Physician-modified versus chimney endografting for pararenal aortic aneurysms: a systematic review and meta-analysis.

INTRODUCTION: We performed a systematic review and meta-analysis to assess the existing published evidence regarding the safety and efficacy of the endovascular aortic repair with chimney technique (ch-EVAR) and physician-modified stent-grafts (PMSGs) for the treatment of pararenal aortic aneurysm repair. EVIDENCE ACQUISITION: A systematic search of all relevant studies reported until October 2023 according to the PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines was performed. The pooled 30-day mortality, peri- and postoperative complication rates were estimated using fixed or random effect methods. EVIDENCE SYNTHESIS: A total of 679 study titles were identified by the initial search strategy, of which 16 were considered eligible for inclusion in the meta-analysis. A total of 1094 patients (ch-EVAR N.=861 and PMSG N.=233) (90% male) were identified. The pooled 30-day mortality rate was 3.4% for ch-EVAR and 2.6% for PMSG. The major adverse events (MAE) in the early period was 14.7% for ch-EVAR and 18.5% PMSG, respectively. Higher occlusion rate was observed of the chimney stents grafts (8.2%) than the bridging stents (1.4%) during the follow-up period. CONCLUSIONS: Ch-EVAR and physician-modified technology are safe with low 30-day mortality in elective settings for pararenal aortic aneurysms repair. No significant differences were seen between the two surgical methods regarding the early major adverse events rate. However, higher occlusion rate for the chimneys can be expected over time.

The Safety and Outcome of Minimally Invasive Staged Segmental Artery Coil Embolization (MIS2ACE) Prior Thoracoabdominal Aortic Aneurysm Repair: A Single-Center Study, Systematic Review, and Meta-Analysis.

BACKGROUND: Minimally Invasive Staged Segmental Artery Coil Embolization (MIS2ACE) is a novel technique of spinal cord preconditioning used to reduce the risk of paraplegia in thoracoabdominal aortic aneurysm (TAAA) repair. In this study, we report our experience with MIS2ACE, including both degenerative and post-dissection TAAA, while we attempt to systematically summarize relevant data available in the literature. DESIGN: single-center observational study with systematic review of the literature and meta-analysis. METHODS: Initial retrospective analysis of 7 patients undergoing MIS2ACE over 12 sessions with a subsequent systematic review of the literature and meta-analysis of the available published data (PROSPERO protocol number: CRD42023477411). Baseline patient and aneurysm characteristics, along with procedural technique and outcomes, were analyzed. One-arm pooling of proportions was used to summarize available published data. RESULTS: We treated seven patients (5 males, 71%) with a median age of 69 years (IQR 55,69). According to the Crawford classification, five patients (1%) had extent II TAAA, and two (29%) had extent III TAAA. Five patients (71%) had post-dissection -TAAA; four of them were after Stanford type A dissection, and one had a chronic type B dissection. Three patients (43%) had connective tissue disease. Of the seven patients, six (86%) underwent previous aortic surgery, while the median aneurysm diameter was 58 mm (IQR 55,58). MIS2ACE was successful in 11 sessions (92%). The median number of embolized arteries was 4 (IQR 1,4). There were no periprocedural complications in any embolization. The median embolization-operation time interval was 37.0 days (IQR 31,78). Two patients had open and five endovascular treatment. There were no events of spinal cord ischemia either after MIS2ACE or after the aortic repair. Out of the 432 initially retrieved articles, we included two studies in the meta-analysis, including patients with MIS2ACE for spinal cord preconditioning in addition to our cohort. The prevalence of pooled postoperative spinal cord ischemia among MIS2ACE patients is 1.9% (95% CI -0.028 to 0.066, p = 0.279; 3 studies; 81 patients, 127 coiling sessions). CONCLUSIONS: While the current published data is limited, our study further confirms that MIS2ACE is a technically feasible and safe option for spinal cord preconditioning.

Fenestrated Physician-Modified Endografts for Preservation of Main and Accessory Renal Arteries in Juxtarenal Aortic Aneurysms.

BACKGROUND: There is a paucity of reporting outcomes of complex aortic aneurysm treatment such as juxtarenal abdominal aortic aneurysms, where additional techniques to preserve renal artery perfusion are required. METHODS: Retrospective analysis of consecutive patients who underwent emergent and elective aortic repair with fenestrated PMEGs between March 2019 and January 2023. Endpoints were technical success, reinterventions, secondary reinterventions and target vessel patency. RESULTS: Forty-seven target vessels in 37 patients (23 male, median age 75 years) were targeted, of which 44 were renal arteries (RAs) with a mean diameter of 5.4 ± 1.0 mm. Thirteen were accessory RAs and six had a diameter ≤ 4 mm. Technical success rate was 87% overall; 97% for main and 62% for accessory RAs respectively. Target vessel patency and freedom from secondary reintervention was 100% and 97% at 30 days and 96% and 91% at one year, respectively. There was no 30-day mortality. CONCLUSION: Fenestrated physician-modified endografts are safe and effective for the treatment of patients with juxtarenal abdominal aortic aneurysms when incorporating main renal arteries. Limited technical success may be expected when targeting accessory renal arteries, especially when small in diameter. Long-term follow-up is needed to confirm durability of PMEGs for renal artery preservation.

European Multicentric Experience With Fenestrated-branched ENDOvascular Stent Grafting After Previous FAILed Infrarenal Aortic Repair: The EU-FBENDO-FAIL Registry.

OBJECTIVE: To report the mid-term outcomes of fenestrated-branched endovascular aneurysm repair (F-BEVAR) following a failed previous endovascular aneurysm repair (pEVAR) or previous open aneurysm repair (pOAR). METHODS: Data from consecutive patients who underwent F-BEVAR for pEVAR or pOAR from 2006 to 2021 from 17 European vascular centers were analyzed. Endpoints included technical success, major adverse events, 30-day mortality, and 5-year estimates of survival, target vessel primary patency, freedom from reinterventions, type I/III endoleaks, and sac growth >5 mm. BACKGROUND: Treatment of a failed previous abdominal aortic aneurysm repair is a complex undertaking. F-BEVAR is becoming an increasingly attractive option, although comparative data are limited regarding associated risk factors, indications for treatment, and various outcomes. RESULTS: There were 526 patients included, 268 pOAR and 258 pEVAR. The median time from previous repair to F-BEVAR was 7 (interquartile range, 4-12) years, 5 (3-8) for pEVAR, and 10 (6-14) for pOAR, P <0.001. Predominant indication for treatment was type Ia endoleak for pEVAR and progression of the disease for pOAR. Technical success was 92.8%, pOAR (92.2%), and pEVAR (93.4%), P =0.58. The 30-day mortality was 6.5% overall, 6.7% for pOAR, and 6.2% for pEVAR, P =0.81. There were 1853 treated target vessels with 5-year estimates of primary patency of 94.4%, pEVAR (95.2%), and pOAR (94.4%), P =0.03. Five-year estimates for freedom from type I/III endoleaks were similar between groups; freedom from reintervention was lower for pEVAR (38.3%) than for pOAR (56.0%), P =0.004. The most common indication for reinterventions was for type I/III endoleaks (37.5%). CONCLUSIONS: Repair of a failed pEVAR or pOARis safe and feasible with comparable technical success and survival rates. While successful treatment can be achieved, significant rates of reintervention should be anticipated, particularly for issues related to instability of target vessels/bridging stents.

Mid-term outcomes of the use of endoanchors during thoracic endovascular aortic repair in multicentre analysis.

OBJECTIVE: To describe mid-term outcomes of the use of EndoAnchors as an adjunct for arch and thoracic endovascular aortic repair (TEVAR). METHODS: A retrospective multicentre series from nine centres using the Heli-FX EndoAnchor System (Medtronic Inc, Minneapolis, USA) at TEVAR over May 2014-May 2019 is presented. The study is registered at ClinicalTrials.gov with number NCT04100499. The primary outcome was freedom from Type I endoleak at EndoAnchors deployments; secondary outcomes included evaluation of aortic wall penetration (AWP) at first computed tomography scan, EndoAnchor-related issues and mortality. RESULTS: 54 high-risk patients (35 males/19 females, age 73 ± 11 years) with arch, thoracic and thoracoabdominal aneurysmal disease (3 chronic post-dissection and one patch pseudoaneurysm), with a mean neck length 19.7 ± 6.6 mm that were treated with multiple hybrid and endovascular techniques were included. A total of 329 EndoAnchors were used with a mean of 6.1 ± 2.5 per patient. Overall adequate AWP was 86%, whereas arch (Ishimaru's zones 0-2) deployments achieved 80.6% when compared to 87.3% in descending thoracic aorta (dTA); although there was no statistical significance. Freedom from type I endoleaks was 88% at 2 year follow-up, due to 4 type IA endoleaks, two of them successfully treated, one with conservative treatment due to complexity of repair and remaining patient died 1 year later due to endograft infection. There were reported five EndoAnchor-related issues; four losses and one renal stent-graft was crushed due to catheter deflection solved with balloon reinflation. None of the losses had clinical significance. Overall mortality is described for 7 (9.5%) patients, one of them aneurysm-related. CONCLUSIONS: The adjunctive use of EndoAnchors in TEVAR and complex TEVAR procedures achieved acceptable outcomes at midterm in a high-risk series with hostile seal zones. Still, they should be still judiciously used as there is lack of data to suggest a more liberal use; therefore, the landing zone should not be compromised in favour of their use.

Prognostic Factors for Mortality in Acute Mesenteric Ischemia.

Postoperative mortality in patients undergoing surgical and/or interventional treatment for acute mesenteric ischemia (AMI) has remained an unsolved problem in recent decades. Here, we investigated clinical predictors of postoperative mortality in a large European cohort of patients undergoing treatment for AMI. In total, 179 patients who underwent surgical and/or interventional treatment for AMI between 2009 and 2021 at our institution were included in this analysis. Associations between postoperative mortality and various clinical variables were assessed using univariate and multivariable binary logistic regression analysis. Most of the patients were diagnosed with arterial ischemia (AI; n = 104), while venous ischemia (VI; n = 21) and non-occlusive mesenteric ischemia (NOMI; n = 54) were present in a subset of patients. Overall inhouse mortality was 55.9% (100/179). Multivariable analyses identified leukocytes (HR = 1.08; p = 0.008), lactate (HR = 1.25; p = 0.01), bilirubin (HR = 2.05; p = 0.045), creatinine (HR = 1.48; p = 0.039), etiology (AI, VI or NOMI; p = 0.038) and portomesenteric vein gas (PMVG; HR = 23.02; p = 0.012) as independent predictors of postoperative mortality. In a subanalysis excluding patients with fatal prognosis at the first surgical exploration (n = 24), leukocytes (HR = 1.09; p = 0.004), lactate (HR = 1.27; p = 0.003), etiology (AI, VI or NOMI; p = 0.006), PMVG (HR = 17.02; p = 0.018) and intraoperative FFP transfusion (HR = 4.4; p = 0.025) were determined as independent predictors of postoperative mortality. Further, the risk of fatal outcome changed disproportionally with increased preoperative lactate values. The clinical outcome of patients with AMI was determined using a combination of pre- and intraoperative clinical and radiological characteristics. Serum lactate appears to be of major clinical importance as the risk of fatal outcome increases significantly with higher lactate values.

Motor evoked potential-guided segmental artery revascularization during open thoracoabdominal aortic aneurysm surgery after coil embolization as a part of the minimally invasive staged segmental artery coil embolization concept.

Sacrifice of the segmental arteries during thoracoabdominal aortic repair carries the risk of spinal cord injury. Staged embolization of segmental arteries has been discussed as an option for preconditioning the spinal cord vascular network. In the present case, periprocedural monitoring of motor-evoked potentials detected spinal cord ischemia after aortic cross-clamping, although embolization of eight segmental arteries had been performed in advance. Implantation of an intercostal artery bypass restored spinal cord perfusion and normalized the motor-evoked potentials. Thus, the preconditioning strategy to stimulate creation of a spinal cord collateral network as an adjunctive method to prevent paraplegia is not perfect.

Risk for Additional Infarction in Emergency Carotid Artery Endarterectomy in Thrombectomy Acute Stroke Patients.

Purpose: Thromboembolic occlusion of the middle cerebral artery with tandem occlusion of the internal carotid artery is a life-threatening condition with unfavorable neurological outcome. We perform emergency carotid endarterectomy in the same anesthesia session as thrombectomy in our angiography suite whenever needed despite the absence of electrophysiological neuromonitoring. Methods: We evaluated 47 thrombectomy patients with emergency CEA in our clinic between June 2013 and November 2020. To determine whether there were additional infarctions due to the surgical procedure, we assessed the initial diagnostic CT imaging for previously infarcted areas, cerebral perfusion, and vascular anatomy, including collateralization in the Circle of Willis (CoW). We then analyzed follow-up imaging with respect to new infarctions that could not be explained by the initial stroke. Results: 5 of 47 (11%) patients had a complete CoW. There was contralateral internal carotid artery (ICA) stenosis or occlusion in 18/47 (38%) patients. Surgical procedure was eversion CEA in 34 (72%) and with a patch graft CEA in 13 (28%) cases. Shunts were used during surgery in 17/47 (36%) patients. Two patients suffered from an additional infarction in a new territory, however this was not caused by the surgical procedure but due to embolism during endovascular thrombectomy. In 1 of these 2 patients a hemodynamic border zone infarction was also observed, which could have developed during thrombectomy as well as during surgery, although this could not be attributed with absolute certainty to the surgery. The final infarction size was significantly larger in patients with contralateral ICA stenosis or occlusion (P = .038). Neither CoW anatomy nor the absence of a shunt during surgery could be identified as risk factors for additional infarction. Conclusion: Emergency surgery in the angiography suite without neuromonitoring was not associated with an increased additional stroke rate in our patient cohort.

Outcome of Elective and Emergency Open Thoraco-Abdominal Aortic Aneurysm Repair in 255 Cases: a Retrospective Single Centre Study.

OBJECTIVE: This study reports on open TAAA repair comparing short and long term patient outcome according to the type of repair defined by the Crawford classification and elective vs. emergency repair. Endpoints were death, acute kidney injury (AKI), sepsis, spinal cord ischaemia (SCI), and re-intervention rate. METHODS: This was a retrospective study reporting the outcomes of 255 patients (between 2006 and 2019), designed according to the STROBE criteria. RESULTS: The TAAA distribution was type I 25%, type II 26%, type III 23%, type IV 18%, and type V 7%. Fifty-one (20%) patients had an emergency procedure. Of all the patients, 51% had a history of aortic surgery, 58% suffered from post-dissection TAAA, and 26% had connective tissue disease. The in hospital mortality rate among electively treated patients was 16% (n = 33) vs. 35% (n = 18) in the emergency subgroup; the total mortality rate was 20% (n = 51). The adjusted odds ratio for in hospital death following emergency repair compared with elective repair was 2.52 (95% confidence interval [CI] 1.15 - 5.48). Temporary renal replacement therapy because of AKI was required in 29% (n = 74) of all patients, sepsis from different cause was observed in 37% (n = 94), and SCI in 7% (n = 18, 10 patients suffering from paraplegia and eight from paraparesis). The mean follow up time was 3.0 years (median 1.5, range 0 - 12.8 years). Aortic related re-intervention was required in 2.8%. The total mortality rate during follow up was 22.5% (n = 46); 5.3% (n = 11) of all patients died because of aortic related events. CONCLUSION: Open TAAA repair is associated with an important morbidity and mortality rate, yet the incidence of spinal cord ischaemia may be favourably low if a neuromonitoring protocol is applied. The aortic related re-intervention and aortic related mortality rate during follow up are low.

A systematic review and meta-analysis of stroke rates in patients undergoing thoracic endovascular aortic repair for descending thoracic aortic aneurysm and type B dissection.

OBJECTIVE: We performed a systematic review and meta-analysis to assess the stroke rates after thoracic endovascular aortic repair (TEVAR) for descending thoracic aortic aneurysms and/or dissections. METHODS: A systematic search of all the literature reported until September 2021 was performed according to the PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines. The pooled perioperative stroke rates and corresponding 95% confidence intervals (CIs) were estimated using fixed or random effect methods. RESULTS: A total of 878 study titles were identified by the initial search strategy, of which 43 were considered eligible for inclusion in the meta-analysis. A total of 5764 patients (63.5% male) were identified among the eligible studies. The pooled any stroke rate was 4.4% (95% CI, 3.60%-5.28%). However, after procedures without left subclavian artery (LSA) ostial coverage (eg, TEVAR deployed within or distal to zone ≥3), the stroke rate was 3.15% (95% CI, 2.21%-4.22%). For the patients with LSA coverage, the pooled stroke rate was 2.8% (95% CI, 1.69%-4.14%) for patients receiving left subclavian artery revascularization. However, the patients without LSA revascularization had a pooled estimated stroke incidence of 11.8% (95% CI, 5.85%-19.12%). CONCLUSIONS: Stroke has been a common finding after TEVAR, especially with LSA coverage without revascularization, validating current clinical practice guidelines recommending routine revascularization, when feasible. Additional studies with larger patient numbers that provide separate data regarding the aortic pathology treated, the anatomic location of the stroke and their association with functional recovery and survival are needed.

Systematic review with pooled data analysis reveals the need for a standardized reporting protocol including the visceral vessels during fenestrated endovascular aortic repair (FEVAR).

OBJECTIVES: To collect and analyse the available evidence in the outcomes of patients treated with fenestrated endovascular aortic repair (f-EVAR) technique focusing specifically on visceral vessel outcomes. METHODS: The current meta-analysis was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. All the studies reporting the f-EVAR technique for the management of degenerative pararenal and/or type IV thoracoabdominal aortic aneurysms (TAAA) were considered eligible for inclusion in the study. The main study outcomes (technical success, type I endoleaks, fracture or occlusion of the bridging stents, overall aneurysm-related mortality, and the reintervention rate) were subsequently expressed as proportions and 95% confidence intervals. RESULTS: Fourteen studies with a total of 1804 patients were included in a pooled analysis. The technical success of the procedure was 95.97% (95%CI = 92.35-98.60). Intraoperatively, the pooled proportion of reported type I endoleak was 7.6% (95%CI = 2.52-14.60) while during a median follow-up of 41 months (range 11-96) follow-up period the pooled rate of fracture and occlusion of the bridging stents was 2.79% (95%CI = 0.00-8.52) and 4.46% (95%CI = 1.93-7.77), respectively. The overall aneurysm-related mortality was detected to be 0.63% (95%CI = 0.04-1.63), and the pooled estimate for re-intervention rate was 15.69%. CONCLUSIONS: Fenestrated endovascular repair for p-AAA is an effective and safe treatment. Target vessel complications and endoleaks remain the two most important concerns for fenestrated endovascular procedures, contributing to most of the secondary interventions. The lack of computed tomography angiography follow-up evaluation does not allow us to draw robust conclusions about the complication rates for the superior mesenteric artery during f-EVAR. Due to the potential implications of SMA complications on aneurysm-related mortality, standardized reporting of short- and long-term target visceral vessel outcomes is required.

Perioperative and long-term outcome after ascending aortic and arch repair with elephant trunk and open thoracoabdominal aortic aneurysm repair.

OBJECTIVE: To describe the outcome of open thoracoabdominal aortic aneurysm (TAAA) repair following previous aortic arch repair including elephant trunk (ET) or frozen elephant trunk (FET) for acute and chronic pathologies. METHODS: This was a retrospective, observational, multicenter study including 32 patients treated between 2006 and 2019 in two aortic centers using identical surgical protocols. Assessment focused on perioperative and long-term outcome, namely in-hospital morbidity and mortality, as well as procedure-related reintervention rate and aortic-related mortality rate. Kaplan-Meier curves with 95% confidence intervals were used to analyze the overall survival after surgery within the cohort. RESULTS: Thirty-two patients (mean age, 45.0 ± 13.6 years; 20 males [62.5%]) were treated because of acute (34.38% [n = 11]) or chronic (65.62% [n = 21]) aortic pathologies, including residual dissection following acute, symptomatic type A dissection (n = 7) and symptomatic mega aortic syndrome (n = 4), as well as post-dissection TAAA (n = 18) and asymptomatic mega aortic syndrome (n = 3). Twenty-eight patients (87.5%) received type II repair, and 4 patients (12.5%) received type III repair after previous ascending aorta and arch repair including ET/FET. Concomitant infrarenal and iliac vessel repair was performed in 38.7% (n = 12) and 29.4% (n = 10), respectively. The in-hospital mortality rate was 18.75% (n = 6). Spinal cord ischemia occurred in two cases, both after one-stage emergency procedure with one case of permanent paraplegia. Temporary acute kidney injury occurred in 41.94% (n = 13). The estimated 1-year survival rate was 78.1% (95% confidence interval, 63.9%-95.6%), with a median follow-up time of 1.29 years (interquartile range, 0.26-3.88 years). No procedure-related reinterventions and one case of aortic-related mortality, namely sepsis because of graft infection, was observed. CONCLUSIONS: Open TAAA repair following aortic arch repair including ET or FET because of acute or chronic aortic pathologies is associated with a relevant perioperative morbidity and mortality rate. During follow-up, a low aortic-related mortality rate and procedure-related reintervention rate were observed.

Retrospective observational study evaluating zinc plasma level in patients undergoing thoracoabdominal aortic aneurysm repair and its correlation with outcome.

Thoracoabdominal aortic aneurysm (TAAA) repair is related to a relevant morbidity and in-hospital mortality rate. In this retrospective observational single-center study including serum zinc levels of 33 patients we investigated the relationship between zinc and patients' outcome following TAAA repair. Six patients died during the hospital stay (18%). These patients showed significantly decreased zinc levels before the intervention (zinc levels before intervention: 60.09 µg/dl [survivors] vs. 45.92 µg/dl [non-survivors]). The post-interventional intensive care SOFA-score (Sepsis-related organ failure assessment) (at day 2) as well as the SAPS (Simplified Acute Physiology Score) (at day 2) showed higher score points in case of low pre-interventional zinc levels. No significant correlation between patient comorbidities and zinc level before intervention, except for peripheral arterial disease (PAD), which was significantly correlated to reduced baseline zinc levels, was observed. Septic shock, pneumonia and urinary tract infections were not associated to reduced zinc levels preoperatively as well as during therapy. Patients with adverse outcome after TAAA repair showed reduced pre-interventional zinc levels. We speculate that decreased zinc levels before intervention may be related to a poorer outcome because of poorer physical status as well as negatively altered perioperative inflammatory response.

First-in-Human Clinical Application of the Medyria TrackCath System in Endovascular Repair of Complex Aortic Aneurysms (ACCESS Trial): A Prospective Multicenter Single-Arm Clinical Trial.

PURPOSE: The Medyria TrackCath Catheter (MedTCC) is an innovative, thermal convection-based blood flow velocity (BFV) tracking catheter that may be used during complex aortic endovascular procedures for identification and catheterization of target orifices. The ACCESS Trial analyzes the safety and performance of the MedTCC for targeted vessel catheterization to generally evaluate the feasibility of thermal convection-based BFV. MATERIALS AND METHODS: We performed a first-in-human, proof-of-concept, prospective single-arm multicenter clinical trial between March 2018 and February 2019 in patients who underwent endovascular aortic procedures at 4 high-volume centers. During these procedures, the MedTCC was advanced over a guidewire through the femoral access. The D-shape was enfolded in the reno-visceral part of the aorta and target orifices were identified and catheterized with a guidewire via the side port of the MedTCC through BFV tracking. BFV measurements were performed at baseline (Baseline-BFV), alignment to the orifice (Orifice-BFV), and following catheterization (Confirmation-BFV) to prove correct identification and catheterization of target orifices. The procedural success rate, the catheterization success rate, procedure-related parameters, and (serious) adverse events ((S)AE) during the follow-up were analyzed. RESULTS: A total of 38 patients were included in the safety group (SG) and 26 in the performance group (PG). The procedural success rate was 89% (PG), the MedTCC catheterization success rate was 98% (PG). The MedTCC reliably measured BFV changes indicated by significant differences in BFV between Baseline-BFV and Orifice-BFV (p<0.05). Median (interquartile range; IQR) fluoroscopy time per orifice was 5.0 (1.5-8.5) minutes [total surgery 49 (26-74) minutes], median (IQR) contrast agent used per orifice was 1.0 (0-5.0) mL [total surgery 80 (40-100) mL], and median (IQR) MedTCC-based procedural time was 3.0 (2.0-6.0) minutes. There was no device-related SAE. CONCLUSIONS: The ACCESS Trial suggests that BFV measurement allows for reliable target orifice identification and catheterization. The use of MedTCC is safe and generates short fluoroscopy time and low contrast agent use, which in turn might facilitate complex endovascular procedures.

Xenogeneic materials for the surgical treatment of aortic infections.

BACKGROUND: The surgical treatment of aortic infections (AIs) is challenging. In situ aortic reconstructions represent nowadays the favored therapy for fit patients and xenogeneic materials are used increasingly. The aim of this study was to present our experience with xenogeneic reconstructions for AI using self-made bovine pericardium tubes and/or the biosynthetic Omniflow® II graft. METHODS: This retrospective single-center study included all patients undergoing xenogeneic aortic and aortoiliac reconstructions from December 2015 to June 2020. Patient comorbidities, symptoms, procedural characteristics, types of pathogens and postoperative outcomes were analyzed. RESULTS: Twenty-eight patients [23 male (82%), median age 68 (range, 28-84) years] were included. Ten patients (36%) had native AIs and 18 (64%) had graft infections, including 3 (11%) aortoesophageal and 2 (7%) aortoduodenal fistulas (ADF). Twenty-four patients (86%) were symptomatic, the most common symptoms being contained aortic rupture (n=8) and sepsis (n=4). The surgical procedures were infra- and juxtarenal aortic repairs (n=11, 39% and n=7, 25%), thoracoabdominal aortic repairs (type IV: n=1, 4%; type V: n=3, 11%), descending thoracic aortic repairs (n=4, 14%) and 2 reconstructions (7%) involving the ascending aorta/aortic arch. Most were urgent (n=10, 43%) or emergent operations (n=11, 35%). Identification of pathogen(s), mostly Gram-positive bacteria, was possible in 25 patients (89%). Twelve patients (43%) had polymicrobial infections and 6 (21%) infections with multi-resistant bacteria. In-hospital mortality was 32% (n=9) due to acute cardiac failure (1/9), endocarditis (1/9), bleeding (3/9) and sepsis (4/9). The most frequent complications were transient need for dialysis (n=12, 43%) and persisting sepsis (n=11, 39%). Two early occlusions of Omniflow® II grafts were observed (7%). Median follow-up (FU), during which 2 patients died of non-aortic causes, was 14 months (95% CI: 9-19 months). Freedom from reoperation was 100%, there was no evidence for reinfection during FU. CONCLUSIONS: Xenogeneic orthotopic reconstructions for AI can be performed at all aortic levels. Combining bovine pericardium and the Omniflow® II graft can be useful for reconstructing the branched aortic segments and both materials show appropriate early to midterm outcomes. Nonetheless, AIs are serious conditions associated with relevant morbidity/mortality rates, even in a specialized center.

The role of surgical and total endovascular techniques in the treatment of ruptured juxtarenal aortic aneurysms.

Background: Ruptured juxtarenal aortic aneurysms (RJAAA) represent a special challenge in clinical practice, but the evidence to guide therapeutic decision-making is scarce. The aim of this study was to present two different approaches, open surgical (OAR) and chimney endovascular repair (CHEVAR), for treating patients with RJAAA. Patients and methods: This retrospective two-center study included all patients per center undergoing OAR or CHEVAR for RJAAA between February 2008 and January 2020. Juxtarenal aortic aneurysms were defined as having an infrarenal neck of 2-5 mm, measured after three-dimensional reconstruction of the computed tomography angiography scan. Results: 12 OAR patients (10 male, median age 73 years [58-90 years]) and 6 CHEVAR patients (all male, median age 74 years [59-83 years]) were included. In the OAR group, the proximal aortic clamping was suprarenal in 7 and interrenal in 5 patients. Cold renal perfusion was used in 4 patients, in 2 with suprarenal aortic clamping and in 2 with interrenal aortic clamping. 3 CHEVAR patients received a single renal chimney, the other 3 received double renal chimneys. Technical success was 12/12 in the OAR group 5/6 in the CHEVAR group. In-hospital mortality and 30-day mortality were 3/12 after OAR and 0/6 after CHEVAR. 2 OAR patients required transient dialysis. Median in-hospital stay was 14 (10-63) and 8 (6-21) days and median follow-up (FU) was 20 (3-37) and 30 (7-101) months, respectively. No further deaths occurred during FU. One OAR patient and 4 CHEVAR patients required aortic reinterventions. Conclusions: RJAAAs are rare. Both OAR and CHEVAR can represent adequate treatments for RJAAAs. OAR is the traditional approach, but CHEVAR has - in a high-volume center - promising early results with nonetheless a need for continuous FU to prevent reinterventions. Defining the studied aortic pathology precisely is essential for future research in order to draw valid conclusions.

Case report: Keeping a cool head - A delayed open repair of a ruptured TAAA.

INTRODUCTION: The limited resources available for complex surgical procedures during the nightshift can influence the postoperative outcome and are associated with increased complication rates and 30-day mortality. On the other hand, cases of the nightshift are often urgent and demand prompt reaction. PRESENTATION OF CASE: Hereby we report a patient with a ruptured thoracoabdominal aortic aneurysm, who was admitted during nightshift and was operated 12 h later to gain optimal conditions for such a complex surgical treatment and bypass the nightshift-effect. DISCUSSION: A review of the literature shows a significant short-term mortality increase on elective procedures performed during the weekend or during the nightshift, however it remains undecisive on the impact of the weekend-effect on emergent procedures. CONCLUSION: The fortunate recovering of the patient during his hospital stay as well as in the following months emphasizes the importance of critical risk assessment during emergency management, which may justify a delayed surgical treatment.

Increase of urinary TIMP-2 and IGFBP7 as potential predictor of acute kidney injury requiring renal replacement therapy and patients' outcome following complex endovascular and open thoracic abdominal aortic aneurysm surgery - a prospective observational study.

Background: Acute kidney injury (AKI) as complication after open and endovascular repair of thoracoabdominal aortic aneurysm (TAAA) is one major predictor of mortality and postoperative complications. We evaluated tissue inhibitor of metalloproteinase 2 (TIMP-2) and insulin-like growth factor-binding protein 7 (IGFBP7) as combined early biomarker for AKI detection and predictor of patients' outcome. Patients and methods: Between 2014 and 2015, 52 patients have been enrolled in this observational study, of whom 29 (55.8%) underwent elective open repair and 23 (44.2%) endovascular repair. TIMP2 × IGFBP7 were measured until 48 hours after admission on intensive-care unit (ICU) and were analyzed regarding their predictive ability for AKI (defined according to the KDIGO criteria) requiring temporary renal replacement therapy (RRT) and 90-day mortality using ROC curves. Results: Mean patient age was 64.5 years (Min: 43, Max: 85), endovascular treated patients were older (p <0.0001). 40.4% (n = 21) developed AKI, and 21.2% (n = 11) required renal replacement therapy. In-hospital and total mortality rates were 7.7% (n = 4) and 9.6% (n = 5), respectively. At no time a significant difference in TIMP2 × IGFB7 levels between patients undergoing open or endovascular surgery was observed. The predictive quality of the TIMP2 × IGFBP7 value on ICU admission was sound regarding AKI requiring temporary renal replacement therapy (sensitivity: 55.56% [38.1-72.1%], specificity: 90.91% [58.7-99.8%] with an area under the curve [AUC]: 0.694 [0.543-0.820]). Mean follow-up was 13.2 months (Min: 2, Max: 20), regarding the 90-day mortality, the predictive property of the TIMP2 × IGFBP7 value was not sufficient (sensitivity: 80% [28.4-99.5%], specificity: 52.38% [36.4-68%], and AUC: 0.607 [0.454-0.746]). Conclusions: TIMP2 × IGFBP7 level measured 6-12 hrs postoperatively may be useful as an early detectable biomarker for AKI requiring temporary renal replacement therapy. It seems not suited to predict patients' outcome following complex thoracoabdominal aortic surgery, regardless if performed by open or endovascular repair.

Emergency Carotid Endarterectomy Instead of Carotid Artery Stenting Reduces Delayed Hemorrhage in Thrombectomy Stroke Patients.

PURPOSE: Data in the literature suggest that thrombectomy with emergency carotid artery stenting (CAS) in acute stroke is associated with an increased hemorrhage rate. As we perform thrombectomy with the patient under general anesthesia, we avoid emergency CAS and perform emergency carotid endarterectomy (CEA) as an alternative to CAS in the same anesthesia session in our angiography suite whenever needed and possible. METHODS: We compared 27 thrombectomy patients with emergency CEA and 62 thrombectomy patients with emergency CAS and glycoprotein (Gp) IIb/IIIa inhibitors and/or dual antiplatelet therapy (DAPT) in the same time span. RESULTS: The symptomatic hemorrhage rate was 0% (0/27) in the CEA group and 8% (5/62) in the CAS group (p = 0.317). The parenchymal hemorrhage rate (PH2) was 7% (2/27) in the CEA group and 16% (10/62) in the CAS group (p = 0.333). Both cases of PH2 in the CEA group occurred during the intervention and were diagnosed on immediate postinterventional imaging, whereas in the CAS group only 2/10 cases of PH2 occurred during the intervention and the remaining 8 PH2 occurred within 3 days after the intervention (p = 0.048). Clinical outcome at 90 days was comparable with 39% of CEA and 51% of CAS patients achieving good clinical outcome (modified Rankin scale, mRS 0-2, p = 0.452). CONCLUSION: The use of CEA is a feasible alternative to CAS in acute stroke and has the advantage that DAPT/GpIIb/IIIa inhibitors are not needed. All PH2 in CEA patients occurred during the intervention, implying that hemorrhage in this group is likely to be caused by reperfusion injury, whereas delayed hemorrhage is likely to be caused by DAPT/GpIIb/IIIa inhibitors.

In-hospital mortality and organ failure after open and endovascular thoraco-abdominal aortic surgery can be predicted by increased levels of circulating dipeptidyl peptidase 3.

OBJECTIVES: Endovascular and open thoraco-abdominal aortic aneurysm (TAAA) repair is associated with specific complications. Circulating dipeptidyl peptidase 3 (cDPP3) is a novel biomarker that shows a strong association with organ failure which has not been assessed in surgical settings. Therefore, the objective of this study was to assess the prognostic capabilities of cDPP3 for predicting patient survival and organ failure following open and endovascular TAAA repair. METHODS: Thirty-three patients undergoing TAAA repair were assessed in this prospective observational single-centre study. cDPP3 levels were serially measured perioperatively until 72 h after admission to the intensive care unit (ICU). In-hospital mortality and any organ failure were the clinical end points. RESULTS: Postoperative organ failure was detected in 17 patients (51.5%), and 6 patients died after surgery (18.2%). At 12 h after admission to the ICU, cDPP3 levels were significantly increased in patients who died or developed organ failure (P < 0.001). cDPP3 levels after surgery demonstrated a remarkable predictive accuracy for in-hospital mortality [12 h area under the receiver operating characteristic curve (AUC): 0.907 (P < 0.001), 24 h AUC: 0.815 (P = 0.016), 48 h AUC: 0.914 (P = 0.003)] and the development of organ failure [12 h AUC: 0.882 (P < 0.001), 24 h AUC: 0.850 (P < 0.001), 48 h AUC: 0.846 (P < 0.001)]. Additionally, a significant correlation between cDPP3, the sequential organ failure assessment score and procalcitonin, C-reactive protein and interleukin-6 levels (P < 0.001, P < 0.001, P = 0.011, P = 0.007, respectively) based on all available measurements and time points was observed. CONCLUSIONS: The present findings highlight the role of cDPP3 as an early, highly specific postoperative biomarker for prediction of in-hospital mortality and organ failure after TAAA repair.