Autotransplantation or In Situ Surgical Treatment of Complex Renal Artery Aneurysm: Surgical Technique and Outcomes.

Background and objective: Renal artery aneurysm (RAA) is a rare condition. Our study investigates the effectiveness and outcomes of surgical treatments for complex RAA, comparing the in situ (IS) and ex vivo autotransplantation (AT) methods. Methods: We conducted a retrospective study from June 2015 to March 2023, including all consecutive patients treated surgically for complex RAA in our center. We focused on patients with complex RAA locations requiring open surgical multidisciplinary treatment, excluding those with simple aneurysms or who were treated endovascularly. Preoperative data including demographics, comorbidities, and cardiovascular risk factors were collected. The measured primary outcome was the absence of residual aneurysm and main renal arterial thrombosis after surgery. The secondary outcomes included pre- and postoperative kidney perfusion analyses and surgical complications as per Clavien-Dindo classification. Differences between AT and IS were assessed by Wilcoxon, chi-square, or Fischer's exact test. Key findings and limitations: Twenty-seven aneurysms were treated in 25 patients. No residual aneurysm or main artery thrombosis was found after surgery. Ten (40%) patients underwent AT surgery. The median kidney perfusion differences were 2 cc (-12; 13), 0 cc (-13; 10), and 2 cc (-10; 13; p = 0.41) in the whole, AT, and IS cohorts, respectively. Clavien-Dindo grade 1 and 2 complications occurred in 11% and 30% of patients, respectively, with no grade 3 or 4 complications observed. Conclusions and clinical implications: Complex RAA can be managed effectively through open surgery, ensuring good ipsilateral renal preservation and tolerable toxicity. Both AT and IS surgeries yielded similar outcomes. Further multicenter studies are warranted to confirm our findings. Patient summary: This study explored the treatment of a rare kidney blood vessel condition called renal artery aneurysm using two surgical approaches. Our findings suggest that both surgical techniques are effective in treating this condition without major complications, ensuring good kidney preservation. These promising results need further confirmation through larger studies across different medical centers.

Feasibility and safety of transfemoral transcatheter aortic valve implantation performed with a percutaneous coronary intervention-like approach.

BACKGROUND: Transfemoral percutaneous transcatheter aortic valve implantation (TF-TAVI) is a safe, reproducible and established procedure, mainly performed under local anaesthesia, which is mostly administered and monitored by a dedicated anaesthesia team (regular approach). Our centre has developed a standardized pathway of care, and eligible patients are selected for a minimalist TF-TAVI, entirely managed by operators without the presence of the anaesthesia team in the operating room, like most interventional coronary procedures ("percutaneous coronary intervention-like" approach [PCI approach]). AIM: To compare the safety and efficacy of TF-TAVI performed with the PCI approach versus the regular approach. METHODS: The analysis population comprised all patients who underwent TF-TAVI with the PCI or regular approach in our institution from November 2016 to July 2019. The two co-primary endpoints were early safety composite and early efficacy composite at 30days as defined by the Valve Academic Research Consortium-2. The PCI (n=137) and Regular (n=221) approaches were compared using the propensity score based method of inverse probability of treatment weighting. RESULTS: No differences were observed after comparison of TAVI performed with the PCI or regular approach regarding the composite safety endpoint (7.3% vs. 11.3%; odds ratio 0.63, 95% confidence interval 0.37 to 1.07; P=0.086) or the composite efficacy endpoint (4.4% vs. 6.3%; odds ratio 0.78, 95% confidence interval 0.41 to 1.49; P=0.45). CONCLUSIONS: This study suggests that the efficacy and safety of TF-TAVI entirely managed by a PCI approach for selected patients are not different to those when TF-TAVI is performed with the attendance of a full anaesthesia care team. The PCI approach appears to be a safe and efficient clinical pathway, providing an appropriate and rational utilization of anaesthesiology resources, and could be used for the majority of TF-TAVI procedures.

Transaxillary compared with transcarotid access for TAVR: a propensity-matched comparison from a French multicentre registry.

AIMS: No randomised study comparing the outcomes of transcarotid (TC) and transaxillary (TAx) TAVR has been conducted to date. The purpose of this study was to understand which approach should be the preferred alternative by comparing their outcomes using a propensity-matched comparison in a French multicentre registry. METHODS AND RESULTS: From 2010 to 2018, a French multicentre prospective registry included 502 patients, with 374 undergoing TC-TAVR and 128 TAx-TAVR for symptomatic aortic stenosis. Patients treated through TAx access were matched 1:2 with patients treated through the TC route by using a propensity score (20 clinical, anatomical and procedural variables) and by date of the procedure. The first outcome was mortality at one-month follow-up. The second outcome was one-month stroke/transient ischaemic attack (TIA). In propensity-matched analyses, the incidence of the primary outcome was similar in the TAx and TC groups (TAx 5.5% vs TC 4.5%, OR 1.23, 95% CI: 0.40-3.70). The secondary outcome was similar in TAx (3.2%) and TC (6.8%, OR 0.52, 95% CI: 0.14-1.84). Minor bleeding (2.7% vs 9.3%, OR 0.26, 95% CI: 0.07-0.92) and main access haematoma (3.6% vs 10.3%, OR 0.034, 95% CI: 0.09-0.92) were significantly more frequent with the TC access. One-month clinical efficacy and safety and one-year mortality did not differ according to the different routes. CONCLUSIONS: One-month mortality, one-month stroke/TIA and one-year mortality are similar with TAx-TAVR and TC-TAVR. However, TC-TAVR is accompanied by more minor bleeding and main access haematoma compared with the transaxillary route.

Clinical significance of electrocardiographic markers of myocardial damage prior to aortic valve replacement.

BACKGROUND: Pre-operative myocardial fibrosis and remodeling impact on outcomes after aortic valve replacement (AVR). We aimed at investigating the prognostic impact of preoperative electrocardiographic (ECG) markers of left ventricular (LV) myocardial damage, i.e. bundle branch block (BBB) and ECG strain pattern after (surgical or transcatheter) AVR for severe aortic stenosis (AS). METHODS: Between April 2008 and October 2017, we explored consecutive patients referred to our Heart Valve Clinic for first AVR for severe AS. Detailed pre-operative phenotyping and ECG analysis were performed. Patients were followed-up after AVR for major cardiac events (ME), i.e. cardiovascular death, cardiac hospitalization for acute heart failure and stroke. RESULTS: BBB and ECG strain were respectively observed in 13.5 and 21% of the 1122 patients included. These ECG markers identified a subgroup of older patients, with higher NYHA class and more advanced myocardial disease as detected by echocardiography, i.e. higher LV mass and lower LV ejection fraction, global longitudinal strain and integrated backscatter, than patients without ECG strain or BBB. ME occurred in 212 (18.6%) patients during a mean follow-up of 4.4 ± 1.5 years with higher incidence in case of ECG strain or BBB (HR 1.56, 95%CI 1.13-2.14, p = 0.006; HR 1.47, 95%CI 1.02-2.13, p = 0.04 respectively). The prognostic value of ECG strain remained significant after adjustment for age, diabetes and pre-operative LVEF. CONCLUSIONS: Pre-operative ECG markers of myocardial damage identify a subgroup of AS patients at high risk of post-AVR cardiovascular complications irrespective of other prognostic factors and should help the multiparametric staging of cardiac damage to guide AVR.

Advanced image processing with fusion and calcification enhancement in transcatheter aortic valve implantation: impact on radiation exposure.

OBJECTIVES: Radiation exposure is a concern for both patients and operators during transcatheter aortic valve implantation (TAVI). Efforts to reduce radiation dose are warranted. We aimed at investigating if per-operative advanced image processing can reduce patient and operator irradiation use during TAVI. METHODS: We performed a prospective single-centre observational study comparing patient and operator radiation exposure using standard fluoroscopy (control group) or a novel technology of live advanced fluoroscopic image processing (test group) among consecutive patients undergoing TAVI between August 2015 and April 2016. Patient irradiation (dose-area product, effective dose and air kerma), contrast media volume and clinical outcomes were assessed. RESULTS: Among 152 elderly [median age (interquartile range): 83 (78-87)] patients (n = 76 per group) undergoing TAVI, baseline clinical characteristics were similar between the control and test groups, except for a higher median EuroSCORE II (2.8% vs 2.3%, P = 0.02) and higher rate of TAVI for failing surgical bioprosthesis (11.8% vs 2.6%, P = 0.03) in the control group. The dose-area product was reduced in the test group: mean reduction of -27.5 Gy × cm2 [95% confidence intervals (CIs): 15.9-39.1, P < 0.001]. Furthermore, effective dose [mean reduction -6.5 (95% CI: 5.9-7.2) mSv, P < 0.001] and air kerma [mean reduction -167.5 (95% CI 163.4-177.3) mGy, P < 0.001] were lower in the test group. Fluoroscopy time, contrast volume and clinical outcomes were similar. CONCLUSIONS: Patient radiation exposure was significantly reduced using a novel live advanced fluoroscopy image processing with calcification enhancement and fusion of the virtual aortic annulus without compromising patient safety.

Transcatheter Aortic Valve Implantation as a Bailout Procedure for Acute Aortic Valve Regurgitation During Endovascular Arch Repair.

PURPOSE: To report emergent transcatheter aortic valve implantation (TAVI) to treat acute severe aortic regurgitation caused by valve cusp dysfunction following proximal migration of an endograft implanted in the ascending aorta during endovascular arch repair. CASE REPORT: A 65-year-old man had been previously treated with thoracic and fenestrated endografts in a 2-stage procedure for a chronic type B dissection. At 2-year follow-up, aneurysmal evolution of the distal arch led to development of a proximal type Ia endoleak. The patient was deemed unfit for open repair because of severe nonrevascularizable coronary artery disease. A custom-made endograft was designed consisting of a double inner branch arch endograft with a proximal component to reline the ascending aorta to avoid iatrogenic type A dissection. The first component was successfully deployed. However, this device migrated toward the aortic valve when the delivery system of the branch device was advanced through the aortic valve. Aortography and transesophageal echography showed acute aortic regurgitation due to obstruction of the left coronary valve cusp. An emergency bailout TAVI procedure was performed to successfully treat the aortic regurgitation. CONCLUSION: TAVI can be used as a bailout procedure for acute aortic valve dysfunction during endovascular arch or ascending aorta repair.

Prognostic value of the ratio between prosthesis area and indexed annulus area measured by MultiSlice-CT for transcatheter aortic valve implantation procedures.

BACKGROUND: Postprocedural aortic regurgitations following transcatheter aortic valve implantation (TAVI) procedures remain an issue. Benefit of oversizing strategies to prevent them isn't well established. We compared different level of oversizing in our cohort of consecutive patients to address if severe oversizing compared to normal sizing had an impact on post-procedural outcomes. METHODS: From January 2010 to August 2013, consecutive patients were referred for TAVI with preoperative Multislice-CT (MSCT) and the procedures were achieved using Edwards Sapien(®) or Corevalve devices(®). Retrospectively, according to pre-procedural MSCT and the valve size, patients were classified into three groups: normal, moderate and severe oversizing; depending on the ratio between the prosthesis area and the annulus area indexed and measured on MSCT. Main endpoint was mid-term mortality and secondary endpoints were the Valve Academic Research Consortium (VARC-2) endpoints. RESULTS: Two hundred and sixty eight patients had a MSCT and underwent TAVI procedure, with mainly Corevalve(®). While all-cause and cardiovascular mortality rates were similar in all groups, post-procedural new pacemaker (PM) implantation rate was significantly higher in the severe oversizing group (P = 0.03), while we observed more in-hospital congestive heart-failure (P = 0.02) in the normal sizing group. There was a trend toward more moderate to severe aortic regurgitation (AR) in the normal sizing group (P = 0.07). CONCLUSIONS: Despite a higher rate of PM implantation, oversizing based on this ratio reduces aortic leak with lower rates of post-procedural complications and a similar mid-term survival.

Stroke Presentation of Acute Type A Aortic Dissection with 100% Perfusion-Weighted Imaging-Diffusion-Weighted Imaging Mismatch: A Call for Urgent Action.

BACKGROUND AND PURPOSE: Acute stroke in the setting of acute type A aortic dissection is not rare and may contraindicate immediate surgery. Evaluating irreversible brain damage is critical in this setting and magnetic resonance imaging is a key determinant in the decision of selecting surgical over medical treatment for these patients. SUMMARY OF CASES: We report herein 2 cases assessed at a tertiary care center for acute stroke. The initial diagnosis workup revealed cerebral hemispheric severe hypoperfusion without any brain infarction. The absence of ischemic lesions prompted surgical repair, despite the severity of clinical symptoms. Both patients demonstrated complete neurological recovery and neuroimaging showed no persistent sequel. CONCLUSION: Acute type A aortic dissection is an important differential diagnosis in the causative workup for stroke. Brain hypoperfusion alone should not be a contraindication for urgent surgical treatment, regardless of initial clinical neurological severity.

Transcarotid Transcatheter Aortic Valve Replacement: Feasibility and Safety.

OBJECTIVES: The purpose of this study was to assess the feasibility and safety of transcarotid transcatheter aortic valve replacement (TAVR). BACKGROUND: Many candidates for TAVR have challenging vascular anatomy that precludes transfemoral access. Transcarotid arterial access may be an option for such patients. METHODS: The French Transcarotid TAVR Registry is a voluntary database that prospectively collected patient demographics, procedural characteristics, and clinical outcomes among patients undergoing transcarotid TAVR. Outcomes are reported according to the updated Valve Academic Research Consortium criteria. RESULTS: Among 96 patients undergoing transcarotid TAVR at 3 French sites (2009 to 2013), the mean age and Society of Thoracic Surgeons predicted risk of mortality were 79.4 ± 9.2 years and 7.1 ± 4.1%, respectively. Successful carotid artery access was achieved in all patients. The Medtronic CoreValve (Medtronic, Inc., Minneapolis, Minnesota) (n = 89; 92.7%) and Edwards SAPIEN valves (Edwards Lifesciences, Irvine, California) (n = 7; 7.3%) were used. Procedural complications included: valve embolization (3.1%), requirement for a second valve (3.1%), and tamponade (4.2%). There were no major bleeds or major vascular complications related to the access site. There were 3 (3.1%) procedural deaths and 6 (6.3%) deaths at 30 days. The 1-year mortality rate was 16.7%. There were 3 (3.1%) cases of Valve Academic Research Consortium-defined in-hospital stroke (n = 0) or transient ischemic attack (TIA) (n = 3). None of these patients achieved the criteria for stroke and none manifested new ischemic lesions on cerebral computed tomography or magnetic resonance imaging. At 30 days, a further 3 TIAs were observed, giving an overall stroke/TIA rate of 6.3%. CONCLUSIONS: Transcarotid vascular access for TAVR is feasible and is associated with encouraging short- and medium-term clinical outcomes. Prospective studies are required to ascertain if transcarotid TAVR yields equivalent results to other nonfemoral vascular access routes.

Transcatheter aortic valve implantation for paradoxical low-flow low-gradient aortic stenosis patients.

OBJECTIVES: We compared the outcomes of transcatheter aortic valve implantation (TAVI) in three different aortic stenosis syndromes: paradoxical low-flow low-gradient aortic stenosis (PLFLG), high-gradient aortic stenosis (HGAS), and low ejection fraction low-gradient severe aortic stenosis (LEF-LG). BACKGROUND: Outcomes for PLFLG patients after TAVI procedure are not well known. METHODS: Between 2010 and 2013, patients with severe (indexed aortic valve area iAVA≤0.6 cm(2)/m(2)) symptomatic aortic stenosis were consecutively referred to our institution for TAVI because of multiple comorbidities and excessive surgical risk. About 262 patients were split into three groups as following, PLFLG: mean gradient MG≤40 mm Hg, stroke volume index SVI≤35 mL/m(2), ejection fraction EF≥55%, valvuloarterial impedance Zva>4.5 mm Hg/mL/m(2), maximal aortic jet velocity MaxV<4 m/s; LEF-LG: MG≤40 mm Hg, MaxV<4 m/s, EF≤50%, SVI≤35 mL/m(2); and HGAS: MaxV>4 m/s, MG>40 mm Hg, EF>55%. The primary endpoint of our study was to evaluate mid-term global and cardiovascular mortalities; secondary endpoints included recommended VARC-2 variables. RESULTS: PLFLG (n = 31) mid-term survival was similar to HGAS (n = 172) (mean follow-up = 13.2 months [4.6-26]). Conversely LEF-LG patients (n = 59) displayed significant higher rates of all-cause (P = 0.01) and cardiovascular mortalities (P = 0.05). Postprocedural outcomes (VARC-2 criteria) were similar in the PLFLG and HGAS groups except regarding major bleeding (P = 0.02), while the LEF-LG group had more congestive heart failure and a higher BNP before discharge (both P < 0.001) than the other groups. 30-days deaths were significantly more frequent in LEF-LG and PLFLG in comparison to HGAS (P = 0.03). CONCLUSION: As opposed to LEF-LG patients, mid-term prognosis after TAVI procedure in PLFLG patients is similar to HGAS patients despite higher perioperative mortality.

Polytetrafluoroethylene expanded prosthesis as replacement of the inferior vena cava in renal cell carcinoma with caval thrombus.

OBJECTIVE: To assess the outcomes of inferior vena cava replacement with polytetrafluoroethylene expanded prosthesis in patients with renal cell carcinoma and caval thrombosis. METHODS: All patients who underwent radical nephrectomy with inferior vena cava replacement by polytetrafluoroethylene expanded prosthesis for renal cancer associated with inferior vena cava thrombosis and a suspicion of inferior vena cava wall invasion from January 2000 to June 2011 were considered for this study. Demographic data, postoperative course, graft patency and survival data were evaluated. RESULTS: A total of 26 patients (median age 59.5 years, range 19.9-85.6 years) were included in the analysis. The median tumor diameter was 10 cm (range 5-14 cm). Histological invasion of the wall of the inferior vena cava was found in 16 (61.5%) cases. The median follow up was 28 months (range 1-136). A graft thrombosis occurred in five (19.2%) patients within the first year. Four of these patients died before the end of the second year. Patency of the inferior vena cava graft at 6 and 12 months was 88% and 79%, respectively. Overall survival probability at 3 years was 64%. CONCLUSION: Prosthetic replacement of the inferior vena cava can be carried out when invasion of the wall of the inferior vena cava is suspected. The postoperative complication rate in this subset of high-risk patients undergoing radical nephrectomy seems acceptable, and the patency of the prostheses is good in most of the cases.

Implantation of a Sapien XT aortic bioprosthesis through the left carotid artery.

Transcatheter aortic valve implantation (TAVI) is still under active investigation. When the femoral route is impossible for anatomic reasons, the transapical, transaxillary and direct aortic approaches have demonstrated their effectiveness. We report the successful implantation of a Sapien XT bioprosthesis with the NovaFlex catheter through a left carotid approach.

To spare or not to spare ? The aortic valve in scleroderma and aortic root aneurysm.

Acute valve-sparing procedures are effective in the treatment of aortic root dilation when there is no valve pathology. In this review, we discuss the role of aortic valve-sparing procedures in the presence of connective tissue disorders such as scleroderma.

Staged procedure to prevent major adverse events in extensive aortic aneurysm repair.

Surgical management of extensive thoracoabdominal aortic aneurysms is associated with high rates of mortality and morbidity, including spinal cord ischemia. We report a successful three-stage repair combining open and endovascular surgery in a patient presenting with an ascending, arch, and thoracoabdominal aneurysm. Spinal cord protective measures included a staged approach, preserved antegrade flow to the left subclavian and hypogastric arteries, absence of aortic cross-clamping, and aggressive perioperative hemodynamic monitoring.

Update on the need for a permanent pacemaker after transcatheter aortic valve implantation using the CoreValve® Accutrak™ system.

AIMS: High rates of permanent pacemaker (PPM) implantation are reported after transcatheter aortic valve implantation (TAVI) using the Medtronic CoreValve® system. The Accutrak™ catheter is designed to allow a more predictable landing zone. Little is known about the real clinical impact of this catheter. The aims of this paper were to describe the potential impact of the Accutrak™ catheter on the accuracy of positioning a 26 or 29 mm CoreValve® across the aortic annulus and its impact on the need for a pacemaker. METHODS AND RESULTS: A total of 134 patients were treated with the CoreValve® Accutrak™ system at two French centres (Lille and Toulouse). Mean age was 82.4 ± 4.7 years; logistic EuroSCORE was 24.3 ± 9.5%. Procedural success rate was 99.2%; mean depth of implantation was 4.9 mm. A final position between 0 and 6 mm was achieved in 85.8% of the patients. All-cause mortality at 30 days was 6%. The PPM implantation rate was 10.6%. Due to a limited number of events, we could not identify any predictor of need for a PPM: pre-existing right bundle branch block (RBBB) (OR 2.72 [0.63-11.87], p=ns), use of a 29 mm prosthesis (OR 2.73 [0.33-22.90], p=ns) and left ventricular septal hypertrophy (OR 2.63 [0.08-83.32], p=ns). CONCLUSIONS: In this cohort of patients treated with the CoreValve® Accutrak™ system, the incidence of permanent pacemaker implantation was low, which may be a consequence of an average small implantation depth. The Accutrak™ catheter seems to be helpful in achieving higher and more predictable implants. Operators could standardise their technique to place the CoreValve® prostheses less than 6 mm below the aortic annulus.

Transcutaneous aortic valve implantation using the left carotid access: feasibility and early clinical outcomes.

BACKGROUND: In some patients, transfemoral, transaxillary, or transapical aortic valve implantation is not possible. Thus, carotid artery access may represent a safe alternative to those accesses, and even offers certain advantages. In this article, we describe aortic valve implantation using the left carotid arterial approach and report our initial experience. METHODS: Using a self-expandable nitinol based device (CoreValve ReValving system, Medtronic Ltd, Luxembourg), we exposed the left carotid artery through a small incision. Arterial puncture and initial 6F sheath introduction were achieved through a contraincision. The same implantation technique as for transaxillary implantation was used. Progressive artery dilatation was achieved using sheaths of increasing diameter. Rapid ventricular pacing was used to reduce cardiac output while performing a routine aortic balloon valvuloplasty. Only then, an 18F sheath was inserted into the carotid artery and pushed down into the ascending aorta. The patients were monitored using cerebral oxymetry to assess cerebral perfusion. RESULTS: Twelve consecutive patients, at high surgical risk, were implanted and studied prospectively. Transfemoral and subclavian catheterization were considered unfeasible or at risk of severe complications. Carotid arterial injury did not occur in any patient. A transient ischemic attack occurred in 1 patient, contralateral to the carotid access. There were no deaths in either intraprocedural or during the 30-day follow-up period. CONCLUSIONS: This initial experience suggests that left carotid transarterial aortic valve implantation, in selected high-risk patients, is feasible and safe with satisfactory short-term outcomes.

Delivery catheter cone separation and embolization after Corevalve dislocation by subclavian approach.

Corevalve dislocation has been reported to significantly increase the perioperative risk for severe complications and poor outcomes. We describe the case of an 87-year-old man who was referred to our center for transcatheter aortic valve implantation and who experienced an original complication after Corevalve dislocation by subclavian approach. Indeed, during the attempt to retrieve the partially expanded and dislocated valve through the subclavian introducer sheath, we experienced a dislodgment of the valve from the housing sheath that led to a delivery catheter cone separation and systemic embolization.