecutive patients (mean age 70.9±12 years; 184 men) with ALI (202, 63.9%) or SLI (114, 36.1%) were enrolled; the only exclusion criterion was irreversible ischemia. The ALI group included 146 (72.3%) participants with category IIb ischemia and 56 (27.7%) with category IIa. Critical limb ischemia was diagnosed in 74 (64.9%) of the 114 patients with SLI. Target occlusions of thrombotic (n=256) or embolic (n=60) origin were located in the femoropopliteal segment (n=231), prosthetic or venous femoropopliteal bypass grafts (n=75), and the aortoiliac segment (n=35). The mean occlusion length was 22.9±14.8 cm. RESULTS: The overall technical success (residual stenosis ≤30%) was 100% after debulking and adjunctive techniques (aspiration, dilation, stenting) at the level of the target lesions. No open surgical or thrombolytic modalities were necessary to bypass or recanalize the target vessels, and no death occurred in association with target occlusion therapy. Additional infrapopliteal interventions were performed in 195 (61.7%) patients (adjunctive thrombolysis in 29) to treat acute, subacute, and chronic lesions. Minor complications directly related to the debulking procedure occurred in 26 (8.2%) patients. Serious complications occurred in 11 (3.5%) patients, including hemorrhage in 8 (2.5%) patients (associated with infrapopliteal thrombolysis in 5). At 30 days, primary and secondary patency rates were 94.3% and 97.2%, respectively; mortality was 0.3% (1 fatal intracranial hemorrhage after adjunctive thrombolysis). Of 229 patients eligible for 1-year follow-up, amputation-free survival was estimated to be 87.4% in 199 patients with available data. CONCLUSION: In this all-comers study, mechanical debulking with the Rotarex alone or with adjunctive techniques is feasible as a primary therapy for occluded supratibial vessels in patients with ALI or SLI.

Video-assisted multivessel revascularization through a left anterior small thoracotomy approach with the Symmetry Aortic Connector System.

OBJECTIVE: We sought to demonstrate the applicability of video-assisted multivessel revascularization through a left anterior small thoracotomy approach with the use of the Symmetry Aortic Connector System (St Jude Medical Anastomotic Technology Group, Inc, St Paul, Minn) as an alternative to the standard median sternotomy approach and to evaluate predischarge angiographically documented graft patency. METHODS: From October 2001 through February 2002, a total of 15 patients with triple-vessel disease were operated on through a left anterior small thoracotomy approach with video-assisted port-access construction of proximal aorta-to-saphenous vein anastomoses with the Symmetry Aortic Connector System and cardiopulmonary bypass with femoral cannulation and without cardioplegic arrest. There were 9 male and 6 female subjects with a mean age of 68.3 +/- 3.6 years and an average ejection fraction of 55.8% +/- 19.6%. Subject inclusion criteria consisted of female sex (initially but not throughout the study), coronary artery reoperations, and sternal bone disease. Subject exclusion criteria consisted of an age younger than 65 years, extensive atheromatous plaques in the ascending aorta, and aortoiliac occlusive disease. All but 1 patient underwent angiographic patency evaluation before discharge. RESULTS: Fifteen operations were performed successfully without any deaths. Twenty-nine sutureless proximal anastomoses were performed, with an average of 3.13 +/- 0.62 distal anastomoses per patient. Eleven (73%) patients underwent a fast track protocol with extubation in the operating room. We did not observe any instances of low cardiac output syndrome, stroke, renal insufficiency, wound complication, or perioperative myocardial infarction. A single episode of atrial fibrillation occurred in this group. Angiographic assessment of 44 bypass grafts and target arteries was performed, and 86% of those examined were widely patent (FitzGibbon score A). CONCLUSIONS: We have demonstrated a potential advantage of the sutureless Symmetry Aortic Connector System as a suitable approach that affords minimal access. Video-assisted multivessel revascularization through a left anterior small thoracotomy approach with an automated mechanical anastomosis device is particularly useful in patients undergoing coronary artery bypass reoperations or those at risk of poor sternal healing or infection. This approach seems to be a safe alternative to standard median sternotomy.

Port access video-assisted proximal anastomosis with the symmetry aortic connector in MIDCABG procedure.

We present an alternative way to create a video-assisted port access proximal anastomosis in the ascending aorta with the Symmetry Bypass System Aortic Connector (St. Jude Medical ATG, St. Paul, MN). This technique was successfully used in a patient undergoing urgent minimally invasive direct coronary artery bypass grafting (MIDCABG), in whom the left internal mammary artery was not harvested owing to subtotal occlusion of the left subclavian artery. Port access use of mechanical anastomotic devices may increase the indications for minimally invasive coronary artery surgery.

New fibrillin gene mutation - possible cause of ascending aortic dilation in patients with aortic valve disease: Preliminary results.

BACKGROUND: Approximately 10% of patients who undergo surgery for aortic valve disease (stenosis or regurgitation) suffer from ascending aortic dilation (AAD). A possible genetic etiology of AAD associated with aortic valve disease has been repeatedly mentioned in the literature, but a specific responsible gene mutation has not been described. METHODS: In the present study, two groups of patients were compared, all of whom underwent surgery for aortic valve disease. Group A was a cohort of 27 patients who suffered from aortic valve disease associated with AAD. Group B was a cohort of 29 patients with structural aortic valve disease, but without concomitant AAD (control group). Genomic DNA was extracted from the white blood cells of peripheral blood samples and was amplified using primers specific for chosen exons of the fibrillin-1 gene, including their intron/exon boundaries. Exons 26 and 27 were selected for analysis. RESULTS: Analysis of the intronic part situated close to exon 27 showed insertion of cytosine between nucleotide 37 682 and 37 683 of query sequence. This insertions was classified as IVS 37 682 and 37 683insC. This mutation was found in all 27 patients from group A (patients with structural aortic valve disease accompanied by significant AAD). The abovementioned mutation was not found in any of the 29 patients from group B. CONCLUSIONS: This finding has potential implications for risk stratification and therapeutic targeting not only for patients with existing disease, but also for the general population. Future studies are needed to determine the clinical utility of the finding; however, the present hypothesis needs to be verified by further molecular studies.