Increased Mortality in Octogenarians Undergoing Endovascular Aortic Aneurysm Repair for Smaller Aneurysms Warrants Caution.

BACKGROUND: Geriatric patients constitute a growing portion of the general population, with particular increase in the prevalence of octogenarians. The incidence and prevalence of abdominal aortic aneurysms (AAAs) have been clearly shown to be associated with advancing age. The effect of advanced age in outcomes from endovascular aneurysm repair (EVAR) is unclear. We study the effect of advanced age, as an independent risk factor for mortality in octogenarian geriatric patients (OGPs) compared to nonoctogenarian geriatric patients (NOGPs) undergoing EVAR. METHODS: The 2011-2017 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Procedure-Targeted Vascular database was queried for geriatric patients (>65 years) undergoing EVAR for symptomatic and asymptomatic indications. A multivariable logistic regression analysis was performed comparing outcomes between OGPs and NOGPs. RESULTS: Of the 10,490 geriatric patients who underwent EVAR, 7,508 (71.6%) were NOGPs and 2,982 (28.4%) were OGPs. Octogenarians were more often female (82.3% vs. 76.7%). In comparison to NOGPs, fewer OGPs were treated for AAA <5.5 cm (46.7% vs. 54.9%, P < 0.001) and AAA <5.0 cm (19.2% vs. 24.0%, P < 0.001). Nearly 90% of male and over 80% of female NOGPs and OGPs treated for AAA <5.0 cm were asymptomatic. Octogenarian geriatric patients (OGPs) had less dyspnea (15.3% vs. 17.3%, P = 0.01), chronic obstructive pulmonary disease (16.1% vs. 20.5%, P < 0.001), diabetes (12.7% vs. 17.8%, P < 0.001), and smoking (13.2% vs. 36.3%, P < 0.001) compared to NOGPs. Octogenarian geriatric patients (OGPs) were found to have a greater length of stay (2 days vs. 1 day, P < 0.001), as well as rate of mortality (3.4% vs. 1.7%, P < 0.001). Both symptomatic and asymptomatic OGPs had a higher rate of mortality than their NOGP counterparts (symptomatic 16% vs. 9.5%, P < 0.001; asymptomatic 1.3% vs. 0.5%, P < 0.001). Multivariate logistic regression analysis showed OGPs to have increased overall associated risk of mortality compared to NOGPs (odds ratio (OR) 1.88, confidence interval (CI) 1.39-2.54, P < 0.001), as well as in the symptomatic (OR 1.54, CI 1.06-2.23, P < 0.001) and asymptomatic cohorts (OR 2.66, CI 1.59-4.45, P < 0.001). CONCLUSIONS: Octogenarian geriatric patients (OGPs) accounted for over a quarter of geriatric patients undergoing EVAR. This elderly group was associated with an increased rate and risk of mortality compared to NOGPs, even when controlling for known risk factors for mortality. Given this increased risk of mortality in OGPs undergoing EVAR, elective treatment of AAAs in this advanced age group should be performed with caution, particularly in those with diameters in which the risk of rupture may not warrant repair.

Intentional Bilateral Renal Artery Coverage During Ruptured Endovascular Paraanastomotic Pseudoaneurysm Repair.

The development of a paraanastomotic pseudoaneurysm is a serious complication after open prosthetic reconstruction of the aorta for occlusive or aneurysmal disease. Open repair of these lesions has previously been associated with high rates of morbidity and mortality. Endovascular repair may provide suitable treatment for proximal paraanastomotic aortic bypass graft pseudoaneurysms in patients who are poor candidates for open surgery. Bilateral renal artery coverage may be necessary to achieve adequate fixation and seal during life-threatening emergency cases of pseudoaneurysm rupture. Due to the infrequency of reported cases, the consequences of bilateral renal artery occlusion during these complex procedures are poorly understood. We present a case of a proximal paraanastomotic aortobifemoral bypass pseudoaneurysm rupture that was managed using endovascular repair with intentional coverage of both renal arteries. We also review the contemporary literature on endovascular management of paraanastomotic aneurysms and discuss the role of bilateral renal artery coverage in treating select patients with complex ruptured aortic pathology.

Iatrogenic Arteriovenous Fistula Formation after Endovenous Laser Treatment Resulting in High-output Cardiac Failure: A Case Report and Review of the Literature.

Formation of a clinically significant iatrogenic arteriovenous fistula after endovenous laser treatment of the great saphenous vein is an extremely rare complication. Because of the infrequency of reported cases, there is no clear consensus on how to best manage this complication. We present a unique case of an iatrogenic high-output superficial femoral artery-common femoral vein fistula resulting in right heart failure and a distal deep vein thrombosis. Deployment of a covered arterial stent graft resulted in resolution of the arteriovenous fistula and high-output cardiac state. Clinically significant arteriovenous fistulas resulting from inadvertent vessel injury during endovenous laser treatment appear to be amenable to percutaneous endovascular interventions. During these challenging endovascular cases, intravascular ultrasonography can be used to help delineate the morphology of the fistula tract and obtain vessel measurements to ensure accurate endoprosthesis sizing and placement.

Unique Case of Recurrent Pelvic Congestion Syndrome Treated with Median Sacral Vein Embolization.

BACKGROUND: Pelvic congestion syndrome (PCS) is defined as noncyclical pelvic pain or discomfort caused by dilated parauterine, paraovarian, and vaginal veins. PCS is typically characterized by ovarian venous incompetence that may be due to pelvic venous valvular insufficiency, hormonal factors, or mechanical venous obstruction. METHODS: We describe a case of a 38-year-old multiparous female with a history of pelvic pressure, vulvar varices, and dyspareunia. She underwent left gonadal vein coil embolization in 2014 for PCS that lead to symptomatic relief of her pain. Four years later, the patient returned for recurrent symptoms. Magnetic resonance venogram demonstrated dilated pelvic varices. The previously embolized left gonadal vein remained thrombosed, and there was no evidence of right gonadal vein insufficiency. However, catheter-based venography revealed a large, dilated, and incompetent median sacral vein. RESULTS: Pelvic venography demonstrated left gonadal vein embolization without any evidence of reflux. The right gonadal vein was also nondilated without reflux. Internal iliac venography showed large cross-pelvic collaterals and retrograde flow via a large, dilated median sacral vein. Coil embolization of the median sacral vein resulted in a dramatic reduction of pelvic venous reflux and resolution of symptoms. CONCLUSIONS: Recurrence of PCS can occur after ovarian vein embolization through other tributaries in the venous network. The median sacral vein is a rare cause of PCS. We present an interesting case of a successfully treated recurrent PCS with coil embolization of an incompetent median sacral vein.

Utilization of Carbon Dioxide Angiography and Percutaneous Balloon Angioplasty for Treatment of Transplant Renal Artery Stenosis.

BACKGROUND: Transplant renal artery stenosis (TRAS) may lead to graft dysfunction and failure. Progressive deterioration of renal allograft function may be exacerbated by contrast-induced nephrotoxicity during iodine contrast administration for renovascular imaging of allografts. We present our institutional experience of endovascular management for TRAS using CO2 digital subtraction angiography (CO2-DSA) and balloon angioplasty to manage failing renal transplants. METHODS: Four patients with renal allografts from March 2017-May 2018 were referred for graft dysfunction and pending renal transplant failure. Indications for referral included refractory hypertension, decreasing renal functioning, and elevated renovascular systolic velocities. RESULTS: Median age of the four patients was 41.5 years (22-60 years). There were two male and female patients. Chronic hypertension and type 2 diabetes mellitus were the most common comorbidities. An average total of 75 mL of CO2 was used, supplemented with 17.4 mL of iodinated contrast. All patients had improvements in renal function following intervention with a mean decrease in systolic and diastolic blood pressure of 25.8% and 21.4%, respectively. We also observed a mean decrease of BUN by 13.6% and creatinine by 37.4%. Additionally, eGFR increased by 37.7%. All allografts survived after surgery, and only one patient required repeat angioplasty for recurrence. CONCLUSIONS: CO2-DSA with balloon angioplasty can be successfully utilized to salvage deteriorating kidney allograft function in patients with TRAS.

In Vivo Assessment of Ascending and Arch Aortic Compliance.

BACKGROUND: Dynamic compliance (Cd) of the adult thoracic ascending and arch aorta has had limited in vivo evaluation in patients with aortic disease. This study evaluates aortic compliance using intravascular ultrasound (IVUS) across a range of thoracic aortic diseases. METHODS: Seventy-nine patients undergoing thoracic aortic endovascular procedures had Cd measurements of the ascending aorta proximal to the origin of the brachiocephalic trunk and distal to the origin of the left common carotid artery using IVUS before endograft deployment. Cd was calculated for each segment using the following equation, Cd = ΔD/(D • ΔP) where ΔD = change in aortic diameter, D = diameter in diastole, and ΔP = pulse pressure. RESULTS: Mean Cd of the ascending aorta in all patients (18.4%/mm Hg) and aortic arch (16.5 %/100 mm Hg) did not differ significantly. Compliance was significantly lower in patients being treated for thoracic aortic aneurysm and penetrating ulcer than in patients with traumatic rupture, acute and chronic dissection (P = 0.009). Compliance was significantly higher in patients with aortic transection compared with thoracic aneurysm or penetrating ulcer (P = 0.001). Compliance decreased with age by 0.44 ± 0.06 (P = 0.001) per year in the ascending aorta and 0.41 ± 0.05 (P = 0.001) per year in the aortic arch. Compliance did not increase with diameter when adjusted for age (P = 0.65). Compliance measured in the ascending aorta in 7 patients after descending thoracic aortic endograft repair decreased to 12.6%/100 mm Hg, although not significant (P = 0.18). CONCLUSIONS: Ascending and aortic arch compliance is significantly higher than reported for peripheral vessels. Thoracic aortic compliance decreases with age and is not related to aortic diameter. The results of the present study are important when considering the development of endoprosthesis devices and long-term effects on the thoracic aorta.

National Trends of Thoracic Endovascular Aortic Repair versus Open Thoracic Aortic Repair in Pediatric Blunt Thoracic Aortic Injury.

BACKGROUND: Blunt thoracic aortic injury (BTAI) occurs in <1% of all trauma admissions. Thoracic endovascular aortic repair (TEVAR) has become the preferred treatment modality in adult patients with BTAI, but its use in pediatrics is currently not supported by device manufacturers and lacks United States Food and Drug Administration approval. We hypothesized that there would also be an increased use of TEVAR in the pediatric population, thus conferring a lower risk of mortality compared with open thoracic aortic repair (OTAR). METHODS: The National Trauma Data Bank (2007-2015) was queried for patients ≤17 years with BTAI. The primary outcomes were the incidences of TEVAR and OTAR. Secondary outcome was risk of mortality in those undergoing intervention. A multivariable logistic regression model was used to determine the risk of mortality in OTAR versus TEVAR. RESULTS: We identified 650 pediatric BTAI patients with 159 (24.5%) undergoing intervention. Of these, 124 underwent TEVAR (78.0%) and 35 (22.0%) underwent OTAR. The rate of TEVAR steadily increased from 2007 to 2015 (15.4% vs. 27.1%, P < 0.001). Patients receiving OTAR and TEVAR had a similar injury severity score and rate of hypotension on admission (P > 0.05). Compared with OTAR, TEVAR patients had a higher rate of any traumatic brain injury (TBI) (63.7% vs. 37.1%, P = 0.005) and shorter hospital and intensive care unit length of stay (LOS) (16.4 vs. 21.4 days, P = 0.02; 10.1 vs. 12.2 days, P = 0.01). TEVAR and OTAR, even when stratified by ≤14 years and 15-17 years, had no difference in risk for mortality (odds ratio 1.20, confidence interval 0.29-5.01, P = 0.80). CONCLUSIONS: The rate of TEVAR in pediatric BTAI nearly doubled from 2007 to 2015. Compared with OTAR, TEVAR was associated with a shorter hospital LOS despite a higher rate of TBI. There was no difference in risk for mortality between TEVAR and OTAR. Longitudinal studies to determine the long-term efficacy and complication rates, including reintervention, development of endoleak, and/or need for further operations, are needed as this technology is being rapidly adopted for pediatric trauma patients.

Locoregional Anesthesia Offers Improved Outcomes after Endovascular Repair of Ruptured Abdominal Aortic Aneurysms.

BACKGROUND: General anesthesia (GA) and locoregional anesthesia (LA) are two anesthetic options for endovascular repair of ruptured abdominal aortic aneurysms (REVAR). Studies on elective endovascular repair of nonruptured aneurysms have indicated that in select patients, LA may provide improved outcomes compared with GA. We aimed to examine the 30-day outcomes in patients undergoing REVAR using GA and LA in a contemporary nationwide cohort of patients presenting with ruptured abdominal aortic aneurysms. METHODS: Patients who underwent REVAR using GA and LA from January 2011 through December 2015, inclusively, were studied in the American College of Surgeons' National Surgical Quality Improvement Program (ACS NSQIP)-targeted EVAR database. Univariate and multivariate analyses were used to compare preoperative demographics, operation-specific variables, and 30-day postoperative outcomes between the two groups. RESULTS: Six-hundred ninety patients were identified to have undergone REVAR from 2011 to 2015, of which 12.5% (86) were performed under LA. For the entire cohort, the mean age was 74.3 years, and 80% were male. Mean aneurysm size was 7.6 cm and did not differ between the two anesthetic groups. Major comorbidities were similar between both groups, except a slightly higher rate of congestive heart failure in the LA group (7.0% vs. 2.5%, P = 0.02). Proximal or distal aneurysm extent also did not differ between the two groups. There was a significantly higher rate of bilateral percutaneous access in the LA group (59.3% vs. 25.2%, P < 0.01). REVAR under LA had shorter mean operative time (132 vs. 166 min, P < 0.01) and lower rate of concomitant lower extremity revascularization (2.3% vs. 10.6%, P < 0.01). There were no differences in need for perioperative transfusion or any other adjunctive procedures. Ultimately, 30-day mortality was significantly lower in the LA group (16.3% vs. 25.2%, P < 0.01). This difference was more pronounced in the subgroup of patients with hemodynamic instability (15.4% vs. 39.4%, P < 0.01). The LA group also demonstrated significantly shorter intensive care unit (ICU) length of stay (3.0 vs. 5.0 days, P = 0.01) and low rates of postoperative pneumonia (3.5% vs. 10.9%, P = 0.03). After adjustment for demographics, comorbid conditions, hypotensive status, and aneurysm characteristics, there was a two-fold higher mortality in patients undergoing REVAR using GA versus LA, with a four-fold increase in the hemodynamically unstable cohort. CONCLUSIONS: The ACS NSQIP-targeted EVAR database shows that LA is used in only 12.5% of patients undergoing REVAR in this nationwide cohort. This rate does not change when examining the subset of patients who are hemodynamically unstable. Other benefits include shorter ICU lengths of stay and lower rates of pneumonia. These data suggest that LA should be considered in patients undergoing REVAR, regardless of hemodynamic instability.

National Trends of Thoracic Endovascular Aortic Repair Versus Open Repair in Blunt Thoracic Aortic Injury.

BACKGROUND: Blunt thoracic aortic injury (BTAI) occurs in <1% of all trauma admissions. Considering the advent of multiple thoracic endovascular aortic repair (TEVAR) devices over the past decade, improved outcomes of TEVAR supported in the literature, rapid diagnosis, and improved preoperative planning of BTAI using computed tomography imaging, we hypothesized that the national incidence of TEVAR in BTAI has increased while open repair has decreased. In addition, we hypothesized that the mortality risk in BTAI patients undergoing TEVAR would be lower than open repair. METHODS: This was a retrospective analysis of the National Trauma Data Bank from 2007 to 2015. The primary end points of interest included the incidence of TEVAR and open repair, as well as mortality in BTAI patients undergoing intervention. Covariates were included in a multivariable analysis to determine risk for mortality in BTAI patients undergoing open repair versus TEVAR. RESULTS: We identified 3,628 BTAI patients undergoing intervention. Of these, 3,226 underwent TEVAR (87.9%), and 445 (12.1%) underwent open repair. Compared with open repair, TEVAR had a shorter mean length of stay (LOS) (19.8 vs. 21.3 days, P < 0.05) and lower rates of acute kidney injury (AKI) (5.6% vs. 9.0%, P < 0.05) and mortality (8.8% vs. 12.8%, P < 0.05). Open repair had greater risk for mortality than TEVAR (odds ratio = 1.63, confidence intervals = 1.19-2.23, P < 0.05). CONCLUSIONS: The rate of open repair decreased from 7.4% in 2007 to 1.9% in 2015, whereas TEVAR increased from 12.1 to 25.7% during the same time period. We confirmed previous findings that endovascular repair is associated with decreased mortality, LOS, and major complications, including AKI. Future investigations should focus on identifying the ideal patient candidate for TEVAR and elucidate precise indications for TEVAR in BTAI.

Feasibility of endovascular repair of ascending aortic pathologies as part of an FDA-approved physician-sponsored investigational device exemption.

OBJECTIVE: Endovascular treatment of ascending aortic lesions has been reported, but to date, no FDA-approved studies have been conducted to define feasibility and the use of endografts in this particular location or to analyze the critical factors involved. METHODS: Patients were consented for entry into an FDA-approved physician-sponsored investigational device exemption study to investigate the outcome of those with ascending aortic pathologies. These patients were suitable according to the instructions for use for endovascular repair with a Valiant Captivia (Medtronic, Inc, Minneapolis, Minn) thoracic stent graft, a device designed specifically for deployment in the ascending aorta. All patients had sequential gated-cardiac computed tomography scans, with data being entered into the VQI Complex TEVAR software (West Lebanon, NH). All procedures were performed in a hybrid room, with the capability to convert to an open repair to ensure maximal patient protection. The first five patients constituted the feasibility study, with continued enrollment based on initial results and submission of an annual report to the FDA. RESULTS: Thirty-nine patients were screened, and six patients were entered into the physician-sponsored investigational device exemption study. Although there was no early mortality, there was one late death. All patients had sequential computed tomographies and cardiac echocardiograms with no evidence of migration, one type 1a endoleak, one postoperative stroke, and regression of the aortic lesions in the excluded aortic segment. CONCLUSIONS: In this feasibility study, the preliminary evaluation of endovascular treatment for ascending aortic pathologies demonstrates uniform accuracy of deployment and secure fixation up to 17.5 months of follow-up. There is positive remodeling of the excluded aortic segments similar to surveillance studies involving the descending aorta.

Results of a multicenter, prospective trial of thoracic endovascular aortic repair for blunt thoracic aortic injury (RESCUE trial).

OBJECTIVE: To evaluate the early outcomes of patients undergoing thoracic endovascular aortic repair for blunt thoracic aortic injuries. METHODS: A prospective, nonrandomized, multicenter trial using the Medtronic Valiant Captivia stent graft was conducted at 20 sites in North America. Fifty patients with blunt thoracic aortic injuries were enrolled between April 2010 and January 2012 and will be followed for 5 years. The injuries were classified into categories (grades I-IV) based on severity: intimal tear, intramural hematoma, pseudoaneurysm, or rupture. The primary end point was 30-day all-cause mortality. Secondary end points were adverse events occurring within 30 days that were related to the procedure, device or aorta, and aortic-related mortality. Technical success was measured as successful device delivery and deployment. RESULTS: Seventy-six percent (38/50) of patients were male with mean age of 41 ± 17 years. Fifty-one Medtronic Valiant Captivia thoracic stent grafts and a single Talent thoracic stent graft were implanted within a median of 1.0 days following injury (mean, 1.8 ± 4.0 days). Seventy percent (35/50) of aortic injuries were grade III or higher, including one patient with free rupture. Mean injury severity score was 38 ± 14. Fifty-four percent of stent grafts were ≤26 mm (28/52). The left subclavian artery was completely covered in 40% of patients (20/50) and partially covered in 18% of patients (9/50). Four patients underwent subclavian artery revascularization: one at the time of the endograft procedure and three others after developing arm ischemia after the initial endograft procedure. Cerebral spinal fluid was drained in two patients. The median procedure time was 91 minutes, and median hospital stay was 12 days. There was 100% successful device delivery and deployment. Four (8%) patients died within 30 days. Nonfatal adverse events within 30 days that were related to the procedure, device, or aorta were experienced by 12% (6/50) of patients. No nonfatal adverse events related to the device were reported; a single death was conservatively adjudicated as device-, procedure-, and aorta-related because of insufficient information. No patient developed spinal cord injury, and there were no cerebrovascular accidents. However, one patient had an anoxic brain injury following aortic rupture. No patient underwent conversion to open repair or required an endovascular reintervention. CONCLUSIONS: Based on the early outcomes, the Medtronic Valiant Captivia stent graft appears to be a promising treatment modality for blunt thoracic aortic injuries. Long-term follow-up is necessary to substantiate the effectiveness of thoracic endovascular aortic repair in treatment of blunt thoracic aortic injuries.

Patient outcomes and thoracic aortic volume and morphologic changes following thoracic endovascular aortic repair in patients with complicated chronic type B aortic dissection.

OBJECTIVE: True and false lumen changes and patient outcomes following thoracic endovascular aortic repair (TEVAR) for patients with stable type B dissection have been described by the The Investigation of Stent Grafts in Aortic Dissection (INSTEAD) trial. However, these changes have not been described in TEVAR patients treated for complications of chronic dissection. METHODS: A single-institution study was conducted of 73 prospectively evaluated patients treated for complications of chronic type B dissection from 2002 to 2010. Spiral computed tomography reconstructions using M2S (Medical Media Systems, West Lebanon, NH) were analyzed for sequential changes in aortic volume and diameter during patient follow-up. Changes in aortic volume and diameter were tabulated as a percent change from preoperative values. Patient outcomes were determined by sequential evaluations postprocedure. RESULTS: TEVAR was successfully performed in 72 out of the 73 patients (99%). Indications for intervention were aortic enlargement (n = 62), failure of medical management (n = 7), and perforation (n = 4). The 30-day all-cause mortality rate was 14%; events were due to retrograde dissection (n = 4), cardiac-related (n = 4), and rupture (n = 2). Eleven out of the 72 patients (15%) required a secondary procedure for endoleak (n = 7) and persistent distal perfusion of the false lumen (n = 4). Mean percentage expansion of the thoracic true lumen was noted during the follow-up period: 38%, 46%, 71%, and 114% at 1-, 3-, 6-, and 12-month follow-up, respectively. Concomitant regression of the thoracic false lumen of -65%, -68%, -84%, and -84% was observed at the same intervals, respectively. Patients with an initial extension of the thoracic dissection into the infrarenal aorta (n = 46) had an increase in mean percentage change of aortic diameter and volume to 21% and 17% at 1 year, respectively. By contrast, in the patient group without infrarenal dissection (n = 14), the infrarenal aortic diameter and volume remained relatively unchanged at 3% and -0.9%, respectively, at 1-year postintervention. CONCLUSIONS: TEVAR is a potential treatment option for patients experiencing complications of chronic type B dissection. During follow-up, there is a predictable expansion of the thoracic true lumen and regression of the thoracic false lumen. These findings correlate with those of the INSTEAD trial, which demonstrated false lumen regression and true lumen expansion in a cohort of patients with stable type B dissection. However, many patients with extension of thoracic dissection into the infrarenal aorta demonstrate continued aortic dilation and, on occasion, the need for secondary intervention for persistent distal perfusion. Further analysis is needed in this subgroup of patients so as to better determine potential predictors and the clinical significance of post-TEVAR infrarenal expansion. Moreover, further investigations may support a role for secondary endovascular intervention in remedying persistent infrarenal aortic expansion after TEVAR for chronic dissection.

Endovascular management of acute complicated type B aortic dissection in North America.

The management of patients with complicated acute type B aortic dissection is challenging. Thoracic endovascular aortic repair has shown promising results in small series; however, using nonstandard definitions and improper inclusion criteria confounds the published results. This article reviews the techniques and outcome of patients who underwent endovascular treatment for complicated acute type B aortic dissection in North America. Primary stent grafting for treatment of complicated acute type B aortic dissection compares favorably with the surgical outcome. Thoracic aortic endovascular repair can be offered with a relatively low postoperative morbidity and mortality in experienced hands. It also appears to have a favorable outcome in mid-term follow-up. Longevity of the repair and durability of the stent grafts in the thoracic aorta are yet to be established.

Management of acute aortoiliac arterial thrombosis in patients with the novel coronavirus disease 2019: A case series and systematic review of the literature.

Objectives: Venous thrombosis has been widely described in the setting of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection; however, arterial thrombosis has rarely been reported. This study aims to assess the incidence, risk factors, interventions, and outcomes of acute aortoiliac arterial thrombosis in patients with active SARS-CoV-2 infections. Methods: We present seven SARS-CoV-2-positive patients from our institution who acutely developed thrombi in the aortoiliac arterial system (7/2020-1/2021). A systematic review of the literature on aortoiliac arterial thrombosis in patients with SARS-CoV-2 infections in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was also performed. The available data from all reported cases in the literature and at our institution were analyzed. Results: Thirty published articles and journal correspondences, including 52 patients, were reviewed and analyzed in addition to our institution's 7 cases. In total, 59 SARS-CoV-2-positive patients were found to have acute aortoiliac thrombosis. The abdominal aorta was the most frequent location for the development of a thrombus. Baseline demographics and medical comorbidities were not significantly different between the symptomatic and asymptomatic cohorts. Seventy-one percent of patients were symptomatic (lower limb ischemia: 75.0%, renal infarction: 20.0%, stroke: 12.5%, mesenteric ischemia: 10.0%). All patients with thrombus involving the ascending aorta, aortic bifurcation, or iliac artery developed thromboembolic or ischemic complications. All patients received systemic anticoagulation. Fifty-three percent of all patients were managed medically. Ninety-four percent of the asymptomatic patients were managed medically. One asymptomatic patient underwent endovascular aspiration of a mobile thrombus. Three (23.1%) deaths occurred in the asymptomatic cohort from hypoxic respiratory failure. Fourteen (36.8%) deaths occurred in the symptomatic cohort. The in-hospital mortality rate was 33.3% overall and 43.8% for patients with thrombi involving more than one aortoiliac segment. Conclusions: The presence of thrombi in the aortoiliac arterial system appears to be a poor prognostic indicator for patients with active SARS-CoV-2 infections. Medical management of patients with asymptomatic aortoiliac thrombi may be considered. The presence of thrombi involving the ascending aorta, aortic bifurcation, or iliac artery may warrant consideration for operative intervention due to the risk for thromboembolic or ischemic complications. Further study is needed to fully delineate the risk factors, optimal treatment, and outcomes of arterial thrombosis in the setting of SARS-CoV-2 infection.

Aortic remodeling, volumetric analysis, and clinical outcomes of endoluminal exclusion of acute complicated type B thoracic aortic dissections.

OBJECTIVE: Structural changes within the aorta after thoracic endovascular aortic repair (TEVAR) for acute complicated type B thoracic aortic dissections (ABAD) remain unknown. This study reviewed and analyzed morphologic changes, volumetric data, and clinical outcomes of patients with ABAD. METHODS: Forty-one consecutive patients with ABAD, all with the volumetric analysis of aortic luminal changes and ≥1 year of follow-up, were treated as a part of a single-center U.S. Food and Drug Administration (FDA)-approved investigational device exemption (IDE) trial from 2002 to 2009. Indications were malperfusion in 17, rupture in 12, chest pain in 6, acute enlargement in 4, and uncontrolled hypertension in 2. Duration of symptoms was ≤14 days. Three-dimensional M2S computed tomography reconstructions (Medical MetRx Solutions, West Lebanon, NH) were analyzed for aortic volume and diameter changes, regression of the false lumen, and expansion of the true lumen. RESULTS: Emergent surgery was required in 17 (42%) patients, excluding one death at induction. Procedural success rate was 92.5%. The 30-day mortality was 4.9% for malperfusion, 4.9% for rupture, and 0% for all others, with late mortality of 0%, 9.8%, and 7.3%, respectively. Mean follow-up was 12.4 months. Permanent stroke and paraplegia rates were 4.9% (n = 2) and 0%. Ten of 12 secondary interventions were performed for 6 proximal endoleaks, 1 distal cuff endoleak, and 3 distal reperfusions. For the 33 patients without endoleaks, the true lumen volume increased by 29% at 1 month, 51% at 1 year, and 80% at 5 years. Volume regression of the false lumen was 69%, 76%, and 86%, respectively. The true lumen volume did not change at 1 month or 1 year in the endoleak group (n = 7) but increased 50% at 2 years after secondary intervention. A 10% reduction of abdominal aortic volume distal to endograft occurred over 5 years in the absence of endoleaks. CONCLUSIONS: TEVAR offers a promising solution to patients with ABAD. Aortic morphologic changes occur shortly after TEVAR and remain predictable up to 5 years with continuous expansion of the true lumen and regression of the false lumen. A lack of increase in the true lumen volume is associated with endoleaks or distal reperfusion.

Initial clinical experience with a sac-anchoring endoprosthesis for aortic aneurysm repair.

OBJECTIVE: All current aortic endografts depend on proximal and distal fixation to prevent migration. However, migration and rupture can occur, particularly in patients with aortic necks that are short or angulated, or both. We present our initial clinical experience with a new sac-anchoring endoprosthesis designed to anchor and seal the device within the aneurysm sac. METHODS: The initial worldwide experience using a new endoprosthesis for the treatment of aortic aneurysms (Nellix Endovascular, Palo Alto, Calif) was reviewed. The endoprosthesis consists of dual balloon-expandable endoframes surrounded by polymer-filled endobags designed to obliterate the aneurysm sac and maintain endograft position. Clinical results and follow-up contrast computed tomography (CT) scans at 30 days and 6 and 12 months were reviewed. RESULTS: The endograft was successfully deployed in 21 patients with infrarenal aortic aneurysms measuring 5.7 ± 0.7 cm (range, 4.3-7.4 cm). Two patients with common iliac aneurysms were treated with sac-anchoring extenders that maintained patency of the internal iliac artery. Infusion of 71 ± 37 mL of polymer (range, 19-158 mL) into the aortic endobags resulted in complete aneurysm exclusion in all patients. Mean implant time was 76 ± 35 minutes, with 33 ± 17 minutes of fluoroscopy time and 180 ± 81 mL of contrast; estimated blood loss was 174 ± 116 mL. One patient died during the postoperative period (30-day mortality, 4.8%), and one died at 10 months from non-device-related causes. During a mean follow-up of 8.7 ± 3.1 months and a median of 6.3 months, there were no late aneurysm- or device-related adverse events and no secondary procedures. CT imaging studies at 6 months and 1 year revealed no increase in aneurysm size, no device migration, and no new endoleaks. One patient had a limited proximal type I endoleak at 30 days that resolved at 60 days and remained sealed. One patient has an ongoing distal type I endoleak near the iliac bifurcation, with no change in aneurysm size at 12 months. CONCLUSION: Initial clinical experience with this novel intrasac anchoring prosthesis is promising, with successful aneurysm exclusion and good short-term results. This new device platform has the potential to address the anatomic restrictions and limitations of current endografts. Further studies with a longer follow-up time are needed.

Endovascular management of blunt aortic injury with an associated aberrant right subclavian artery: a report of three cases.

Traumatic rupture of the aorta in the rare setting of the aberrant right subclavian artery (ARSA) requires special consideration to prevent the occurrence of a devastating posterior cerebral circulation stroke. We present three cases managed by using an endovascular approach, with a discussion of important preoperative and operative issues. Three patients involved in motor vehicle collisions with multiple injuries were managed at two institutions. Computed tomography revealed transection of the aorta with incidental ARSA. All three cases were managed with a different approach. One patient did not undergo a preoperative bypass because imaging confirmed an adequate landing zone distal to the origin of the left subclavian artery. Two patients received preoperative right carotid-to-subclavian bypass for anticipated endograft coverage of both subclavian arteries to preserve single vertebral arterial flow. In one patient, an endovascular occlusion device was deployed in the ARSA before aortic endograft deployment. In the other, ARSA occlusion was performed 4 days later for a persistent type II endoleak. The patient who underwent bypass and preoperative ARSA occlusion suffered a fatal posterior circulation stroke shortly after surgery. The other two patients had no procedural complications and have not required any reinterventions at follow-up after 2 and 5 years. One patient is still undergoing rehabilitation after 5 years of follow-up for traumatic brain injury unrelated to the endograft repair. Although the incidence of ARSA is very low, preoperative imaging and assessment of cerebral blood flow are critical to prevent a perioperative stroke. Revascularization, if required to achieve a secure proximal landing zone, must be performed before endograft deployment. Bilateral subclavian revascularization is indicated if anomalies of the cerebral circulation are present.

Distribution of intimomedial tears in patients with type B aortic dissection.

OBJECTIVE: Thoracic endovascular aortic repair is a promising means of treating patients with complicated type B aortic dissection by excluding the intimomedial tears. This study aims to characterize the location of tears and to propose a classification of type B aortic dissections based on these findings. METHODS: Advanced protocols in computed tomography scans of patients with type B aortic dissection were used to identify the size and location of intimomedial tears in relation to the origin of the left subclavian artery. Aortic imaging details in 72 un-operated patients were used as a reference standard. From 1999 to 2005, 44 patients underwent primary endovascular treatment for complications of type B aortic dissection. RESULTS: Each patient had an average of 2.8 +/- 2.11 intimomedial tears. The median intimomedial tear surface area was 0.63 cm(2). The presence of >or=3 or >or=5 intimomedial tears in the descending thoracic aorta did not correlate with aortic branch malperfusion (P > .05). Thirteen of 26 (50%) patients with a tear >1.9 cm(2) had aortic branch malperfusion (P = .032). Ten of 14 (71%) patients with a tear >4.86 cm(2) (mean plus one standard deviation) had aortic branch malperfusion (P = .002). The location of tears ranged from -6 mm to +459.2 mm from the left subclavian artery orifice: 80.5% (n = 99) of these tears were above the reference origin of the celiac artery. Eight of 13 patients (62%) with a tear distal to 282 mm (the orifice of the celiac artery) had aortic branch malperfusion in (P = .04). A classification for the location of intimomedial tears is proposed with potential clinical relevance to endovascular repair: type 1 has no identifiable tears; type 2 has one or more tears with no tears distal to the orifice of the celiac artery; type 3 has tears involving the branch vessels of the abdominal aorta; and type 4 has intimomedial tears distal to the aortic bifurcation. CONCLUSIONS: Characterization and location of intimomedial tears using computed tomography (CT) imaging is feasible and represents an important step in the management of type B aortic dissection. The location and surface area of tears is associated with malperfusion. Based on the proposed classification and anatomic reference data, three out of every four patients may have a favorable constellation of intimomedial tears (type 1 or 2) that would be amenable to endovascular repair and reverse aortic remodeling. The clinical correlation will be established in upcoming studies.

Central venous catheter placement leading to an emergent paramedian sternotomy: a case report.

Perioperative cardiac tamponade during central venous catheter placement is rare. We present a case of tamponade from pulmonary artery injury during dialysis catheter placement resulting in complicated sternotomy and hospital course. A 52-year-old female experienced intraoperative hypotension, rapidly identified as tamponade, that was treated with an emergent paramedian sternotomy. Patient experienced postdischarge dehiscence and osteomyelitis requiring multiple reoperations. This case is the first report of a deviated paramedian sternotomy performed mainly through ribs. The complications experienced outline the importance of effective multidisciplinary knowledge of best practices to stabilize tamponade pathology, mitigating morbidity and mortality.