Spinal cord ischemia after endovascular repair of thoracoabdominal aortic aneurysms with fenestrated and branched stent grafts.

OBJECTIVE: The aim of this study was to report the incidence and associated risk factors of perioperative spinal cord ischemia (SCI) after endovascular repair of thoracoabdominal aortic aneurysms (TAAAs) with fenestrated and branched stent grafts. METHODS: The study included consecutive patients with TAAA treated with fenestrated and branched stent grafts within the period January 2004 to December 2014. Suprarenal abdominal aortic aneurysms treated with fenestrated and branched grafts, even if including all four visceral vessels, were excluded. Patients who died within 30 days after the procedure were excluded from the analysis for SCI. All data were collected prospectively. RESULTS: A total of 218 patients (167 men; mean age, 68.8 ± 7.5 years) were treated. Thirty-day mortality was 17 patients (7.8%). TAAA distribution among the 201 surviving patients was as follows: type I, n = 17 (8.5%); type II, n = 55 (27.4%); type III, n = 63 (31.3%); type IV, n = 54 (26.9%); and type V, n = 12 (5.9%). In the surviving patients, 21 (10.4%) developed perioperative SCI. At 30 days postoperatively, 13 (6.5%) of those patients had transient lower limb weakness, 5 patients (2.5%) had persistent lower limb weakness requiring assistance to stand or to walk, and 3 patients (1.5%) had persistent paraplegia. Five of the 21 patients awoke from anesthesia with a neurologic deficit. The remaining 16 patients had a later postoperative onset of SCI, with the majority of them (14 of 16) within 72 hours after the operation. Multivariate analysis using logistic regression identified operation time >300 minutes (odds ratio [OR], 7.4; 95% confidence interval [CI], 2.6-21.1; P < .001), peripheral arterial disease (OR, 6.6; 95% CI, 2-21.9; P = .002), and baseline renal insufficiency (glomerular filtration rate <30 mL/min; OR, 4.1; 95% CI, 1.1-16.1; P = .04) as independent risk factors for SCI. CONCLUSIONS: In our experience, most SCI events after endovascular TAAA repair are transient, with persistent paraplegia being rare. Patients with prolonged procedure duration, peripheral arterial disease, and baseline renal insufficiency appear to be at higher risk for development of SCI after endovascular TAAA repair.

Retrograde Target Vessel Catheterization as a Salvage Procedure in Fenestrated/Branched Endografting.

PURPOSE: To present retrograde target vessel catheterization as a bailout technique in fenestrated and branched endografting (F/B-EVAR). METHODS: Between November 2003 and November 2014, 11 (1.6%) of 671 consecutive patients with juxtarenal, suprarenal, and thoracoabdominal aortic aneurysms required retrograde target vessel access as a bailout measure during F/B-EVAR due to failure of an antegrade approach. The target vessels involved the left renal artery (LRA) in 6 patients, the celiac artery (CA) in 3 patients, the right renal artery (RRA) in 1 patient, and both renal arteries in 1 patient. RESULTS: The target vessels were successfully catheterized and secured with stent-grafts in 10 patients; a single case was unsuccessful because the fenestration was in the wrong position and blocked against the arterial wall. One (9.1%) patient died within 30 days. Major perioperative complications occurred in 6 patients, including 3 with renal function deterioration, 2 with access-site wound dehiscence, and a case of pneumonia. Median hospital stay was 20 days (range 7-60) and median intensive care unit stay was 2.5 days (range 0-9). Over a mean 26-month follow-up (range 1-60), one unrelated death occurred. Reintervention was required in 1 patient due to progression of an aneurysm of the right iliac artery. CONCLUSION: Retrograde target vessel access in F/B-EVAR is a feasible bailout procedure when antegrade cannulation fails. Secondary technical success is high, but the procedure is associated with higher perioperative morbidity and longer hospital stay.

Drug utilization of ezetimibe in rehabilitation centres: registry analysis of factors influencing prescription and effectiveness of treatment.

BACKGROUND: While randomized controlled trials (RCTs) generate informative data about clinical outcomes, by their nature they cannot provide information about drug utilization and factors influencing prescribing decisions. In the secondary prevention of patients with cardiac events, lipid lowering therapy with statins and other agents, such as cholesterol absorption inhibitors (CAI, e.g. ezetimibe) plays a pivotal role and is often initiated or modified in rehabilitation centres. The aims of the present study were to analyse factors that influence the prescribing decisions of physicians, and to investigate success rates of lipid lowering therapy with ezetimibe after adjustment for covariates. METHODS: Ninety-three rehabilitation centres throughout Germany documented a total of 17029 patients in cardiac rehabilitation, of which 6976 (41.6%) were prescribed a CAI. A logistic regression model with forward selection based on 31 potential regressors for ezetimibe prescription (demographics, diagnosis, risk factors etc.) was used to construct a propensity score, which reflects the inclination of physicians to prescribe CAI. This score was subsequently used for bias reduction in the comparison of co-medications and success rates. RESULTS: Nineteen variables were associated with ezetimibe prescriptions, the most important ones being total cholesterol, level of education, unstable angina pectoris and arterial hypertension. Ezetimibe was more frequently prescribed together with simvastatin and pravastatin than with other statins, and frequently together with aspirin or beta blockers, respectively. After adjustment for baseline lipid values and covariates, the probability of target level achievement appears to be substantially higher for patients on ezetimibe than for those without ezetimibe. CONCLUSIONS: Other factors than conventional risk factors contribute to the CAI prescription habits of physicians. Additional lipid level reductions due to ezetimibe are seen in routine health care corresponding to findings from randomized studies.

Treatment algorithms for patients with (sub)acute type B aortic dissections.

Aortic dissection is the most common acute aortic syndrome and constitutes a potentially catastrophic cardiovascular condition. Traditionally, complicated acute type B dissection has been considered an indication for surgical treatment, whereas patients with uncomplicated dissection have been treated medically. In recent years, there has been a clear paradigm shift towards endovascular treatment of complicated type B dissection. This is founded in numerous reviews and meta-analyses demonstrating a lower perioperative mortality and morbidity for TEVAR in comparison to open surgical repair. In uncomplicated patients, treatment options are still a matter of debate. Best medical therapy shows acceptable early results with respect to in-hospital mortality and morbidity but fails to address the issue of late aortic expansion and aortic-related adverse events in a significant number of patients. There is increasing evidence that early TEVAR promotes false lumen thrombosis, induces remodeling of the aortic wall and should be considered preventively in selected patients with suitable anatomy. This report gives an overview of current literature on treatment options and optimal time of intervention, and finally proposes a treatment algorithm for acute type B aortic dissection.

Clinical and Doppler ultrasonography data of a polyurethane vascular access graft for haemodialysis: a prospective study.

BACKGROUND: Absence of a permanent vascular access in most patients starting haemodialysis remains a cause of high morbidity and costs. This study obtained new clinical and colour Doppler ultrasound (CDU) data of a polyurethane vascular access graft (PVAG) proposing early post-operative cannulation. METHODS: Baseline characteristics were determined in 15 patients and the PVAGs were evaluated prospectively including first cannulation, patency and complications. CDU was used post-operatively and after 1 year for assessing graft morphology and access blood flow. RESULTS: PVAGs were cannulated at a median of 4 days post-operatively. The 1-year primary patency of the PVAG was 66.7%. During the 15 months observation three grafts thrombosed, one was replaced because of infection and one because of ischaemia. CDU measurements at the feeding brachial artery revealed a mean initial access volume flow of 773+/-89 ml/min, being significantly higher in patients without thrombosis compared to patients with thrombotic events (930+/-90 vs 375+/-143 ml/min, P<0.05). The initial inability to directly monitor PVAGs by CDU changed at sites of frequent centesis, where Doppler signals and luminal morphology could be evaluated in the follow up examination. CONCLUSIONS: The PVAG offers early access for urgent haemodialysis. CDU for access volume flow measurement at the feeding brachial artery contributes to predict access thrombosis. Direct non-invasive graft imaging is limited and the ultrasonographical changes in the polyurethane material enabling graft monitoring after repeated cannulation might indicate an injury of the graft with increased risk for access failure.