Staged single-port thoracoscopic R2 sympathicotomy as a reproducible, safe and effective treatment option for debilitating severe facial blushing.

OBJECTIVES: Our goal was to investigate the safety, feasibility, success rate, complication rate and side effects of staged single-port thoracoscopic R2 sympathicotomy in the treatment of severe facial blushing. Facial blushing is considered a benign condition; however, severe facial blushing can have a major impact on quality of life. When nonsurgical options such as medication and psychological treatments offer no or insufficient relief, surgical treatment with thoracoscopic sympathicotomy should be considered. METHODS: All patients who underwent a staged thoracoscopic sympathicotomy at level R2 for severe facial blushing between January 2016 and September 2021 were included. Clinical and surgical data were prospectively collected and analysed. RESULTS: A total of 16 patients with low operative risk (American Society of Anesthesiologists class 1) were treated. No major perioperative complications were encountered. One patient experienced postoperative unilateral Horner's syndrome that resolved completely after 1 week. Two patients experienced compensatory hyperhidrosis. The success rate was 100%. One patient experienced a slight recurrence of blushing symptoms after 3 years that did not interfere with their quality of life. All patients were satisfied with the results and had no regrets of having undergone the procedure. CONCLUSIONS: Staged single-port thoracoscopic R2 sympathicotomy is a reproducible, safe and highly effective surgical treatment option with low compensatory hyperhidrosis rates and the potential to significantly improve quality of life in carefully selected patients suffering from severe facial blushing. We would like to increase awareness among healthcare professionals for debilitating facial blushing and suggest timely referral for surgical treatment.

Results of endovascular aortic arch repair using the Relay Branch system.

OBJECTIVES: Our goal was to evaluate results of endovascular aortic arch repair using the Relay Branch system. METHODS: Forty-three patients with thoracic aortic pathology involving the aortic arch have been treated with the Relay Branch system (Terumo Aortic, Sunrise, FL, USA) in 10 centres. We assessed in-hospital mortality, neurological injury, treatment success according to current reporting standards and the need for secondary interventions. In addition, outcome was analysed according to the underlying pathology: non-dissective disease versus residual aortic dissection (RAD) (defined as remaining dissection after previous type A repair, chronic type B aortic dissections). RESULTS: In-hospital mortality was 9% (0% in patients with RAD). Disabling stroke occurred in 7% (0% in patients with RAD); non-disabling stroke occurred in 19% (7% in patients with RAD). Early type IA and B endoleak formation occurred in 4%. Median follow-up was 16 ± 18 months. During the follow-up period, 23% of the patients died. Aortic-related deaths were low (3% in patients with RAD). CONCLUSIONS: The results of endovascular aortic arch repair using the Relay Branch system in a selected patient population with regard to technical success are good. In-hospital mortality is acceptable, the number of disabling strokes is low and technical success is high. Non-disabling stroke is a major concern, and every effort has to be taken to reduce this to a minimum. The best outcome is seen in patients with underlying RAD. Finally, more data are needed.

Total Endovascular Repair of the Aortic Arch: Initial Experience in the Netherlands.

BACKGROUND: We report procedural and early results in the Netherlands of the Relay Branch device (Terumo Aortic, Sunrise, FL) for total endovascular repair of the aortic arch. METHODS: Between 2014 and 2018, all consecutive patients who received the Aortic Relay double-branched stent graft in the Netherlands were included in a multicenter, retrospective registry. RESULTS: The Relay Branch device was used in 11 patients to treat saccular (n = 4), fusiform (n = 5), or false aneurysms (n = 2) in the aortic arch. Patients were deemed unfit or extreme high-risk for open (redo) surgery. The brachiocephalic trunk and left common carotid artery were branched using a retrograde approach in all cases. Additional surgical left subclavian artery revascularization was performed in 8 patients. The main device and the branches were successfully introduced, positioned, and deployed with complete exclusion of the aortic pathology in all patients (100% technical success). There was no retrograde type A dissection or conversion to open surgery. Two procedure-related deaths occurred, both caused by perioperative or postoperative strokes. There were 2 minor strokes with full recovery. One patient recovered from transient paraplegia after spinal fluid drainage. No permanent paraplegia was observed. Follow-up imaging showed persistent adequate exclusion of aortic arch pathology. Mean follow-up was 17 months (range, 3-42 months). CONCLUSIONS: Total endovascular aortic arch repair using the Relay Branch device is technically feasible and effective in excluding aortic arch pathology. The observed stroke rate in the initial experience, however, was considerable. Although appealing, this new less-invasive technique should be carefully introduced and its progress thoroughly evaluated.

Isolated left vertebral artery and its consequences for aortic arch repair.

A left vertebral artery (LVA) originating directly from the aortic arch is the second most common supra-aortic branching anomaly. This isolated LVA can also terminate in the posterior inferior cerebellar artery without contributing to the circle of Willis, limiting treatment options, especially in cases with an incomplete circle. Here, we describe our consideration of the treatment options for a 79-year-old patient with a large distal aortic arch aneurysm combined with an isolated LVA and incomplete circle of Willis that may endanger adequate (intraoperative) cerebral perfusion.

Retrograde Type A Intramural Hematoma Treated Endovascularly in Two Cases.

Type A aortic dissection is a highly lethal condition, which warrants swift open surgical intervention to prevent death by rupture or malperfusion. The aim is to resect the proximal intimal tear and realign the dissected wall layers. We describe two patients who recently presented in our center with a retrograde type A intramural hematoma and a clear intimal tear distal to the left subclavian artery, that were treated in emergency by endovascular means instead of open surgery, with satisfactory short-term and one-year follow-up results. In conclusion, in selected cases, less invasive thoracic endovascular aortic repair can treat retrograde type A intramural hematoma originating from an intimal tear distal to the left subclavian artery, with good one-year results.

The GORE TAG conformable thoracic stent graft with the new ACTIVE CONTROL deployment system.

OBJECTIVE: The aim of this study was to describe single-center intraoperative details and early outcome of the new GORE TAG conformable stent graft with ACTIVE CONTROL (C-TAG ACTIVE CONTROL; W. L. Gore & Associates, Flagstaff, Ariz). METHODS: Between September 2017 and June 2018, a consecutive 30 patients underwent thoracic endovascular aortic repair with C-TAG ACTIVE CONTROL. This new system provides an intermediate deployment step at 50% and optional angulation control of the proximal part of the stent graft. Indications for thoracic endovascular aortic repair varied widely, including chronic postdissection and degenerative aneurysms, complicated acute dissections, and intramural hematomas, among others, in an elective (63.3%), urgent (13.3%), or emergent (23.3%) setting. The proximal landing zone (LZ) was LZ 2 in 23.3%, LZ 3 in 43.3%, and LZ 4 in 33.3%. Data were collected retrospectively and analyzed for technical and clinical success. RESULTS: In all patients, the stent graft was successfully introduced and deployed at the intended position, with complete exclusion of aortic disease and without intraoperative mortality (primary technical success, 100%). One emergent patient died at 2 days of ongoing septic shock (clinical success at 30 days, 96.6%). Median follow-up was 107 days (range, 33-271 days); late mortality was 3.4% (one patient died of stent graft infection at 40 days). Freedom from type I and type III endoleak at the early follow-up was 100%. No patients required other surgical or endovascular procedures for the primary treated aortic disease. CONCLUSIONS: Our reported initial experience in 30 patients with the C-TAG ACTIVE CONTROL showed excellent early results, with high deployment accuracy and conformability. The additional features of staged deployment and angulation control may be of great help in challenging aortic arch diseases, allowing precise positioning and preventing bird-beak effect.

Surgical left subclavian artery revascularization for thoracic aortic stent grafting: a single-centre experience in 101 patients.

OBJECTIVES: To evaluate the indications, perioperative strategy and postoperative outcome of surgical left subclavian artery (LSA) revascularization combined with thoracic endovascular aortic repair (TEVAR) covering the LSA. METHODS: Between 2000 and 2017, a total of 101 consecutive patients underwent surgical revascularization of the LSA prior to, concomitant or following TEVAR. Revascularization was performed through a small supraclavicular incision and consisted of a transposition or bypass graft, using intraoperative transcranial Doppler monitoring. Data regarding indication, procedural details and postoperative results were retrospectively analysed. RESULTS: In total, 63 subclavian-carotid bypass grafts and 38 subclavian-carotid transpositions were performed in the context of TEVAR. The majority was performed prior to stent grafting to reduce the risk of stroke (n = 50), spinal cord ischaemia (n = 20), left arm malperfusion (n = 10) or to preserve a patent left internal mammary artery coronary bypass graft (n = 2). Secondary revascularization was performed in 14 patients, 2 times immediately due to acute left arm malperfusion and 12 times to treat invalidating left arm claudication. No in-hospital mortality and permanent spinal cord ischaemia occurred. Two (2%) ischaemic strokes were observed in patients with concomitant procedures, and none when separate, staged procedures were performed. Additional complications observed were permanent peripheral nerve palsies (9%), chyle leakage requiring diet (6%) and 1 bypass occlusion requiring a redo procedure. CONCLUSIONS: In patients predominantly selected upon the anticipated risk of (posterior) stroke, spinal cord ischaemia and left arm malperfusion, surgical revascularization of the LSA proved to be a safe treatment option to preserve antegrade LSA flow in the context of TEVAR.

Results From a Nationwide Registry on Scalloped Thoracic Stent-Grafts for Short Landing Zones.

PURPOSE: To report the perioperative results and short-term follow-up of patients treated with scalloped thoracic stent-grafts. METHODS: A multicenter registry in the Netherlands captured data on 30 patients (mean age 68 years; 17 men) with thoracic aortic pathology and a short (<20 mm) proximal or distal landing zone who received a custom-made scalloped stent-graft between January 2013 and February 2016. Patients were treated for saccular (n=13) aneurysms, fusiform (n=9) aneurysms, pseudoaneurysms (n=4), or chronic type B dissections (n=4). The scallop was used to preserve flow in the left subclavian artery (LSA) (n=17), left common carotid artery (n=5), innominate artery (n=1), and celiac trunk (n=7). In 7 (23%) patients, the scallop also included the adjacent artery. RESULTS: Technical success was achieved in 28 (93%) patients. In 1 patient, a minor type Ia endoleak was observed intraoperatively, which was no longer visible on computed tomography angiography at 3 months. In another patient, the LSA was unintentionally obstructed due to migration of the stent-graft on deployment. Concomitant carotid-carotid or carotid-subclavian bypass was performed in 4 patients. There was no retrograde type A dissection or conversion to open surgery. In-hospital mortality was 3%, and the perioperative ischemic stroke rate was 3%. At a mean follow-up of 9.7 months (range <1 to 31), 29 of 30 target vessels were patent. CONCLUSION: The scalloped stent-graft appears to be a safe and relatively simple alternative for the treatment of thoracic aortic lesions with short landing zones. Larger patient series and long-term follow-up are required to confirm these early results.

Hybrid repair of a large pseudoaneurysm of the proximal right subclavian artery in a Marfan patient.

A pseudoaneurysm of the proximal right subclavian artery is rare and most commonly caused by penetrating or blunt trauma. We report a case of a Marfan patient with a large iatrogenic pseudoaneurysm of the right subclavian artery, induced by a puncture lesion during central venous catheter placement for an elective endovascular thoracic aortic procedure. The patient was successfully treated with a hybrid approach, which consisted of endovascular coiling and balloon occlusion of the adjacent vessels, followed by open surgical exploration and uneventful closure of the puncture hole with the use of bovine pericardium-reinforced sutures.