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OBJECTIVE: Vascular complications (VCs) associated with extracorporeal membrane oxygenation (ECMO) during index hospitalization are prevalent and associated with increased mortality. Few studies have evaluated late VCs following ECMO; this study aims to assess occurrence and management practices of late VCs following discharge. METHODS: A retrospective single-institution review was performed of all patients surviving initial hospitalization after being cannulated for central or peripheral veno-venous (VV) or veno-arterial (VA) ECMO between January 1, 2019, and December 31, 2020. Primary outcomes were to categorize and determine the rate of late VCs. Late VCs were defined as any cannulated vessel injury resulting from ECMO cannulation presenting after discharge from index hospitalization. Analysis was conducted by cannulated vessel and stratified by VV or VA ECMO configurations. RESULTS: A total of 229 patients were identified, of which 50.6% (n = 116) survived until discharge. Late VCs occurred in 7.8% of the surviving cohort (n = 9/116); with a median time until presentation of 150 days (interquartile range, 83-251 days). The most common late VC was infection (n = 5; 55.6%) followed by progression to limb-threatening ischemia (n = 4; 44.4%). Urgent procedures were required in 55.6% of patients (n = 5), whereas 44.4% (n = 4) were elective interventions. Interventions performed for management of late VCs included lower extremity arterial revascularization (n = 6; 66.7%), major (n = 1; 11.1%) or minor amputation (n = 1; 11.1%), and wound debridement (n = 1; 11.1%). The majority of patients presenting with late VCs had initially been cannulated for peripheral VA ECMO (n = 8; 88.9%), and one patient (11.1%) was cannulated for peripheral VV ECMO. VCs during index hospitalization were seen in 77.8% of patients (n = 7) returning with late VCs. Odds for late VCs were significantly increased in patients that had been cannulated for ECMO as part of extracorporeal cardiopulmonary resuscitation (odds ratio, 8.4; P = .016) and in cases where patients had experienced an index VC during index hospitalization (odds ratio, 19.3; P = .001). CONCLUSIONS: Late vascular complications after peripheral ECMO cannulation are not rare, particularly after arterial cannulation. Patients should be followed closely early after surviving ECMO with wound evaluation and formal assessment of perfusion with ankle-branchial indices in the cannulated limb.
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BACKGROUND: Vascular complications remain a prevalent and devastating complication of extracorporeal membrane oxygenation (ECMO). Risks for vascular complications have risen as the volume and medical complexity of ECMO cases has rapidly increased in recent years. This study assesses occurrence and clinical impact of vascular complications across all ECMO modes and cannulation methods in a high-volume academic center. METHODS: A retrospective single-institution review was performed of all ECMO cannulations for central or peripheral venovenous (VV) or venoarterial (VA) ECMO in 2019-2020. Patients who expired during cannulation were excluded. Primary outcomes of vascular consultation rates at or after ECMO placement, limb loss, and mortality were assessed during index hospitalization. RESULTS: A total of 229 patients were identified during the 2-year study period. VA ECMO was used in the majority of patients (n = 137, 60%), with 83% (N = 114) undergoing peripheral cannulation. Vascular surgery was consulted in 54 (23.6%) patients. Complication rates ranged from 33.9% in peripheral VA cannulation to 7% in jugular VV cannulation. Overall, 65% of vascular consults required operative intervention; interventions were highest in peripheral VA ECMO (n = 30 of 114, 26.3%). Across all ECMO types, acute limb ischemia (ALI) was the most common complication (n = 38, 16.5%), with rates ranging from 26.1% in central VA ECMO to 4.8% in jugular VV ECMO. Distal antegrade perfusion catheters (DPCs) were employed in n = 68 of 114 (59.6%) of all peripheral VA ECMO cases. Prophylactic DPCs were found to be incorrectly placed in 10.2% (n = 7 of 68) of cases, which obscured the ability to fully evaluate the effect of prophylactic DPCs on reducing rates of ALI. Major amputation (Below Knee Amputation/Above Knee Amputation) occurred in six peripheral VA patients (5.3%), two central VA patients (8.65), and two femoral-femoral VV patients (4%). Patients with ALI experienced significantly lower rates of in-hospital survival in Kaplan-Meier analysis (32.5% vs 54%, log-rank = 0.023). CONCLUSIONS: This study highlights the prevalence of vascular complications, and their associated mortality impact, across all modes of ECMO and additionally identifies several areas for institutional performance improvement. ALI was the most common complication across all cohorts and was associated with decreased in-hospital survival. The impact of DPC on ALI was difficult to elucidate due to nonstandardized placement patterns and selective use. In the care of these medically complex patients on multidisciplinary teams, review of outcomes and group discussions targeting areas for improvement are critical to success; in this study, findings resulted in the development of a lower extremity perfusion management protocol.
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Doenças Cardiovasculares , Cateterismo Periférico , Oxigenação por Membrana Extracorpórea , Doenças Cardiovasculares/etiologia , Cateterismo Periférico/métodos , Oxigenação por Membrana Extracorpórea/efeitos adversos , Artéria Femoral/cirurgia , Humanos , Isquemia/diagnóstico , Isquemia/etiologia , Isquemia/terapia , Estudos Retrospectivos , Fatores de RiscoRESUMO
BACKGROUND: Acute normovolemic hemodilution (ANH) is a blood conservation strategy in cardiac surgery, predominantly used in coronary artery bypass graft (CABG) and/or valve procedures. Although higher complexity cardiac procedures may benefit from ANH, concerns for hemodynamic instability, and organ injury during hemodilution hinder its wider acceptance. Laboratory and physiological parameters during hemodilution in complex cardiac surgeries have not been described. STUDY DESIGN AND METHODS: This observational cohort (2019-2021) study included 169 patients who underwent thoracic aortic repair, multiple valve procedure, concomitant CABG with the aforementioned procedure, and/or redo sternotomies. Patients who received allogeneic blood were excluded. Statistical comparisons were performed between ANH (N = 66) and non-ANH controls (N = 103). ANH consisted of removal of blood at the beginning of surgery and its return after cardiopulmonary bypass. RESULTS: Intraoperatively, the ANH group received more albumin (p = .04) and vasopressor medications (p = .01), while urine output was no different between ANH and controls. Bilateral cerebral oximetry (rSO2 ) values were similar before and after hemodilution. During bypass, rSO2 were discretely lower in the ANH versus control group (right rSO2 p = .03, left rSO2 p = .05). No differences in lactic acid values were detected across the procedural continuum. Postoperatively, no differences in extubation times, intensive care unit length of stay, kidney injury, stroke, or infection were demonstrated. DISCUSSION: This study suggests hemodilution to be a safe and comparable blood conservation technique, even without accounting for potential benefits of reduced allogenic blood administration. The study may contribute to better understanding and wider acceptance of ANH protocols in high-risk cardiac surgeries.
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Procedimentos Cirúrgicos Cardíacos , Hemodiluição , Transfusão de Sangue , Circulação Cerebrovascular , Hemodiluição/métodos , Humanos , OximetriaRESUMO
BACKGROUND AND AIM: Perioperative blood transfusion is associated with increased morbidity and mortality. Acute normovolemic hemodilution (ANH) is a blood conservation strategy associated with variable success, and rarely studied in more complex cardiac procedures. The study aim was to evaluate whether ANH improves coagulopathy and reduces blood transfusions in thoracic aortic surgeries. METHODS: Single-center observational cohort study comparing ANH and standard institutional practice in patients who underwent thoracic aortic repair with cardiopulmonary bypass (CPB) from 2019 to 2021. RESULTS: A total of 89 patients underwent ANH and 116 standard practice. There were no significant differences between the groups in terms of demographic or major perioperative characteristics. In the ANH group coagulation tests before and after transfusion of autologous blood showed decreased INR and increased platelets, fibrinogen, all with p < 0.0005. Coagulation results in the ANH and control groups were not statistically different. The average number of transfused allogeneic products per patient was lower in the ANH versus control group: FFP 1.1 ± 1.6 versus 1.9 ± 2.3 (p = 0.003), platelets 0.6 ± 0.8 versus 1.2 ± 1.3 (p = 0.0008), and cryoprecipitate 0.3 ± 0.7 versus 0.7 ± 1.1 (p = 0.008). Reduction in red blood cell transfusion was not statistically significant. The percentage of patients who received any transfusion was 53.9% in ANH and 59.5% in the control group (p = 0.42). There was no significant difference in major adverse outcomes. CONCLUSIONS: ANH is a safe blood conservation strategy for surgical repairs of the thoracic aorta. Laboratory data suggests ANH can improve some coagulation values after separation from CPB, and significantly reduce the number of transfused FFP, platelets and cryoprecipitate.
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Ponte Cardiopulmonar , Transplante de Células-Tronco Hematopoéticas , Testes de Coagulação Sanguínea , Transfusão de Sangue , Estudos de Coortes , Hemodiluição , HumanosRESUMO
OBJECTIVES: To describe outcomes after suprasternal (SS) transcatheter aortic valve replacement (TAVR) as a new alternative access approach. BACKGROUND: There still remains a cohort of the TAVR population who are not suitable for a transfemoral (TF) approach. SS-TAVR is a safe and effective alternative to TF-TAVR and has now become our preferred alternative access route. METHODS: We retrospectively reviewed all patients from New York Presbyterian Hospital, Columbia University Medical Center and Princeton Baptist Medical Center who underwent SS-TAVR from 2015 to July 2018. A total of 84 patients were included in the study. RESULTS: Technical success was achieved in all cases. Thirty-day survival was 98.8% (n = 83). There were minimal complications. Most notably, there were no transient ischemic attacks or strokes (0%, n = 0). Reexploration for bleeding was 3.6% (n = 3), and major bleeding was 1.7% (n = 1). We also achieved satisfactory results with a mean aortic valve gradient of 6.07 ± 3.79 mmHg and an aortic valve area of 2.21 ± 0.51 cm2 . No patients had anything more than mild paravalvular leak. The mean length of stay (LOS) in the intensive care unit was 1.42 ± 1.23 days, and hospital LOS was 4.20 ± 3.29 days. CONCLUSIONS: SS access for TAVR is an extremely important technique to have in any valve team's alternative access armamentarium. This technique can be safely and reliably reproduced with any standard hybrid operating room setup and no additional equipment, and it can be used with any commercially available valve system. In the current experience, minimal complications and excellent early term results were obtained.
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Estenose da Valva Aórtica/cirurgia , Valva Aórtica/cirurgia , Substituição da Valva Aórtica Transcateter , Idoso , Idoso de 80 Anos ou mais , Alabama , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/fisiopatologia , Estenose da Valva Aórtica/diagnóstico por imagem , Estenose da Valva Aórtica/mortalidade , Estenose da Valva Aórtica/fisiopatologia , Feminino , Hemodinâmica , Humanos , Masculino , Cidade de Nova Iorque , Complicações Pós-Operatórias/etiologia , Recuperação de Função Fisiológica , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Substituição da Valva Aórtica Transcateter/efeitos adversos , Substituição da Valva Aórtica Transcateter/mortalidade , Resultado do TratamentoRESUMO
Valve sparing aortic root replacement remains a complex procedure despite various improvements that have been made to this operation. Specifically, a hemostatic proximal anastomosis is one of the most important factors for successful completion of the operation without complication. Here we describe a double mattress suture line technique, which facilitates a secure and hemostatic proximal suture line.
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Aorta/cirurgia , Valva Aórtica , Implante de Prótese Vascular/métodos , Tratamentos com Preservação do Órgão/métodos , Técnicas de Sutura , HumanosRESUMO
We demonstrate the usefulness of two- and live/real time three-dimensional transesophageal echocardiography in a procedure, which combined transcatheter mitral valve-in-valve deployment and paraprosthetic leak closure in the same setting using the less invasive transfemoral approach in an adult patient with bioprosthetic mitral valve degeneration. We also highlight the additive value of three-dimensional echocardiography over the two-dimensional technique.
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Ecocardiografia Transesofagiana/métodos , Implante de Prótese de Valva Cardíaca/métodos , Valva Mitral/diagnóstico por imagem , Valva Mitral/cirurgia , Falha de Prótese , Idoso de 80 Anos ou mais , Ecocardiografia Tridimensional , Próteses Valvulares Cardíacas , Humanos , MasculinoRESUMO
We present two cases of Amplatzer® device deployment that exhibited long-term failure necessitating surgical correction. The first case illustrates recanalization of a ruptured Valsalva aneurysm with worsening aortic insufficiency after percutaneous repair with the Amplatzer Vascular Plugs and Amplatzer duct occluder, while the second case illustrates recanalization after deployment of the Amplatzer septal occluder in a patient with a pseudoaneursym in a bovine aorta after type I aortic dissection repair. These two cases illustrate the potential long-term complications and limitations in durability with these devices.
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Falso Aneurisma/etiologia , Falso Aneurisma/cirurgia , Aorta/cirurgia , Ruptura Aórtica/cirurgia , Insuficiência da Valva Aórtica/cirurgia , Falha de Equipamento , Dispositivo para Oclusão Septal/efeitos adversos , Seio Aórtico/cirurgia , Idoso , Dissecção Aórtica/cirurgia , Insuficiência da Valva Aórtica/etiologia , Bioprótese , Implante de Prótese Vascular , Humanos , Masculino , Pessoa de Meia-Idade , Reoperação , Fatores de TempoRESUMO
Extracorporeal membrane oxygenation (ECMO) has proven to be an invaluable method of cardiopulmonary support in cases of severe cardiogenic shock. In an emergency, femoral artery and vein cannulation is the easiest and quickest access to initiate support. Often, with peripheral venous-arterial ECMO (VA ECMO), an inadequate reduction in left ventricular end-diastolic pressure (LVEDP) is present secondary to increased afterload from retrograde flow, inadequate RV drainage or persistent bronchial circulation. Elevated LVEDP has been known to be associated with poor myocardial recovery, LV thrombus formation and significant pulmonary edema. A cannulation strategy to achieve partial ventricular unloading is of paramount importance when considering ECMO support following cardiogenic shock to increase the potential for myocardial recovery. We present a novel case of emergent peripheral VA ECMO cannulation with a trans-diaphragmatic left ventricular (LV) vent in a 61-year-old, 79 kg male with end-stage liver disease and hepatitis B cirrhosis who suffered cardiac arrest during orthotopic liver transplantation.
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Derivação Arteriovenosa Cirúrgica , Doença Hepática Terminal/cirurgia , Oxigenação por Membrana Extracorpórea , Transplante de Fígado/efeitos adversos , Choque Cardiogênico/terapia , Remodelação Ventricular , Doença Hepática Terminal/complicações , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Choque Cardiogênico/etiologiaRESUMO
OBJECTIVE: Outcomes after hemiarch repair for acute DeBakey Type I aortic dissection remain unfavorable, with high rates of major adverse events and negative aortic remodeling. The PERSEVERE study evaluates safety and effectiveness of the AMDS Hybrid prosthesis, a novel bare metal stent, in patients presenting with pre-operative malperfusion. METHODS: PERSEVERE is a prospective, single arm, investigational study conducted at 26 sites in the United States. Ninety-three patients underwent acute DeBakey Type I aortic dissection repair with AMDS implantation. The 30-day primary endpoints are composite rate of 4 major adverse events and rate of distal anastomotic new entry tears. The secondary endpoints include aortic remodeling. RESULTS: Clinical malperfusion was documented in 76 patients (82%), with the remaining having only radiographic malperfusion. Median follow-in 93 patients was 5.6 months. Within 30-days, there were 9 deaths (9.7%), 11 patients (11.8%) with new disabling stroke, 18 patients (19.4%) with new onset renal failure requiring ≥ 1 dialysis treatment, and no myocardial infarction. The composite rate of major adverse events (28%) was less than the reference cohort (58%). There were no distal anastomotic new entry tears. Technical success was achieved in 99% of patients. Early remodeling indicated total aortic diameter stability, true lumen expansion, and false lumen reduction in the treated aortic segment. CONCLUSIONS: Early results show significant reduction in major adverse events and distal anastomotic new entry tears, successfully meeting both primary endpoints. The technical success rate was high. AMDS can be used safely in patients with acute DeBakey type I dissection with malperfusion.
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Endovascular devices have become increasingly available, which has led to an increase in use of frozen elephant trunk stents for extended repair during type A aortic dissection. Frozen elephant trunk deployment is usually done under direct visualization of both the true and false lumen but rarely, the endograft can inadvertently end in the false lumen. This can lead to false lumen pressurization and end-organ malperfusion. Herein we describe a novel intraoperative rescue technique for misplaced frozen elephant trunk into the false lumen, easily executed in a standard operating room using transesophageal echocardiography and intravascular ultrasound guidance.
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Aneurisma da Aorta Torácica , Implante de Prótese Vascular , Procedimentos Endovasculares , Humanos , Prótese Vascular , Implante de Prótese Vascular/métodos , Aneurisma da Aorta Torácica/cirurgia , Resultado do Tratamento , Stents , Aorta Torácica/cirurgia , Procedimentos Endovasculares/métodosRESUMO
Management of rare ascending aortic complications after transcatheter aortic valve replacement (TAVR) remains a poorly defined area of knowledge. Furthermore, because most patients undergoing TAVR are at intermediate to high surgical risk, the treatment of such complications often requires endovascular approaches. Herein, we present a novel technique of endovascular ascending aorta stent graft delivery from the innominate artery for the treatment of a type A aortic dissection after self-expandable TAVR implantation, specifically addressing the landing of the aortic stent within the crown of the TAVR valve.
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Estenose da Valva Aórtica , Dissecção da Aorta Ascendente , Procedimentos Endovasculares , Substituição da Valva Aórtica Transcateter , Humanos , Substituição da Valva Aórtica Transcateter/efeitos adversos , Substituição da Valva Aórtica Transcateter/métodos , Aorta/cirurgia , Stents , Procedimentos Endovasculares/efeitos adversos , Resultado do Tratamento , Estenose da Valva Aórtica/cirurgia , Estenose da Valva Aórtica/etiologia , Valva Aórtica/cirurgia , Fatores de RiscoRESUMO
BACKGROUND: Patients with valvular heart disease require cardiopulmonary bypass and cardiac arrest. Here, we test the hypothesis that exosomal hemoglobin formed during cardiopulmonary bypass mediates acute cardiac injury in humans and in an animal model system. METHODS: Plasma exosomes were collected from arterial blood at baseline and 30 minutes after aortic cross-clamp release in 20 patients with primary mitral regurgitation and 7 with aortic stenosis. These exosomes were injected into Sprague-Dawley rats and studied at multiple times up to 30 days. Tissue was examined by hematoxylin and eosin stain, immunohistochemistry, transmission electron microscopy, and brain natriuretic peptide. RESULTS: Troponin I levels increased from 36 ± 88 ng/L to 3622 ± 3054 ng/L and correlated with exosome hemoglobin content (Spearman r = 0.7136, < .0001, n = 24). Injection of exosomes isolated 30 minutes after cross-clamp release into Sprague-Dawley rats resulted in cardiomyocyte myofibrillar loss at 3 days. Transmission electron microscopy demonstrated accumulation of electron dense particles of ferritin within cardiomyocytes, in the interstitial space, and within exosomes. At 21 days after injection, there was myofibrillar and myosin breakdown, interstitial fibrosis, elevated brain natriuretic peptide, and left ventricle diastolic dysfunction measured by echocardiography/Doppler. Pericardial fluid exosomal hemoglobin content is fourfold higher than simultaneous plasma exosome hemoglobin, suggesting a cardiac source of exosomal hemoglobin. CONCLUSIONS: Red blood cell and cardiac-derived exosomal hemoglobin may be involved in myocardial injury during cardiopulmonary bypass in patients with valvular heart disease.
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Exossomos , Traumatismos Cardíacos , Doenças das Valvas Cardíacas , Humanos , Ratos , Animais , Ratos Sprague-Dawley , Peptídeo Natriurético Encefálico , Miócitos Cardíacos , Modelos Animais de DoençasRESUMO
OBJECTIVE: Implantation of a transcatheter valve-in-mitral annular calcification (ViMAC) has emerged as an alternative to traditional surgical mitral valve (MV) replacement. Previous studies evaluating ViMAC aggregated transseptal, transapical, and transatrial forms of the procedure, leaving uncertainty about each technique's advantages and disadvantages. Thus, we sought to evaluate clinical outcomes specifically for transatrial ViMAC from the largest multicenter registry to-date. METHODS: Patients with symptomatic MV dysfunction and severe MAC who underwent ViMAC were enrolled from 12 centers across the United States and Europe. Clinical characteristics, procedural details, and clinical outcomes were abstracted from the electronic record. The primary end point was all-cause mortality. RESULTS: We analyzed 126 patients who underwent ViMAC (median age 76 years [interquartile range {IQR}, 70-82 years], 28.6% female, median Society of Thoracic Surgeons score 6.8% [IQR, 4.0-11.4], and median follow-up 89 days [IQR, 16-383.5]). Sixty-one (48.4%) had isolated mitral stenosis, 25 (19.8%) had isolated mitral regurgitation (MR), and 40 (31.7%) had mixed MV disease. Technical success was achieved in 119 (94.4%) patients. Thirty (23.8%) patients underwent concurrent septal myectomy, and 8 (6.3%) patients experienced left ventricular outflow tract obstruction (7/8 did not undergo myectomy). Five (4.2%) patients of 118 with postprocedure echocardiograms had greater than mild paravalvular leak. Thirty-day and 1-year all-cause mortality occurred in 16 and 33 patients, respectively. In multivariable models, moderate or greater MR at baseline was associated with increased risk of 1-year mortality (hazard ratio, 2.31; 95% confidence interval, 1.07-4.99, P = .03). CONCLUSIONS: Transatrial ViMAC is safe and feasible in this selected, male-predominant cohort. Patients with significant MR may derive less benefit from ViMAC than patients with mitral stenosis only.
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In the present case report, we have described concomitant, rapidly expanding, abdominal and thoracic mycotic aortic pseudoaneurysms in a patient who had originally presented for right arm superficial thrombophlebitis and a right-hand abscess in the presence of methicillin sensitive Staphylococcus aureus bacteremia. Within 12 days, the patient had developed a rapidly expanding paravisceral mycotic abdominal aortic pseudoaneurysm that required open surgical repair. After the initial operation, she developed a thoracic mycotic aortic aneurysm that ultimately required open surgical repair. Her postoperative course after the initial operation was complicated by decompensated hepatitis C cirrhosis that required convalescence before repair of the thoracic aneurysm. Follow-up data were available for ≤10 months after the initial operation.
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Despite advances in detection and treatment, acute traumatic aortic injury (ATAI) is associated with high rates of morbidity and mortality. Both physical and hemodynamic forces have been postulated as mechanisms of aortic injury during a traumatic event. For patients who survive the initial injury, rapid detection is critical for diagnosis and procedural planning, which requires a thorough knowledge of both its clinical presentation and the available diagnostic imaging modalities. Radiography, computed tomography (CT), and magnetic resonance imaging (MRI) can each have a role in the diagnosis of ATAI. After stabilization of the patient, the management of ATAI is guided by the severity of injury. Appropriately selected patients with low grade injuries may be managed non-operatively. When treatment is required, there are both open surgical and endovascular options. In current practice, endovascular approaches with stent-graft placement are preferred due to their high clinical success and low rates of complications. Complications from endograft placement can include: endoleak, endograft collapse, infection, endograft failure, and endograft migration. Open surgical repair is now reserved for patients with unfavorable anatomy for endovascular therapies. This review provides a comprehensive overview of ATAI including its epidemiology and demographics, mechanisms of injury, clinical and radiographic diagnosis, treatment options, and post-therapeutic follow-up.
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An 81-year-old female with severe aortic valve stenosis underwent TAVR using the right femoral approach. Shortly after successful deployment of a 29 mm Evolut Pro valve (Medtronic), the patient became hypotensive and ST depressions were noted on telemetry. Selective left coronary angiography revealed coronary embolism to the left anterior descending/ first diagonal bifurcation. Mechanical aspiration was performed and a small piece of debris was retrieved. We believe it was a broken-off fragment of the femoral artery that migrated on the tip of the TAVR delivery system. This is the first reported case of such a complication.
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Estenose da Valva Aórtica , Próteses Valvulares Cardíacas , Substituição da Valva Aórtica Transcateter , Animais , Valva Aórtica/cirurgia , Estenose da Valva Aórtica/diagnóstico , Estenose da Valva Aórtica/cirurgia , Catéteres , Gatos , Feminino , Próteses Valvulares Cardíacas/efeitos adversos , Humanos , Índigo Carmim , Desenho de Prótese , Sucção , Substituição da Valva Aórtica Transcateter/efeitos adversos , Resultado do TratamentoRESUMO
Endovascular stenting of the ascending aorta has been described for various aortic pathologies, including type A dissection in patients who are prohibitive risk for open surgery. Endovascular treatment of ascending aortic pathology poses unique anatomic and technical challenges related to aortic morphology. Herein, we present a novel technique of endovascular ascending stent graft delivery from a transfemoral approach for treatment of an acute type A dissection, utilizing a snare-guided deployment technique to facilitate favorable device deployment.
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Aorta/cirurgia , Aneurisma da Aorta Torácica/cirurgia , Dissecção Aórtica/cirurgia , Implante de Prótese Vascular/métodos , Prótese Vascular , Procedimentos Endovasculares/métodos , Doença Aguda , Idoso , Dissecção Aórtica/diagnóstico , Aorta/diagnóstico por imagem , Aneurisma da Aorta Torácica/diagnóstico , Aortografia/métodos , Feminino , Humanos , Microcirurgia/métodos , Desenho de Prótese , StentsRESUMO
Background Suprasternal access is an alternative access strategy for transcatheter aortic valve replacement (TAVR) where the innominate artery is cannulated from an incision above the sternal notch. To date, suprasternal access has never been compared with transfemoral TAVR. Thus, we sought to assess safety, feasibility, and early clinical outcomes between suprasternal and transfemoral access for patients undergoing TAVR. Methods and Results We evaluated patients from 2 institutional prospective, observational registries containing 1348 patients. Patients were selected in a 2:1 ratio (transfemoral:suprasternal) on the basis of propensity score matching. The primary outcome was in-hospital mortality, and secondary outcomes included the incidence of ischemic stroke, major bleeding, vascular injury, left bundle-branch block, and permanent pacemaker implantation at 30-day follow-up. Propensity score matching identified 89 patients undergoing suprasternal TAVR and 159 patients undergoing transfemoral TAVR suitable for analysis. There was no significant difference between suprasternal TAVR and transfemoral TAVR with respect to in-hospital mortality (1.1% versus 0.6%; odds ratio [OR], 1.80; 95% CI, 0.11-29.06; P=0.680). No patients in either cohort suffered an ischemic stroke. The incidence of major bleeding (2.2% versus 2.5%; OR, 0.89; 95% CI, 0.16-4.96; P=0.895) and vascular injury (1.1% versus 1.9%; OR, 0.59; 95% CI, 0.06-5.77; P=0.651) did not differ significantly. The frequency of left bundle-branch block (9.4% versus 15.8%; OR, 0.56; 95% CI, 0.24-1.30; P=0.177) and permanent pacemaker implantation (11.2% versus 5.9%; OR, 2.01; 95% CI, 0.75-5.45; P=0.169) were not statistically significantly different. Conclusions Suprasternal TAVR was safe and achieved promising short-term clinical outcomes when compared with transfemoral TAVR. Future studies seeking to identify the optimal alternative access site should evaluate suprasternal TAVR access alongside other substitutes for transfemoral TAVR.