Stent-assisted balloon-induced intimal disruption and relamination in complicated chronic residual type B aortic dissection after frozen elephant trunk treatment.

CASE REPORT: a 77-year-old man presented to our Emergency Department for worsening dyspnea. A chest CT scan showed a type A aortic dissection with a dilatation of the ascending and descending aorta. After evaluating the case with cardiac surgeons, it was decided to perform an aortic arch replacement through the frozen elephant trunk technique. Three months after cardiac surgery, a TC scan showed a residual 58 mm dissecting aneurysm of the descending thoracic aorta and a collapse of the true lumen so we decided to perform an endovascular treatment of the thoracoabdominal aorta according to the STABILISE technique. Due to the impossibility of cannulating the left renal artery (originating from the false lumen), a partial dilation of the dissecting stent was performed at the origin of the renal arteries, maintaining the communication between true and false lumen at the level of the aortic bifurcation. DISCUSSION: the STABILISE technique can be applied safely and effectively even in selected cases of residual chronic aortic dissection, constituting a safe and effective alternative to open thoracoabdominal surgery. CONCLUSIONS: the presence of a proximal artificial neck without proximal tears in the aortic arch can be a great advantage for subsequent endovascular interventions. It is therefore desirable to design a common surgical strategy within an aortic team to achieve a more favorable preoperative anatomy. KEY WORDS: Chronic dissection, Frozen elephant trunk, STABILISE.

Short Term Outcomes of Distal Extended EndoVascular Aortic Repair (DEEVAR) Petticoat in Acute and Subacute Complicated Type B Aortic Dissection.

OBJECTIVE: The aim of this study was to evaluate the peri-operative and short term results of institutional experience with the Distal Extended EndoVascular Aortic Repair PETTICOAT (DEEVAR PETTICOAT) procedure. METHODS: This was a single centre, observational study. From January 2015 to December 2019, 53 patients were admitted to the institution for treatment of acute and subacute complicated type B aortic dissection. Among them, data on 16 patients deemed suitable for a PETTICOAT procedure extended at infrarenal and iliac level by means of a bifurcated endograft were prospectively collected. Patients with persistent pain, visceral or lower limb malperfusion, true lumen collapse, and distal extension with computed tomography angiography (CTA) evidence of entry tears in the infrarenal or iliac zone were included. A CTA scan was performed in all patients at the baseline, before hospital discharge and then at six and 12 months post-operatively to assess aortic remodelling. Complete aortic remodelling was defined as stable aortic size (maximum enlargement < 5 mm) with complete true lumen re-expansion and complete false lumen exclusion or disappearance. RESULTS: Technical success was obtained in all patients. One patient (7%) had intra-operative infrarenal aortic rupture during balloon dilation of the distal end of the bare stent, successfully treated by deployment of a bifurcated endograft. Additional covered stenting of the visceral arteries was necessary in nine patients (56%) and malperfusion resolved immediately in all cases. There were no spinal cord ischaemia or other peri-procedural complications, and no post-operative death, stroke, paraplegia/paraparesis, or acute renal failure was observed. Follow up ranged from one month to 24 months (median 7.5 months). One patient (7%) with a history of drug abuse died from sepsis. At the last CTA check, all patients showed complete remodelling of the thoraco-abdominal aorta and iliac arteries without vessel enlargement. CONCLUSION: The present findings suggest that the DEEVAR PETTICOAT procedure provides effective sealing of all distal tears without increased risk of major peri-procedural complications. Further studies with larger number of patients and longer follow up are needed to confirm the safety and durability of this technique.

Early outcomes associated with use of the Zenith TX2 Dissection Endovascular Graft for the treatment of Stanford type B aortic dissection.

OBJECTIVE: To evaluate short term outcomes related to the use of the Zenith TX2 Dissection Endovascular Graft (ZDEG) and the Zenith Dissection Bare stent (ZDES) for the treatment of Stanford type B aortic dissections. METHODS: This retrospective multicenter case cohort study collated data from 10 European institutions for patients with both complicated and uncomplicated type B aortic dissection treated with ZDEG and ZDES between 2011 and 2018. The primary end point was mortality at 30 and 90 days. Secondary end points included complications related to TEVAR, such as, type Ia endoleak, stroke, paraparesis, paraplegia, and retrograde type A dissection (RTAD). Statistical analysis was carried out using the t test, or one-way analysis of variance and the χ2 or Fisher exact tests. RESULTS: We treated 120 patients (87 male; mean age, 62.7 ± 12.2years) either in the acute 76 (63.3%), subacute 16 (13.3%), or chronic 28 (23.3%) phase. Seven patients (5.8%) died within 30 days after the index procedure and two (1.7%) between 30 and 90 days. There was one instance of postoperative RTAD in a patient treated for rupture. Stroke and paraplegia occurred in three (2.5%) and five (4.2%), patients, respectively. Eight patients (6.7%) had a type Ia endoleak in the perioperative period. There were no instances of paraplegia, no permanent dialysis, and no requirement for adjunctive superior mesenteric or celiac artery stenting in the 33 patients (27.5%) who were treated by concurrent placement of ZDES distal to the ZDEG. The length and distal oversizing of ZDEG components used was less in this group. CONCLUSIONS: The present series demonstrates a low (<1%) RTAD rate and favorable morbidity and mortality. The lower rate of paraplegia, dialysis, and visceral artery stenting in the cohort that had adjunctive use of ZDES is compelling and merits further assessment.

Six-Month Survival After Extracorporeal Membrane Oxygenation for Severe COVID-19.

OBJECTIVES: The authors evaluated the outcome of adult patients with coronavirus disease 2019 (COVID-19)-related acute respiratory distress syndrome (ARDS) requiring the use of extracorporeal membrane oxygenation (ECMO). DESIGN: Multicenter retrospective, observational study. SETTING: Ten tertiary referral university and community hospitals. PARTICIPANTS: Patients with confirmed severe COVID-19-related ARDS. INTERVENTIONS: Venovenous or venoarterial ECMO. MEASUREMENTS AND MAIN RESULTS: One hundred thirty-two patients (mean age 51.1 ± 9.7 years, female 17.4%) were treated with ECMO for confirmed severe COVID-19-related ARDS. Before ECMO, the mean Sequential Organ Failure Assessment score was 10.1 ± 4.4, mean pH was 7.23 ± 0.09, and mean PaO2/fraction of inspired oxygen ratio was 77 ± 50 mmHg. Venovenous ECMO was adopted in 122 patients (92.4%) and venoarterial ECMO in ten patients (7.6%) (mean duration, 14.6 ± 11.0 days). Sixty-three (47.7%) patients died on ECMO and 70 (53.0%) during the index hospitalization. Six-month all-cause mortality was 53.0%. Advanced age (per year, hazard ratio [HR] 1.026, 95% CI 1.000-1-052) and low arterial pH (per unit, HR 0.006, 95% CI 0.000-0.083) before ECMO were the only baseline variables associated with increased risk of six-month mortality. CONCLUSIONS: The present findings suggested that about half of adult patients with severe COVID-19-related ARDS can be managed successfully with ECMO with sustained results at six months. Decreased arterial pH before ECMO was associated significantly with early mortality. Therefore, the authors hypothesized that initiation of ECMO therapy before severe metabolic derangements subset may improve survival rates significantly in these patients. These results should be viewed in the light of a strict patient selection policy and may not be replicated in patients with advanced age or multiple comorbidities. CLINICAL TRIAL REGISTRATION: identifier, NCT04383678.

Vascular plug oversizing to treat an endoleak after hybrid surgery of the aortic arch.

A patient with prior ascending aortic replacement for a type A acute dissection and a bovine arch presented with an asymptomatic chronic dissecting innominate artery aneurysm extending to both carotid arteries. As the patient refused redo open surgery, we performed a hybrid procedure with reverse extra-anatomic aortic arch debranching and a fenestrated endograft. The aneurysm was still partially perfused due to an endoleak and corrected 1 week later with vascular plugs.

Distal Extended Endovascular Aortic Repair PETTICOAT: A Modified Technique to Improve False Lumen Remodeling in Acute Type B Aortic Dissection.

BACKGROUND: Data from the literature suggest that in patients with acute, complicated type B aortic dissection (cTBAD), initial successful treatment with thoracic endovascular aneurysm repair (TEVAR) is not necessarily associated with favorable remodeling of the dissected aorta during follow-up, and long-term results indicate that TEVAR failed to completely suppress false lumen patency. Sealing of all relevant distal reentries, infrarenal and/or iliac, seems to be the key issue to induce total false lumen thrombosis in abdominal aorta as well as the iliac arteries, especially in complicated patients presenting with malperfusion or complete true lumen collapse. MATERIALS AND METHODS: Of the 34 consecutive patients diagnosed with cTBAD at our hospital from January 2015 to April 2018, 30 had complicated dissections receiving endovascular treatment according to the standard Provisional ExTension To Induce COmplete ATtachment (PETTICOAT) technique and were excluded from this study, whereas 4 patients with radiologic evidence of multiple reentry tears at detached lumbar arteries and iliac bifurcation with complete true lumen collapse and clinical evidence of malperfusion were treated with a modified PETTICOAT technique with distal extension of the aortic stent, balloon expansion of the stented true lumen, and use of the AFX bifurcated endograft system to preserve the natural aortic bifurcation and provide complete distal sealing of reentry tears. RESULTS: Primary technical success was achieved in all patients. No postoperative deaths were observed, but 1 patient experienced an hemorrhagic shock on the second postoperative day. No patient suffered postoperative stroke, paraplegia, paraparesis, or acute renal failure. CONCLUSIONS: Using an abdominal aortic bifurcated endograft with PETTICOAT to treat acute cTBAD seems to be a feasible approach in high-risk patients to improve aortic remodeling. The AFX bifurcated endograft system meets the requirements of anatomical fixation and sealing of distal tears.

Mycotic abdominal aortic aneurysm after adjuvant therapy with bacillus Calmette-Guérin in patients with urothelial bladder cancer: a rare but misinterpreted complication.

Bacillus Calmette-Guérin (BCG) therapy is often associated with side effects. The most feared is disseminated sepsis that may occur rarely with the development of mycotic aortic aneurysms. Twenty cases of patients treated with intravesical BCG complicated by mycotic abdominal aortic aneurysm have been reported in the literature, including 2 cases of the present study. Delayed vascular work-up represents a critical aspect. Mycotic aneurysms evidence a rapid progression. Primary care physicians and urologists should be sensitized to recognize unspecified symptoms such as potential clinical manifestations of a mycotic abdominal aortic aneurysm, even several months or years after BCG therapy.

Risk-scoring methods in predicting the immediate outcome after emergency open repair of ruptured abdominal aortic aneurysm.

BACKGROUND: Rupture of an abdominal aortic aneurysm (RAAA) is associated with a risk of death approaching 80%. Prediction of immediate postoperative death in this condition assumes obvious relevance because it may be helpful in preoperative risk stratification. METHODS: One hundred fourteen patients underwent emergency open repair of RAAA. Data were retrospectively collected, and preoperative risk assessment was done according to the Glasgow aneurysm score, the Hardman index, and the Chen calculated risk. RESULTS: Fifty-one patients (44.7%) died during the immediate postoperative period. The area under the receiver operating characteristics curve for the Glasgow aneurysm score, the Hardman index, and the Chen calculated risk was 0.906, 0.834, and 0.672, respectively. The mortality rate among patients with a Glasgow aneurysm score >85 was 88.9%, whereas in those with a lower score it was 15.9% (P < .0001). The mortality rate among patients with a Hardman index > or =2 was 81.1%, whereas it was 27.3% in those with a lower score (P < .0001). The mortality rate in patients with a Chen calculated mortality risk >37% was 62.0%, whereas it was 31.3% in those with a calculated risk < or =37% (P = .001). CONCLUSIONS: The present study showed that the Glasgow aneurysm score and, to a somewhat lower extent, the Hardman score are valuable predictors of immediate postoperative death after emergency open repair of RAAA.

Outcome after emergency repair of symptomatic, unruptured abdominal aortic aneurysm: results in 42 patients and review of the literature.

OBJECTIVE: To evaluate the results of our experience in the management of patients with symptomatic, unruptured abdominal aortic aneurysm (AAA), to identify the predictors of immediate outcome and to define the worldwide postoperative mortality rate through a review of previous studies on this condition. PATIENTS AND METHODS: Forty-two patients underwent emergency repair for symptomatic, unruptured AAA. RESULTS: Four patients (9.5%) died during the in-hospital stay, three of myocardial infarction and one of multiorgan failure. Only preoperative creatinine was predictive of postoperative death (p = 0.04, OR 1.31). The Glasgow Aneurysm Score tended to be predictive of postoperative death (p = 0.06), survivors having had a median score of 76.0 (IQR, 75.5-82.1) and patients who died of 87.1 (78.9-89.9). The receiver operating characteristic (ROC) curve analysis showed that the Glasgow Aneurysm Score had an area under the curve of 0.789 (95% CI: 0.596-0.983, SE: 0.099, p = 0.06). Its best cut-off value in predicting postoperative death was 85 (specificity 86.8%, sensitivity 75.0%). The postoperative mortality rate among patients with a Glasgow Aneurysm Score <85 was 2.9%, whereas it was 37.5% among those with a score >85 (p = 0.003). A review of the results of previous studies on this condition, including also the present series, showed that 207 out of 1312 patients (15.8%) died after emergency operation for symptomatic, unruptured AAA. CONCLUSION: Emergency open repair of symptomatic, unruptured AAA is associated with a high risk of postoperative death. The results of this study suggest that a rather good postoperative survival rate can be expected in patients with a Glasgow Aneurysm Score <85. A watchful waiting policy or, alternatively, emergency endovascular repair should be advocated in patients with a higher score.

Predictors of development of anastomotic femoral pseudoaneurysms after aortobifemoral reconstruction for abdominal aortic aneurysm.

BACKGROUND: The pathogenesis of anastomotic femoral pseudoaneurysms (AFPs) is still unclear. We have performed this long-term retrospective study of patients who underwent aortobifemoral reconstruction for abdominal aortic aneurysm (AAA) in order to better establish the long-term rate of AFP and to identify the predictors of its late occurrence. METHODS: The long-term outcome of 178 patients who underwent and survived aortobifemoral reconstruction for infrarenal AAA was reviewed. RESULTS: During a median follow-up of 5.2 years, 28 AFPs developed in 19 patients. Six AFPs were recurrent. The mean linearized rate of AFPs was 1.88% per year. At 15 years, the survival-freedom rate from AFPs was 60%, and from repair of AFPs it was 62%. The survival-freedom rate from AFP was significantly poorer in patients with chronic obstructive pulmonary disease (P = 0.017; at 10 years: 64.3% versus 92.3%), hyperlipidemia (P = 0.0056; at 10 years: 59.2% versus 87.5%), current smoking (P <0.0001; at 10 years: 65.8% versus 94.5%), and postoperative inguinal wound infection (P <0.0001; at 10 years: 42.8% versus 86.8%). Multivariate analysis showed that chronic obstructive pulmonary disease (relative risk [RR]: 3.05, 95% confidence interval [CI]: 1.04 to 8.95), current smoking (RR: 5.38, 95% CI: 1.62 to 17.90), and postoperative inguinal wound infection (RR: 9.04, 95% CI: 2.76 to 29.96) were significantly associated with the development of AFPs. The linearized rate of AFPs was significantly higher only among current smokers (P <0.0001, 4.4% versus 0.8% per year) and among those who had inguinal wound infection (P = 0.001, 9.2% versus 1.5% per year). CONCLUSIONS: Current smoking and inguinal wound infection may contribute to the development of AFP after aortobifemoral reconstruction for AAA, likely by affecting reparative connective tissue mechanisms at the anastomotic site.

Topical head cooling during rewarming after experimental hypothermic circulatory arrest.

BACKGROUND: The aim of this study was to evaluate the potential neuroprotective effect of topical head cooling during the first 2 postoperative hours after experimental hypothermic circulatory arrest. METHODS: Twenty pigs underwent a 75-minute period of hypothermic circulatory arrest and were randomly assigned to rewarming to 37 degrees C or to undergo topical cooling of the head for 2 hours from the start of rewarming followed by a period of external rewarming to 37 degrees C. RESULTS: The 7-day survival rate was 70% in the control group and 60% in the topical head cooling group. Despite brain tissue oxygenation, intracranial pressures, mixed oxygen venous saturation, oxygen consumption, and extraction tended to be favorable in the topical head cooling group as a clear effect of mild hypothermia. The latter group had significantly higher postoperative brain lactate and pyruvate ratios, and lactate and glucose ratios. Furthermore, the topical head cooling group had worse fluid balance throughout the postoperative period. Brain histopathologic scores were comparable with the study groups, but among 7-days survivors these scores tended to be worse in the topical head cooling group. CONCLUSIONS: Topical cooling of the head during the first 2 postoperative hours after experimental hypothermic circulatory arrest does not appear to provide any neuroprotective effect.

Major vessel injuries during laparoscopic cholecystectomy: a case report.

The aim of the study was to investigate major vascular injury during laparoscopic cholecystectomy, which is a rare but potentially lethal complication if not recognized and treated swiftly, usually secondary to placement of the Veress needle or trocar. We report on our experience with a 35-year-old woman presenting an aortic laceration of the anterior wall and a puncture wound penetrating the anterior wall of the inferior vena cava. Repair of the injuries was done using a 5-0 Prolene suture mounted on pledgets. In addition, it was necessary to suture three mesenteric vascular injuries in the posterior peritoneum with Vicryl 2-0. The estimated blood loss was 1300 cc. The patient did well and was discharged on postoperative day 13. The distal abdominal aorta, inferior vena cava and large pelvic vessels are particularly prone to injury during laparoscopic cholecystectomy. In most cases, the vascular defect can be closed by direct suturing. Rarely is it necessary to reconstruct the injured vessel with an alloplastic prosthetic patch or a prosthetic implant.

Increase of intracranial pressure after hypothermic circulatory arrest in a chronic porcine model.

OBJECTIVE: An increase in intracranial pressure has been shown to threaten the outcome of patients with ischemic or traumatic brain injury. Its impact on the outcome of pigs undergoing hypothermic circulatory arrest has been evaluated in this study. DESIGN: Fifty-six pigs underwent a 75-min period of hypothermic circulatory arrest at 20 degrees C. Intracranial pressure, cerebral microdialysis, hemodynamic and metabolic parameters were monitored throughout the experiment. The animals were allowed to survive until the 7th postoperative day and, then, electively killed. RESULTS: The 7-day survival rate was 60.7%, and among survivors, 20 of them (58.8%) developed brain infarction. A significant increase in intracranial pressure as compared with the baseline level was observed since the end of cooling (p = 0.047) and the difference became larger during all the postoperative intervals (p < 0.0001). Animals that died postoperatively tended to have higher intracranial pressure levels during all the postoperative intervals, but such a difference reached significance only at the 4-h postoperative interval (p = 0.040). The same tendency was observed among animals that survived until the 7th postoperative day and that developed brain infarction or not, but the difference between these two groups did not reach statistical significance. The animals that died or developed postoperatively brain infarction had higher intracranial pressure values postoperatively as compared with those that survived without developing brain infarction and such a difference reached significance at the 2-h (p = 0.015) and 4-h postoperative intervals (p = 0.035). The peak intracranial pressure was 17.2 mmHg (IQR, 13.7-20.8) in animals that died or developed brain infarction and 14.1 mmHg (IQR, 11.8-16.4) in those that survived 7 days without developing brain infarction (p = NS). CONCLUSION: Intracranial pressure increases significantly after 75 min of experimental hypothermic circulatory arrest and such an increase is associated with a high risk of postoperative death and brain infarction.