Cardiovascular risk in chronic myeloid leukaemia: A multidisciplinary consensus on screening and management.

INTRODUCTION: Tyrosine kinase inhibitors (TKIs) have become the mainstay of treatment for chronic myeloid leukaemia (CML), but cardiovascular (CV) risk and exacerbation of underlying risk factors associated with TKIs have become widely debated. Real-world evidence reveals little application of CV risk factor screening or continued monitoring within UK CML management. This consensus paper presents practical recommendations to assist healthcare professionals in conducting CV screening/comorbidity management for patients receiving TKIs. METHODS: We conducted a multidisciplinary panel meeting and two iterative surveys involving 10 CML specialists: five haematologists, two cardio-oncologists, one vascular surgeon, one haemato-oncology pharmacist and one specialist nurse practitioner. RESULTS: The panel recommended that patients commencing second-/third-generation TKIs undergo formal CV risk assessment at baseline, with additional investigations and involvement of cardiologists/vascular surgeons for those with high CV risk. During treatment, patients should undergo CV monitoring, with the nature and frequency of testing dependent on TKI and baseline CV risk. For patients who develop CV adverse events, decision-making around TKI interruption, cessation or change should be multidisciplinary and balance CV and haematological risk. CONCLUSION: The panel anticipates these recommendations will support healthcare professionals in implementing CV risk screening and monitoring, broadly and consistently, and thereby help optimise TKI treatment for CML.

The use of video motion analysis to determine the impact of anatomic complexity on endovascular performance in carotid artery stenting.

OBJECTIVE: Video motion analysis (VMA) uses fluoroscopic sequences to derive information on catheter and guidewire movement and is able to calculate two-dimensional catheter tip path length (PL) on the basis of frame-by-frame pixel coordinates. The objective of this study was to evaluate the effect of anatomic complexity on the efficiency of completion of defined stages of simulated carotid artery stenting as measured by VMA. METHODS: Twenty interventionists each performed a standardized easy, medium, and difficult carotid artery stenting case in random order on an ANGIO Mentor (Simbionix, Airport City, Israel) simulator. Videos of all procedures were analyzed using VMA software, and performance was expressed in terms of two-dimensional guidewire tip trajectory distance (PL). Comparisons of PL were used to identify differences in cannulation performance of the participants between the three cases of varying difficulty. The procedure was subdivided into four procedural phases: arch navigation, common carotid artery (CCA) cannulation, external carotid manipulation, and carotid lesion crossing. Comparisons of PL were used to identify differences in performance between the three cases of varying difficulty for each of the procedural phases. RESULTS: There were significant differences in PL in relation to anatomic complexity, with a stepwise increase in PL from easy to difficult cases: easy, median of 5000 pixels (interquartile range, 4075-5403 pixels); intermediate, 9059 (5974-14,553) pixels; difficult, 17,373 (11,495-26,594) pixels (P < .001). Similarly, during CCA cannulation, there was a stepwise increase in PL from easy to difficult cases: easy, 749 (603-1403) pixels; intermediate, 3274 (1544-8142) pixels; difficult, 8845 (5954-15,768) pixels (P < .001). There were no observed differences across the groups of anatomic difficulty for the phases of arch navigation, external carotid manipulation, and carotid lesion crossing. CONCLUSIONS: Increasing anatomic complexity leads to significant increases in PL of endovascular tools, in particular during CCA cannulation. This increase in tool movement may have a bearing on clinical outcome.

Targeted genetic analysis in a large cohort of familial and sporadic cases of aneurysm or dissection of the thoracic aorta.

PURPOSE: Thoracic aortic aneurysm/aortic dissection (TAAD) is a disorder with highly variable age of onset and phenotype. We sought to determine the prevalence of pathogenic variants in TAAD-associated genes in a mixed cohort of sporadic and familial TAAD patients and identify relevant genotype-phenotype relationships. METHODS: We used a targeted polymerase chain reaction and next-generation sequencing-based panel for genetic analysis of 15 TAAD-associated genes in 1,025 unrelated TAAD cases. RESULTS: We identified 49 pathogenic or likely pathogenic (P/LP) variants in 47 cases (4.9% of those successfully sequenced). Almost half of the variants were in nonsyndromic cases with no known family history of aortic disease. Twenty-five variants were within FBN1 and two patients were found to harbor two P/LP variants. Presence of a related syndrome, younger age at presentation, family history of aortic disease, and involvement of the ascending aorta increased the risk of carrying a P/LP variant. CONCLUSION: Given the poor prognosis of TAAD that is undiagnosed prior to acute rupture or dissection, genetic analysis of both familial and sporadic cases of TAAD will lead to new diagnoses, more informed management, and possibly reduced mortality through earlier, preclinical diagnosis in genetically determined cases and their family members.

Preoperative thoracic false lumen branches relate to aortic remodeling after thoracic endovascular aortic repair for DeBakey IIIb aortic dissection.

OBJECTIVE: This study evaluated the association between thoracic false lumen branches (TFLBs; dissected thoracic branches fed by a false lumen) and distal thoracic aortic enlargement (DTAE) after thoracic endovascular aortic repair (TEVAR) for DeBakey IIIb aortic dissection. METHODS: We retrospectively analyzed the records of 67 patients with DeBakey IIIb dissection initially treated with TEVAR between January 2011 and December 2013. Preoperative and postoperative computed tomography angiography images were reviewed to evaluate the number of preoperative TFLBs and aortic diameter change after TEVAR. Patients were stratified into two groups by the estimated optimal cutoff value of preoperative TFLBs for the prediction of DTAE: group A (n = 28), preoperative TFLBs ≥8; group B (n = 39), preoperative TFLBs <8. The diameter changes over time were modeled by mixed models of repeated data. Multivariable Cox regression analysis was used to assess the independent association between preoperative TFLBs and DTAE after TEVAR. RESULTS: Baseline demographics, clinical features, and devices implanted were largely similar between the two groups. Group A had more preoperative abdominal false lumen branches (7 [4-8] vs 4 [1-6]; P = .02) and a greater proportion of preoperative patent thoracic false lumen (83.9% vs 66.7%; P = .04). Twelve patients experienced DTAE during a median imaging follow-up period of 12.2 months (interquartile range, 4.3-26.6 months). Log-rank testing revealed a significant increase in cumulative estimated proportion with DTAE in group A (P < .01). The maximum thoracic aortic diameter decreased significantly in group B (P < .01) but not in group A. The overall change in the maximum thoracic aortic diameter was statistically different between the two groups (P < .01). Each group exhibited a significant increase in true lumen diameter and a significant decrease in false lumen diameter postoperatively. However, a lower degree of false lumen regression in group A was detected compared with group B (P = .03). Multivariable analysis identified that preoperative TFLBs were independently associated with DTAE after TEVAR (hazard ratio [for one increase], 1.46; 95% confidence interval, 1.20-1.77) after adjustment for gender, hyperlipidemia, length of dissected aorta and height index, preoperative abdominal false lumen branches, and preoperative false lumen status of thoracic aorta. CONCLUSIONS: Preoperative TFLBs are independently associated with DTAE after TEVAR in DeBakey IIIb aortic dissection. Long-term follow-up is necessary to further verify the preliminary finding.

Experience with a novel custom-made fenestrated stent graft in the repair of juxtarenal and type IV thoracoabdominal aneurysms.

OBJECTIVE: Fenestrated stent grafting has become increasingly popular as a means to manage complex aortic pathology, including juxta- and pararenal aneurysms. The design of a recently developed custom-made fenestrated stent graft, in theory, confers advantages when managing anatomically challenging aortic morphology. This study evaluated its feasibility in anatomically challenging scenarios. METHODS: Over a 12-month period, 20 patients received fenestrated stent grafts. Among those, 13 patients with juxtarenal or type IV thoracoabdominal aortic aneurysms underwent endovascular repair with the novel fenestrated stent graft at a single UK institution. Data on aneurysm morphology and immediate and short-term results were collected prospectively. RESULTS: The mean aneurysmal sac size was 7.3 cm (range, 5.5-10.0 cm). The mean infrarenal neck length was 4.4 mm (range, 0-9 mm), and in three cases was lined by a pre-existing infrarenal stent graft. Nine cases had an infrarenal neck angulation of 60(°) or more in either the anteroposterior or coronal planes. Five cases had ≥50% thrombus at the proximal landing zone. A total of 35 target vessels were cannulated, of which six right renal and four left renal arteries were angulated ≥120(°). Two-thirds of cannulated celiac trunks were angulated ≥120(°), and one cannulated superior mesenteric artery was angulated ≥ 140(°). Seven of the cannulated targets were stenosed more than 60%. One patient had two right renal arteries arising 3 mm from each other. Four right and four left common iliac arteries were angulated ≥90(°) in relation to the infrarenal aorta. Technical success was 100%. Median time from date of procedure to most recent follow-up with computed tomography scanning was 33 weeks. There was no type I or III endoleak. One type II endoleak was observed at the time of most recent computed tomography scanning and treated expectantly. There was a single incident of left renal artery occlusion. One patient required repair of a brachial artery, fasciotomies, and temporary haemofiltration. One patient died from ischemic heart disease 77 weeks after the procedure. CONCLUSIONS: The use of the novel fenestrated stent graft system in patients with hostile aortic aneurysmal morphology is feasible with acceptable short-term outcomes.

Robot-assisted uterine artery embolization: a first-in-woman safety evaluation of the Magellan System.

PURPOSE: To provide a technical description of robot-assisted uterine artery embolization and to investigate the safety and feasibility of the Magellan (Hansen Medical, Mountain View, California, USA) robotic catheter in this complex arterial bed. MATERIALS AND METHODS: Five women (mean age, 48.8 y) underwent robot-assisted bilateral uterine artery embolization over a 10-month period using the Magellan robotic catheter. Demographic, clinicopathologic, and endovascular performance metric data (fluoroscopy and cannulation times) were recorded as well as short-term outcomes. RESULTS: Robotic cannulation of bilateral internal iliac and uterine arteries was successful in all cases. Median right and left internal iliac artery cannulation and total fluoroscopy times were 3 minutes (interquartile range [IQR], 1.5-4 min), 2 minutes (IQR, 1.5-4 min), and 11 minutes (IQR, 9.5-14 min). Median right and left uterine artery cannulation times were both 11 minutes (IQR, 6.5-15 min and 8-12 min, respectively). Technical success was 100%. All patients were discharged on postoperative day 1, and there were no major or access site complications. At 6 months after the procedure, all patients reported significant improvement of symptoms, with a median increase in health-related quality-of-life score of 58% (48.5%-61.75%). CONCLUSIONS: The use of the new-generation Magellan system in uterine artery embolization is feasible and appears to be safe. The additional navigational capability and added maneuverability of the NorthStar catheter (Hansen Medical, Mountain View, California) may facilitate selective catheterization of small iliac artery divisions and may be useful in any procedure where complex arterial selection is needed.

The role of teamworking in error reduction during vascular procedures.

BACKGROUND: To examine the associations between teamworking processes and error rates during vascular surgical procedures and then make informed recommendations for future studies and practices in this area. METHODS: This is a single-center observational pilot study. Twelve procedures were observed over a 3-week period by a trained observer. Errors were categorized using a standardized error capture tool. Leadership and teamworking processes were categorized based on the Malakis et al. (2010) framework. Data are expressed as frequencies, means, standard deviations and percentages. RESULTS: Errors rates (per hour) were likely to be reduced when there were effective prebriefing measures to ensure that members were aware of their roles and responsibilities (4.50 vs. 5.39 errors/hr), communications were kept to a practical and effective minimum (4.64 vs. 5.56 errors/hr), when the progress of surgery was communicated throughout (3.14 vs. 8.33 errors/hr), and when team roles changed during the procedure (3.17 vs. 5.97 errors/hr). CONCLUSIONS: Reduction of error rates is a critical goal for surgical teams. The present study of teamworking processes in this environment shows that there is a variation that should be further examined. More effective teamworking could prevent or mitigate a range of errors. The development of vascular surgical team members should incorporate principles of teamworking and appropriate communication.

Umbilical artery catheter, aortic dissection, carotid cannulation, and pseudoaneurysm in a neonate: A tale of propagating pathology.

Arterial dissections are uncommon in neonates. Complications include thrombosis, bleeding, dissection, aneurysm and pseudoaneurysm. We report an unusual case of multisite pathology (dissection and pseudoaneurysm) following common vascular interventions. A term neonate with antenatal diagnosis of congenital heart block secondary to maternal lupus deteriorated clinically at 5 days of life. He was found to have an abdominal aortic thrombus secondary to abdominal aortic dissection, following umbilical arterial catheter placement. Attempted percutaneous treatment was complicated by dissection of the left common carotid artery and formation of a large pseudoaneurysm. Neonatal lupus is associated with weakened vessel wall which may be vulnerable to injury from line placement and endovascular interventions. Various options are available to manage arterial dissection, thrombus, and pseudoaneurysm, but consequences of these options need to be carefully weighed to minimize further complications.

In vitro investigation of a new thrombus aspiration and autologous blood reinfusion system.

PURPOSE: The aim of the study was to evaluate the feasibility of a new venous-thrombus aspiration and autologous blood (auto-blood) reinfusion system. MATERIALS AND METHODS: We constructed the venous model from polyvinyl chloride (PVC) tubes and three-way unions using a fresh clot of chicken blood as the venous thrombus. Eight French and 12F aspiration catheters were used to aspirate the thrombus in the right-pulmonary-artery model, 8 French and 14F aspiration catheters were used in the inferior-vena cava model, and 8 French and 10F aspiration catheters were used in the left-iliofemoral-vein model. A thrombus filtration and auto-blood reinfusion bottle was used to filter the thrombus and re-infuse auto-blood. We evaluated the thrombus aspiration capability of each catheter by comparing pre-aspirated with the post-aspirated thrombus volume, and we evaluated the difference in aspiration capability between the two catheters in each model by comparing their thrombus aspiration rates. We used Student's t-test for statistical analysis. RESULTS: Differences between pre-aspirated and post-aspirated thrombus volumes for each catheter were insignificant, as were those between the thrombus aspiration rates of the two catheters in each venous model. Using the thrombus aspiration and auto-blood reinfusion system, each aspiration catheter could fluently aspirate the thrombus out of the venous model. CONCLUSION: In this study, we designed a new venous-thrombus aspiration system. This system could be used to aspirate acute venous thrombi and re-infuse autologous blood.

Thoracic endovascular aortic repair (TEVAR) in proximal (type A) aortic dissection: Ready for a broader application?

OBJECTIVE: Thoracic endovascular aortic repair (TEVAR) has demonstrated encouraging results and is gaining increasing acceptance as a treatment option for aortic aneurysms and dissections. Yet, its role in managing proximal aortic pathologies is unknown-this is important because in proximal (Stanford type A) aortic dissections, 10% to 30% are not accepted for surgery and 30% to 50% are technically amenable for TEVAR. We describe our case series of type A aortic dissections treated by using TEVAR. METHODS: Between year 2009 and 2016, 12 patients with acute, subacute, or chronic type A aortic dissection with the proximal entry tear located between the coronaries and brachiocephalic artery were treated with TEVAR at 3 centers. Various stent-graft configurations were used to seal the proximal entry tear in the ascending aorta under rapid pacing. RESULTS: A total of 12 patients (9 male, 3 female), mean age 81 ± 7 years, EuroSCORE II 9.1 ± 4.5, underwent TEVAR for the treatment of type A aortic dissection. Procedural success was achieved in 11 of 12 patients (91.7%). There was 1 minor stroke and 1 intraprocedural death. No additional deaths were reported at 30 days. At 36 months, there were 4 further deaths (all from nonaortic causes). The mean survival of these 4 deceased was 23 months (range 15-36 months). Follow-up computed tomography demonstrated favorable aortic remodeling. CONCLUSIONS: TEVAR is feasible and reveals promising early results in selected patients with type A aortic dissection who are poor candidates for surgical repair. The current iteration of stent-graft technology, however, needs to be adapted to features specific to the ascending aorta.

Fluid structure interaction of patient specific abdominal aortic aneurysms: a comparison with solid stress models.

BACKGROUND: Abdominal aortic aneurysm (AAA) is a dilatation of the aortic wall, which can rupture, if left untreated. Previous work has shown that, maximum diameter is not a reliable determinant of AAA rupture. However, it is currently the most widely accepted indicator. Wall stress may be a better indicator and promising patient specific results from structural models using static pressure, have been published. Since flow and pressure inside AAA are non-uniform, the dynamic interaction between the pulsatile flow and wall may influence the predicted wall stress. The purpose of the present study was to compare static and dynamic wall stress analysis of patient specific AAAs. METHOD: Patient-specific AAA models were created from CT scans of three patients. Two simulations were performed on each lumen model, fluid structure interaction (FSI) model and static structural (SS) model. The AAA wall was created by dilating the lumen with a uniform 1.5 mm thickness, and was modeled as a non-linear hyperelastic material. Commercial finite element code Adina 8.2 was used for all simulations. The results were compared between the FSI and SS simulations. RESULTS: Results are presented for the wall stress patterns, wall shear stress patterns, pressure, and velocity fields within the lumen. It is demonstrated that including fluid flow can change local wall stresses slightly. However, as far as the peak wall stress is concerned, this effect is negligible as the difference between SS and FSI models is less than 1%. CONCLUSION: The results suggest that fully coupled FSI simulation, which requires considerable computational power to run, adds little to rupture risk prediction. This justifies the use of SS models in previous studies.

Preliminary comparative study of small amplitude helical and conventional ePTFE arteriovenous shunts in pigs.

Intimal hyperplasia (IH), which causes occlusion of arterial bypass grafts and arteriovenous (A-V) shunts, develops preferentially in low wall shear, or stagnation, regions. Arterial geometry is commonly three-dimensional, generating swirling flows, the characteristics of which include in-plane mixing and inhibition of stagnation. Clinical arterial bypass grafts are commonly two-dimensional, favouring extremes of wall shear. We have developed small amplitude helical technology (SwirlGraft) devices and shown them to generate physiological-type swirling flows. Expanded polytetrafluorethylene (ePTFE) grafts, although widely used as A-V shunts for renal dialysis access, are prone to thrombosis and IH. In a small preliminary study in pigs, we have implanted SwirlGraft ePTFE carotid artery-to-jugular vein shunts on one side and conventional ePTFE carotid artery-to-jugular vein shunts contralaterally. There was consistently less thrombosis and IH in the SwirlGraft than conventional shunts. At eight weeks (two animals), the differences were marked, with virtually no disease in the SwirlGraft devices and occlusion of the conventional grafts by thrombosis and IH. The study had limitations, but the lesser pathology in the SwirlGraft devices is likely to have resulted from their geometry and the associated swirling flow. The results could have implications for vascular biology and prolongation of the patency of arterial bypass grafts and A-V shunts.

Apical suction device facilitating off-pump bypass for recurrent coarctation: case report.

Apical suction devices to perform complete surgical revascularization without cardiopulmonary bypass have been recently introduced in cardiac surgical practice. We have increasingly explored the possibility of using these devices to perform other procedures on a beating heart that have previously necessitated the need for cardiopulmonary bypass. We present a case of recurrent coarctation in which an ascending-to-abdominal aorta bypass graft was successfully facilitated by the use of an apical suction device. The surgical technique and advantages and disadvantages of this method are highlighted.

Thoracic endovascular aortic repair: the basics.

Endografting for the treatment of thoracic aortic pathology continues to gain popularity; in some countries, numbers of endovascular aortic repairs now exceed those of open surgical cases. The skills and understanding of open surgical teams are not always translated into endovascular intervention teams, which may be led by cardiologists or vascular surgeons with little knowledge of thoracic pathology. Our experience with more than 400 thoracic interventional cases leads us to believe that that the cardiovascular surgeon is crucial to the success of any thoracic endovascular aortic repair program. Experienced surgeons should be involved in preoperative planning of cases, assessment of access vessels, creation of landing zones with revascularization procedures, passage of stents through the thoracic aorta, and protection of the spinal cord. In addition, surgeons should be familiar with the most common complications of thoracic endovascular aortic repair and be able to use both open surgical and endovascular strategies for complication management.

An instantiability index for intra-operative tracking of 3D anatomy and interventional devices.

The tracking of tissue deformation, imaging probes and surgical instruments is an integral part of intra-operative surgical guidance. While the recent introduction of shape instantiation provides a systematic framework for tracking 3D anatomy in real-time, deviations to the desired imaging location can affect the accuracy of the predicted shape. To examine the sensitivity of the prescribed image planes to such errors, we introduce in this paper a new Instantiability Index for providing the intrinsic level of robustness while using such scan planes for the tracking of anatomy and interventional devices. Optimisation of the Index is applied to 3D anatomical reconstruction and the localisation of an intraoperative imaging device. Results are shown on detailed phantom experiments for both real-time 3D shape instantiation and imaging catheter tracking.

Transoesophageal echocardiogram identifying the source of endoleak after combined open/endovascular repair of a type 3 thoracoabdominal aortic aneurysm.

Open repair of thoracic aortic aneurysms is associated with significant morbidity and mortality. The introduction of endovascular repair has reduced both the morbidity and mortality. However, endovascular stent repair can be complicated by endoleaks. We report here the successful treatment of a type 2 endoleak following endovascular repair of a thoracoabdominal aortic aneurysm, using transesophageal echocardiography to assist in the localization of the thoracic endoleak.

Laparoscopic remodeling of abdominal aortic aneurysms after endovascular exclusion: a technical description.

We report our experience with a novel combined laparoscopic-endovascular procedure to treat endoleaks and graft migration. The operative procedure consisted of the following steps: laparoscopic exposure of the aorta, clipping of lumbar arteries and of the inferior mesenteric artery, incision of the sac of the aneurysm without clamping the aorta, and removal of thrombus material. Laparoscopic sutures were placed externally to attach the endograft to the aortic neck. Laparoscopy was performed a mean interval of 20.2 months after endovascular abdominal aortic aneurysm repair in four cases and immediately after endovascular abdominal aortic aneurysm exclusion in eight consecutive patients. We have yet to prove whether this combined approach is superior to a purely endovascular technique.

Enhancing foot skin blood flux in peripheral vascular disease using intermittent pneumatic compression: controlled study on claudicants and grafted arteriopaths.

Intermittent pneumatic leg compression (IPC) increases arterial calf inflow and foot skin blood flux in normal subjects and claudicants. Our hypothesis was that IPC could enhance foot skin blood flux after infrainguinal grafting and thus promote distal perfusion in limbs with tissue loss. The aim of this study was to compare the effects of three IPC modes [applied to the foot (IPCfoot), the calf (IPCcalf), or both (IPCfoot+calf)] on foot skin perfusion in healthy individuals, claudicants, and patients after infrainguinal arterial revascularization performed for critical or subcritical limb ischemia. Altogether, 20 healthy limbs, 22 claudicating limbs, and 36 limbs of arteriopaths with prior successful autologous femoropopliteal and femorodistal (18 each) grafts were examined. Five-minute laser Doppler recordings were obtained from the pulp of the big toe in the sitting position, at rest, and during random applications of IPCfoot, IPCcalf, and IPCfoot+calf delivered at 120 mmHg for 4 seconds three times per minute. Foot skin blood flux increased using all IPC modes (p <0.001), with IPCfoot and IPCfoot+calf generating higher flux levels than IPCcalf (p <0.01) in all groups. Intergroup differences of flux with each of the three IPC modes were not significant. IPCfoot and IPCfoot+calf similarly (p > 0.14) produced a higher percentage flux increase than IPCcalf in all groups (p <0.004). Controls had a higher percentage flux increase with both IPCcalf and IPCfoot than did claudicants (p? 0.016). No differences were documented between normal and grafted limbs (p > 0.05). The percentage flux increase with IPCfoot+calf and IPCcalf was significantly higher in femorodistal grafts than in femoropopliteal ones (p ? 0.026). IPC enhances skin blood flux in limbs with infrainguinal bypass, claudication, and normal arteries, with IPCfoot and IPCfoot+calf being more effective than IPCcalf. Our findings suggest that IPC may be beneficial in limbs with impaired distal perfusion and thus may have clinical implications in the treatment of leg ulcers either prior to or after revascularization.