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OBJECTIVE: Endovascular treatment has largely replaced open reconstruction of proximal brachiocephalic and left common carotid ostial arterial stenoses. The objective of this study was to report the technical feasibility and safety of a flow-based embolic protection system in stenting of single and tandem stenotic lesions of supra-aortic arch vessels. METHODS: All cases used flow-based neuroprotection by the ENROUTE Transcarotid Neuroprotection System (Silk Road Medical, Sunnyvale, Calif). Case specifics, such as the stents used, the details of flow-based neuroprotection, the order in which lesions were treated, and the case-specific exceptions, are detailed in the body of the publication. The primary end point of this study was the occurrence of stroke or transient ischemic attack. RESULTS: Sixteen patients (12 women) with an average age of 68 years (range, 54-83 years) underwent endovascular stenting to treat single (11 patients) or tandem (5 patients) stenotic lesions of supra-aortic arch vessels. A total of 21 lesions were treated: 7 in the innominate artery, 1 in the right common carotid artery, 8 in the left common carotid artery, and 5 in the internal carotid artery (tandem cases). Eleven patients (69%) were symptomatic, and the stenoses of the five asymptomatic patients were identified during routine workup for comorbidities. Technical success was obtained in all cases. There were no strokes or transient ischemic attacks during the 30 days after the procedure. Minor complications included a minor wound dehiscence that healed secondarily without sequelae and a hematoma at the neck incision that resolved spontaneously without further intervention. CONCLUSIONS: The use of a transcarotid retrograde approach with flow-based neuroprotection is technically feasible for the endovascular stenting of single and tandem stenotic lesions of the supra-aortic arch vessels. These data further support the advantages of a transcarotid approach and flow-based neuroprotection to minimize the risk of intraoperative complications and embolic events during and after the procedure.
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Arteriopatías Oclusivas/terapia , Tronco Braquiocefálico , Estenosis Carotídea/terapia , Circulación Cerebrovascular , Dispositivos de Protección Embólica , Procedimientos Endovasculares/instrumentación , Stents , Anciano , Anciano de 80 o más Años , Arteriopatías Oclusivas/complicaciones , Arteriopatías Oclusivas/diagnóstico por imagen , Arteriopatías Oclusivas/fisiopatología , Tronco Braquiocefálico/diagnóstico por imagen , Tronco Braquiocefálico/fisiopatología , Estenosis Carotídea/complicaciones , Estenosis Carotídea/diagnóstico por imagen , Estenosis Carotídea/fisiopatología , Procedimientos Endovasculares/efectos adversos , Estudios de Factibilidad , Femenino , Humanos , Ataque Isquémico Transitorio/etiología , Ataque Isquémico Transitorio/fisiopatología , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Factores de Riesgo , Accidente Cerebrovascular/etiología , Accidente Cerebrovascular/fisiopatología , Factores de Tiempo , Resultado del Tratamiento , Estados UnidosRESUMEN
The abdominal viscera blood supply is derived from anterior branches of the abdominal aorta. Visceral artery aneurysms (VAAs) include aneurysms of the following arteries and their branches: the celiac artery, the hepatic artery, the splenic artery, the superior mesenteric artery, the inferior mesenteric artery, the pancreaticoduodenal artery, and the gastroduodenal artery. Overall VAAs comprise < 2% of all types of arterial aneurysms. Asymptomatic VAAs are now being encountered more frequently due to the widespread use of advanced diagnostic abdominal imaging. The incidental finding of a VAA frequently leaves clinicians with a dilemma as to the best course of management. The focus of this review is on current treatment options and management guidelines for both symptomatic and asymptomatic VAAs.
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PURPOSE OF REVIEW: Spinal cord ischemia (SCI) is a devastating complication after open or endovascular aortic repair for thoracoabdominal aortic disease. The underlying pathogenesis is not fully understood but appears multifactorial. Multiple spinal cord protection strategies and monitoring techniques are currently utilized with variable results seen. The purpose of this review is to summarize important and recent findings related to cause, monitoring and impact of multiple spinal cord protection strategies. RECENT FINDINGS: Recent data suggests collateral blood flow as the major determinant of spinal cord perfusion instead of individual intercostal vessels, potential role of transcutaneous near-infrared spectroscopy for monitoring of spinal cord perfusion and positive impact of implementing multimodal spinal cord protection strategies on reducing the risk of SCI. SUMMARY: SCI leading to paraplegia is a multifactorial complication that remains a major concern in complex aortic surgeries. Although there are no sufficient data to document the efficacy of spinal cord protection techniques individually, their effect on lowering the risk of SCI is most evident when used concomitantly using a multimodal approach that encompasses the perioperative and early postoperative period.
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Aneurisma de la Aorta Torácica/cirugía , Procedimientos Endovasculares/efectos adversos , Monitorización Neurofisiológica Intraoperatoria/métodos , Paraplejía/prevención & control , Isquemia de la Médula Espinal/prevención & control , Circulación Colateral , Procedimientos Endovasculares/métodos , Humanos , Hipotermia Inducida/métodos , Paraplejía/etiología , Perfusión/métodos , Atención Perioperativa/métodos , Reimplantación/métodos , Espectroscopía Infrarroja Corta/métodos , Médula Espinal/irrigación sanguínea , Isquemia de la Médula Espinal/diagnóstico , Isquemia de la Médula Espinal/etiología , Arterias Torácicas/cirugíaRESUMEN
BACKGROUND: Uncomplicated type B dissections have historically been treated medically with hemodynamic control. Early progression of the disease and late aneurysmal dilation have been considered as indications for intervention. The aim of this study is to analyze growth rate patterns of type B dissections based on computed tomography (CT) measurements over time. METHODS: We conducted a retrospective review of patients with acute type B dissection from 2008 to 2014 who had at least 2 follow-up CT scans. Patients with rapid progression requiring interventions were also included. Using M2S software (M2S, Lebanon, NH), we calculated the mean centerline diameter of the true and false lumens at 3 different sites of the descending aorta. Growth rate was calculated as the change in maximal diameter between the first interval and last available CT scans. Primary outcome was to compare the growth rate pattern between the 2 time intervals. Secondary outcomes included early and delayed aortic intervention and overall mortality (OM). RESULTS: A total of 108 patients were included. Average age of patients was 58.7 years. Median follow-up time was 3 months for the first CT and 32 months for the second. OM was 27.8% (n = 30), whereas the disease-specific mortality was 11.1% (n = 12). Thirty-seven percent (n = 40) required operative intervention (18 open and 22 endovascular repair): 20 at 30 days, 12 at 12 months, and 8 patients at >1 year. Mean aortic growth rate was higher in the first time interval compared with the second: 0.89 vs. 0.19 mm/month (P < 0.05) at the proximal descending aorta, 1.01 vs. 0.18 mm/month (P < 0.05) at the mid-descending aorta, and 0.65 vs. 0.28 mm/month; (P < 0.05) at the distal descending aorta. Those who underwent intervention had a higher aortic growth rate at early and late interval (P < 0.05). Age and number of comorbidities were associated with OM. Thrombosis of the false lumen did not affect the mortality and intervention rate. CONCLUSIONS: Type B dissection is associated with aortic growth over time. The overall growth rate was not linear with a more prominent initial phase. Faster aortic growth rate is associated with an increased intervention rate, whereas advanced age and number of comorbidities are associated with increased mortality. Prospectively designed studies are needed to identify the subgroup of patients who may benefit from early intervention based on growth rate measurements.
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Aorta Torácica/diagnóstico por imagen , Aneurisma de la Aorta Torácica/diagnóstico por imagen , Disección Aórtica/diagnóstico por imagen , Aortografía/métodos , Angiografía por Tomografía Computarizada , Adulto , Factores de Edad , Anciano , Anciano de 80 o más Años , Disección Aórtica/mortalidad , Disección Aórtica/patología , Disección Aórtica/cirugía , Aorta Torácica/patología , Aorta Torácica/cirugía , Aneurisma de la Aorta Torácica/mortalidad , Aneurisma de la Aorta Torácica/patología , Aneurisma de la Aorta Torácica/cirugía , Comorbilidad , Dilatación Patológica , Progresión de la Enfermedad , Femenino , Humanos , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Interpretación de Imagen Radiográfica Asistida por Computador , Estudios Retrospectivos , Factores de Riesgo , Programas Informáticos , Factores de Tiempo , Tiempo de Tratamiento , Resultado del Tratamiento , Adulto JovenRESUMEN
Traumatic aortic injuries in children and adolescents are rare. Although endovascular repair has become the preferred approach for such injuries in adults, open repair has endured as the gold standard in children owing mainly to the smaller aortic and access vessel diameter and the scarcity of long-term follow-up data. We report a successful endovascular repair of a traumatic thoracic aortic injury in an 8-year-old girl using a Zenith Alpha thoracic endograft (Cook Medical, Bloomington, IN). We also review the literature on endovascular treatment of traumatic aortic injuries in the pediatric population.
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Aneurisma Falso/cirugía , Aorta Torácica/cirugía , Aneurisma de la Aorta Torácica/cirugía , Implantación de Prótesis Vascular , Procedimientos Endovasculares , Lesiones del Sistema Vascular/cirugía , Accidentes de Tránsito , Aneurisma Falso/diagnóstico por imagen , Aneurisma Falso/etiología , Aorta Torácica/diagnóstico por imagen , Aorta Torácica/lesiones , Aneurisma de la Aorta Torácica/diagnóstico por imagen , Aneurisma de la Aorta Torácica/etiología , Aortografía/métodos , Prótesis Vascular , Implantación de Prótesis Vascular/instrumentación , Niño , Angiografía por Tomografía Computarizada , Procedimientos Endovasculares/instrumentación , Femenino , Humanos , Diseño de Prótesis , Stents , Resultado del Tratamiento , Lesiones del Sistema Vascular/diagnóstico por imagen , Lesiones del Sistema Vascular/etiologíaRESUMEN
BACKGROUND: The dissection of the carotid sinus nerve in eversion carotid endarterectomy (eCEA) has been hypothesized to cause an increase in postoperative blood pressure (BP). The objective of this study is to evaluate the effect of eCEA on BP and changes in BP medications over the course of year-long follow-up after eCEA compared with longitudinal incision carotid endarterectomy patch angioplasty (pCEA). METHODS: A retrospective review of patients who underwent CEA between July 1, 2009 and June 30, 2014 in the Vascular Surgery Department at The University of Iowa Hospital and Clinics was conducted. Demographics, comorbidities, BP, and number, dosage, and type of antihypertensive medications were collected preoperatively, at 30 days, and at 12 months. The differences in BP and medications between pCEA and eCEA patients were compared. Demographic data and comorbidities were compared using t-tests and chi-squared analysis. Differences in BP and medication dosages were analyzed using multivariate analysis of variance. RESULTS: In total, 363 CEA procedures were performed during the study period, of which 275 procedures were included in the final analysis. Thirty percent of the patients underwent eCEA. Fifty-four percent of the patients who underwent eCEA and 60% of the patients who underwent pCEA were symptomatic. Thirty-day mortality was 1.4% and 12-month mortality was 6.4% for the entire population. No postoperative neurologic deficits, including stroke, were observed. Analysis of BP did not yield a significant difference among preoperative, 30-day, and 12-month follow-up measurements (P = 0.893). There was no significant change to the number and total daily dose of BP medications preoperatively, at 30 days, or at 12 months. CONCLUSIONS: There is no statistical difference in mortality, morbidity, and patency rates at 30 days and 12 months between pCEA and eCEA. eCEA is also not associated with long-term BP changes compared with pCEA.
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Presión Sanguínea , Enfermedades de las Arterias Carótidas/cirugía , Endarterectomía Carotidea , Anciano , Antihipertensivos/uso terapéutico , Presión Sanguínea/efectos de los fármacos , Enfermedades de las Arterias Carótidas/diagnóstico por imagen , Enfermedades de las Arterias Carótidas/mortalidad , Enfermedades de las Arterias Carótidas/fisiopatología , Distribución de Chi-Cuadrado , Comorbilidad , Endarterectomía Carotidea/efectos adversos , Endarterectomía Carotidea/mortalidad , Femenino , Hospitales Universitarios , Humanos , Hipertensión/tratamiento farmacológico , Hipertensión/etiología , Hipertensión/fisiopatología , Iowa , Masculino , Persona de Mediana Edad , Análisis Multivariante , Recurrencia , Estudios Retrospectivos , Factores de Riesgo , Factores de Tiempo , Resultado del Tratamiento , Grado de Desobstrucción VascularRESUMEN
Spontaneous iliac vein rupture resulting in a retroperitoneal hematoma is extremely rare and can present as a life-threatening emergency. There is often a delay in diagnosis with no established treatment recommendations. We report the case of a 39-year-old woman who presented with hypovolemic shock, a large left retroperitoneal hematoma, and left lower extremity phlegmasia in the setting of a previously asymptomatic May-Thurner syndrome. She was successfully treated with a combined open and endovascular approach. We also reviewed the literature on the evolution of diagnosis and treatment of this rare condition and present our recommendations for management.
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Hematoma/patología , Vena Ilíaca/patología , Síndrome de May-Thurner/diagnóstico , Adulto , Femenino , Humanos , Síndrome de May-Thurner/patología , Rotura EspontáneaRESUMEN
A fistula formation between the esophagus and an aberrant right subclavian artery is a rare but fatal complication that has been mostly described in the setting of prolonged nasogastric intubation and foreign body erosion. We report a case of a young morbidly obese patient who underwent sleeve gastrectomy that was complicated by a postoperative leak at the level of the gastroesophageal junction. A covered esophageal stent was placed endoscopically to treat the leak. The patient developed massive upper gastrointestinal bleeding secondary to the erosion of the stent into an aberrant retroesophageal right subclavian artery twelve days after stent placement. She was ultimately treated by endovascular stenting of the aberrant right subclavian artery followed by thoracotomy and esophageal repair over a T-tube. This case report highlights the multidisciplinary approach needed to diagnose and manage such a devastating complication. It also emphasizes the need for imaging studies prior to stent deployment to delineate the vascular anatomy and rule out the possibility of such an anomaly in view of the growing popularity of esophageal stents, especially in the setting of a leak.
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McKittrick-Wheelock syndrome is a rare disease characterized by a large hypersecretory rectosigmoid villous adenoma resulting in persistent large volume diarrhea, electrolyte abnormalities, and renal dysfunction. We report an unusual presentation of this syndrome in a patient who developed persistent diarrhea along with dermatomyositis and rectal prolapse and was later discovered to have a large rectal villous adenoma along with a smaller sigmoid tubulovillous adenoma. In our literature review, we were able to find one case report of a dermatomyositis occurring in conjunction with a tubulovillous adenoma and few case reports of rectal prolapse in the setting of a secretory villous adenoma. However, there were no reports on both occurring in association with McKittrick-Wheelock syndrome. This report highlights the variable manifestations of colorectal adenomas and the importance of searching for an underlying neoplastic entity in patients with new onset dermatomyositis or rectal prolapse or both.