Treatment of aortic arch rupture grade III with hybrid arch replacement: the key role of perfusion preservation.

Hybrid arch replacement is a well-accepted method for the treatment of lesions involving the aortic arch, though its benefits compared to classic surgical techniques remain controversial. Multiple surgical approaches have been analyzed in the literature for the treatment of such a challenging pathology. In this case report, we describe the surgical management of a 72-year-old man presenting with a complicated aortic arch rupture. The patient was treated urgently with a type I hybrid arch replacement in two stages, with total preservation of cerebral and systemic perfusion. Our case shows that hybrid arch methods are applicable even in emergency cases.

Current issues on simultaneous TAVR (Transcatheter Aortic Valve Replacement) and EVAR (Endovascular Aneurysm Repair).

Simultaneous EVAR and TAVR is technically feasible and is a reliable option in high-risk patients.

Aortocoronary saphenous vein graft aneurysm misdiagnosed as aortic arch aneurysm.

Coronary artery bypass grafting is the mainstay of revascularization worldwide. However, the most widely used saphenous vein grafts are related to a number of late sequelae. Aortocoronary saphenous vein graft aneurysms mainly diagnosed incidentally are one of these complications. Although rare, given the fatal risk of rupture if left untreated, management either with percutaneous intervention or open redo surgery should be considered. However, no guidelines are established in current scarce literature. Hereby, we present the successful percutaneous management of a huge saphenous vein graft aneurysm via coiling, avoiding the risks of repeat sternotomy.

A multicenter "real-world" study of the valiant NAVION stent graft.

BACKGROUND: The aim of the present study was to evaluate early results of thoracic endovascular aortic repair (TEVAR) using the Valiant Navion™ stent graft in a "real-world" scenario. METHODS: All patients who underwent TEVAR with the Valiant Navion™ endograft between November 2018 and November 2019 were included in this retrospective multicenter study (six European centers). The primary endpoints were technical success, incidence of major adverse events (MAEs), access failure, deployment failure, deployment accuracy, and rate of intraoperative endoleaks (ELs). RESULTS: One hundred-sixteen patients with varying thoracic aortic diseases were included. Eighteen patients (15.5%) were treated for an off-label condition. The technical success rate was 100%, without any access or deployment failures. The proximal and distal deployment accuracy rates were 99.1% and 97.4%, respectively. There were no intraoperative MAEs, including death. Two (1.7%) type Ib ELs were detected at the first postoperative CTA, all of which were in off-label procedures and related to the short length of the sealing neck. No type III ELs were detected. The median hospitalization time was 8 days (IQR 4-12), including a median intensive care unit stay of 1 day (IQR 1-2). The in-hospital mortality rate was 4.3%. At a median follow-up time of 98 days (IQR 39-187), there were no aortic-related mortalities or new onset of endoleaks. CONCLUSION: Our initial experience with the Valiant Navion™ endograft in a wide variety of aortic diseases showed safe early outcomes, especially for on-label procedures.

Preoperative Planning for EndoAnchor Use During Thoracic Endovascular Aortic Repair in the Distal Aortic Arch.

PURPOSE: To describe steps related to intraoperative C-arm orientations that can be taken during preoperative planning of thoracic stent-graft repair to facilitate the deployment of EndoAnchors in the distal aortic arch. TECHNIQUE: Previous experience from transcatheter aortic valve implantation (TAVI) may be helpful in addressing issues with C-arm orientation. In TAVI, preoperative computed tomography (CT) images are routinely obtained to generate a patient-specific curve that represents a virtually complete rotation of the C-arm perpendicular to the annulus. The curve clearly demonstrates that each adjustment in cranial or caudal view needs parallax correction in the left or right anterior oblique direction to remain perpendicular, and vice versa. This experience can be translated to the preoperative planning of EndoAnchor use in the aortic arch. By placing markers along the circumference of the proximal landing zone of the preoperative CT scan, the required C-arm orientations can be determined for each marker. CONCLUSION: Determining the optimal C-arm orientation during preoperative planning will facilitate successful EndoAnchor deployment and may contribute to improved durability of endovascular repair in hostile necks in the aortic arch.

Aortic rupture during endovascular repair of a postoperative coarctation pseudoaneurysm in an adult: Emergency lifesaving stent graft implantation.

We present a case with aortic rupture during an operation of thoracic endovascular aortic repair of an anastomotic pseudoaneurysm. This happened after the use of a low-pressure remodeling balloon inside the covered part of the deployed endografts. It was successfully treated with a second more centrally in the aortic arch-implanted endograft with full coverage of the left subclavian artery orifice. This patient had a history of surgically operated aortic coarctation.

Repair of descending thoracic aortic aneurysms with Ankura Thoracic Stent Graft.

OBJECTIVE: The aim of the study was to present the results for patients with atherosclerotic aneurysm of the descending thoracic aorta (DTA) treated with a novel thoracic stent graft. METHODS: A single-center retrospective review of prospectively collected data was performed. We extracted demographic variables as well as atherosclerotic comorbidities and operation-related and imaging-related data from patients' medical records. We estimated technical success rate, in-hospital and 30-day mortality, and mortality at the end of follow-up as well as complication and reintervention rate in our study cohort. Follow-up computed tomography angiography was performed after 1 month and 6 months and yearly thereafter. RESULTS: A total of 30 patients (80% male; mean age, 73.7 ± 6.33 years) were treated with Ankura Thoracic Stent Graft (Lifetech, Shenzhen, China) for DTA aneurysm from February 2014 until June 2017. Technical success of the thoracic endovascular aortic repair (TEVAR) was 97% (29/30 patients). A surgical conduit was required in one patient; in three patients, we intentionally covered the left subclavian artery because of insufficient proximal landing zone. No aorta-related deaths were recorded during follow-up. During the early postoperative period, two patients (7%) with long DTA coverage developed paralysis or paraparesis, which immediately resolved after lumbar drainage. No renal complications requiring dialysis were observed. One patient (3%) developed postoperative pulmonary infection, whereas access site complications were 7%. Two symptomatic patients treated outside instructions for use (7%) developed early type IA endoleak and one patient (3%) developed type IB endoleak; type II endoleak was recorded in 3% of the study cohort. During the 30-day postoperative period, two patients died of non-TEVAR-related causes, one of gastrointestinal bleeding and the other of pulmonary infection. During a median follow-up of 31.7 (range, 38.4) months, two more patients also died of non-TEVAR-related causes, one of stroke from carotid artery disease and the other of motor vehicle trauma. In the rest of the cohort, no other adverse events were noted. CONCLUSIONS: This novel endograft showed early evidence of a safe, effective, and durable endoprosthesis for the treatment of DTA aneurysms.

Single stage repair for aortic root aneurysm in a patient with coexisting coarctation incorporating the Cabrol technique: a case report.

BACKGROUND: A 44 year old man who presented with a history of chest pain and dyspnoea was found to have an aneurysm of the aortic root, aortic valve insufficiency, and coarctation of the aorta. CASE PRESENTATION: The patient underwent a single stage procedure to treat the aortic root, valve and coarctation with a composite valved conduit and extra-anatomic bypass of the coarctation. The modified Cabrol technique was necessary to attach the coronary buttons due to grossly abnormal anatomy. The patient made a remarkable recovery and was discharged on the 8th post-operative day. CONCLUSION: This case report highlights the feasibility and efficacy of performing a single stage procedure on complex coarctation with associated cardiac defects. To the best of our knowledge, this is the first report of the modified Cabrol technique being used in this particular setting.

Ascending Aorta Endovascular Repair of a Symptomatic Penetrating Atherosclerotic Ulcer with a Custom-Made Endograft.

BACKGROUND: Thoracic endovascular aortic repair (TEVAR) has become lately the procedure of choice in the treatment of most pathologies of descending thoracic aorta. Aortic arch aneurysms also came to be treated by TEVAR with various hybrid techniques or custom-made scalloped/fenestrated stent grafts. Zone 0; ascending TEVAR is more challenging than TEVAR of the descending thoracic aorta or aortic arch because of the more complex pathology, hemodynamics, and anatomy. Ascending TEVAR can be a lifesaving treatment in selected high surgical risk patients. CASE REPORT: A 71-year-old male with known history of respiratory insufficiency, coronary artery disease, and low left ventricle ejection fraction, presented to emergency department with acute thoracic pain. As the initial laboratory tests and the electrocardiogram were negative for acute coronary syndrome, a computed tomography (CT) scan was performed that showed a 20 mm large and 17 mm depth penetrating atherosclerotic ulcer (PAU) in the middle portion of ascending thoracic aorta. After medical therapy administration, the thoracic pain was controlled, and due to the high surgical risk of the patient, high incidence of aortic rupture due to PAU, and favorable anatomic conditions was scheduled the implantation of a custom-made (due to short ascending aorta) stent graft (Bolton, Relay Plus). A pacemaker was implanted 1 week before the operation to induce rapid ventricular pacing during the stent-graft deployment. During the operation, the patient was under general anesthesia as it was our first case treated in this way. The delivery of the graft was achieved through a right femoral artery cut open by an extra-stiff guide wire (Lunderquist Cook) that was placed through an angio-catheter into the left ventricle of the heart. The final positioning and deployment of the graft was achieved under rapid ventricular pacing, and the final angiogram after the withdraw of the graft delivery system showed exclusion from circulation of PAU, patency of coronary arteries, and brachiocephalic trunk with competent aortic valve. CONCLUSIONS: TEVAR of the ascending aorta is a safe and feasible technique indicated mainly unfit for open surgery patients.

The Bolton Treo endograft for treatment of abdominal aortic aneurysms: just another trimodular platform?

INTRODUCTION: The Treo abdominal aortic stent graft system (Bolton Medical, Barcelona, Spain) is a trimodular endovascular endoprosthesis recently introduced for the endovascular repair of abdominal aortic aneurysms (AAA). It presents some unique structural characteristics such as the combination of suprarenal and infrarenal fixation, variability of the main-body length, lock-stent mechanism in the iliac limbs to enhance their stability. Areas covered: This article discusses the technical features and clinical performance of Treo as well as the interesting hemodynamic consequences of its design. Expert commentary: The Treo aortic stent-graft provides accurate deployment, secure proximal seal and fixation as well as efficient conformability in angulated necks. Early results drawn from single-center studies are promising with acceptable technical and clinical success. Moreover, the custom-made solution provided with the Treo platform is one of the most intriguing challenges in current endovascular era and is expected to broaden significantly the armamentarium of endovascular specialists.

Ascending Aorta to Hepatic and Mesenteric Artery Bypassing, in Patients with Chronic Mesenteric Ischemia and Extensive Aortic Disease-A Case Report and Review of the Literature.

Chronic mesenteric ischemia (CMI) is a rare disorder caused by severe stenosis of the mesenteric arterial supply that results in postprandial pain and weight loss. Treatment options are surgical or endovascular. Surgical bypass can be performed in an antegrade fashion from the supraceliac abdominal aorta (AA) or the distal descending thoracic aorta or in a retrograde fashion from the infrarenal aorta or the common iliac artery. However, in some patients with disease of the descending thoracic aorta or the AA, another site for the proximal anastomosis needs to be found. In this article, we report the case of a 69-year-old man with a thoracoabdominal aortic aneurysm and CMI in whom we performed bypass grafts to the hepatic and superior mesenteric arteries using the ascending aorta as the site for the proximal anastomoses via a median sternolaparotomy. In addition, we performed a literature review of all similar cases and provide an analysis of this technique and an assessment of the success rates.

Iatrogenic dissection of the descending aorta: Conservative or endovascular treatment?

Transcatheter aortic valve implantation (TAVI) is without any doubt a standard technique and the treatment of choice of severe aortic valve stenosis (AVS) in very high-operative risk patients. However, a number of complications may occur and has been described. Improper valve position, valve migration, paravalvular regurgitation, conduction disturbances, stroke and aortic dissection have been succeeded despite the perfection of the technique. For anyone of the complications above described, a solution may be invented. We present an interesting case of an 81-year-old woman with severe AVS treated through TAVI due to very high operative risk. This female, 12 days later presented with thoracic pain and shortness of breath and through the computed tomography of the chest performed was diagnosed a dissection of the descending aorta. She successfully underwent on thoracic endovascular aortic repair. In this report, we refer the bibliographic data and we discuss the treatment options in these cases.

Hybrid treatment of a true thyreocervical trunk aneurysm in a patient with Type B aortic dissection.

We would like to describe a case with a complex aortic disease treated in hybrid fashion. We present an interesting case of a 65-year-old man with a medical history of hypertension, hyperlipidemia, and coronary artery disease percutaneously treated. An acute Type B aortic dissection occurred and treated with the implantation of a stent-graft which occluded the left subclavian artery due to its extension to the aortic arch. This event required a carotid-subclavian artery bypass due to ischemia of the left arm. An aneurysm in the innominate artery also detected, was treated with another stent-graft implantation 3 months later. At 5-year follow-up, an aneurysm of the thyreocervical trunk was found while the stent-graft of the aorta was well-tolerated without endoleak and the carotid-subclavian graft was patent. The aneurysm was asymptomatic but considering the risk of spontaneous rupture of an aneurysm of this size, elective surgery was indicated. Because the aneurysm was very close to the brachiocephalic bifurcation, open surgical repair would require a sternotomy. The right common carotid artery and right subclavian artery were exposed. The thyrocervical trunk, right internal mammary artery and right vertebral artery were occluded by ligations to isolate the aneurysm. An 8-mm Dacron graft was anastomosed end-to-end to the distal part of subclavian artery. We would like through this case, discuss the role of the hybrid cardiovascular surgery to minimize the postoperative complications in complex cardiovascular pathology. We also discuss the international bibliography about the thyreocervical trunk aneurysm and the treatment options.

Lipomatous hypertrophy of the interatrial septum and fibrosing mediastinal lymphadenopathy causing superior vena cava obstruction.

Lipomatous hypertrophy of the interatrial septum (LHIS) is an uncommon cause of superior vena cava syndrome (SVCS). Fibrosing mediastinal lymphadenopathy is another cause of SVCS. We present a 65-year-old female patient with a history of tuberculosis (TB) and the coexistence of LHIS and fibrosing mediastinitis due to TB of the lung. Fibrosing or sclerosing mediastinitis is a rare entity with few cases published in the western literature. She presented with mild symptomatology of SVCS and she underwent on transthoracic and transesophageal echocardiography, computed tomography scan, magnetic resonance imaging, and venography. Due to the development of an abundant collateral venous system seen on venography and her negation for any treatment, she did not undergo yet on any intervention. To our knowledge, this is the first case reported in the international bibliography in which LHIS and sclerosing lymphadenopathy are simultaneously diagnosed in the same patient.

Papillary fibroelastoma of the aortic valve in a ß-thalassemia patient.

Papillary fibroelastomas are uncommon benign tumors with frond-like growths usually arising from the heart valves. The identification of their presence is of major clinical importance owing to the fact that although rarely symptomatic they can cause coronary occlusion, stroke, and even sudden cardiac death. We present an asymptomatic 38-year-old woman with homozygous ß-thalassemia in whom transthoracic echocardiography incidentally discovered an aortic mass. Two-dimensional echocardiography and magnetic resonance imaging confirmed the diagnosis of papillary fibroelastoma. Valvesparing tumor resection, even in asymptomatic patients, is recommended as the standard therapy procedure.

Cor triatriatum presenting as heart failure with reduced ejection fraction: a case report.

Cor triatriatum is a rare congenital cardiac malformation and it usually refers to the left atrium. We report an unusual case of cor triatriatum in a 33 - year old woman presented with congestive heart failure caused by left ventricular systolic dysfunction.

Frozen Elephant Trunk: a technique which can be offered in complex pathology to fix the whole aorta in one setting.

We report a case of treating complex aortic pathology with the use of the Frozen Elephant Trunk technique in a patient with chronic type B aortic dissecting aneurysm associated with arch and ascending aorta dilatation, proximal aortic disease and coronary disease. The case was further complicated due to the involvement of the abdominal vessels and preexisting femoral to femoral crossover bypass. In addition the patient had a tracheostomy for laryngeal cancer.We emphasize the role of the Frozen Elephant Trunk to fix the whole aorta in one setting with special attention given to the changes taking place in vascular perfusion following correction and reconstitution of the true lumen.