Stereolithographic (SLA) 3D Printing for Preprocedural Planning in Endovascular Aortic Repair of a Thoracic Aneurysm.

BACKGROUND: When treating aortic aneurysm patients with complex anatomical features, preprocedural planning aided by 3D-printed models offers valuable insights for endovascular intervention. This study highlights the use of stereolithographic (SLA) 3D printing to fabricate a phantom of a challenging aortic arch aneurysm with a complex neck anatomy. CLINICAL CASE: A 75-year-old female presented with a 58 mm descending thoracic aortic aneurysm (TAA) extending to the distal arch, involving the left subclavian artery (LSA) and the left common carotid artery (LCCA). The computed tomography (CT) scans underwent scrutiny by radiology and vascular teams. Nevertheless, the precise spatial relationships of the ostial origins proved to be challenging to ascertain. To address this, a patient-specific phantom of the aortic arch was fabricated utilizing an SLA printer and a biomedical resin. The thoracic endovascular aortic repair (TEVAR) procedure was simulated using fluoroscopy on the phantom to enhance procedural preparedness. Subsequently, the patient underwent a right carotid-left carotid bypass and a right carotid-left subclavian bypass. After a 24-hour interval, the patient underwent the TEVAR procedure, during which a 37 mm × 150 mm stent graft (CTAG, WL Gore and Associates, Flagstaff, AZ, USA) and a 40 mm × 200 mm stent graft (CTAG, WL Gore and Associates, Flagstaff, AZ, USA) were deployed, effectively covering the LSA and LCCA. Notably, the aneurysm exhibited complete sealing, with no indications of endoleaks or graft infoldings. At the 12-month follow-up, the patient remains in good health, with no evidence of endoleaks or any other surgery-related complication. CONCLUSION: This report showcases the successful use of a 3D-printed endovascular phantom in guiding the decision-making process during the preparation for a TEVAR procedure. The simulation played a pivotal role in selecting the appropriate stent graft, ensuring an intervention protocol optimized based on the patient-specific anatomy.

Factors Affecting False Lumen Thrombosis In Type B Aortic Dissection. / Fatores que Afetam a Trombose da Falsa Luz na Dissecção Aórtica Tipo B.

BACKGROUND: Complete thrombosis of the false lumen facilitates remodeling of type B aortic dissection (TBAD). Morphological characteristics affect thrombosis in the false lumen. OBJECTIVES: Discuss the factors present before admission that influence false lumen thrombosis in patients with TBAD. METHODS: We studied 282 patients diagnosed with TBAD in our hospital between January 2008 and December 2017. We divided the subjects into a thrombotic group and a non-thrombotic group based on whether any thrombus was detectable in the false lumen. We analyzed the differences between the two groups with respect to clinical data, the vertical length of the dissection, and the diameter of the aorta. P values < 0.05 were considered statistically significantly different. RESULTS: Significant differences between the thrombotic group and non-thrombotic group were found with respect to age (53.92 ± 11.40 vs. 50.36 ± 10.71, p = 0.009) and proportion of patients with renal insufficiency (7.83% vs. 16.38%, p = 0.026). In zones 3-9, the true lumen diameter of the thrombotic group was significantly larger than in the non-thrombotic group (p < 0.05). Binary logistic regression analysis showed that true lumen diameter in zone 5 and renal insufficiency were independent predictors of false lumen thrombosis. CONCLUSIONS: Age and renal function were associated with thrombosis in the false lumen. Potentially, the difference between the diameter of the true lumen diameter and that of the false lumen may influence the thrombosis of the false lumen.

FUNDAMENTO: A trombose completa da falsa luz facilita a remodelação da dissecção aórtica tipo B (DATB). As características morfológicas afetam a trombose na falsa luz. OBJETIVOS: Discutir os fatores pré-admissão presentes, que influenciam a trombose da falsa luz em pacientes com DATB. METODOLOGIA: Ao todo, 282 pacientes diagnosticados com DATB em nosso hospital foram estudados, no período entre janeiro de 2008 e dezembro de 2017. Os indivíduos foram divididos em um grupo trombótico e um grupo não trombótico, com base na detecção de qualquer trombo na falsa luz. Analisamos as diferenças entre os dois grupos com relação aos dados clínicos, o comprimento vertical da dissecção e o diâmetro da aorta. Valores de p < 0,05 foram considerados estatisticamente diferentes de modo significativo. RESULTADOS: Diferenças significativas entre o grupo trombótico e o grupo não trombótico foram encontradas com relação à idade (53,92 ± 11,40 vs. 50,36 ± 10,71, p = 0,009) e proporção de pacientes com insuficiência renal (7,83% vs. 16,38%, p = 0,026). Nas zonas 3­9, o diâmetro da luz verdadeira do grupo trombótico foi significativamente maior do que no grupo não trombótico (p < 0,05). A análise de regressão logística binária mostrou que o diâmetro da luz verdadeira na zona 5 e a insuficiência renal foram preditores independentes de trombose da falsa luz. CONCLUSÕES: A idade e a função renal estiveram associadas à trombose na falsa luz. Potencialmente, a diferença entre o diâmetro da luz verdadeira e o da falsa luz pode influenciar na trombose da falsa luz.

Postoperative acute kidney injury after thoracic endovascular aortic repair for acute type B aortic dissection.

BACKGROUND: Thoracic endovascular aortic repair (TEVAR) has evolved as the standard for treating complicated acute type B aortic dissection (ATBAD). Acute kidney injury (AKI) is a common complication in critically ill patients and is commonly observed in patients with ATBAD. The purpose of the study was to characterize AKI after TEVAR. METHODS: All patients who underwent TEVAR for ATBAD from 2011 through 2021 were identified using the International Registry of Acute Aortic Dissection. The primary end point was AKI. A generalized linear model analysis was performed to identify a factor associated with postoperative AKI. RESULTS: A total of 630 patients presented with ATBAD and underwent TEVAR. The indication for TEVAR was complicated ATBAD in 64.3%, high-risk uncomplicated ATBAD in 27.6%, and uncomplicated ATBAD in 8.1%. Of 630 patients, 102 (16.2%) developed postoperative AKI (AKI group) and 528 patients (83.8%) did not (non-AKI group). The most common indication for TEVAR was malperfusion (37.5%). In-hospital mortality was significantly higher in the AKI group (18.6% vs 4%; P < .001). Postoperatively, cerebrovascular accident, spinal cord ischemia, limb ischemia, and prolonged ventilation were more commonly observed in the AKI group. The expected mortality was similar at 2 years between the two groups (P = .51). Overall, the preoperative AKI was observed in 95 (15.7%) in the entire cohort consisting of 60 (64.5%) in the AKI group and 35 (6.8%) in the non-AKI group. A history of CKD (odds ratio, 4.6; 95% confidence interval, 1.5-14.1; P = .01) and preoperative AKI (odds ratio, 24.1; 95% confidence interval, 10.6-55.0; P < .001) were independently associated with postoperative AKI. CONCLUSIONS: The incidence of postoperative AKI was 16.2% in patients undergoing TEVAR for ATBAD. Patients with postoperative AKI had a higher rate of in-hospital morbidities and mortality than those without. A history of CKD and preoperative AKI were independently associated with postoperative AKI.

Lower Body Perfusion Reduces the Morbidity of Postoperative Acute Kidney Injury in Type A Dissection: A Propensity-Matched Analysis.

INTRODUCTION: Lower body perfusion (LBP) is a technique used to provide blood perfusion to distal organs and spinal cord during circulatory arrest. However, the effect of LBP on the prognosis of aortic arch surgery, especially on postoperative renal function, remains unclear. METHODS: A total of 304 patients with acute type A aortic dissection who underwent total aortic arch replacement combined with frozen elephant trunk implantation between May 2016 and December 2021 were retrospectively analyzed. The patients were divided into LBP group (group L, n=85) and non-LBP group (group NL, n=219). Routine lower body circulatory arrest was applied during operation in group NL, and antegrade LBP combined was applied during operation in group L. Perioperative data were recorded. Propensity score matching was used for statistical analysis. RESULTS: After propensity score matching, 85 pairs of patients were successfully matched. Two groups significantly differed in circulatory arrest time (six minutes vs. 30 minutes, P=0.000), cross-clamping time (101 minutes vs. 92 minutes, P=0.010), minimum nasopharyngeal temperature (29.4ºC vs. 27.2ºC, P=0.000), and highest lactate value during cardiopulmonary bypass (2.3 µmol/L vs. 4.1 µmol/L, P=0.000). Considering the postoperative indicators, the drainage volume (450 mL vs. 775 mL, P=0.000) and the incidence of level I acute kidney injury (23.5% vs. 32%, P=0.046) in group L was lower than those in group NL. CONCLUSION: LBP resulted as a safe and feasible approach in aortic arch surgery, as it could significantly shorten the circulatory arrest time, which might reduce the incidence of postoperative level I acute kidney injury.

Surgical correction of the ascending aorta and an aortic root aneurysm associated with coarctation of the descending aorta.

This case report shows how to perform simultaneously an open surgical correction of an aortic root aneurysm and aortic stenosis by interposition of an aortic composite graft and the transdiaphragmatic extra-anatomical correction of an aortic coarctation.

A Catastrophic Complication of Thoracic Endovascular Aortic Repair: Aortoesophageal Fistula.

A 62-year-old man was admitted to the hospital due to sepsis secondary to a hemodialysis catheter-related infection that, upon diagnostic evaluation, demonstrated to be caused by P. aeruginosa and was treated with meropenem. Eradication of the infectious episode was confirmed by blood workup, including cultures. One month after the initial episode, the patient was readmitted due to a symptomatic penetrating aortic ulcer, which was classified as a cardiovascular emergency. The patient underwent an aortic stent-graft placement. Four weeks later, he presented to the emergency department with a 2-hour onset of thoracic pain and massive hematemesis. The esophagus and aortic segment with aortic stent graft were resected en bloc after an aortoesophageal fistula was diagnosed.

Midterm outcomes of emergency surgery for acute type A aortic dissection in octogenarians.

OBJECTIVE: The incidence of elderly patients with acute type A aortic dissection is increasing. A recent analysis of the International Registry of Acute Aortic Dissection failed to show a mortality benefit with surgery compared with medical management in octogenarians. Therefore, we compared our institutional outcomes of emergency surgery for acute type A aortic dissection in octogenarians versus septuagenarians to understand the outcomes of surgical intervention in elderly patients. METHODS: From 2002 to 2017, 70 octogenarians (aged ≥80 years) and 165 septuagenarians (70-79 years) underwent surgery for acute type A aortic dissection (N = 235, total). Quality of life was assessed by the RAND Short Form-36 quality of life survey. Midterm clinical and functional data were obtained retrospectively. RESULTS: At baseline, septuagenarians had a higher prevalence of diabetes (20.6% vs 5.7%, P = .01). The prevalence of cardiopulmonary resuscitation was 4.8% versus 10.0% (P = .24) in septuagenarians and octogenarians. The prevalence of cardiogenic shock was 18.2% versus 27.1% (P = .17). Thirty-day/in-hospital mortality was 21.2% versus 28.6% (P = .29). Multivariable logistic regression identified cardiogenic shock as an independent risk factor for in-hospital mortality (odds ratio, 10.07; 95% confidence interval, 2.30-44.03) in octogenarians. Survival at 5 years was 49.7% (42.1%-58.6%) versus 34.2% (23.9%-48.8%) in septuagenarians and octogenarians, respectively. Responses to the quality of life survey were no different between septuagenarians and octogenarians across all 8 quality of life categories. CONCLUSIONS: Clinical outcomes after surgery for acute type A aortic dissection are similar in octogenarians and septuagenarians. For discharged survivors, quality of life remains favorable and does not differ between the 2 groups.

Cirugía convencional del aneurisma tóraco-abdominal / Open surgical treatment of thoracoabdominal aortic aneurysm. Experience in 45 patients

BACKGROUND: Thoracoabdominal aortic aneurysm (TAAA) is an infrequent disease and demands a highly specialized and experienced management. Open repair (OR) is the gold standard but it is associated with significant morbidity and mortality. Paraplegia and renal failure are the most important complications. AIM: To report our results with OR treatment of TAAA. MATERIAL AND METHODS: Descriptive study including all patients with TAAA operated electively and consecutively by OR between 1983 and 2019. Main outcomes are operative mortality, renal and neurological morbidity, and long-term survival. RESULTS: We report 45 operated patients aged 33 to 84 years, 74% males. Aneurysm extension according to Crawford classification was I in 18%, II in 18 %, III in 36% and IV in 29%. Operative mortality was 4%. The frequency of paraplegia or paraparesis at discharge was 9%. No patient was discharged on hemodialysis. Survival at 5 and 10 years were 60% and 40% respectively. CONCLUSIONS: OR of TAAA is a complex procedure. Our results show perioperative mortality rates comparable to highly experienced centers. Although being a major procedure, OR remains an alternative to treat this serious condition.

Uptake of Screening and Recurrence of Bicuspid Aortic Valve and Thoracic Aortic Aneurysm Among At-Risk Siblings of Pediatric Probands.

OBJECTIVE: To determine uptake of cardiac screening and recurrence of bicuspid aortic valve (BAV) and thoracic aortic aneurysm (TAA) in a population of at-risk siblings of pediatric probands. STUDY DESIGN: A retrospective chart review of pediatric patients with known BAV and/or TAA was performed. Echocardiogram data from identified siblings were collected to determine screening uptake and recurrence of BAV and TAA. Statistical analyses were performed using Wilcoxon signed-rank test and chi-square. RESULTS: The cohort included 251 probands and 388 at-risk siblings. Among the siblings, 150 had at least 1 echocardiogram, giving an overall screening uptake of 38.7%. The only factor found to be associated with increased uptake was documented recommendation for screening of first-degree relatives in the proband's initial cardiology note (P = .03). A total of 11 screened siblings (7.3%) had BAV and 19 had TAA (12.7%), with an overall combined recurrence of 15.3%. Siblings of probands who had both BAV and TAA had increased recurrence of TAA compared with siblings of probands with isolated BAV (16.1% vs 3.9%, respectively). CONCLUSIONS: Given low uptake in at-risk siblings, the opportunity exists to assess barriers for families in pursuing the recommended screening. Furthermore, the relatively high recurrence of BAV and TAA in at-risk siblings highlights the potential for improved health outcomes through increased screening and early detection. Developing standardized guidelines and promoting early cardiac screening in at-risk siblings while counseling families about hereditary risk for BAV and TAA may help improve uptake and optimize clinical management in at-risk pediatric patients.

Hemoptysis as a warning sign of thoracic aorta pseudoaneurysm: A case report. / Hemoptisis como signo de alarma de pseudoaneurisma de la aorta torácica: reporte de caso.

Pseudoaneurysm is defined as a reperfused pulsatile hematoma, encapsulated and communicated with the damaged vessel's lumen. It originates when there is a disruption of the arterial wall. Hemoptysis is a very rare sign/symptom of a thoracic aortic aneurysm or pseudoaneurysm. There is little information on hemoptysis associated with aortic aneurysm rupture, whose mechanisms are not explained by the presence of an aortopulmonary fistula. Among the hypotheses to explain this phenomenon, is the ability of the bronchial arteries to become hyperplasic and tortuous in the presence of a lesion that modifies the pulmonary architecture, being more susceptible to rupture. There are also descriptions of direct lung parenchymal injury from ruptured aneurysm. The present case illustrates that we must consider the hemoptysis as a warning sign in differential diagnosis of aortic aneurysms and pseudo aneurysms, among other causes, that it can be fatal in a short time due to massive hemorrhage.

El pseudoaneurisma se define como un hematoma pulsátil repermeabilizado, encapsulado y en comunicación con la luz de un vaso dañado. Se origina cuando hay una disrupción de la pared arterial. La hemoptisis es un signo/síntoma de presentación muy rara de aneurisma aórtico torácico y de pseudoaneurisma aórtico torácico. Hay poca información sobre la hemoptisis asociada con la ruptura del aneurisma aórtico cuyo mecanismo no se explica por la presencia de una fístula aortopulmonar. Entre las hipótesis para explicar este fenómeno, se encuentra la capacidad de las arterias bronquiales de volverse hiperplásicas y tortuosas en presencia de una lesión que modifica la arquitectura pulmonar, siendo más susceptibles a la ruptura. También hay descripciones de lesiones directas del parénquima pulmonar por aneurisma roto. El presente caso nos ilustra que debemos considerar a la hemoptisis como signo de alarma en el diagnóstico diferencial de los aneurismas y pseudoaneurismas aórticos entre otras causas que puede ser fatal en breve tiempo por una hemorragia masiva.

[Open surgical treatment of thoracoabdominal aortic aneurysm. Experience in 45 patients]. / Cirugía convencional del aneurisma tóraco-abdominal.

BACKGROUND: Thoracoabdominal aortic aneurysm (TAAA) is an infrequent disease and demands a highly specialized and experienced management. Open repair (OR) is the gold standard but it is associated with significant morbidity and mortality. Paraplegia and renal failure are the most important complications. AIM: To report our results with OR treatment of TAAA. MATERIAL AND METHODS: Descriptive study including all patients with TAAA operated electively and consecutively by OR between 1983 and 2019. Main outcomes are operative mortality, renal and neurological morbidity, and long-term survival. RESULTS: We report 45 operated patients aged 33 to 84 years, 74% males. Aneurysm extension according to Crawford classification was I in 18%, II in 18 %, III in 36% and IV in 29%. Operative mortality was 4%. The frequency of paraplegia or paraparesis at discharge was 9%. No patient was discharged on hemodialysis. Survival at 5 and 10 years were 60% and 40% respectively. CONCLUSIONS: OR of TAAA is a complex procedure. Our results show perioperative mortality rates comparable to highly experienced centers. Although being a major procedure, OR remains an alternative to treat this serious condition.

Contained rupture of an aortic arch aneurysm in a patient with syphilitic aortitis. A case report / Ruptura contida de um aneurisma do arco aórtico em paciente com aortite sifilítica. Um relato de caso

Abstract Syphilitic aortitis is a rare complication of tertiary syphilis, which can lead to aortic aneurysm formation, aortic valvular insufficiency, and ostial coronary stenosis. Syphilis has re-emerged worldwide over recent decades and vascular surgeons should be aware of its cardiovascular manifestations. Atypical clinical presentation, such as hemoptysis and a computed tomography angiography pattern of a thicker aneurysmal wall with ulcer-like aneurysm projections, should raise suspicion of syphilitic aortic aneurysm. An early diagnosis and appropriate surgical and medical therapies significantly contribute to successful treatment and favorable prognosis. Herein is reported the case of an 82-year-old male patient, positive for syphilis infection, with impending aortic arch aneurysm rupture treated with a hybrid arch repair. After 7 months, the patient was brought to the emergency room in cardiac arrest. Unsuccessful cardiopulmonary resuscitation maneuvers were performed, and an autopsy showed cardiac tamponade due to rupture of the ascending aorta.

Resumo A aortite sifilítica é uma complicação rara da sífilis terciária, que pode levar a formação de aneurisma aórtico, insuficiência valvar aórtica e estenose ostial coronariana. Ao longo das últimas décadas, a sífilis ressurgiu ao redor do mundo, e os cirurgiões vasculares devem estar atentos às suas manifestações cardiovasculares. Apresentações clínicas atípicas, como a hemoptise, e um padrão na angiotomografia computadorizada de parede aneurismática mais grossa com projeções de aneurisma com aparência de úlcera devem levantar a suspeita de aneurisma sifilítico da aorta. O diagnóstico precoce e terapias cirúrgica e clínica adequadas contribuem significativamente para um tratamento bem-sucedido e prognóstico favorável. Relatamos o caso de um paciente do sexo masculino, de 82 anos, que apresentou infecção por sífilis com ruptura iminente de aneurisma do arco aórtico. Ele foi tratado com reparo híbrido do arco. Após 7 meses, o paciente deu entrada na emergência com parada cardiorrespiratória. As manobras de reanimação cardiopulmonar foram realizadas, mas não obtiveram sucesso, e a autópsia mostrou tamponamento cardíaco devido à ruptura da aorta ascendente.

Hemoptisis como signo de alarma de pseudoaneurisma de la aorta torácica: reporte de caso / Hemoptysis as a warning sign of thoracic aorta pseudoaneurysm: a case report

El pseudoaneurisma se define como un hematoma pulsátil repermeabilizado, encapsulado y en comunicación con la luz de un vaso dañado. Se origina cuando hay una disrupción de la pared arterial. La hemoptisis es un signo/síntoma de presentación muy rara de aneurisma aórtico torácico y de pseudoaneurisma aórtico torácico. Hay poca información sobre la hemoptisis asociada con la ruptura del aneurisma aórtico cuyo mecanismo no se explica por la presencia de una fístula aortopulmonar. Entre las hipótesis para explicar este fenómeno, se encuentra la capacidad de las arterias bronquiales de volverse hiperplásicas y tortuosas en presencia de una lesión que modifica la arquitectura pulmonar, siendo más susceptibles a la ruptura. También hay descripciones de lesiones directas del parénquima pulmonar por aneurisma roto. El presente caso nos ilustra que debemos considerar a la hemoptisis como signo de alarma en el diagnóstico diferencial de los aneurismas y pseudoaneurismas aórticos entre otras causas que puede ser fatal en breve tiempo por una hemorragia masiva.

Pseudoaneurysm is defined as a reperfused pulsatile hematoma, encapsulated and communicated with the damaged vessel's lumen. It originates when there is a disruption of the arterial wall. Hemoptysis is a very rare sign/symptom of a thoracic aortic aneurysm or pseudoaneurysm. There is little information on hemoptysis associated with aortic aneurysm rupture, whose mechanisms are not explained by the presence of an aortopulmonary fistula. Among the hypotheses to explain this phenomenon, is the ability of the bronchial arteries to become hyperplasic and tortuous in the presence of a lesion that modifies the pulmonary architecture, being more susceptible to rupture. There are also descriptions of direct lung parenchymal injury from ruptured aneurysm. The present case illustrates that we must consider the hemoptysis as a warning sign in differential diagnosis of aortic aneurysms and pseudo aneurysms, among other causes, that it can be fatal in a short time due to massive hemorrhage.

Thoracic Aortic Aneurysm Surgery in Marfan Patients: a Perspective from the UK.

OBJECTIVE: Cardiovascular complications in Marfan patients include progressive aortic root dilation which can precipitate acute aortic dissection, ruptured aorta, severe aortic regurgitation, or all the aforementioned. Such complications can be fatal and the cause of death prior to any surgical intervention. We set out to identify the Marfan population in England and Wales and present their surgical outcomes. METHODS: A total of 306 patients with Marfan syndrome who underwent aortic root surgery were identified between April 2007 and March 2013 from NICOR database. We examined the perioperative characteristics of such cohort along with in-hospital outcomes and survival. RESULTS: Root and ascending segment procedures on Marfan patients performed in 3.3% of the total cohort by NICOR root surgery patients. The median reported age was 40 years (IQR = 29-49 years) and 100 (32.7%) were female. Of the patients analysed, 17.3% were treated non-electively and 68.6% of them received concomitant valve procedure. The in-hospital mortality was 2.0%. Reoperation for bleeding was required in 8.2% of patients and 1.3% of them suffered a cerebrovascular accident (CVA). Mortality at 1 year was reported as 5.5%. CONCLUSION: The outcomes of surgery on the root and ascending aorta in Marfan patients in the United Kingdom are satisfactory; however, the overall complexities of this patient population are not well understood and would benefit from further investigations.

Thoracic aortic aneurysm surgery in marfan patients: a perspective from the uk

Abstract Objective: Cardiovascular complications in Marfan patients include progressive aortic root dilation which can precipitate acute aortic dissection, ruptured aorta, severe aortic regurgitation, or all the aforementioned. Such complications can be fatal and the cause of death prior to any surgical intervention. We set out to identify the Marfan population in England and Wales and present their surgical outcomes. Methods: A total of 306 patients with Marfan syndrome who underwent aortic root surgery were identified between April 2007 and March 2013 from NICOR database. We examined the perioperative characteristics of such cohort along with in-hospital outcomes and survival. Results: Root and ascending segment procedures on Marfan patients performed in 3.3% of the total cohort by NICOR root surgery patients. The median reported age was 40 years (IQR = 29-49 years) and 100 (32.7%) were female. Of the patients analysed, 17.3% were treated non-electively and 68.6% of them received concomitant valve procedure. The in-hospital mortality was 2.0%. Reoperation for bleeding was required in 8.2% of patients and 1.3% of them suffered a cerebrovascular accident (CVA). Mortality at 1 year was reported as 5.5%. Conclusion: The outcomes of surgery on the root and ascending aorta in Marfan patients in the United Kingdom are satisfactory; however, the overall complexities of this patient population are not well understood and would benefit from further investigations.

Outcomes after thoracic endovascular aortic repair in patients with chronic kidney disease in the Medicare population.

OBJECTIVE: Thoracic endovascular aortic repair has been increasingly performed in higher-risk patients with renal failure. The objective was to compare Medicare patients with preoperative chronic kidney disease with patients with normal renal function to determine differences in postoperative survival and complications. METHODS: From 2000 to 2014, 27,079 Medicare fee-for service patients underwent thoracic endovascular aortic repair. Patients were stratified by kidney function, and 23,375 patients (86%) had no chronic kidney disease, 2957 patients (11%) had chronic kidney disease stage I/IV, and 747 patients (3%) had end-stage renal disease or hemodialysis. Groups were then compared with determined differences in adjusted all-cause mortality and rates of postoperative complications. RESULTS: Overall survival was significantly worse among patients with chronic kidney disease and end-stage renal disease or hemodialysis compared with patients with no chronic kidney disease (1-year survival no chronic kidney disease: 78%; chronic kidney disease I/II: 77%; chronic kidney disease III: 67%; chronic kidney disease IV: 58%; and end-stage renal disease or hemodialysis: 48%, P < .001). Mortality was significantly increased among patients with chronic kidney disease III (hazard ratio [HR], 1.29; P < .001), chronic kidney disease IV (HR, 1.74; P < .001), and end-stage renal disease or hemodialysis (HR, 2.03; P < .001). No mortality difference was found between patients with no chronic kidney disease and patients with chronic kidney disease stage I/II. At 30 days after thoracic endovascular aortic repair, sepsis was increased for patients with chronic kidney disease stage III/IV (HR, 1.7; P < .001) and end-stage renal disease or hemodialysis (HR, 2.7; P < .001). CONCLUSIONS: In this elderly Medicare population undergoing thoracic endovascular aortic repair, patients with chronic kidney disease stage III, chronic kidney disease stage IV, or end-stage renal disease/hemodialysis had poor survival and increased morbidity compared with those with normal kidney function. These data may suggest that patients with chronic kidney disease stage III, chronic kidney disease stage IV, or end-stage renal disease/hemodialysis should be more cautiously evaluated for thoracic endovascular aortic repair, weighing the benefits of the procedure against the high expected mortality.

Annuloaortic Ectasia and Arteritis: Clinical Features, Treatments of Choice, and Causative Relations.

The roles that aortitis plays in the development of annuloaortic ectasia (AAE) remain uncertain, while clinical features of AAE in arteritis are largely unknown. This study was designed to highlight the clinical features of AAE, the treatments of choice, and the causative relations between aortitis and AAE. The morphology of the aortic valve leaflets was normal in half of the patients, while the valves were thin and overstretched in the other half. Most patients had an aortic aneurysm. Half of the patients had severe aortic valve insufficiency, and one-quarter of them had dilation of the sinuses of Valsalva. Takayasu arteritis was prone to develop coronary artery lesions, whereas giant cell arteritis were not. Aortic branch lesions in Takayasu arteritis were stenotic or occlusive in 92.9% of the patients, while in giant cell arteritis, they were all dilated lesions. Most patients (94.7%) required surgical treatment with steroid therapy. However, long-term follow-up results showed a higher anastomotic dehiscence rate, particularly in patients with Takayasu arteritis. Further morphometric and pathological research on AAE in arteritis should be undertaken, and more feasible measures should be warranted for preventing postoperative anastomotic dehiscence.

Annuloaortic ectasia and arteritis: clinical features, treatments of choice, and causative relations

Abstract The roles that aortitis plays in the development of annuloaortic ectasia (AAE) remain uncertain, while clinical features of AAE in arteritis are largely unknown. This study was designed to highlight the clinical features of AAE, the treatments of choice, and the causative relations between aortitis and AAE. The morphology of the aortic valve leaflets was normal in half of the patients, while the valves were thin and overstretched in the other half. Most patients had an aortic aneurysm. Half of the patients had severe aortic valve insufficiency, and one-quarter of them had dilation of the sinuses of Valsalva. Takayasu arteritis was prone to develop coronary artery lesions, whereas giant cell arteritis were not. Aortic branch lesions in Takayasu arteritis were stenotic or occlusive in 92.9% of the patients, while in giant cell arteritis, they were all dilated lesions. Most patients (94.7%) required surgical treatment with steroid therapy. However, long-term follow-up results showed a higher anastomotic dehiscence rate, particularly in patients with Takayasu arteritis. Further morphometric and pathological research on AAE in arteritis should be undertaken, and more feasible measures should be warranted for preventing postoperative anastomotic dehiscence.

Anterior spinal artery syndrome and aortic dissection.

BACKGROUND: Anterior spinal artery syndrome, usually resulting in flaccid paraplegia, is a rare but disastrous complication that can occur after surgery of aortic aneurysms and aortic dissections. Spinal cord infarct as the initial clinical presentation of aortic dissection is a very rare finding. CASE REPORT: A 42-year-old male patient who comes to the emergency department due to severe chest pain associated with presyncope and paraplegia of the lower limbs in the context of type A aortic dissection. CONCLUSIONS: Recognizing this atypical clinical presentation of aortic dissection and knowing how to approach it is critical for an early diagnosis and to minimize the risk of spinal cord ischemia during surgery.

ANTECEDENTES: La lesión de la médula espinal, generalmente resultante en paraplejia flácida, es una complicación rara, pero desastrosa, que puede ocurrir tras intervenciones quirúrgicas de aneurismas o disecciones de aorta. La presentación clínica inicial de una disección de aorta como un síndrome de la arteria espinal anterior es un hallazgo muy infrecuente. CASO CLÍNICO: Varón de 42 años que acude al servicio de urgencias hospitalario por dolor torácico intenso asociado a cuadro presincopal y paraplejia de miembros inferiores en el contexto de una disección de aorta tipo A. CONCLUSIONES: Reconocer esta forma de presentación clínica y saber cómo realizar un abordaje adecuado es fundamental para el diagnóstico precoz y para minimizar el riesgo quirúrgico de presentar isquemia medular.