2024 TSOC/TSPS Joint Consensus: Strategies for Advanced Vascular Wound Management in Arterial and Venous Diseases.

The Taiwan Society of Cardiology (TSOC) and Taiwan Society of Plastic Surgery (TSPS) have collaborated to develop a joint consensus for the management of patients with advanced vascular wounds. The taskforce comprises experts including preventive cardiologists, interventionists, and cardiovascular and plastic surgeons. The consensus focuses on addressing the challenges in diagnosing, treating, and managing complex wounds; incorporates the perfusion evaluation and the advanced vascular wound care team; and highlights the importance of cross-disciplinary teamwork. The aim of this joint consensus is to manage patients with advanced vascular wounds and encourage the adoption of these guidelines by healthcare professionals to improve patient care and outcomes. The guidelines encompass a range of topics, including the definition of advanced vascular wounds, increased awareness, team structure, epidemiology, clinical presentation, medical treatment, endovascular intervention, vascular surgery, infection control, advanced wound management, and evaluation of treatment results. It also outlines a detailed protocol for assessing patients with lower leg wounds, provides guidance on consultation and referral processes, and offers recommendations for various wound care devices, dressings, and products. The 2024 TSOC/TSPS consensus for the management of patients with advanced vascular wounds serves as a catalyst for international collaboration, promoting knowledge exchange and facilitating advancements in the field of advanced vascular wound management. By providing a comprehensive and evidence-based approach, this consensus aims to contribute to improved patient care and outcomes globally.

Case report of Modified Viabahn Open Revascularization TEChnique (VORTEC) as a rescue strategy for hepatic artery dissection after initial endovascular treatment of postpancreaticoduodenectomy hemorrhage.

RATIONALE: Currently endovascular treatments are commonly utilized to treat postpancreaticoduodenectomy hemorrhage. However, when endovascular procedure went wrong, open surgery with ligation of the culprit vessels would be the most common salvage method. With Modified Viabahn Open Revascularization TEChnique (VORTEC), we can try to rescue the vessel without sacrificing it by introduction of another endovascular stent under direct method. PATIENT CONCERNS: A 76-year-old man with stage IIIA ampulla vater adenocarcinoma underwent pancreaticoduodenectomy and experience pancreatic leak complicated with postpancreaticoduodenectomy hemorrhage. DIAGNOSIS: Emergent angiography revealed extravasation from proper hepatic artery. INTERVENTIONS: A 6 mm Viabahn stent was deployed but no distal runoff. Operation was shifted to emergent laparotomy and revealed intimal dissection of hepatic artery. Modified VORTEC was performed with guidewire redirected to true lumen and another stent was deployed under direct vision. OUTCOMES: Patient's hepatic artery was preserved and with no consequent liver failure. LESSON: Modified VORTEC method could be used as salvage strategy for artery dissection after initial endovascular treatment failed.

Efficacy and Safety of Veno-Arterial Extracorporeal Membrane Oxygenation in the Treatment of High-Risk Pulmonary Embolism: A Retrospective Cohort Study.

Objectives: Veno-arterial extracorporeal membrane oxygenation (ECMO) is increasingly used to treat high-risk pulmonary embolism (PE). However, its efficacy and safety remain uncertain. This retrospective cohort study aimed to determine whether ECMO could improve the clinical outcomes of patients with high-risk PE. Methods: Forty patients with high-risk PE, who were admitted to Kaohsiung Chang Gung Memorial Hospital between January 2012 and December 2019, were included in this study. Demographic data and clinical outcomes were compared between patients treated without ECMO (non-ECMO group) and those treated with ECMO (ECMO group). Appropriate statistical tools were used to compare variables between groups and the survival was analyzed using the Kaplan-Meier method. Results: The overall in-hospital mortality rate was 55%, in which 65% (26/40) of patients presented with cardiac arrest with a mortality rate of 77%, which was higher than that of patients without cardiac arrest (14%). There was no significant difference in major complications and in-hospital mortality between the non-ECMO and ECMO groups. However, in subgroup analysis, compared with patients treated without ECMO, earlier ECMO treatment was associated with a reduced risk of cardiac arrest (P = 0.023) and lower in-hospital mortality (P = 0.036). A log-rank test showed a significantly higher cumulative overall survival in the earlier ECMO treatment group (P = 0.033). Conclusions: In this retrospective cohort study, earlier ECMO treatment was associated with lower in-hospital mortality among unstable patients without cardiac arrest. Our findings suggest that ECMO can be considered as an initial treatment option for patients with high-risk PE in higher-volume hospitals.

CT characteristics and clinical implications of acute type A aortic intramural hematoma.

Objectives: Computed tomography (CT) has been increasingly used in the diagnosis of acute aortic syndrome, and a number of high-risk CT imaging features have been reported. We aimed to identify CT imaging findings suggesting high-risk for acute aortic syndrome by examining clinical outcomes of patients with acute type A aortic intramural hematoma (TAIMH). Methods: This retrospective study analyzed the relationship of clinical patient characteristics and imaging features with mortality and aortic events in 63 patients receiving initial medical treatment for TAIMH. Multivariate regression analysis was used to determine the predictors of aortic events, and the Kaplan-Meier method was used to analyze survival and aortic events. Results: During a median follow-up of 4.2 years, 25 patients experienced aortic events and 40% of these occurred within 7 days of admission. In total, 12 patients experienced aortic death and 12 patients underwent open aortic surgery or endovascular stenting for aortic disease. In multivariate regression analysis, penetrating atherosclerotic ulcers (PAUs) or ulcer-like projections (ULPs) (P = 0.04) and pericardial effusion (P = 0.03) were independent predictors of aortic events. In the Cox regression model, PAUs/ULPs (P = 0.04) and pericardial effusion (P = 0.04) were independently associated with lower aortic event-free survival. Conclusion: Identification of high-risk CT features is important for clinical decision-making during TAIMH treatment. Early and frequent CT imaging follow-up is required in patients receiving medical treatment. PAUs/ULP and pericardial effusion were the strongest predictors of adverse aortic events.

Aortic Thrombus in a Nonaneurysmal Ascending Aorta.

BACKGROUND: Ascending aortic thrombus (AAT) in a nonaneurysmal aorta is an extremely rare event and has potentially catastrophic complications, with a life-threatening risk of myocardial infarction and cerebral embolization. This systematic review aims to elucidate the clinical manifestations and to compare the outcomes of anticoagulation therapy versus open aortic surgery for AAT. METHODS: The MEDLINE/PubMed databases were extensively searched between 1995 and 2019. All relevant publications on AAT in adults were reviewed, and individual patient data were pooled in this meta-analysis. The primary outcome was AAT resolution. The adverse outcome variables were recurrent arterial embolic events, complications related to open aortic surgery, and mortality during the study period. Chi-squared test and logistic regression analysis were used to compare groups and identify any predictors of mortality. RESULTS: Overall, 107 patients from 101 articles were included, of whom 29 patients who received anticoagulation therapy and 59 who underwent open aortic surgery were included in the outcome analysis. Among 29 patients treated with initial anticoagulation therapy, the persistence of AAT was observed in 11 patients (38%) and recurrent arterial embolization was developed in 6 patients (21%). All 11 patients in the anticoagulation group underwent secondary aortic surgery for the persistence of AAT with uneventful postoperative course. Compared with patients treated with primary aortic surgery, patients treated with initial anticoagulation therapy had higher risk of recurrent embolization (P = 0.002). No significant difference existed in the mortality rates between the groups (P = 0.106). Hemodynamic instability was an independent predictor of mortality (P = 0.008). CONCLUSIONS: Anticoagulation therapy and open aortic surgery for AAT show similar results; however, open aortic surgery reliably removes AAT and reduces the risk of recurrent embolization compared with anticoagulation therapy. Furthermore, the preoperative hemodynamic status significantly influences the clinical outcome and is a strong predictor of prognosis.

Clinical course and outcome of patients with acute pulmonary embolism rescued by veno-arterial extracorporeal membrane oxygenation: a retrospective review of 21 cases.

BACKGROUND: Veno-arterial extracorporeal membrane oxygenation (ECMO) is increasingly being utilized in patients with massive pulmonary embolism (PE). However, the efficacy and the safety remain uncertain. This study aimed to investigate clinical courses and outcomes in ECMO-treated patients with acute PE. METHODS: Twenty-one patients with acute PE rescued by ECMO from January 2012 to December 2019 were retrospectively analysed. Clinical features, laboratory biomarkers, and imaging findings of these patients were reviewed, and the relationship with immediate outcome and clinical course was investigated. RESULTS: Sixteen patients (76.2%) experienced refractory circulatory collapse requiring cardiopulmonary resuscitation (CPR) or ECMO support within 2 h after the onset of cardiogenic shock, and none could receive definitive reperfusion therapy before ECMO initiation. Before or during ECMO support, more than 90% of patients had imaging signs of right ventricular (RV) dysfunction. In normotension patients, the computed tomography (CT) value was a valuable predictor of rapid disease progression compared with cardiac troponin I level. Ultimately, in-hospital death occurred in ten patients (47.6%) and 90% of them died of prolonged CPR-related brain death. Cardiac arrest was a significant predictor of poor prognosis (p = 0.001). CONCLUSIONS: ECMO appears to be a safe and effective circulatory support in patients with massive PE. Close monitoring in intensive care unit is recommended in patients with RV dysfunction and aggressive use of ECMO may reduce the risk of sudden cardiac arrest and improve clinical outcome.

Lethal acute aortic dissection complicated with ischemic bowels in the third trimester of pregnancy: A case report.

OBJECTIVE: Aortic dissection is a rare but lethal disease. We demonstrate a rare case of acute complicated Stanford type A aortic dissection in the third trimester. CASE REPORT: A 41-year-old primiparous patient with chronic hypertension was brought to our emergency department at 34 weeks of gestation. She presented with acute tearing chest pain radiating to her back. Computed tomography revealed a Stanford type A aortic dissection. Primary cesarean section followed by open cardiovascular surgery was performed. However, ischemic bowels and bowel perforation occurred on the 9th and 11th postoperative days, respectively, and the patient died of septic shock on the 12th postoperative day. CONCLUSION: Aortic dissection must be taken into consideration for pregnant women with chronic hypertension who present with acute tearing chest pain and pulseless unilateral extremities. Bowel ischemia may occur in patients with complicated Stanford type A aortic dissection.

Natural courses and long-term results of type A acute aortic intramural haematoma and retrograde thrombosed type A acute aortic dissection: a single-centre experience.

OBJECTIVES: Few reports on the outcomes of patients treated for Stanford type A acute aortic intramural haematoma (TAAIMH) and retrograde thrombosed type A acute aortic dissection exist. This study aimed to evaluate their long-term results and predictors of adverse outcomes. METHODS: We retrospectively analysed 40 patients with TAAIMH and retrograde thrombosed type A acute aortic dissection. All patients underwent urgent surgery on presentation of life-threatening complications. Before discharge, 18 patients underwent open aortic surgery, and 22 were treated with medical therapy alone. Clinical features of these patients and image appearances were reviewed, and the relationship with overall survival, aortic events, and aortic death was investigated. RESULTS: The in-hospital mortality rate was 4.5% (1 patient) with medical therapy alone and 11.1% (2 patients) with surgical intervention. No patient with initial medical therapy required urgent surgery for life-threatening complications beyond 3 days of admission. The overall survival and aortic death-free survival rates at 1, 5 and 10 years were 85.0%, 72.5% and 59.8% and 90.0%, 81.6% and 77.1%, respectively. TAAIMH associated with penetrating aortic ulcer (PAU) was a risk factor of aortic events (P = 0.020) and significantly influenced aortic death-free survival (P = 0.003). CONCLUSIONS: Urgent surgery for complicated TAAIMH and retrograde thrombosed type A acute aortic dissection patients and initial medical therapy for uncomplicated patients show favourable long-term survival rates. TAAIMH is frequently associated with PAU; PAU enlargement is common. Although PAU can remain stable for years, it is a strong predictor of poor prognosis. For optimal long-term results, surgical repair is recommended for TAAIMH associated with PAU.

Thoracic Endovascular Aortic Repair for Type A Intramural Hematoma and Retrograde Thrombosed Type A Aortic Dissection: A Single-Center Experience.

BACKGROUND: The aim of this study is to present our experience of thoracic endovascular aortic repair (TEVAR) for type A intramural hematoma (TAIMH) and retrograde thrombosed type A aortic dissection (rt-TAAD) with the entry tear in the descending aorta or the abdominal aorta and discuss the outcomes. METHODS: We retrospectively reviewed total 6 patients who underwent TEVAR for TAIMH (n = 2) or rt-TAAD (n = 4) in our hospital between September 2017 and July 2019. The mean age of the patients (5 men and 1 woman) was 74 ± 13 years, and the mean follow-up duration was 13 ± 7 months. RESULTS: TEVAR was successfully performed in the acute phase in all patients without relevant complications. After TEVAR, the shrinkage of enlarged thoracic aorta and complete resorptions of the false lumen of the entire thoracic aorta were achieved in 4 patients. In the remaining 2 patients, one had residual thrombosed false lumen of the ascending aorta due to a new development of PAU at the distal aortic arch and another needed additional endovascular intervention for ascending aorta hematoma progression. Late aorta-related adverse event was observed in one patient, who needed open aortic repair. There was no death during follow-up. CONCLUSIONS: Tear-oriented endovascular aortic repair is a potential option in selected patients of TAIMH and rt-TAAD and has shown favorable immediate outcomes and aortic remodeling. However, the late aorta-related adverse event is not negligible, and their long-term outcome has not been fully clarified. More research is warranted.

Double-Barreled and Branched Endografting for Thoracoabdominal Aortic Aneurysm: The Hexapus Technique.

OBJECTIVE: To treat thoracoabdominal aortic aneurysm (TAAA), we introduced an alternative "Hexapus" technique by double-barreled and branched endografting. TECHNIQUE AND RESULT: We established 2 transfemoral and 2 transaxillary access routes first and then deployed two abdominal bifurcated stentgrafts landing at the descending thoracic aorta through transfemoral routes, respectively. Two pairs of parallel stentgrafts were deployed via bilateral transaxillary route from each of contralateral limbs of main body stentgrafts to visceral arteries. Finally, we extended the ipsilateral limbs of main body stentgrafts to bilateral common iliac arteries as distal landings. The creation of six branches (four viscerals and two iliacs) resembles a hexapus. We have executed this Hexapus technique in three patients, and the final angiography during operation and postoperative 12-month image follow-up showed patent visceral branches and no any endoleaks. CONCLUSION: Our Hexapus technique is feasible in treating TAAA if patient is inoperable or no commercial fenestrated or branched stentgraft is available.

The feasibility of endovascular aortic repair strategy in treating infected aortic aneurysms.

BACKGROUND: Open surgical treatment for an infected aortic aneurysm has a high rate of surgical morbidity and mortality and does not guarantee eradication of the infected nidus. The use of endovascular aortic repair (EVAR) might simplify the procedure and provide a good alternative for this critical condition, but this remains to be proved. This study assessed the efficacy and outcome of EVAR with an adjunctive antibiotic treatment strategy. METHODS: We focused on the experiences and results of the management of infected aortic aneurysms with positive blood cultures. We drew the blood for culture study, immediately prescribed broad-spectrum antibiotics, performed EVAR procedures, and followed this with sensitive antibiotics and adjunctive procedures. RESULTS: Twelve consecutive patients (mean age, 70 years) were included in this EVAR strategy. Three patients had thoracic, two thoracoabdominal, and the remaining seven had infected abdominal aneurysms. Ten Salmonella, one Staphylococcus, and one Streptococcus spp were identified. There was no hospital death. Three patients underwent computed tomography (CT)-guided drainage, and one underwent open laparotomy debridement. Mean follow-up was 24 months. One late death occurred but was unrelated to reinfection. All patients seemed well, with no evidence of EVAR graft infection at a mean follow-up of 23.6 months. CONCLUSIONS: This small multi-institutional study summarizing the experiences of patients with an infected aortic aneurysm managed by EVAR and an aggressive antibiotic strategy revealed that this EVAR strategy might be a suitable approach to treating this disease. These favorable results may be typical for Salmonella infection, which was present in most of the patients. Further experience is needed to assess whether this therapeutic strategy works equally well in aneurysm infection caused by other organisms.

Infective endocarditis caused by Streptococcus bovis complicated by a superior mesenteric artery mycotic aneurysm and systemic septic emboli in a patient with colon diverticulitis.

To date, Streptococcus bovis endocarditis complicated by a superior mesenteric artery mycotic aneurysm and systemic septic emboli in a patient with colon diverticulitis has never been reported. A 46-year-old man, with a history of colon diverticulitis identified by diagnostic colon fiberscope and with hypertension, presented with a 14-day history of intermittent fever. An echocardiogram revealed severe mitral regurgitation with two large floating vegetations attached to both mitral leaflets. A blood culture grew S. bovis. Abdominal pain and left leg weakness developed 10 days after admission. Computerized tomography identified a 5×3cm mycotic aneurysm, and angiography revealed a saccular aneurysm at the distal branch of the superior mesenteric artery. A duplex study revealed an intravascular mass at the left femoral artery bifurcation. The patient accordingly underwent surgical resection of the mycotic aneurysm, removal of the mycotic thrombi, and mitral valve replacement. The patient's recovery was unremarkable.

Video-assisted thoracoscopic surgery for hydrothorax in peritoneal dialysis patients - check-air-leakage method.

Hydrothorax developing from pleuroperitoneal communication as a complication of peritoneal dialysis was first described in 1967 [Edward SR, Unger AM. Acute hydrothorax-a new complication of peritoneal dialysis. JAMA 1967; 199:853-5. ]. The incidence of hydrothorax is approximately 1.6-2% of continuous ambulatory peritoneal dialysis (CAPD) patients. The key to successful therapy is obliteration of the transdiaphragmatic route of dialysate leakage with video-assisted thoracoscopic surgery (VATS). The method in which air leakage is checked intraoperatively is the preferred choice and better than all other procedures.