Editor's Choice - Therapeutic Options and Outcomes in Midaortic Syndrome: A Systematic Review and Meta-analysis.

OBJECTIVE: Midaortic syndrome (MAS) is narrowing of the distal thoracic and or abdominal aorta with congenital, inflammatory, or idiopathic aetiology. If left untreated, the prognosis is poor due to hypertensive complications. Follow up data after treatment are sparse, contrary to aortic coarctation. This study aimed to investigate hypertension during follow up after medical, endovascular, and surgical therapy in juveniles and adults. DATA SOURCES: A meta-analysis of case series and reports was performed, focusing on the incidence of hypertension during the follow up of juvenile (i.e., age 0-17 years) and adult MAS patients after medical, endovascular, or surgical therapy. REVIEW METHODS: Search queries were performed in PubMed, Embase, and Web of Science, and eligible articles underwent quality control. Descriptive statistics were reported based on available data, and individual patient data meta-analyses were performed using a one stage approach, accounting for clustering by case series or decades of reporting for case reports. For the meta-analysis, missing outcome and aetiology data were multiply imputed. RESULTS: The number of juveniles and adults who underwent endovascular therapy (33.7% vs. 27.3%; p = .42) and surgery (52.2% vs. 58.0%; p = .46) was similar. At baseline, 92.4% of juveniles and 87.5% of adults were hypertensive, decreasing to 23.2% and 24.1% during a follow up of 23 months (juveniles) and 18 months (adults), respectively. More hypertension was found compared with surgery in juveniles after endovascular therapy (38.1% vs. 10.8%; p = .020). Meta-analysis also demonstrated a trend for hypertension after endovascular therapy in juveniles, whereas hypertension was more prevalent following surgery in adults compared with endovascular therapy or medication. CONCLUSION: This review and meta-analysis investigated therapeutic options for MAS in juveniles and adults. It found that complications and hypertension during follow up were more common in juveniles after endovascular treatment, whereas surgery in adults was associated with more hypertension.

Outcome in Patients after Autologous Femoral Vein Reconstruction for Primary Aortic Infection and Aortic Graft Infection: A Case Series.

BACKGROUND: For surgical treatment of primary aortic infection and aortic graft infection, in situ reconstruction with autologous vein(s) has the lowest rates of re-infection and of graft thrombosis. In this study, we have assessed the outcome after autologous femoral vein reconstruction in patients with aortic (graft) infection and we provide insights into the specific technical surgical considerations of the procedure. METHODS: In this retrospective single-center study, all patients who underwent autologous femoral vein reconstruction because of primary aortic infection or aortic graft infection between January 2012 and January 2020 were included. The primary outcome parameter was 30-day mortality. RESULTS: Twenty-nine patients with autologous femoral vein reconstruction for a primary aortic infection (n = 3) or aortic graft infection (n = 26) were included. An aorto-enteral fistula was detected in 13 patients (49%). Venous reconstruction of the aorta was performed with a single femoral vein in 17 patients (59%), and two femoral veins in 12 patients (41%). Thirty-day mortality was 17%. Relapse of infection occurred in two patients (7%) and no amputations were needed. One year after surgery, only three patients (10%) still needed stockings and after 2 years none of the patients used stockings. CONCLUSIONS: Central aortic reconstruction with femoral veins is a durable solution for primary aortic and aortoiliac graft infections with a low incidence of reinfections, amputations, and venous hypertension.

The efficacy of autologous femoropopliteal vein reconstruction for primary aortic and aortic graft infection.

BACKGROUND: The objective of our study was to analyze the efficacy of autologous superficial femoropopliteal vein reconstruction for primary aortic or aortic graft infection. METHODS: We performed a retrospective analysis of 14 patients treated for an infected aortic prosthesis or primary infected aorta between 2012 and 2014. Three patients had a primary mycotic aneurysm caused by a Salmonella or Coxiella burnetti infection. Seven patients were treated previously for aortic aneurysms with a conventional Dacron vascular prosthesis and 4 with an endovascular prosthesis. All infected prostheses were explanted via median laparotomy with subsequent debridement of the aortic aneurysm wall. Aortic reconstruction was performed with 1 or 2 superficial femoropopliteal veins, interpositioning the greater omentum when possible. The primary outcome measure was 30-day mortality. Secondary outcome measures were reoperation, operating time, amputation rate, length of intensive care unit (ICU) and hospital stay, reinfection rate, and limb edema requiring compression therapy. RESULTS: The 30-day mortality was 28%. Two patients died of an abdominal sepsis, one patient of a cerebrovascular accident and another of a hypovolemic shock. One patient died at home 2 years after surgery of unknown cause. Four patients required a reoperation. The median intraoperative blood loss was 1,500 mL (500-8000). Median operating time was 364 min (264-524). Median length of ICU stay was 3.5 days (1-47), and median hospital stay was 20 days (10-47). There were no limb amputations. Mild edema of the donor leg was documented in 2 patients. Compression stockings were not worn by any patients. Postoperative antibiotic treatment was administered for at least 6 weeks. No recurrent infections were diagnosed. CONCLUSIONS: Autologous venous reconstruction of the aorta offers advantages over other therapeutic approaches and deserves a prominent place in the treatment of the primary infected aorta or an infected aortic prosthetic graft.

Myxomatous Mitral Valve Disease in Large Breed Dogs: Survival Characteristics and Prognostic Variables.

Myxomatous mitral valve disease (MMVD) is the most common acquired heart disease in dogs and its occurrence in small-and medium-sized dogs has been extensively investigated. MMVD has been described in large breed dogs as well, but substantial knowledge gaps remain. The aim of this study was to provide characteristics, survival times, and prognostic variables in large breed dogs with MMVD. Medical records of dogs diagnosed with MMVD, between 2012 and 2021, were retrospectively reviewed and 202 dogs were analyzed. Median survival time (MST) for all-cause mortality was 800 days for stage B1 dogs, 274 days for stage B2 dogs, and 184 days for stage C dogs. The MST for cardiac-related death for B1 dogs could not be calculated (because survival was greater than 50% at the last timepoint) and for stage B2 and C dogs the MST were 484 and 252 days, respectively. These findings suggest that the frequency of cardiac-related death is low in large breed dogs with stage B1 MMVD. In addition, increased left atrial and ventricular size, evidence of systolic dysfunction, a thrilling murmur, and increased early trans-mitral peak velocity are predictors of cardiac-related death. Data also suggest that the risk of a negative outcome increases profoundly when large breed dogs advance from ACVIM stage B1 into stage B2 or C.

Progressive Right Ventricular Obstruction Caused by a Double-Chambered Right Ventricle Resulting in Shunt-Reversal via a Concomitant Congenital Ventricular Septal Defect and Subsequent Erythrocytosis in a Dog.

A 3-year-old Chihuahua was presented because of exercise intolerance, respiratory distress, and syncopal episodes. At the age of 10 weeks, the dog was diagnosed with a congenital small left-to-right shunting ventricular septal defect and a mild right ventricular outflow tract obstruction via echocardiography. At that time, the dog was asymptomatic, but the breeder's veterinarian heard a murmur. Both cardiac defects were judged to be clinically non-relevant at that time. However, at 3 years of age, echocardiography revealed a severe right ventricular obstruction, known as a double-chambered right ventricle, along with right-to-left shunting via the ventricular septal defect. Because of chronic hypoxemia due to the right-to-left shunting, erythrocytosis developed. Flow reversal via the shunt was caused by a progressively worsening right ventricular obstruction leading to a supra-systemic right ventricular systolic pressure. Because of the poor prognosis, the dog was euthanized, and the heart was submitted for post-mortem examination. Gross pathologic findings revealed the close proximity of the right ventricular obstructive lesion to the ventricular septal defect. Histopathology revealed localized muscular hypertrophy and severe endocardial fibrosis. The suspected pathogenesis of the progressive obstruction was infiltrative myocardial fibrosis due to turbulent blood flow from the left-to-right shunting ventricular septal defect, as described in humans.

[Preoperative geriatric screening in care path 'AAA']. / Preoperatieve geriatrische screening in zorgpad 'AAA'.

AIM: Determining the added value of preoperative geriatric screening (POGS) in the care path 'Infrarenal abdominal aortic aneurysm'. DESIGN: Retrospective observational study in a university hospital. METHOD: For patients (>60 years) with non-acute aortic pathology, data on preoperative screening (including frailty measures) and treatment was automatically generated from medical records for the period 2018-2021 (42 months). Data has been analysed with descriptive and test statistics. Completeness of the data was checked manually by reading the medical files for the period 2020-2021 (24 months). RESULTS: A total of 343 cases were included; POGS was performed in 90 patients (26%). In 84.2% of the cases the vascular surgeon adhered to the geriatrician's advice. In the other cases, the treatment is less (10.5%) or more (5.3%) intrusive than the POGS advice; the patient's preference seems to be particular decisive here. The geriatric advice is most consistent with the measures from the Clinical Frailty Scale. From the manual data collection, we learned that about 20% of the POGS were missing. CONCLUSION: Introducing geriatric screening in the care pathway is likely to lead to a more considered choice by healthcare professionals as well as patients. The added value seems embraced by geriatricians and vascular surgeons as the adherence to the geriatric advice is strong. A cardiovascular nurse can use the Clinical Frailty Scale to select the patients that really need a geriatric advice. The advice is to include POGS in the care path 'Infrarenal abdominal aortic aneurysm' and possibly also in other care paths.

A Case of Congenital Pulmonary Vein Stenosis with Secondary Post-Capillary Pulmonary Hypertension and Left Sided Congestive Heart Failure in a Cat.

A five-month-old, 3.8 kg intact male Maine coon cat presented for dyspnea characterized by increased respiratory effort in addition to open-mouth breathing. Thoracic radiographs showed pectus excavatum, enlarged cardiac silhouette, and generalized interstitial patterns. Echocardiography revealed normal left atrial (LA) and left ventricular dimensions. A large tubular structure, suspected to be a distended pulmonary vein (PV), was identified as draining into the LA. Severe eccentric and concentric right ventricular hypertrophy and paradoxical septal motion were noted. Based on Doppler echocardiography, both pulmonary venous and pulmonary artery pressure was severely elevated. Clinical, radiographic, and echocardiographic abnormalities were hypothesized to result from pulmonary vein stenosis (PVS), causing severely elevated pulmonary venous pressures and resulting in clinical signs of left-sided congestive heart failure (L-CHF) and severe post-capillary pulmonary hypertension (Pc-PH). The prognosis for good quality of life was assessed as poor, and the owner elected euthanasia. Necropsy confirmed the presence of PVS with severe dilation of the PVs draining all but the left cranial lung lobe. All lung lobes except the left cranial lobe had increased tissue density and a mottled cut surface. This case report shows that, in rare cases, both L-CHF and Pc-PH may be present without LA enlargement. To the authors' knowledge, this is the first report on PVS in veterinary medicine.

[A rare cause of hoarseness]. / Een zeldzame oorzaak van heesheid.

BACKGROUND: Hoarseness caused by Ortner's syndrome is a rare diagnosis, first described in 1897 in a patient with an enlarged left atrium due to mitral valve stenosis. Due to mechanical compression on the left recurrent laryngeal nerve patients present with hoarseness. CASE DESCIPTION: A 70 year old male presents with hoarseness and an inability to swallow. Examination reveals a paresis of the left vocal cord. A Computed Tomography scan shows a saccular aneurysm of the proximal descending thoracic aorta, consistent with Ortner's syndrome. Patient was successfully treated with a thoracic endovascular aortic repair procedure. CONCLUSION: Hoarseness is rarely caused by cardiovascular conditions, a more common condition is a lung neoplasm. Thoracic aneurysms as a cause of Ortner's syndrome are often described in combination with a dissection of the aneurysm. Diagnostic work-up of persisting hoarseness without laryngeal pathology should include a contrast enhanced computed tomography (CT) scan to rule our life-threatening conditions.

Reversible pulmonary hypertension associated with lungworm infection in a young cat.

Two ten-week-old kittens presented with dyspnea. Two weeks later dyspnea had worsened and both kittens had developed a heart murmur. One kitten died and necropsy showed severe granulomatous pneumonia and moderate bronchi(oli)tis and peribronchi(oli)tis caused by Aelurostrongylus abstrusus. The results from echocardiography, thoracic radiography and the other kitten's fecal examination were interpreted as severe parasitic pneumonia caused by A. abstrusus infection with pulmonary hypertension. Repeated administration of milbemycine-oxime and praziquantel resulted in cessation of larvae shedding and resolution of clinical, radiographic and echocardiographic signs of bronchopneumonia and pulmonary hypertension.

Feasibility of a branched stent-graft in common iliac artery aneurysms.

PURPOSE: To evaluate the short-term feasibility, efficacy, and safety of a modular bifurcated stent-graft with an internal iliac artery (IIA) side branch for endovascular repair of aortoiliac aneurysms. METHODS: Between 2002 and 2005, 10 male patients (median age 75 years, range 59-83) were treated with a bifurcated stent-graft that included a unilateral side branch for the IIA. The median diameters of the abdominal aortic and common iliac artery (CIA) aneurysms were 56 mm (range 33-80) and 40 mm (range 27-60), respectively. Four patients were treated mainly for the CIA aneurysm. Postoperative endoleaks, patency rate, and vessel morphology were determined with contrast-enhanced computed tomography (CT). RESULTS: All endografts were implanted in the desired position. One IIA occluded intraoperatively, and 1 external iliac artery occlusion was noted 6 months postoperatively; both occlusions were asymptomatic and remain untreated. Three graft-related endoleaks were treated with implantation of adjunctive stent-grafts (2 intraoperative and 1 late). Median follow-up by CT was 2 months (1 week to 32 months). One patient died of myocardial infarction 13 days postoperatively; the stent-graft was patent at autopsy. CONCLUSION: Stent-grafts with an IIA side branch offer an opportunity to repair aortoiliac aneurysms without sacrificing the IIA. Implantation of the IIA branch is more complex than routine endovascular aneurysm repair and may have contributed to a periprocedural cardiac death. More patients and longer follow-up are needed to verify these data.