Clinical Study on the Management of Aortic Dissection Involving the Aortic Arch through Endovascular Isolation and In Situ Fenestration with Covered Stent.

Objective: This study aimed to investigate the clinical effectiveness of the SilverFlow branch stent through endovascular isolation and in situ fenestration (ISF) for the treatment of aortic dissection (AD) involving the aortic arch. Methods: A total of 21 patients with AD involving the aortic arch, admitted to our hospital between September 2021 and January 2023, were selected for this prospective study. All patients underwent treatment with an endoluminal isolated ISF-covered stent, with the branch stent being the SilverFlow, developed by Shenzhen Xianjian Company. We assessed the success rate of the ISF procedure stent-related complications and compared the volumes of the true and false cavities before and after treatment. Follow-up evaluations were conducted 1, 3, and 6 months post-operation, focusing on neurological complications, mortality, and the need for secondary interventional treatment. Results: Among the 21 AD patients with aortic arch involvement, 20 (95.23%) underwent non-emergency surgery, while 1 (4.76%) required emergency surgery due to cardiac ischemia and signs of dissection rupture. All surgeries were successfully completed. After treatment, the average volume of the true lumen significantly decreased compared to pre-treatment levels, while the volume of the false lumen significantly increased (P < .05). The success rate was 100%, with only one case (4.76%) experiencing type I internal leakage. There were no cases of stent displacement, distortion, or fenestration vessel occlusion. One patient (4.76%) succumbed to acute pericardial tamponade, resulting in a mortality rate of 4.76%. Another patient (4.76%) suffered from upper limb ischemia, significantly improving with antithrombotic drug treatment. No occurrences of stroke, visceral ischemia, or other complications were reported, and no secondary interventional treatments were required. Conclusions: The application of the SilverFlow branch stent for endovascular isolation of ISF in AD cases involving the aortic arch demonstrates a high success rate, low complication and mortality rates, and significant clinical feasibility and value.

Virtual Reality to Ease Endovascular Repair of Thoracoabdominal Aneurysms Under Local Anesthesia.

Purpose: Virtual reality (VR) has both a non-pharmacological analgesic and anxiolytic action that can be used as an alternative to general anesthesia for very high-risk patients. Case report: We present here the case of a patient treated for a complex endovascular thoracoabdominal aortic aneurysm exclusion using a 4-fenestrated aortic endograft using VR. The patient had no postoperative complications and was safely discharged from the hospital on postoperative day 6. Conclusion: This case demonstrates that the use of VR in addition to local anesthesia can be a safe alternative to general anesthesia.

"Awake" Spinal Cord Monitoring Under Local Anesthesia and Conscious Sedation in Fenestrated and Branched Endovascular Aortic Repair.

INTRODUCTION: Endovascular repair of thoracoabdominal aortic aneurysms carries a risk of spinal cord ischemia, the causes of which remain uncertain. We hypothesized that local anesthesia (LA) with conscious sedation could abrogate the potential suppressive cardiovascular effects of general anesthesia (GA) and facilitate intraoperative monitoring of neurological function. Here, we examine the feasibility of this technique during fenestrated (FEVAR) or branched endovascular aortic repair (BEVAR). MATERIALS AND METHODS: Consecutive patients undergoing FEVAR or BEVAR under LA and conscious sedation by a team at a single center were analyzed. Patients received conscious sedation using intravenous remifentanil and propofol infusions in conjunction with a local anesthetic agent. No patient had a prophylactic spinal drain inserted. Outcome measures included conversion to GA, need for vasopressors and/or spinal drainage, length of stay, complications, and patient survival. RESULTS: A total of 44 patients underwent FEVAR or BEVAR under LA and conscious sedation. The cohort included thoracoabdominal aortic aneurysms (n=41) and pararenal aneurysms treated with endografts covering the supraceliac segment (n=3). Four patients (9%) required conversion to GA at a median operative duration of 198 minutes (range 97-495 minutes). Vasopressors were required intraoperatively in 3 of the cases that were converted to GA. No patient developed spinal cord ischemia and none had insertion of a spinal drain. The median hospital length of stay was 4 days (range 2-41 days). Postoperative delirium and hospital-acquired pneumonia was seen in 7% of patients. All patients survived to 30 days, with 95% alive at a median follow-up of 15 months (range 3-26 months). CONCLUSION: LA and conscious sedation is a feasible anesthetic technique for the endovascular repair of thoracoabdominal aortic aneurysms.

A Case Report of Thoracic Endovascular Aneurysm Repair under Local Anesthesia with Resolution of Acute Onset Lower Extremity Paraplegia from an Acute Complicated Type B Aortic Dissection.

Spinal cord ischemia (SCI) is a rare presenting symptom of acute complicated type B aortic dissection, occurring in approximately 3% of patients . We present a case report of a patient with this presentation who had observed resolution of his paraplegia symptoms immediately after placement of a thoracic stent graft under local anesthesia. The temporal association between true lumen flow restoration and paraplegia resolution intraoperatively is a novel finding. We feel that this case report may provide support for recognized cord perfusion theory , as well as contribute to the understanding of the time frame associated with SCI and reversibility of paraplegia.

Type A Aortic Dissection in the United Kingdom: The Untold Facts.

There is a lack of evidence on multiple levels for appropriate recognition, management, and outcome results in Type A aortic dissection management in the United Kingdom. A huge amount of retrospective data exists in the literature which provides nonmeaningful prospect to a service that meets the current era. Electronic searches were performed on PubMed and Cochrane databases with no limits placed on dates. Search terms were charted to MeSH terms and combined using Boolean operations, and also used as key words. Papers were selected on the basis of title and abstract. The reference lists of selected papers were reviewed to identify any relevant papers that might be suitable for inclusion in the study. Papers were selected based on providing primary end points of death, rupture, or dissection and/or information regarding aortic aneurysm growth. Papers were not excluded based on patient population age. We demonstrated the lack of evidence for quality outcomes in type A aortic dissection in the United Kingdom. This highlighted the unwarranted variation seen in this entity and the caveats needed to improve structuring of type A aortic dissection from early identification in emergency departments to arrival at destination site for optimum intervention. Emergency services should be restructured to meet the immediate affirmation of diagnosis with gold standard imaging modality available. Management of this dire disease should be instituted at local hospitals prior to transportation and results should be audited regularly to improve quality outcomes. Attempts should be made to create local area networks to improve the efficiencies and outcomes of the service and transfer to centers with concentration of expertise. Recognition of regional networks by the UK Government Care Quality Commission should in part based on cumulative evidence sought after from virtual multidisciplinary teams. Unwarranted variation is an avenue that requires to be addressed to rise with service provision that meets our patients aspiration and be of current evidence in the 21st era.

Emergent Endovascular Treatment of Thoracoabdominal Aortic Rupture in Behcet's Disease.

BACKGROUND: Aortic rupture in Behcet's disease is associated with high mortality rates. Endovascular approach with parallel graft technique can be a valid solution in emergency setting for the treatment of thoraco-abdominal aorta involvement in Behcet's disease. METHODS: We describe the clinical case of a 41-year-old man, urgently hospitalized for a rupture of thoraco-abdominal aorta with occlusion of the celiac trunk and involvement of superior mesenteric artery. The patient also presented a massive right hemothorax and a massive left pulmonary thromboembolism. An aortic endoprosthesis was deployed from the third bottom of the thoracic aorta to the origin of the renal arteries. Parallel stent-graft technique was used to preserve the patency of the superior mesenteric artery. The procedure was performed with local anaesthesia due to the critical conditions of the patient. The patient was discharged in good clinical conditions. RESULTS: The angio-computed tomography performed 6 months after surgery showed good deployment of the endoprosthesis and patency of the superior mesenteric artery. CONCLUSION: In high risk for surgery patients, endovascular treatment with parallel stent graft of thoraco-abdominal aorta rupture is safe and feasible.

Reversal of Spinal Cord Ischemia Following Endovascular Thoracic Aortic Aneurysm Repair With Hyperbaric Oxygen and Therapeutic Hypothermia.

BACKGROUND: Neurological adverse events with spinal cord ischemia (SCI) remain one of the most feared complications in patients undergoing thoracic endovascular aortic repair (TEVAR). These patients can develop irreversible paraplegia with lifelong consequences with physical and psychological agony. CASE PRESENTATION: We herein present a patient who developed SCI with bilateral lower leg paraplegia on the third postoperative day following TEVAR. Spinal catheter was inserted for spinal fluid drainage. A hyperbaric oxygen therapy was initiated for 90 minutes for 2 days, which was followed by therapeutic hypothermia for 24 hours with a target temperature of 33°C. The patient exhibited significant neurological recovery following these treatments, and he ultimately regained full neurological function without spinal deficit. DISCUSSION: This represents the first reported case of full neurological recovery of a patient who developed complete SCI following TEVAR procedure. The neurological recovery was due in part to immediate therapeutic hypothermia and hyperbaric oxygen therapy which reversed the spinal ischemia.

Diagnosis and treatment of uncomplicated type B aortic dissection.

A type B dissection involves the aorta distal to the subclavian artery, and accounts for 25-40% of aortic dissections. Approximately 75% of these are uncomplicated with no malperfusion or ischemia. Multiple consensus statements recommend thoracic endovascular aortic repair (TEVAR) as the treatment of choice for acute complicated type B aortic dissections, while uncomplicated type B dissections are traditionally treated with medical management alone, including strict blood pressure control, as open repairs have a prohibitively high morbidity of up to 31%. However, with medical treatment alone, the morbidity, including aneurysm degeneration of the affected segment, is 30%, and mortality is 10% over 5 years. For both chronic and acute uncomplicated type B aortic dissections, emerging evidence supports the use of both best medical therapy and TEVAR. This paper reviews the current diagnosis and treatment of uncomplicated type B aortic dissections.

Utility of a preloaded fenestrated graft in thoracoabdominal aneurysm repair.

An 84-year-old man with a thoracoabdominal aortic aneurysm was treated using a fenestrated stent graft with a preloaded guidewire system under local anesthesia. He suffered from severe chronic obstructive pulmonary disease. We successfully placed 4 bridging stent grafts for perfusion of the celiac artery, superior mesenteric artery, and bilateral renal arteries via the 4 fenestrations. A preloaded wire system was used to insert a catheter into the celiac artery from the left brachial artery. Our findings indicate that a fenestrated stent graft with a preloaded wire system may expand the indication for treating thoracoabdominal aortic aneurysms in high-risk patients.

Autologous platelet-rich plasma reduces transfusions during ascending aortic arch repair: a prospective, randomized, controlled trial.

BACKGROUND: Blood conservation using autologous platelet-rich plasma (aPRP), a technique of whole blood harvest that separates red blood cells from plasma and platelets before cardiopulmonary bypass with retransfusion of the preserved platelets after completion of cardiopulmonary bypass, has not been studied extensively. We sought to prospectively determine whether aPRP reduces blood transfusions during ascending and transverse aortic arch repair. METHODS: We randomly assigned 80 patients undergoing elective ascending and transverse aortic arch repair using deep hypothermic circulatory arrest to receive either aPRP (n = 38) or no aPRP (n = 42). Volume of aPRP retransfused was 726 ± 124 mL. The primary end point was transfusion amount. Secondary end points were death, stroke, renal failure, pulmonary failure, and transfusion costs. Perioperative transfusion rate was defined as blood transfusions given during surgery and up to 72 hours afterward. The surgeon and intensivist were blinded to the treatment arm. Because an anesthesiologist initiated the protocol, the surgeon was not aware of aPRP collection, as this occurred only after the sterile drape was in place. In addition, because cell salvage was performed on all cases, differentiation in perfusionist activities (during spinning of aPRP) was not evident. Platelet, fresh frozen plasma, and cryoprecipitate intraoperative transfusions were performed only after heparin was reversed and the patient was judged as coagulopathic on the basis of associated criteria: cryoprecipitate transfusion for fibrinogen level less than 150 µg/dL, platelet transfusion for platelet count less than 80,000, and fresh frozen plasma when thromboelastogram test was suggestive or a partial thromboplastin time was greater than 55 seconds, and prothrombin time was greater than 1.6 seconds. RESULTS: Early mortality, stroke, and respiratory complications were similar between groups. Only acute renal failure was reduced in the aPRP group, 7% versus 0% (p < 0.014). Mean transfusion rate of packed red blood cells was reduced by 34%, fresh frozen plasma by 52.8%, cryoprecipitate by 70%, and platelets by 56.7% in the aPRP group (p < 0.02). Hospital length of stay (9.4 ± 5.3 days versus 12.7 ± 6.3 days; p < 0.014) and transfusion costs ($1,396 ± $1,755 versus $2,762 ± $2,267; p < 0.004) were reduced in the aPRP group. CONCLUSIONS: The use of aPRP reduced allogeneic transfusions during ascending and transverse aortic arch repair with deep hypothermic circulatory arrest. This translated to less acute renal failure, decreased length of stay, and lower transfusion costs. Further studies examining the coagulation factors of aPRP are required.

[Thoracic Endovascular Aortic Repair (TEVAR) Combined with Embolization Technique for Saccular Aortic Arch Aneurysm].

Many of saccular aortic arch aneurysms exist near left subclabian artery(LSA). The thoracic endovascular aneurysm repair( TEVAR) landing on zone 2 is a less invasive and suitable procedure for this type of aneurysm. However, there are several cases with the aneurysm located close to LSA necessitate landing TEVAR on zone 1 or zone 0, otherwise the aneurysm could not be sealed completely. And this procedure seems to increase the invasiveness. In order to complete the sealing of the aneurysm and also keep the less invasiveness, we performed TEVAR using an axillo-axillary bypass or simple occlusion of LSA followed by an embolization using metal coil and NBCA through the catheter which detained in the saccular aneurysm beforehand. We report our experience of seven cases have been successfully treated by this procedure with good results.

Emergency treatment of the thoracic aorta: results in 113 consecutive acute patients (the Talent Thoracic Retrospective Registry).

BACKGROUND: Elective thoracic endovascular aortic repair in selected patients with suitable aortic anatomy is associated with low morbidity and mortality, and is gaining widespread acceptance. Its benefit in acute thoracic aorta diseases, however, has not yet been demonstrated in high-numbered studies. This report presents data of the Talent Thoracic Retrospective Registry (TTR) of all patients who underwent endovascular stent grafting for acute thoracic aorta pathology. METHODS: Between December 1996 and July 2004 data were collected regarding 113 consecutive patients who underwent emergent endovascular stent grafting of the thoracic aorta using the Talent thoracic stent graft (Medtronic, Inc., Santa Rosa, California) in 7 European referral centers. Acute thoracic aorta pathology consisted of 41 (36.3 %) traumatic aortic injuries, 37 (32.7 %) Stanford type B dissections, 5 (4.4 %) intramural hematomas, 18 (15.9 %) thoracic aorta aneurysms, 4 (3.5 %) pseudoaneurysms and 8 (7.1 %) penetrating ulcers. RESULTS: In all patients the stent graft system could be introduced via the common femoral artery. Conversion to open surgical repair was necessary in 2 patients, one in the early phase due to persistent bleeding via backflow in the false lumen from a distal entry tear, and another patient in a late phase due to retrograde dissection. Intraoperative mortality was 1.8%, one patient suffered a massive myocardial infarction, and another died of tamponade secondary to retrograde dissection. Overall hospital mortality was 8.0% (9 patients). In only 2 of them, it was considered a stent graft procedure related death. New neurological symptoms were seen in 6.2% (7 patients), with complete recovery in 5 patients. Mean follow-up was 15 months (range 1-69 months). Late mortality was 8.7% (9 patients). Only one late death was considered aorta related. Overall re-intervention rate was 8.9% (n=10) and was mainly for type I endoleak or persistent false lumen perfusion. CONCLUSION: Sub-analysis of the Talent Thoracic Retrospective Registry for endovascular stent grafting of acute thoracic aorta pathology in over 100 consecutive patients demonstrated its feasibility, with low morbidity and acceptable low mortality rates.

Transfemoral endografting of thoracic aortic aneurysm under local anesthesia: a simple, safe and fast track procedure.

BACKGROUND: Endovascular aneurysm grafting of the descending thoracic aorta is a minimally invasive catheter technique, which is performed under general anesthesia. We describe a technique allowing to perform transfemoral endovascular repair of thoracic aortic repair under local anesthesia. PATIENTS AND METHODS: In 9 consecutive patients local anesthesia was performed in order to gain an opened femoral artery access for the delivery system, and a percutaneous access to the left brachial artery. A pigtail catheter was then placed through the left brachial artery for the location of the origin of the left subclavian artery and/or the aneurysm and self-expanding endoprosthesis was released under fluoroscopic guidance. For the deployment of the endograft a short period of controlled hypotension with nitroglycerin bolus application was produced. RESULTS: All the aneurysms could be successfully sealed with the intended endovascular technique. There was no vascular access complication or pulmonary or ischemic (cardiac, cerebral or peripheral) complication. In the follow-up period of 6 +/- 3 months one patient needed a redo endovascular procedure because of the development of a severe and symptomatic distal endoleak 6 weeks postoperative. This procedure was again performed under local anesthesia. CONCLUSIONS: From a technical point of view, transfemoral endovascular repair of thoracic aneurysm can be performed under local anesthesia. This is a very simple and fast track procedure which combines a minimally invasive catheter technique and a less invasive anesthetic management.