Practice of neuromonitoring in open and endovascular thoracoabdominal aortic repair-an international expert-based modified Delphi consensus study.

OBJECTIVES: Spinal cord injury is detrimental for patients undergoing open or endovascular thoracoabdominal aortic aneurysm (TAAA) repair. The aim of this survey and of the modified Delphi consensus was to gather information on current practices and standards in neuroprotection in patients undergoing open and endovascular TAAA. METHODS: The Aortic Association conducted an international online survey on neuromonitoring in open and endovascular TAAA repair. In a first round an expert panel put together a survey on different aspects of neuromonitoring. Based on the answers from the first round of the survey, 18 Delphi consensus questions were formulated. RESULTS: A total of 56 physicians completed the survey. Of these, 45 perform open and endovascular TAAA repair, 3 do open TAAA repair and 8 do endovascular TAAA repair. At least 1 neuromonitoring or protection modality is utilized during open TAAA surgery. Cerebrospinal fluid (CSF) drainage was used in 97.9%, near infrared spectroscopy in 70.8% and motor evoked potentials or somatosensory evoked potentials in 60.4%. Three of 53 centres do not utilize any form of neuromonitoring or protection during endovascular TAAA repair: 92.5% use CSF drainage; 35.8%, cerebral or paravertebral near infrared spectroscopy; and 24.5% motor evoked potentials or somatosensory evoked potentials. The utilization of CSF drainage and neuromonitoring varies depending on the extent of the TAAA repair. CONCLUSIONS: The results of this survey and of the Delphi consensus show that there is broad consensus on the importance of protecting the spinal cord to avoid spinal cord injury in patients undergoing open TAAA repair. Those measures are less frequently utilized in patients undergoing endovascular TAAA repair but should be considered, especially in patients who require extensive coverage of the thoracoabdominal aorta.

Arterial Occlusion Effectiveness of Space Blanket‒Improvised Tourniquets for the Remote Setting.

INTRODUCTION: Control of severe extremity hemorrhage by tourniquet can save lives. In remote areas or in mass casualty incidents with multiple severely bleeding victims, lack of conventional tourniquets may make it necessary to improvise tourniquets. METHODS: Occlusion of the radial artery and delayed onset of capillary refill time resulting from windlass-type tourniquets were experimentally investigated by comparing a commercial tourniquet and a space blanket‒improvised tourniquet with a carabiner as a rod. This observational study was conducted on healthy volunteers in optimal application circumstances. RESULTS: Operator-applied Combat Application Tourniquets were deployed more swiftly (27 s, 95% CI: 25.7-30.2 vs 94 s, 95% CI: 81.7-114.4) and achieved 100% complete radial occlusion compared with improvised tourniquets, as assessed by Doppler sonography (P<0.001). When space blanket‒improvised tourniquets were used, traces of radial perfusion persisted in 48% of the applications. In Combat Application Tourniquets, capillary refill times were significantly delayed (7 s, 95% CI: 6.0-8.2 vs 5 s, 95% CI: 3.9-6.3) compared with those when using improvised tourniquets (P=0.013). CONCLUSIONS: Improvised tourniquets should be considered only in dire circumstances with uncontrolled extremity hemorrhage and when no commercial tourniquets are available. Complete arterial occlusion was achieved in only half of the applications using a space blanket‒improvised tourniquet when a carabiner was used as a windlass rod. The speed of application was inferior to that for Combat Application Tourniquets. Similar to Combat Action Tourniquets, the correct assembly and application of space blanket‒improvised tourniquets on upper and lower extremities have to be trained. TRIAL REGISTRATION: ClinicalTrials.gov identifier: BASG No.: 13370800/15451670.

Acute type A aortic dissection in adolescents and young adults under 30 years of age: demographics, aetiology and postoperative outcomes of 139 cases.

OBJECTIVES: The prevalence and aetiology of acute aortic dissection type A (AADA) in patients ≤30 years is unknown. The aims of this clinical study were to determine the prevalence and potential aetiology of AADA in surgically treated patients ≤30 years and to evaluate the respective postoperative outcomes in this selective group of patients in a large multicentre study. METHODS: Retrospective data collection was performed at 16 participating international aortic institutions. All patients ≤30 years at the time of dissection onset were included. The postoperative results were analysed with regard to connective tissue disease (CTD). RESULTS: The overall prevalence of AADA ≤30 years was 1.8% (139 out of 7914 patients), including 51 (36.7%) patients who were retrospectively diagnosed with CTD. Cumulative postoperative mortality was 8.6%, 2.2% and 1.4%. Actuarial survival was 80% at 10 years postoperatively. Non-CTD patients (n = 88) had a significantly higher incidence of arterial hypertension (46.6% vs 9.8%; P < 0.001) while AADA affected the aortic root (P < 0.001) and arch (P = 0.029) significantly more often in the CTD group. A positive family history of aortic disease was present in 9.4% of the study cohort (n = 13). CONCLUSIONS: The prevalence of AADA in surgically treated patients ≤30 years is <2% with CTD and arterial hypertension as the 2 most prevalent triggers of AADA. Open surgery may be performed with good early results and excellent mid- to long-term outcomes.

Risk of Permanent Pacemaker Implantation Following Bentall Operation.

Conduction disorders following cardiac surgery are common complications with incidences of permanent pacemaker dependency up to 5%. However, data on pacemaker implantation rates in the long-term follow-up after Bentall operations are scarce. In a retrospective study, a mixed cohort of 260 patients including endocarditis and aortic dissection undergoing Bentall operation between March 1996 and December 2015 was analyzed. Median follow-up time was 60 (12-107) months. Early and late rates of permanent pacemaker implantation and associated risk factors were investigated. In the postoperative course 31 (11.9%) permanent pacemakers were implanted. The 30-day incidence of pacemaker implantations was 7.7% with operations performed after a median of 6 (3-12) days after the Bentall operation. After ten years, 21% of the Bentall patients were permanent pacemaker dependent. The risk factors for permanent pacemaker dependency included age above 75 years (16.1% vs 5.7%; P < 0.001), preoperative cardiac conduction disturbance (32.3% vs 22.7%, P = 0.018), aortic valve stenosis (38.7% vs 23.1, P = 0.008), infective endocarditis (19.4% vs 7.4%, P = 0.004), tricuspid valve reconstruction (6.5% vs 0.9%, P = 0.033), sepsis (12.9% vs 4.4%, P < 0.001) and non-cardiac reoperation (19.4% vs 8.7%, P = 0.004). Pacemaker implantation significantly increased the length of initial hospitalization (13 [8-26] days vs 8 [7-13] days; P = 0.003). In the long-term follow-up, mortality was not different between the groups. Permanent pacemaker dependency is a frequent complication in the short- and long-term follow-up after Bentall operations. Screening for cardiac conduction disturbances in the short- and long-term follow-up is recommended.

Rescue Blankets as Multifunctional Rescue Equipment in Alpine and Wilderness Emergencies-A Narrative Review and Clinical Implications.

The utilization of rescue blankets in pre-hospital emergency medicine exceeds protection from hypothermia and enhanced visibility by far. In this narrative review, we focus on emphasizing the alternative applications of these fascinating multifunctional tools in the pre-hospital setting. A literature search in PubMed® and Web of ScienceTM yielded 100 results (last update was on 8 July 2022), a total number of 26 of which were included in this narrative review. Nine articles assessing alternative functions of rescue blanket were further evaluated and described in more detail. In addition, we performed various experimental and observational trials to test the functionality of rescue practice in mountain emergency medicine. Newly fabricated rescue blankets proved to possess impressive robustness. We evaluated rescue blankets in their applicability to not only protect from hypothermia, but also as practical tools to treat catastrophic hemorrhage and bleeding limbs, to perform open pneumothorax chest seals in sucking chest wounds, to prevent damage to unprotected eyes on the glacier and as alternative instruments for transportation in the inaccessible areas. Rescue blankets are important rescue equipment in alpine and wilderness emergencies with multifunctional applications, and must be part of every personal medical kit.

Rescue blankets as multifunctional rescue equipment in alpine and wilderness emergencies: a commentary.

Emergency applications of rescue blankets go far beyond protection from hypothermia. In this review alternative applicabilities of these remarkable multifunctional tools were highlighted. Newly fabricated rescue blankets prove impressive robustness. The high tensile strength along with its low weight enable further applications, e.g. immobilization of injured extremities, splinting, wound dressing, a makeshift chest seal in sucking chest wounds, amongst others. Furthermore, the foil can be used as a vapour barrier, as eye protection and it can even be used to construct a stopgap bivouac sack, as alternative tool for transportation in the remote area and a wind shield or a water reservoir in the wilderness. During search-and-rescue missions the light reflection from the gold surface enhances visibility and increases the chance to be found. Rescue blankets are essential parts of first aid kits and backpacks in alpine and wilderness environment with multifunctional applicabilities. In this commentary to a review we want to evaluate the numerous applicabilities of rescue blankets in the treatment of emergencies by wilderness medicine and pre-hospital EMS.

Rescue Blanket as a Provisional Seal for Penetrating Chest Wounds in a New Ex Vivo Porcine Model.

BACKGROUND: Open pneumothorax after a penetrating thorax trauma is a life-threatening disease with high mortality. An emergency application of a chest seal (CS) allowing the release of trapped air is the optimum initial therapy until surgical chest drainage is available. METHODS: In a newly developed experimental porcine model of open pneumothorax, we tested 3 different materials regarding their applicability for acute treatment of sucking chest wounds in prehospital emergency care, namely a commonly used rescue blanket (RB), plastic foil from a gauze package (packing material), and a commercial CS. RESULTS: An ex vivo open pneumothorax model using a porcine chest wall and a vacuum-assisted drainage system was successfully established. RB segments sized 70 × 100 mm achieved significantly higher rates of successful sealing than plastic foils from a gauze package sized 100 × 100 mm when the devices were applied to the moistened chest wall and fixed on 3 sides (5/5 [100%] vs 0/5 [0%], respectively; P = .002). Loosely fixed RBs efficiently released injected air (10/10 [100%]) and consequently sealed the wound in all cases (10/10). CONCLUSIONS: RBs, applied wet, are appropriate CSs with good occlusive and adherence properties. Fixation on 2 sides of the dressing is sufficient to allow trapped air to exit while providing appropriate sealing of the chest wound. RBs were superior to plastic foils from a gauze package and were seen to function as a potent makeshift CS when no commercial CS is available.

Bicuspid Aortic Valve Is Associated with Less Coronary Calcium and Coronary Artery Disease Burden.

(1) Background. Bicuspid aortic valve (BAV) is associated with genetic defects (NOTCH 1, GATA 5) and aortopathy. Differences in the flow patterns and a genetic predisposition could also affect coronary arteries. The objective was to assess the coronary artery calcium score (CACS) and coronary artery disease (CAD) burden by coronary computed tomography angiography (CTA) in patients with BAV stenosis, as compared to stenotic tricuspid aortic valves (TAV). (2) Methods. A retrospective case-control study. A total of 47 patients with BAV stenosis (68.9 years ± 12.9, 38.3% females) who underwent CTA were matched with 47 TAV stenosis patients for age, gender, smoking, arterial hypertension, dyslipidemia, diabetes, body-mass-index and chronic kidney disease. (3) Results. The coronary artery calcium score (CACS) was lower in BAV (237.4 vs. 1013.3AU; p < 0.001) than in TAV, and stenosis severity was less (CAD-RADTM: p < 0.001). More patients with BAV had CACS zero (27.7% vs. 0%; p < 0.001). The majority (68.1%) of patients with BAV had no or non-obstructive CAD but only 25.5% of TAV (p < 0.001). Obstructive CAD (>50% stenosis) by CTA was more frequently observed in patients with TAV (68.1%; p < 0.001). (4) Conclusions and Relevance. Patients with BAV stenosis have markedly less coronary calcium and less severe coronary stenosis. CTA succeeds to rule out obstructive CAD in the majority of BAV, with adherent implications for TAVR planning.

Impact of the coronavirus disease 2019 (COVID-19) pandemic on the care of patients with acute and chronic aortic conditions.

OBJECTIVES: To evaluate the impact of the coronavirus disease 2019 (COVID-19) pandemic on acute and elective thoracic and abdominal aortic procedures. METHODS: Forty departments shared their data on acute and elective thoracic and abdominal aortic procedures between January and May 2020 and January and May 2019 in Europe, Asia and the USA. Admission rates as well as delay from onset of symptoms to referral were compared. RESULTS: No differences in the number of acute thoracic and abdominal aortic procedures were observed between 2020 and the reference period in 2019 [incidence rates ratio (IRR): 0.96, confidence interval (CI) 0.89-1.04; P = 0.39]. Also, no difference in the time interval from acute onset of symptoms to referral was recorded (<12 h 32% vs > 12 h 68% in 2020, < 12 h 34% vs > 12 h 66% in 2019 P = 0.29). Conversely, a decline of 35% in elective procedures was seen (IRR: 0.81, CI 0.76-0.87; P < 0.001) with substantial differences between countries and the most pronounced decline in Italy (-40%, P < 0.001). Interestingly, in Switzerland, an increase in the number of elective cases was observed (+35%, P = 0.02). CONCLUSIONS: There was no change in the number of acute thoracic and abdominal aortic cases and procedures during the initial wave of the COVID-19 pandemic, whereas the case load of elective operations and procedures decreased significantly. Patients with acute aortic syndromes presented despite COVID-19 and were managed according to current guidelines. Further analysis is required to prove that deferral of elective cases had no impact on premature mortality.

A new way to use transit-time flow measurement for coronary artery bypass grafting.

OBJECTIVES: Transit-time flow measurement is a recognized method for graft evaluation in coronary surgery. However, single flow measurement has been associated with a low specificity for detecting graft dysfunction. The goal of this study was to assess the value of transit-time flow measurement for assessing in situ internal mammary artery grafts during non-existent native coronary circulation and the relevance of collateral blood flow in target vessels. METHODS: Between 2014 and 2018, a total of 134 patients undergoing on-pump coronary artery bypass grafting were evaluated using transit-time flow measurement. We analysed 111 single left internal mammary artery and 57 single right internal mammary artery bypasses. Correlations between coronary relevant parameters were calculated using Spearman's ρ coefficient. Risk factors for decreased flow with an arrested heart (FAH) <30 ml/min and an increased pulsatility index (PI) >3.0 as well as flow reduction >30% were calculated. RESULTS: FAH correlated with the diameter of the target vessel (Spearman's ρ = 0.32; P < 0.001), the amount of blood distribution (Spearman's ρ = 0.34; P < 0.001), the PI (Spearman's ρ = 0.19; P = 0.019) and the degree of stenosis (Spearman's ρ = -0.17; P = 0.042). The percentage of flow change was found to correlate with the PI (Spearman's ρ = -0.47; P < 0.0001), the degree of stenosis (Spearman's ρ = 0.42; P < 0.001), the diameter of the target vessel (Spearman's ρ = -0.22; P = 0.008) and the area of blood distribution (Spearman's ρ = -0.19; P = 0.018). A small blood distribution area was the only risk factor for decreased FAH [odds ratio (OR) 8.43, confidence interval (CI) 95% (3.04-23.41); P < 0.001]. Binary logistic regression identified PI [OR 2.05, CI 95% (1.36-3.10); P = 0.001], FAH [OR 0.98, CI 95% (0.97-0.99); P = 0.005] and degree of stenosis [OR 0.95, CI 95% (0.92-0.99); P = 0.011] as risk factors for decreased flow after cardiopulmonary bypass (<30 ml/min). An increased PI (>3) was mainly influenced by percentage of flow change [OR 0.99, CI 95% (0.98-1.00); P = 0.031]. CONCLUSIONS: FAH and percentage of flow change are related to the dimensions of the target vessel and the degree of stenosis. The addition of flow measurements with the heart arrested provides additional information about the bypass graft, the quality of the anastomosis and the physiology of the coronary circulation.

Extra-anatomic carotid bypass in acute aortic dissection type A with carotid artery malperfusion.

Acute aortic dissection type A with subtotal or total occlusion of one carotid artery is a complex situation. An additional extra-anatomic carotid artery bypass can restore carotid artery perfusion after standard emergency surgery with aortic replacement.

Differences in coronary vasodilatory capacity and atherosclerosis in endurance athletes using coronary CTA and computational fluid dynamics (CFD): Comparison with a sedentary lifestyle.

BACKGROUND: The aim was to assess the effect of endurance exercise on coronary vasodilatory capacity and atherosclerosis by coronary computed tomography angiography (CTA) and computational fluid dynamic (CFD) modelling. METHODS: 100 subjects (age 56.2y±11, 29 females) who underwent coronary CTA were included into this retrospectively matched cohort study. Endurance athletes (≥1 h per unit and ≥3 times per week training) were compared to controls with a sedentary lifestyle, and within subgroups with and without sublingual nitroglycerin preparation. CTA image analysis included coronary stenosis severity (CADRADS), total (segment involvement score = SIS) and mixed plaque burden (G-score), high-risk plaque criteria, the coronary artery calcium score (CACS) and CFD analysis including Fractional Flow Reserve (FFRCT), myocardial mass (M), total vessel lumen volume (V) and volume-to-mass (V/M) ratio. RESULTS: The prevalence of atherosclerosis by CTA was 65.4 % and >50 % coronary stenosis was found in 17.3 % of athletes. Coronary stenosis severity (CADRADS), total and mixed non-calcified plaque burden (SIS and G-score) were lower in athletes (p = 0.003 and p < 0.001) but not CACS (p = 0.055) and less high-risk plaques were found (p < 0.001). The G-score was correlated with distal FFRCT (p = 0.025). V/M-ratio was different between athletes who received nitroglycerin compared with those who did not (V/M: 21.1 vs. 14.8; p < 0.001), but these differences were not observed in the control subjects. CONCLUSION: Endurance training improves coronary vasodilatory capacity and reduces high-risk plaque and mixed non-calcifed plaque burden as assessed by coronary CTA angiography. Our study may advocate coronary CTA with FFRCT for evaluation of coronary artery disease in endurance athletes.

Immediate Surgery in Acute Type A Dissection and Neurologic Dysfunction: Fighting the Inevitable?

BACKGROUND: Neurologic dysfunction remains an ongoing challenge in the diagnosis of type A aortic dissection (AAD). Our study analyzed the impact of preoperative neurologic dysfunction (PND) on outcome and assessed a potential link between PND and specific patterns of postoperative neurologic injury. METHODS: Medical records of 338 patients (70.1% men; mean age, 59.3 ± 13.7 years) undergoing surgical repair for AAD were screened for the presence of PND. Preoperative characteristics, surgical treatment, and hospital and neurologic outcomes were analyzed according to patients with PND (PND+) and without PND (PND-) RESULTS: There were 50 patients (14.8%) admitted with PND. PND+ patients showed significantly higher rates of postoperative neurologic injury (44.4%) than PND- patients (14.3%; P < .001) with a specific pattern of ischemic lesions in accordance with preoperative neurologic status. While PND+ patients suffered mainly from right hemispheric strokes (66.7% vs 32.4% in PND- patients, P = .024), PND- patients more frequently presented with bilateral cerebral ischemia (56.8% vs 13.3% in PND+ patients, P = .004). Multivariable analysis identified presence of PND (odds ratio, 2.977; 95% confidence interval, 1.357-6.545) as an independent predictor for new postoperative neurologic injury. PND was associated with impaired survival (P = .005). CONCLUSIONS: This study identified an association of preoperative neurologic status and specific stroke patterns after surgical repair of AAD. Irrespective of timing of surgery and reperfusion strategies, preoperative neurologic dysfunction is strongly associated with impaired neurologic outcome.

Intracavitary right coronary artery - Or just a wrap? A cardiac CT imaging series.

Intracavitary right coronary artery (RCA) is a very rare anomaly occurring in less than 0.1%1 and up to 0.4% reported by coronary computed tomography angiography (CTA).2 Literature is scarce, however its recognition is crucial, especially prior to surgical or interventional procedures such as coronary artery bypass graft (CABG) surgery, right heart catheterization or device implantation: Hereby the RCA is at risk of injury with fatal bleeding, or suturing a CABG anastomosis may be difficult or impossible.

[Traumatic aortic rupture - diagnosis and managment]. / Die traumatische Aortenruptur.

Road traffic accidents are the main cause of traumatic aortic ruptures, mostly in combination with other severe injuries. The pre-hospital mortality rate is high. Suspected aortic trauma, following a high traumatic aortic injury score, is an indication for computer tomography. Injuries are triaged and the treatment priority of the aortic trauma is ascertained based on the severity of the aortic and concomitant injuries and the condition of the patient. Until definitive treatment of the aortic lesion is completed, the blood pressure of the patient must be kept low. Grade I and II lesions can be managed under strict monitoring with initial conservative treatment in individual cases. Grade III (contained perforation) and grade IV (open rupture) lesions need surgical or interventional treatment as swiftly as possible. In selected cases, a delayed treatment can also be advantageous.The endovascular stent graft therapy has established itself as the preferred form of treatment.

Standards of reporting in open and endovascular aortic surgery (STORAGE guidelines).

The number of patients undergoing surgery on the thoracic and thoraco-abdominal aorta has been steadily increasing over the past decade. This document aims to give guidance to authors reporting on results in aortic surgery by clarifying definitions of aortic pathologies, open and endovascular techniques and by listing clinical parameters that should be provided for full presentation of patients' clinical profile and in particular, their outcome. The aim is to help find a common language in the treatment of aortic disease and to contribute to a better understanding of this patient population.

Relationship of exercise to coronary artery disease extent, severity and plaque type: A coronary computed tomography angiography study.

BACKGROUND: While exercise has been associated with favorable coronary artery disease (CAD) outcomes, the relationship between endurance exercise levels and CAD findings has not been well explored. PURPOSE: To evaluate the relationship of endurance exercise to CAD findings by coronary computed tomographic angiography (CCTA). METHODS: We evaluated consecutive patients referred to CCTA who filled out a survey instrument between 2015 and 2017, and who graded their level of weekly endurance exercise as: none, low (1-2 times per week), moderate (3-5 times per week) or high (5-7 times per week); along with the number of hours per week engaged in exercise as: low (<30 min), moderate (1 h) or high (>1-3 h). CCTA: analysis included measurement of maximum per-patient, per-vessel and per-segment stenosis severity, which was judged as minimal (<25%), mild (<50%), moderate (50-70%), and severe (>70%). CAD extent and severity was also summated CADRADS score, plaque burden by segment involvement score (SIS), and non-calcified plaque score (G-score). High-risk plaque (HRP), as defined by the presence of low attenuation plaque, positive arterial remodelling, spotty calcifications and napkin ring signs, was assessed. Finally, coronary artery calcium scores (CCS), as determined by Agatston units, were quantified. RESULTS: The study cohort comprised 252 patients (55.3y ±10.1, 39.7% females) with 97 inactives, 87 with low and 68 with moderate-to-high recreational endurance exercise levels (>=3x/week ≥ 1 h) included. Prevalence of subclinical CAD was 57.4%. Prevalence of >50% stenosis was with 13.2% lower at moderate-to-high exercise levels as compared to inactives (p = 0.04). Stenosis severity score (p = 0.04), total (p = 0.036) non-calcified plaque burden were lower (p = 0.026) in athletes, and in the absence of confounding risk factors, the effect strenghtened (SIS and G-score, p = 0.012 and 0.008). There was no difference in the CCS. High-risk plaque prevalence was higher in controls as compared to athletes with moderate-to-high exercise levels (13.4% vs 0%, p = 0.002), and HDL was lower (p < 0.001), respectively. MACE rate was 0%, and ICA rate of >50% stenosis 3.5% at 1 year follow-up. CONCLUSION: Regular moderate-to-high endurance exercise results in lower total and non-calcified plaque burden and less high-risk plaque.