Immune cell dynamics deconvoluted by single-cell RNA sequencing in normothermic machine perfusion of the liver.

Normothermic machine perfusion (NMP) has emerged as an innovative organ preservation technique. Developing an understanding for the donor organ immune cell composition and its dynamic changes during NMP is essential. We aimed for a comprehensive characterization of immune cell (sub)populations, cell trafficking and cytokine release during liver NMP. Single-cell transcriptome profiling of human donor livers prior to, during NMP and after transplantation shows an abundance of CXC chemokine receptor 1+/2+ (CXCR1+/CXCR2+) neutrophils, which significantly decreased during NMP. This is paralleled by a large efflux of passenger leukocytes with neutrophil predominance in the perfusate. During NMP, neutrophils shift from a pro-inflammatory state towards an aged/chronically activated/exhausted phenotype, while anti-inflammatory/tolerogenic monocytes/macrophages are increased. We herein describe the dynamics of the immune cell repertoire, phenotypic immune cell shifts and a dominance of neutrophils during liver NMP, which potentially contribute to the inflammatory response. Our findings may serve as resource to initiate future immune-interventional studies.

Static cold storage compared with normothermic machine perfusion of the liver and effect on ischaemic-type biliary lesions after transplantation: a propensity score-matched study.

BACKGROUND: Given the susceptibility of organs to ischaemic injury, alternative preservation methods to static cold storage (SCS), such as normothermic machine perfusion (NMP) are emerging. The aim of this study was to perform a comparison between NMP and SCS in liver transplantation with particular attention to bile duct lesions. METHODS: The outcomes of 59 consecutive NMP-preserved donor livers were compared in a 1 : 1 propensity score-matched fashion to SCS control livers. Postoperative complications, patient survival, graft survival and bile duct lesions were analysed. RESULTS: While patients were matched for cold ischaemia time, the total preservation time was significantly longer in the NMP group (21 h versus 7 h, P < 0.001). Patient and graft survival rates at 1 year were 81 versus 82 per cent (P = 0.347) and 81 versus 79 per cent (P = 0.784) in the NMP and SCS groups, respectively. The postoperative complication rate was comparable (P = 0.086); 37 per cent NMP versus 34 per cent SCS patients had a Clavien-Dindo grade IIIb or above complication. There was no difference in early (30 days or less) (NMP 22 versus SCS 19 per cent, P = 0.647) and late (more than 30 days) (NMP 27 versus SCS 36 per cent, P = 0.321) biliary complications. However, NMP-preserved livers developed significantly fewer ischaemic-type bile duct lesions (NMP 3 versus SCS 14 per cent, P = 0.047). CONCLUSION: The use of NMP allowed for a significantly prolonged organ preservation with a lower rate of observed ischaemic-type bile duct lesions.

Assessment of the Clinical Impact of a Liver-Specific, BCAA-Enriched Diet in Major Liver Surgery.

BACKGROUND: The relationship between nutrition and liver disease is relevant for the outcome after surgery. Patients with liver cirrhosis characteristically show protein-energy malnutrition with decreased levels of branched-chain amino acids (BCAA) and increased levels of aromatic amino acids. MATERIALS AND METHODS: We conducted a prospective controlled clinical trial including 57 patients after liver transplantation or major liver resection surgery in order to test the effect of early postoperative nutrition on the outcome and nutrition profile of these patients. The test group received a dietetic program composed of ingredients naturally rich in BCAA (BCAA group), and the control group received standard hospital meals. Patient survival, liver function tests, subjective well-being, and a nutritional status including amino acid profiles were analyzed immediately and 14 days after major liver surgery (secondary end points). General health and well-being were assessed using the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (primary end point). RESULTS: In-depth analysis of amino acid profiles was performed for patients undergoing liver resection (n = 21) and liver transplantation (n = 36). Interestingly, amino acid profiles did not correlate with body mass index or the Model for End-Stage Liver Disease score. Patients scheduled for liver transplantation showed significantly lower levels of BCAA pretransplant compared to patients undergoing liver resection. Patients in the liver resection subgroup were more likely to benefit from the BCAA cuisine in terms of significantly higher food intake and subjective rating. The clinical liver function tests, however, did not show statistical difference between the BCAA group and the control group in the examination period of 14 days. CONCLUSION: Our specifically designed BCAA-enriched diet resulted in greater patient satisfaction and compliance with nutrition. A larger trial or longer-term follow-up may be required to identify an effect on survival, recovery, surgical complications, protein profiles, and amino acid profiles.

Outcomes of pancreas retransplantation in patients with pancreas graft failure.

BACKGROUND: Pancreas retransplantation is still a controversial option after loss of a pancreatic graft. This article describes the experience of pancreas retransplantation at a high-volume centre. METHODS: This was a retrospective observational study of all pancreas retransplantations performed in a single centre between 1997 and 2013. Pancreatic graft loss was defined by the return to insulin dependence. Risk factors for graft loss as well as patient and graft survival were analysed using logistic and time-to-event regression models. RESULTS: Of 409 pancreas transplantations undertaken, 52 (12·7 per cent) were identified as pancreas retransplantations. After a median follow-up of 65·0 (range 0·8-174·3) months, 1- and 5-year graft survival rates were 79 and 69 per cent respectively, and 1- and 5-year patient survival rates were 96 and 89 per cent. During the entire follow-up, 22 grafts (42 per cent) were lost. Patient survival was not associated with any of the donor- or recipient-related factors investigated. Five-year graft survival was better after simultaneous kidney-pancreas retransplantation than pancreas retransplantation alone: 80 per cent (16 of 20) versus 63 per cent (20 of 32) (P = 0·226). Acute rejection (odds ratio 4·49, 95 per cent c.i. 1·59 to 12·68; P = 0·005) and early surgical complications (OR 3·29, 1·09 to 9·99, P = 0·035) were identified as factors with an independent negative effect on graft survival. CONCLUSION: Pancreas retransplantation may be considered for patients whose previous graft has failed.

Integrating interventional oncology in the treatment of liver tumors.

BACKGROUND: Percutaneous ablation techniques offer a vast armamentarium for local, minimally invasive treatment of liver tumors, nowadays representing an established therapeutic option, which is integrated in treatment algorithms, especially for non-resectable liver tumors. The results of ablative treatment compare very well to surgical treatment in liver lesions, and confirm that these techniques are a valuable option for bridging for transplantation. Different techniques have been established to perform tumor ablation, and the feasibility varies according to the procedure and technical skills of the operator, depending on the size and location of the liver lesion. In recent years, stereotactic multi-needle techniques using 3D trajectory planning, general anesthesia, and tube disconnection during needle placement have had a strong impact on the application range of ablation for liver tumors. CONCLUSION: It is well known that creating a sufficient ablation margin and overlapping ablation zones is one key issue to enable ablation of large liver lesions with tumor-free margins (A0 ablation in analogy to R0 resection). Image fusion during treatment and follow-up assure highly accurate staging procedures and interventional planning. NOVEL ASPECTS: Review on the standards in ablation techniques for the treatment of liver tumors. Update on different ablation techniques, indications, and contraindications for percutaneous liver tumor treatment. Summary of recently published reports on liver tumor ablation.

Endoconduits with "Pave and Crack" Technique Avoid Open Ilio-femoral Conduits with Sustainable Mid-term Results.

OBJECTIVE/BACKGROUND: The objective was to evaluate the feasibility and mid-term outcomes of endoconduits (EC) with the "pave and crack" technique during endovascular aneurysm repair (EVAR) of varying complexity. METHODS: This was a retrospective study. All patients undergoing EC between July 2009 and October 2015 were included. The primary endpoint was technical success of the EC defined as the ability to successfully deliver the aortic stent graft through the EC without rupture, dissection, or thrombosis of the iliac or femoral arteries, and with the absence of haemodynamically significant blood loss related to the EC. Secondary outcomes included EC patency and mortality. RESULTS: Nineteen patients underwent EVAR with EC (16 juxtarenal or thoraco-abdominal, two infrarenal and one thoracic; four were ruptured). Fourteen patients (73.7%) had TASC D lesions. In 10 cases (52.6%) adjunctive open/endovascular procedures to improve the femoral outflow were required. EC was technically successful in all cases and all EC were patent at EVAR completion. Thirty day mortality occurred in two cases (10.5%) One of these patients had been treated for rupture. One patient required two endovascular re-interventions at 1 and 5 years post-operatively to restore patency of the EC. No open re-interventions related to the EC were necessary. After a median follow-up period of 17 (interquartile range 5-37) months, the primary assisted patency of the EC was 88.9% (SE 10.5). No new onset of claudication or lower limb amputations occurred during the follow-up. CONCLUSION: EC allows EVAR of varying complexity without the need for open surgical ilio-femoral conduits in patients with concomitant advanced iliac occlusive disease. Intra-operative haemodynamic instability was always avoided and mid-term patency was high.

Outcome After Ruptured AAA Repair in Octo- and Nonagenarians in Sweden 1994-2014.

OBJECTIVE: To report the outcome after ruptured abdominal aortic aneurysm (rAAA) repair in octo- and nonagenarians from the Swedish Vascular Registry 1994-2014. MATERIAL AND METHODS: 2335 intact AAA (iAAA) and 1538 rAAA were identified in patients aged 80 years and older. Crude, long-term, and relative survival data were analysed using the Kaplan-Meier method. Crude survival was calculated including all deaths. Long-term survival was analysed excluding AAA repair related mortality, defined as death within 90 days of surgery. Relative survival was assessed by comparing the observed long-term survival after AAA repair with the expected survival of a Swedish population adjusted for age, gender, and operation year. Differences were compared using log-rank tests. The multivariate Cox model was used for adjusting for confounding factors between open repair (OR) and endovascular aneurysm repair (EVAR). RESULTS: Crude survival after rAAA repair was 30 days (55%), 90 days (50%), 1 year (45%), 5 years (26%), and 10 years (9%). Long-term survival was 1 year (90%), 5 years (53%), and 10 years (18%). When individuals with rAAA were categorized into males and females, crude and long-term survival showed no significant differences (p = .204 and p = .134). When rAAA patients were categorized into age groups (80-84 years, 85-89 years, 90+) crude survival diminished with increasing age, but long-term survival was not (p = .009 and p = .368). Compared with the general population, rAAA patients showed only a minor decrease in relative survival. Crude survival after rAAA was better for EVAR compared with OR (p = .007), hazard ratio 1.3 (95% CI 1.1-1.6, p < .012). CONCLUSIONS: There is a high (50%) peri-operative mortality after surgery for rAAA in octo- and nonagenarians, with no significant differences between the sexes and worse survival with increasing age. However, if a patient has survived the initial 90 days, long-term survival in this very old cohort is surprisingly good at more than 50% after 5 years, only slightly less than the general population.

The Long-term Durability of Intra-operatively Placed Palmaz Stents for the Treatment of Type Ia Endoleaks After EVAR of Abdominal Aortic Aneurysm.

OBJECTIVE/BACKGROUND: The objective was to analyze the long-term durability of intra-operatively placed Palmaz stents for type Ia endoleaks, and the evolution of aneurysm neck morphology. METHODS: This was a retrospective cohort study conducted at a tertiary referral centre. Patients treated between 1998 and 2012 were reviewed with regard to pre-, intra-, and post-operative data. Crude and relative survival estimates were calculated, with the latter referring only to patients with ≥ 3 months' follow-up. RESULTS: In total, 125 patients were included (83 elective, 22 ruptures, 20 symptomatic). Nine patients died perioperatively (two elective, seven acute). Median follow-up was 43 months (range 15-72). Seven patients had late abdominal aortic aneurysm related deaths. There were 51 re-interventions (seven type Ia endoleak related). Five year crude primary, primary assisted, and secondary success rates were 55 ± 5%, 66 ± 5%, and 70 ± 5%, respectively. These crude rates were superior for elective patients (p = .008, p = .031, and p = .037, respectively), but the relative rates were not (p = .187, p = .640, p = .558, respectively). Primary and assisted freedom from type Ia endoleak 5 years post-operatively were 84 ± 4% and 89 ± 3%, respectively. These rates were superior in elective patients (p = .066 and p = .145, respectively), especially when relative rates were analysed (p = .025 and p = .063, respectively). The visceral aortic diameter increased significantly between the first and the last post-operative imaging in 15/91 (16%), 12/91 (13%), 34/91 (37%), and 30/91 (33%) patients at the levels of coeliac trunk, superior mesenteric artery, lowest renal artery, and 9 mm distal to lowest renal artery, respectively. CONCLUSION: Intra-operatively placed Palmaz stents confer high long-term freedom from type Ia endoleak. Palmaz stents are an acceptable intra-operative bailout tool in the acute setting, but should not be used to extend elective infrarenal endovascular aneurysm repair to more demanding anatomies.

Mid-term Outcomes of Renal Branches Versus Renal Fenestrations for Thoraco-abdominal Aneurysm Repair.

OBJECTIVE/BACKGROUND: The objective was to investigate renal outcomes following endovascular repair of thoraco-abdominal aortic aneurysms (TAAA) comparing fenestrations with branches for the renal arteries. METHODS: Renal outcomes following TAAA endovascular repair performed with renal branches were collected from five high volume European centers and compared with renal outcomes following TAAA endovascular repair performed with renal fenestrations at one center. Renal re-intervention and occlusion rates, and freedom from any renal outcome and death were analyzed by patient and target vessel. Estimated glomerular filtration rate (eGFR) was calculated and collected pre-operatively and at the last available follow up. RESULTS: In total, 449 patients were included in this retrospective study (235 treated with branched devices [BEVAR] and 214 with fenestrated devices [FEVAR]). Altogether, 856 renal vessels were analyzed (445 perfused by branches and 411 by fenestrations). Both groups were comparable except for sex and smoking habits. Technical success rates were 95% and 99%, respectively. Mean ± SD follow up was 19 ± 18 months after BEVAR and 24 ± 20 months after FEVAR. During follow up, renal re-intervention rates were similar in both groups (4.7% vs. 5.2%). The renal occlusion rate was significantly higher following BEVAR (9.6% vs. 2.3%; p < .01), and the 2 year freedom for renal occlusion rate was 90.4% (SE 85.8-95.3%) following BEVAR and 97.1% (SE 94.6-99.7%) following FEVAR (p < .01). During follow up, a 12% median decrease in eGFR was observed following BEVAR versus 9% following FEVAR (non-significant). The 2 year survival rates were 73.4% (SE 66.6-80.9%) and 81.8% (SE 76.1-87.9%) following BEVAR and FEVAR, respectively. CONCLUSION: Mid-term renal outcomes following endovascular repair of TAAA are satisfactory. Endograft designs incorporating renal fenestrations rather than renal branches are associated with significantly lower occlusion rates. A prospective trial is now required to confirm these results.

Editor's Choice - Effect of Branch Stent Choice on Branch-related Outcomes in Complex Aortic Repair.

OBJECTIVES: The use of branched stent grafts for the treatment of thoracoabdominal aneurysms [TAAA] is increasing, but mating stent graft choice has not been studied. This study combined experience of five high volume centres to assess a preferred mating stent. METHODS: Data from five centres were retrospectively combined. Patients were included if they underwent stent graft for treatment of TAAA that used only branches to mate with visceral and renal vessels. All patients with fenestrations in their device were excluded. Perioperative details, reintervention, occlusion, and death were recorded. Outcome of occlusion or reintervention, as well as a composite outcome of any death, occlusion, or reintervention was planned using a per-patient, and per-branch analysis. RESULTS: In 235 included patients, there were 940 vessels available for placement of mating stent. The average age of included patients was 70 years (SD 7.9), and 179 of the 235 were male. Medical comorbidities included diabetes in 29/234 (12.4%), current smoker in 81/233 (34.8%), and COPD in 77/234 (32.9%). The primary stent deployed was self-expanding in 556 branches, balloon expandable in 231 branches, and was unknown in 92 branches. After a mean of 20.7 months (SD 25) follow-up, there have been 44 incidents of occlusion or reintervention, of which 40 culprit stents are known. Where the stent placed is known, the event rate in renal branches (35/437, 8%) is higher than that of visceral branches (8/443, 1.8%). There is no difference in occlusion or reintervention between self-expanding and balloon expandable stents (HR 0.95, p = .91) but there is a statistically significant difference between renal and visceral artery occlusions (HR 3.51, p = 0.001). CONCLUSION: There appears to be no difference in occlusion or reintervention rate for branch vessels mated with balloon expandable compared with self-expanding stents. Renal events appear to outnumber visceral events in this population.

Laser Generated In situ Fenestrations in Dacron Stent Grafts.

OBJECTIVE/BACKGROUND: To evaluate if the creation of laser generated in situ fenestrations in polyester/Dacron stent grafts causes embolization. METHODS: In seven pigs, Dacron stent grafts were implanted from the infrarenal aorta to the right iliac artery. Prior to placing the stent graft, a carotid artery protection filter, with a pore size of 70-200 µm, was placed in the proximal left common iliac artery. An excimer laser catheter was then advanced antegradely through the stent graft and positioned at the level of origin of the left iliac artery. A fenestration was then created with the laser probe. The carotid filter was retrieved and inspected macroscopically with magnifying glasses, for emboli and clot. RESULTS: Seven pigs with a median weight of 90 kg (range 78-98 kg) were tested. The median operating time was 170 minutes. All laser fenestrations were successfully completed. No emboli or clot could be detected in the protection filters. CONCLUSION: Creation of laser generated, in situ fenestrations do not produce macroscopically visible emboli/clot. This might indicate safe usage of laser created fenestrations for endovascular arch repair and left subclavian artery revascularization.

[Single Incision Laparoscopic Cholecystectomy (SILC) - A Novel Technique in Comparison with the Gold Standard]. / Single-Port-Cholezystektomie: Ein Vergleich mit dem Goldstandard.

BACKGROUND: Currently multiport laparoscopic cholecystectomy (LC) represents the gold standard for gall bladder removal. However, a single-incision approach might succeed it as the future leading technique. To date, final proof for safety and applicability remain elusive. METHODS: A retrospective analysis of prospectively collected data from 459 patients subjected to multiport (LC) or single incision laparoscopic cholecystectomy (SILC) was performed. RESULTS: From 2010 to 2011, 115 SILC (25 %) and 344 LC (75 %) interventious were performed. Mean follow-up was 13.2 (2.1/24.6) months. The SILC group comprised more females (SILC: m : f 1 : 3.4 vs. LC: 1 : 1.2) and younger patients (SILC: 44.7 vs. LC: 54.9 years) with a slightly lower (ASA) score (SILC:1.7 ± 0.3 vs. LC:1.9 ± 0.5). SIL cholecystectomy was performed more frequently in an elective setting (SILC: 81.7 vs. LC: 55.5 %). Complication rates were low and did not differ significantly between groups (wound infections: SILC: 2.3 vs. LC: 3.19 %; incisional hernias: SILC: 0.86 vs. LC: 2.3 %, bile leakage: SILC: 0.86 vs. LC: 0.57 %). SILC was associated with shorter operative times (SILC: 70 ± 31 vs. LC: 80 ± 27 minutes; p < 0.001) and reduced postoperative hospital stay (SILC: 3.02 ± 1.4 vs. LC: 4.6 ± 2.8 days; p < 0.001). No conversion to open surgery was required with SILC when compared to LC (6 %; 21/334). Within the SILC group, additional ports had to be placed in 2.6 % (3/115). CONCLUSION: SILC displays a minimised surgical trauma. Compared to LC, SILC showed no disadvantage concerning risk profiles, operative times or hospital stay. We believe that SILC can be regarded as a natural evolution in the era of minimally invasive surgery.

Utility of Intra-operative Cone Beam Computed Tomography in Endovascular Treatment of Aorto-iliac Occlusive Disease.

OBJECTIVE: Endovascular treatment of aorto-iliac occlusive disease (AIOD) is well established, but to maintain long-term patency, secondary interventions are common. Multiple stents and iliac artery tortuosity often make it difficult to evaluate stent compression intra-operatively and this might be a cause for later failure. Completion angiography (CA) and pressure gradient (PG) measurement are often used to assess the final intra-operative result. The purpose of this study was to evaluate the role of intra-operative cone beam computed tomography (CBCT) to optimize the primary operation results. METHOD: Fifty-three patients (28 females) were enrolled in a prospective study. All patients underwent endovascular aorto-iliac revascularization. Final intra-operative results were evaluated with additional CBCT, after CA and PG were found to be satisfactory. Imaging findings and imaging based adjunctive procedures were recorded. RESULTS: One hundred and sixty five stents were placed because of AIOD. Twenty patients underwent adjunctive procedures after the primary stenting. In 24.5% (13/53) cases, adjunctive procedures were indicated solely by the CBCT findings, as both standard CA and PG were normal. Twenty-six of the 53 patients had kissing stents placed at the aortic bifurcation. Of the kissing stent patients, 34.6% required adjunctive procedures and in two thirds these stent compressions were detected only by CBCT. CONCLUSION: The use of CBCT revealed a significant number of stent compressions that were not found with CA and PG. When performing endovascular procedures at the aortic bifurcation, CBCT is an excellent intra-operative evaluation method to assess the configuration of deployed stents. In this study, CBCT improved the technical results intra-operatively, which might influence the long-term patency positively.

Editor's Choice ­ Durability of Endovascular Repair in Blunt Traumatic Thoracic Aortic Injury: Long-Term Outcome from Four Tertiary Referral Centers.

OBJECTIVES: To analyze the early and long-term survival and re-intervention rate in patients undergoing TEVAR for blunt traumatic thoracic aortic injury. METHODS: This was a consecutive case series. Between the years 2001 and 2010, a total of 74 patients underwent TEVAR for blunt traumatic thoracic aortic injury at four tertiary referral centers, three in Sweden and one in Switzerland. The median age of the patients was 41 years, and 16% were women. Demographic, procedural, and outcome data were collected and reviewed retrospectively. The patients were followed up during 2013-2014. RESULTS: Early (30 day) mortality was 9% (7 patients), with only two cases directly related to the aortic injury; in hospital mortality was 14% as three patients died during the primary hospital admission within the first 6 months. Most patients had sustained severe injuries to other organ systems, and among all in hospital deaths brain injury was the predominant cause. Five year survival in the whole group was 81%. Re-intervention was needed in 16% (12 patients) during the first year, half of them within the first month. Only one patient underwent re-intervention more than 1 year after the initial procedure. Infolding and partial stentgraft collapse was the reason for the secondary procedure in five of the 13 patients; in three it occurred within 3 weeks of the acute TEVAR. CONCLUSION: TEVAR allows rapid and effective therapy in trauma patients with blunt aortic injury. The outcome is dependent on the severity of the concomitant injuries. The treatment is durable during the first decade after the procedure, but even longer follow up is needed to determine the impact of TEVAR in young patients on the degenerative changes that take place in the aging aorta.

Treatment with tetrahydrobiopterin overcomes brain death-associated injury in a murine model of pancreas transplantation.

Brain death (BD) has been associated with an immunological priming of donor organs and is thought to exacerbate ischemia reperfusion injury (IRI). Recently, we showed that the essential nitric oxide synthase co-factor tetrahydrobiopterin (BH4) abrogates IRI following experimental pancreas transplantation. We therefore studied the effects of BD in a murine model of syngeneic pancreas transplantation and tested the therapeutic potential of BH4 treatment. Compared with sham-operated controls, donor BD resulted in intragraft inflammation reflected by induced IL-1ß, IL-6, VCAM-1, and P-selectin mRNA expression levels and impaired microcirculation after reperfusion (p < 0.05), whereas pretreatment of the BD donor with BH4 significantly improved microcirculation after reperfusion (p < 0.05). Moreover, BD had a devastating impact on cell viability, whereas BH4-treated grafts showed a significantly higher percentage of viable cells (p < 0.001). Early parenchymal damage in pancreatic grafts was significantly more pronounced in organs from BD donors than from sham or non-BD donors (p < 0.05), but BH4 pretreatment significantly ameliorated necrotic lesions in BD organs (p < 0.05). Pretreatment of the BD donor with BH4 resulted in significant recipient survival (p < 0.05). Our data provide novel insights into the impact of BD on pancreatic isografts, further demonstrating the potential of donor pretreatment strategies including BH4 for preventing BD-associated injury after transplantation.

Intra-operative cone beam computed tomography can help avoid reinterventions and reduce CT follow up after infrarenal EVAR.

OBJECTIVE/BACKGROUND: Re-interventions after endovascular abdominal aortic aneurysm repair (EVAR) are common and therefore a strict imaging follow up protocol is required. The purpose of this study was to evaluate whether cone beam computed tomography (CBCT) can detect intra-operative complications and to compare this with angiography and the 1 month CT follow up (computed tomography angiography [CTA]). METHODS: Fifty-one patients (44 men) were enrolled in a prospective trial. Patients underwent completion angiography and CBCT during infrarenal EVAR. Contrast was used except when pre-operative renal insufficiency was present or if the maximum contrast dose threshold was reached. CBCT reconstruction included the top of the stent graft to the iliac bifurcation. Endoleaks, kinks, or compressions were recorded. RESULTS: CBCT was technically successful in all patients. Twelve endoleaks were detected on completion digital subtraction angiography (CA). CBCT detected 4/5 type 1 endoleaks, but only one type 2 endoleak. CTA identified eight type 2 endoleaks and one residual type I endoleak. Two cases of stent compression were seen on CA. CBCT revealed five stent compressions and one kink, which resulted in four intra-operative adjunctive manoeuvres. CTA identified all cases of kinks or compressions that were left untreated. Two of them were corrected later. No additional kinks/compressions were found on CTA. Groin closure consisted of 78 fascia sutures, nine cut downs, and 11 percutaneous sutures. Seven femoral artery pseudoaneurysms (<1 cm) were detected on CTA, but no intervention was needed. CONCLUSION: CA is better than CBCT in detecting and categorizing endoleaks but CBCT (with or without contrast) is better than CA for detection of kinks or stentgraft compression. CTA plus CBCT identified all significant complications noted on the 1 month follow up CTA. The use of intra-operative CA and CBCT could replace early CTA after standard EVAR thus reducing overall radiation and contrast use. Technical development might further improve the resolution and usefulness of CBCT.

Optimizing imaging for aortic repair.

Imaging is an integral part of an aortic program. Careful preoperative planning is essential to successful evaluation and treatment of aortic pathology. Computed tomography angiography (CTA) is the dominant modality for such preoperative planning. The use of a dedicated workstation for 3D postprocessing is very favorable and is considered mandatory when treating complex aortic pathology. Intraoperative imaging during aortic repair still depends heavily on standard fluoroscopy and angiography. However, the introduction of image fusion has the potential to reduce the use of both contrast and radiation, for the benefit of both patients and operators. Using cross-sectional imaging intraoperatively also has the potential to reduce the need for early imaging follow-up and to reduce the technical failures of endovascular aneurysm repair (EVAR). Imaging follow-up after EVAR has changed dramatically since the introduction of minimally invasive aortic repair. CTA remains the gold standard but a significant shift towards ultrasound surveillance has occurred. With the introduction of newer generation EVAR devices, results have improved and a trend towards less rigorous follow-up is expected.

Short-term outcome of spinal cord ischemia after endovascular repair of thoracoabdominal aortic aneurysms.

OBJECTIVE: To analyze the incidence and short-term outcome of SCI after endovascular repair of thoracoabdominal aneurysms (eTAAA). METHODS: All patients undergoing eTAAA with branched and fenestrated stent grafts between 2008 and 2014 were retrospectively reviewed concerning pre-, intra- and post-operative clinical data and imaging. RESULTS: Seventy-two patients (53 males, 68 [64-73] years old) underwent eTAAA (51 elective, 21 acute including 7 ruptures). Patients were classified anatomically according to Crawford: type I (n=11), type II (n=26), type III (n=18), and type IV (n=17). Thirty-day mortality was 6.9 % (3.9% for elective, 7.1% for symptomatic and 28.6% for ruptures, including one intra-operative death). Twenty-two of the 71 patients who survived the operation (31.0%) developed SCI: type I (n=2, 20.0%), type II (n=13, 50.0 %), type III (n=3, 16.7%), type IV (n=4, 23.5%). SCI incidence decreased in the latter part of the experience (23.7% vs. 39.4%, p = .201). SCI development was independently associated with Crawford type II TAAA (OR 4.497 (1.331-15.195), p = .016) and higher contrast volume (OR 3.736 [1.054-13.242], p = .041). Fifteen of these 22 patients with SCI showed some improvement of their deficits before hospital discharge. The introduction of a standardized protocol in the last 38 patients aiming at the early diagnosis and treatment of SCI led to more frequent regression of SCI symptoms (100% vs. 46.2%, p = .017) and a higher rate of regaining ambulatory capacity (55.6% vs. 15.4%, p = .027). After the introduction of this protocol, the residual SCI rate at hospital discharge was 13.2% as opposed to 33.3% in the initial group. CONCLUSION: eTAAA has low peri-operative mortality, but SCI incidence is high albeit that it decreased with increasing experience. More extensive repair and use of larger volumes of contrast were associated with higher risk of SCI. Acute repair does not significantly increase SCI risk. A standardized protocol for early diagnosis and treatment of SCI leads to a higher recovery rate with a greater likelihood of regaining ambulatory capacity.

Anatomic feasibility of endovascular reconstruction in aortic arch aneurysms.

The purpose was to estimate the proportion of current open aortic arch reconstructions that might be feasible for endovascular repair. From all elective repair made in Southern Sweden in one center between 2005 and 2012, 129 open and eight endovascular aortic arch repairs were identified. The anatomy of the ascending arch and descending aorta as well as the arch vessels was categorized from multiplanar and axial computed tomography scans. Of 129 open cases, only two (1.5%) were suitable for endovascular repair. Among 137 all arch open and endovascular arch reconstructions performed during the study period, only 10 (7%) were candidates for endovascular repair. The most common exclusion for endovascular repair was an excessively large ascending aortic diameter. In conclusion, only a small proportion of patients having an open arch repair are suitable for endovascular arch repair, a finding related to the large diameter of the ascending aorta.