Outcome of Endovascular and Open Treated Penetrating Aortic Ulcers.

PURPOSE: Penetrating aortic ulcer (PAU) is a rare etiology of acute aortic syndrome. Few studies exist regarding the perioperative outcome. The aim was to analyze clinical outcome and risk factors of mortality in this treatment population. METHODS: Retrospective, monocentric study from 2010 to 2021. Clinical data of endovascular or open treated PAU were analyzed. In-hospital mortality was selected as the primary study endpoint. Angio-morphologies were analyzed and risk factors for mortality were identified by using univariate analysis. RESULTS: Overall, 133 patients were identified. 29% (n=38) of patients presented symptomatically. In 64% (n=85), the PAU was localized in the thoracic aorta. On average, PAUs had a depth of 15.4±10.1 mm and a width of 17.9±9.6 mm. The patients had a median of 2 (95% confidence interval [CI]=2-3) high-risk features (HRF) as PAU depth >10 mm, PAU width >20 mm, aortic diameter >40 mm, symptomatic, intramural hematoma (IMH), pleural effusion. Significantly more HRF were observed in symptomatic patients (p=0.01). 53% (n=71) of patients were treated with thoracic endovascular aortic repair (TEVAR), 41% (n=54) by endovascular aortic repair (EVAR), and 6% (n=8) by open surgery. A hybrid procedure with cervical debranching was performed in 16% (n=21) and complex endovascular repair with fenestrated or branched endografts in 15% (n=20). Overall, complications greater than grade II according to the Clavien-Dindo classification occurred in 19% (n=25) and of the patients. In-hospital mortality manifested in 6% (n=8). Factors associated with increased mortality were the diameter of the aorta >40 mm (88% vs 39%, p=0.03), as well as symptomatic patients (63% vs 26%, p=0.04), coincident IMHs (38% vs 10%, p=0.05), and complex endovascular procedures (50% vs 50% p<0.01). Penetrating aortic ulcer width >20 mm tended to show higher mortality (75% vs 40%, p=0.06). Routine follow-up was available for 89% (n=117) for a median of 39 months (95% CI=25-42). One-year and 5-year survival were 83% and 60%, respectively, with 1 aortic pathology-related death. CONCLUSIONS: Treatment of PAU is associated with an acceptable perioperative morbidity and mortality. Risk factors associated with increased mortality are an elevated aortic diameter, the presence of IMHs, clinical symptomatology at presentation, and complex endovascular procedures.

Midterm survival after aortic repair versus conservative treatment in patients with penetrating aortic ulcer.

Background: The clinical outcomes and survival of patients with penetrating aortic ulcers (PAU) were evaluated in a tertiary care hospital, comparing those who underwent aortic repair to those treated conservatively. Patients and methods: A retrospective single-centre analysis included all patients that underwent a computed tomography angiography (CT-A) scan with the diagnosis of a PAU between January 2009 and May 2019. "PAU" was identified in 1,493 of 112,506 CT-A scan reports in 576 patients. Clinical and angiomorphological data were collected. The primary outcome was overall survival (OS), with secondary outcomes focusing on identifying risk factors for poor OS. Survival probabilities were analysed by the Kaplan-Meier method using the log-rank test. A Cox hazard model using survival as dependent variable with stepwise backward eliminations based on the likelihood ratios was employed. Results: 315 PAUs were identified in 278 patients. The prevalence in the cohort was 0.8%. The mean age of the patients was 74.4 years, and they were predominantly male (n = 208, 74.8%). The mean ulcer depth was 11.8 mm (range 2-50 mm). Out of the patients, 232 were asymptomatic (83.5%). Among 178 PAUs (56.5%), high-risk factors, such as ulcer depth >10 mm, aortic diameter >40 mm, and ulcer length >20 mm, were observed. Aortic repair was associated with a better mean OS compared to conservatively managed patients (72.6 versus 32.2 months, p = 0.001). The Cox hazard model showed that ulcer depth >1 mm was associated with poor OS (HR 0.67, p = 0.048), while aortic repair was related to a better OS (HR 4.365, p<0.013). Conclusions: Aortic repair is associated with better OS, but this finding should be interpreted with caution because of differences in age and comorbidities between the groups. Further evaluation is warranted through prospective studies with randomized groups. Further assessment for angiomorphological parameters is recommended to identify patients at increased risk for poor OS.

Radiation therapy for cancer is potentially associated with reduced growth of concomitant abdominal aortic aneurysm.

PURPOSE: Co-prevalence of abdominal aortic aneurysm (AAA) and cancer poses a unique challenge in medical care since both diseases and their respective therapies might interact. Recently, reduced AAA growth rates were observed in cancer patients that received radiation therapy (RT). The purpose of this study was to perform a fine-grained analysis of the effects of RT on AAA growth with respect to direct (infield) and out-of-field (outfield) radiation exposure, and radiation dose-dependency. METHODS: A retrospective single-center analysis identified patients with AAA, cancer, and RT. Clinical data, radiation plans, and aneurysm diameters were analyzed. The total dose of radiation to each aneurysm was computed. AAA growth under infield and outfield exposure was compared to patients with AAA and cancer that did not receive RT (no-RT control) and to an external noncancer AAA reference cohort. RESULTS: Between 2003 and 2020, a total of 38 AAA patients who had received well-documented RT for their malignancy were identified. AAA growth was considerably reduced for infield patients (n = 18) compared to outfield patients (n = 20), albeit not significantly (0.8 ± 1.0 vs. 1.3 ± 1.6 mm/year, p = 0.28). Overall, annual AAA growth in RT patients was lower compared to no-RT control patients (1.1 ± 1.5 vs. 1.8 ± 2.2 mm/year, p = 0.06) and significantly reduced compared to the reference cohort (1.1 ± 1.5 vs. 2.7 ± 2.1 mm/year, p < 0.001). The pattern of AAA growth reduction due to RT was corroborated in linear regression analyses correcting for initial AAA diameter. A further investigation with respect to dose-dependency of radiation effects on AAA growth, however, revealed no apparent association. CONCLUSION: In this study, both infield and outfield radiation exposure were associated with reduced AAA growth. This finding warrants further investigation, both in a larger scale clinical cohort and on a molecular level.

Results after intraoperative open and endovascular revascularization of acute mesenteric ischemia requiring a laparotomy.

BACKGROUND: Acute mesenteric ischemia (AMI) is a dreaded condition with a difficult diagnosis and high mortality. Due to different baseline situations, the frequently performed comparison between endovascular and open surgical treatment is interfered with selection bias. The purpose of this study was to review outcomes in AMI treatment with an open or endovascular approach in association with laparotomy and to evaluate the endovascular-first strategy in similar clinical situations. METHODS: The clinical data of 74 patients treated for AMI from 2007 to 2021 were retrospectively reviewed and compared. In-hospital mortality was appointed as the primary study endpoint. Risk factors for mortality were identified by using univariate and multivariate analysis. RESULTS: In total, 61 patients (82%) were treated open surgically (OT) and, 13 patients (18%) with an endovascular approach (ET) in combination with laparatomy. The etiology of AMI was 49% arteriosclerotic and 51% thromboembolic occlusions. The total in-hospital mortality manifested at 43% (n =32) (OT 41% vs. ET 53.8%; P=0.54). As independent risk factors for in-hospital mortality, pneumatosis intestinalis (P=0.01), increased lactate concentration (P=0.04), and ischemic intestinal sections (P=0.01) were identified. Additionally, on univariate analysis patient age, congestive heart failure (> NYHA II) and atrial fibrillation were related with higher mortality. CONCLUSIONS: Morbidity and mortality of AMI remains at a high level. Conventional open or intraoperative endovascular therapy achieved similar results in patients with indication for laparotomy. Advanced disease stage with ischemic intestinal sections at presentation and cardiovascular comorbidities were associated with adverse outcome.

Cancer, cancer treatment and aneurysmatic ascending aorta growth within a retrospective single center study.

Background: Multi-morbidity poses a substantial challenge for health care in an aging population. Recent studies did not provide evidence for general side effects of anti-cancer therapy regarding the growth rate of coincident abdominal aortic aneurysms, although it was suggested that specific therapeutic substances might accelerate growth. Aneurysm pathology, however, differs with respect to localization. Hence, we present the first ever analysis on the association of cancer and cancer therapy with growth alteration of aneurysms of the ascending aorta (AscAA). Patients and methods: A retrospective single-center identification of AscAA+cancer patients was performed in the institutional picture archiving and communication system (PACS). Included were all patients with ≥2 CT angiograms over ≥6 months and additional malignancy. Clinical data and aneurysm diameters were retrieved and analyzed for an association of cancer (stratified by tumor entity) or cancer therapy (stratified by several classes of chemotherapeutic agents and radiation therapy) with annual growth rate, respectively. Statistics included t-test, Wilcoxon test, and a linear regression model accounting for initial AscAA diameter and type of treatment. Results: From 2003 to 2021, 151 patients (median age 70 years; 85% male) with AscAA and coincident 163 malignancies were identified. Prostate (37%) and hematologic cancer (17%) were most frequent. One-hundred-eleven patients (74%) received chemotherapy and 75 patients (50%) had radiation. After exclusion of six patients with an initial AscAA diameter >55 mm, the average annual AscAA growth rate was 0.18±0.64 mm/year, with only 12 patients experiencing a growth rate >1mm/year. Neither tumor entity nor radiation or chemotherapy - alone or in combination - were significantly associated with an alteration of the annual AscAA growth rate. Likewise, a subanalysis for singular chemotherapeutic agents did not reveal a specific association with AscAA growth alteration. Conclusions: Growth rates of AscAA are low in this cohort with coincident malignancy. Cancer and/or chemotherapy or radiation are not associated with an alteration of the annual growth rate. Additional control examinations seem unnecessary.

Radiation and Chemotherapy are Associated with Altered Aortic Aneurysm Growth in Patients with Cancer: Impact of Synchronous Cancer and Aortic Aneurysm.

OBJECTIVE: The purpose of this study was to assess the associations between malignancy, therapeutic regimens, and aorto-iliac aneurysm (i.e., abdominal aortic aneurysm [AAA]) growth rates. METHODS: A retrospective single centre analysis identified patients with an AAA plus cancer. Patients who had two or more computed tomography angiograms over six months or more and additional malignancy were included. Clinical data and aneurysm diameters were analysed. AAA growth under cancer therapy (chemotherapy or radiation) was compared with a non-cancer AAA control cohort and to meta-analysis data. Statistics included t tests and a linear regression model with correction for initial aortic diameter and type of treatment. RESULTS: From 2003 to 2020, 217 patients (median age 70 years; 92% male) with 246 aneurysms (58.8% AAA) and 238 malignancies were identified. Prostate (26.7%) and lung (15.7%) cancer were most frequently seen. One hundred and fifty-seven patients (72.3%) received chemotherapy, 105 patients (48.4%) radiation, and 79 (36.4%) both. Annual AAA growth (mean ± standard deviation) was not statistically significantly different for cancer and non-cancer patients (2.0 ± 2.3 vs. 2.8 ± 2.1 mm/year; p = .20). However, subgroup analyses revealed that radiation was associated with a statistically significantly reduced mean aneurysm growth rate compared with cancer patients without radiation (1.1 ± 1.3 vs. 1.6 ± 2.1 mm/year; p = .046) and to the non-cancer control cohort (1.7 ± 1.9 vs. 2.8 ± 2.1 mm/year; p = .007). Administration of antimetabolites resulted in statistically significantly increased AAA growth (+ 0.9 mm/year; p = .011), while topoisomerase inhibitors (- 0.8 mm/year; p = .17) and anti-androgens (- 0.5 mm/year; p = .27) showed a possible trend for reduced growth. Similar observations were noted for iliac aneurysms (n = 85). Additionally, the effects persisted for chemotherapy combinations (2.6 ± 1.4 substances/patient). CONCLUSION: Patients with cancer and concomitant aortic aneurysms may require intensified monitoring when undergoing specific therapies, such as antimetabolite treatment, as they may experience an increased aneurysm growth rate. Radiation may be associated with reduced aneurysm growth.

Surgical and endovascular revascularization of chronic mesenteric ischemia.

PURPOSE: Chronic mesenteric ischemia (CMI) is a rare but life-threatening disease. This study reviewed outcomes in patients treated surgically for CMI by open treatment (OT) and endovascular treatment (ET), analyzing risk factors for endovascular failure. METHODS: Clinical data for 36 patients treated for CMI from 2007 to 2017 were retrospectively analyzed. The study's primary endpoint was symptom-free survival. The secondary endpoint was the primary technical success for endovascular and open surgical treatments. Risk factors for endovascular failure were identified by using univariate analysis. RESULTS: Patients were analyzed as treated: 21 patients (58.3%) in the ET and 15 (41.6%) in the OT group. Overall, 20 patients (56%) presented with abdominal angina, 9 (25%) with rest pain, and 7 (19%) without symptoms. An ET was initially attempted in 31 patients (86.1%). The conversion rate from ET to OT was 32.3%, which resulted in a primary technical success of 67.6% in ET and 100% in OT. Six patients from the ET group (19.3%) required surgical revision due to restenosis. One-year (OT 91.6% vs. ET 96.8%; n.s.) and three-year primary patency (OT 91.6% vs. ET 80.6%; n.s.) as well as 3-year symptom-free survival did not differ between the groups (OT 62.5% vs. ET 69.4%; n.s). Overall, in-hospital mortality was 2.8% (n = 1), which was not statistically different between the groups (OT 6% vs. ET 0%; n.s.). High-grade stenosis of the superior mesenteric artery tended to be associated with higher technical failure (P = 0.06). CONCLUSIONS: ET showed a comparable perioperative outcome with higher technical failure. OT was distinguished by excellent early and late technical success.

Concomitantly discovered visceral artery aneurysms do rarely grow during cancer therapy.

Visceral artery aneurysms (VAA) are a rare entity of arterial aneurysms with the imminent threat of rupture. The impact of cancer and chemotherapy on the growth of VAAs is unknown. A retrospective dual center cohort study of patients with concomitant VAA and different types of cancer was conducted and the impact of various chemotherapeutic agents on VAA growth was studied by sequential CT analysis. For comparison, a non-cancer all comer cohort with VAAs and no cancer was studied to compare different growth rates. The primary endpoint was aneurysm progress or regression >1.75 mm. Chi-square test, Fisher's exact test and Mann-Whitney test was used for statistical comparison. In the 17-year-period from January 2003 to March 2020, 59 patients with 30 splenic artery aneurysms, 14 celiac trunk aneurysms, 11 renal artery aneurysms and 4 other VAA and additional malignancy were identified. 20% of patients suffered from prostate cancer, the rest were heterogeneous. The most prevalent chemotherapies were alkylating agents (23%), antimetabolites (14%) and mitose inhibitors (10%). Eight patients had relevant growth of their VAA and one patient showed diameter regression (average growth rate 0.1 ± 0.5 mm/year). Twenty-nine patients with 14 splenic, 11 RAAs (seven right) and 4 celiac trunk aneurysms were available in the non-cancer comparison cohort (average growth rate 0.5 ± 0.9 mm/year, p = 0.058). However, the growth rate of patients receiving operative treatment for relevant VAA growth was significantly higher (p = 0.004). VAAs grow rarely, and rather slow. Cancer and/or chemotherapy do not significantly influence the annual growth rate. Additional control examinations seem unnecessary.

Impact of Dietary Sodium Reduction on the Development of Obesity and Type 2 Diabetes in db/db Mice.

The impact of dietary sodium reduction on mouse models of type 2 diabetes is not well understood. Therefore, we analyzed the effect of a low-salt diet on obesity and parameters of type 2 diabetes in db/db mice. Five-week-old male db/db and lean db/m mice were fed a normal salt (0.19% Na+, NS) or a low-salt diet (<0.03% Na+, LS) for 5 weeks. Body and organ weight and parameters of glucose and insulin tolerance were analyzed. Plasma levels of steroids were determined by liquid chromatography tandem mass spectrometry. Body weight, glucose, and insulin tolerance were not affected by LS. The amount of gonadal adipose tissue showed a trend to be increased by LS whereas liver, pancreas, kidney, heart, and adrenal weight remained unaffected. LS reduced urinary sodium-to-creatinine ratio but did not affect plasma Na+ levels in both genotypes. Plasma and urinary potassium-to-creatinine ratio did not differ in all groups of mice. Aldosterone as a major determinant of changes in dietary sodium remained unaffected by LS in db/db mice as well as further investigated steroid hormones. The present study showed reduced sodium-to-creatinine ratio, but no additional effects of dietary sodium reduction on major metabolic parameters and steroid levels in obese and hyper-glycemic db/db mice.

Management and outcome of true visceral and renal artery aneurysm repair.

PURPOSE: Visceral and renal artery aneurysms (VAA, RAA) are very rare pathologies. Both surgical and endovascular therapies are discussed as therapeutic options for ruptured and non-ruptured aneurysm repair; we describe our experience in the open and endovascular management of these entities. METHODS: Retrospective database analysis of 60 treated VAA and RAA in 59 patients between 1994 and 2020. Outcome data was descriptively analyzed. RESULTS: Thirty-seven aneurysms were surgically treated and 23 interventionally. In the total study cohort, we observed a mortality of 1.7% and a morbidity of 18.6%. One major complication occurred. The morbidity was higher after surgical repair in ruptured and non-ruptured cases. The mean aneurysm diameter was 30.5 ± 15.6 mm. Patients with hepatic or pancreaticoduodenal artery aneurysms presented more often in the stage of rupture, without differences in aneurysm size. The length of hospital stay after endovascular repair was significantly shorter compared to open surgical treatment (7.2 ± 6.9 days versus 11.8 ± 6.7 days, p = 0.014), but only in elective cases. Primary technical success was significantly better in patients that underwent surgical repair in an intention to treat analysis (100% versus 79.3%). The mean follow-up of the cohort was 53.5 months (range 3-207 months). CONCLUSION: Elective endovascular therapy and open surgery of VAA and RAA are safe procedures with a good periprocedural and long-term outcome. Surgical revascularization showed a better primary technical success but was associated with longer length of hospital stays.

[Open thoracic and thoracoabdominal aortic repair vs. f/bTEVAR - complementary or competitive?] / Offener thorakaler und thorakoabdominaler Aortenersatz vs. f/b(T)EVAR ­ komplementär oder kompetitiv?

The classical approach of open repair (OR) for thoracic and thoracoabdominal aortic pathologies, including aneurysms and dissection, has been outnumbered by the use of fenestrated/branched (thoracic) endovascular aortic repair (f/b[T]EVAR) in recent years. Providing OR for complex cases in an aortic service requires a dedicated surgical setup and a huge body of expertise in this particular field.In order to reduce specific complications, such as perioperative mortality, kidney failure, spinal cord ischemia, stroke or bowel ischemia, it is necessary to apply cerebrospinal-spinal fluid drainage, point-of-care coagulation therapy, distal and retrograde aortic perfusion and sequential clamping. Despite the predominance of endovascular solutions, the specific OR expertise is still needed for specific indications, such as young patients, connective tissue disorder or aortic graft infections.Currently, the short and mid term results for f/b(T)EVAR outweigh those for OR, including the shorter hospital stay and less invasive procedures. However, OR provides better long-term results for overall mortality, re-intervention rates and secondary complications.In conclusion, in our opinion OR is a service that is still necessary for dedicated aortic centres, but will most likely become more frequent again in the years to come.

Detection of Deteriorating Patients on Surgical Wards Outside the ICU by an Automated MEWS-Based Early Warning System With Paging Functionality.

BACKGROUND: The establishment of early warning systems in hospitals was strongly recommended in recent guidelines to detect deteriorating patients early and direct them to adequate care. Upon reaching predefined trigger criteria, Medical Emergency Teams (MET) should be notified and directed to these patients. The present study analyses the effect of introducing an automated multiparameter early warning score (MEWS)-based early warning system with paging functionality on 2 wards hosting patients recovering from highly complex surgical interventions. METHODS: The deployment of the system was accompanied by retrospective data acquisition during 12 months (intervention) using 4 routine databases: Hospital patient data management, anesthesia database, local data of the German Resuscitation Registry, and measurement logs of the deployed system (intervention period only). A retrospective 12-month data review using the same aforementioned databases before the deployment of the system served as control. Control and intervention phases were separated by a 6-month washout period for the installation of the system and for training. RESULTS: Data from 3827 patients could be acquired from 2 surgical wards during the two 12-month periods, 1896 patients in the control and 1931 in the intervention cohorts. Patient characteristics differed between the 2 observation phases. American Society of Anesthesiologists risk classification and duration of surgery as well as German DRG case-weight were significantly higher in the intervention period. However, the rate of cardiac arrests significantly dropped from 5.3 to 2.1 per 1000 admissions in the intervention period (P < 0.001). This observation was paralleled by a reduction of unplanned ICU admissions from 3.6% to 3.0% (P < 0.001), and an increase of notifications of critical conditions to the ward surgeon. The primary triggers for MET activation were abnormal ECG alerts, specifically asystole (n = 5), and pulseless electric activity (n = 8). CONCLUSION: In concert with a well-trained and organized MET, the early deterioration detection of patients on surgical wards outside the ICU may be improved by introducing an automated MEWS-based early warning system with paging functionality.

Aortic stiffness and related complications after endovascular repair of blunt thoracic aortic injury in young patients.

Background: This study aimed to evaluate the changes in aortic stiffness in young patients undergoing thoracic endovascular aortic repair (TEVAR) after blunt thoracic aortic injury (TBAI) and to examine the associated cardiovascular complications during follow-up. Patients and methods: We included survivors of TBAI who underwent stent graft placement between November 2009 and November 2019 and gave their consent to participate. Patients with relevant cardiovascular risk factors, comorbidities with potential impact on arterial stiffness, and prior aortic surgical or endovascular interventions were excluded. Fourteen TEVAR patients prospectively underwent clinical and noninvasive examinations and morphological imaging (mean time of follow-up and duration of implanted stent graft: 5.3 ± 1.8 years; mean age: 35.1 ± 8.7 years) and were compared to 14 healthy controls (matched for sex, age, height, and body mass index) in order to evaluate aortic stiffness. During the follow-up examinations, we assessed the pulse wave velocity (PWV; m/s) and development of arterial hypertension or heart failure, as indicated by N-terminal pro-brain natriuretic peptide (NT-proBNP; pg/mL) levels and performed echocardiography. Results: A significant increase in PWV values was recorded in the TEVAR group (median = 10.1; interquartile range [IQR] = 8.9-11.6) compared to the healthy controls (median = 7.3; IQR = 6.7-8.4), with an increase in the rank mean PWV (+ 3.8; Mann-Whitney U test p < .001). NT-proBNP levels of patients after TEVAR did not vary significantly compared to those of healthy controls (Mann-Whitney U test, p = .154). After TEVAR, five patients developed arterial hypertension during the follow-up, and three of them exhibited diastolic dysfunction. Conclusions: In young patients, TEVAR after TBAI may cause adverse cardiovascular complications due to increased aortic stiffness; therefore, screening for arterial hypertension during follow-up is recommended.

AV loop free flap: an interdisciplinary approach for perineal and sacral defect reconstruction after radical oncological exenteration and radiation in a colorectal cancer patient.

BACKGROUND: The free flap transfer of a latissimus dorsi flap (LDF) for the closure of sacral wound defects after pelvic exenteration and radiation therapy offers a successful tool of the plastic surgeon. This case report shows the successful coverage using an upstream arterio-venous (AV) loop in combination with an LDF. CASE PRESENTATION: We describe the case of a patient who underwent a pelvic exenteration and radiation therapy due to a local recurrence of rectal cancer. The initially used VRAM flap could not ensure a satisfactorily wound closure. An interdisciplinary approach first yielded an AV loop using both greater saphenous veins and was connected to the arteria and vena femoris followed by a free LDF transfer, which was performed 11 days later. The result was an excellent reconstructive and plastic coverage of the sacral wound defect with a well-perfused LDF. The long-term result showed a perfectly integrated flap in the sacral region. CONCLUSION: We recommend the free LDF for the coverage of large wound defects in irradiated areas after the failure of VRAM flap. If an AV loop is necessary within the flap transfer, we recommend conducting two procedures to guarantee the perfusion of the AV loop.

The incidence of delayed complications in acute type B aortic dissections is underestimated.

OBJECTIVE: Acute type B aortic dissections (TBADs) can have immediate or delayed complications within the first 2 weeks. Because the majority of clinical series retrospectively categorized TBAD, the incidence and outcome of delayed complications in initially uncomplicated TBAD within the first 14 days are not well described. METHODS: We retrospectively analyzed 86 patients (78% male; age, 62.5 ± 13 years) with acute TBAD treated consecutively between January 2004 and May 2016 at a tertiary referral center. All TBADs were confirmed by computed tomography angiography (CTA) on admission, after 2 to 5 days, and after 10 to 14 days. Study end points were the incidence of immediate and delayed complications (aortic rupture, malperfusion, rapid aortic expansion >4 mm, pain or hypertension resistant to medical therapy) and in-hospital mortality. In addition, we looked at CTA-detected morphometric variables (maximum diameters of descending aorta, false lumen [FL], and primary entry tear; number of intimal tears; FL configuration; true lumen collapse; course of the dissection) and their association with delayed complications. Finally, we assessed treatment modalities and clinical outcomes. RESULTS: Of all TBADs, 22 (26%) presented with immediate complications (rupture, n = 11); 64 patients (74%) were initially assessed as having uncomplicated TBAD. Of these 64 patients, 24 (28% of all 86) suffered from delayed complications (malperfusion, n = 10; aortic rupture, n = 3; early expansion >4 mm, n = 8; refractory pain, n = 2; uncontrollable hypertension, n = 1) at a median interval of 7.1 (2-14) days after symptom onset. During the first 14 days, 40 patients (46%) remained uncomplicated. The CTA analysis revealed a significant association of initial thoracic aortic diameter (P = .009), size of the primary entry tear (P = .018), true lumen collapse (P = .019), and partially thrombosed FL (P = .019) with the occurrence of delayed complications within the first 14 days. Of the patients with delayed complications, 87.5% underwent surgery (90% thoracic endovascular aortic repair, 10% peripheral revascularization); 12.5% in this group died following aortic rupture before they received surgical repair. The mortality of patients with delayed complicated TBAD was significantly higher compared with those who remained uncomplicated within the 14-day period (12.5% vs 0%; P = .0221). CONCLUSIONS: Delayed complications in initially uncomplicated acute TBAD are not infrequent. Morphologic variables like maximum diameter of the descending aorta, primary entry tear, true lumen collapse, and partially thrombosed FL were associated with an increased risk of delayed complications in initially uncomplicated TBAD. Future clinical research must verify the predictive role of clinical and morphologic variables in the acute phase, particularly with regard to a possible early surgical treatment to prevent a fatal outcome.

Cathepsin S is associated with degradation of collagen I in abdominal aortic aneurysm.

BACKGROUND: Cathepsins have been described in the pathogenesis of abdominal aortic aneurysm (AAA), their exact role, especially in collagen degradation, is still unclear. The aim of the present study was therefore to analyse relevant cathepsins in human AAA tissue samples in relation to collagen I, III, and their degradation products. MATERIALS AND METHODS: Samples from 37 AAA patients obtained from elective open surgical repair and eight healthy non-aneurysmatic aortas from kidney donors were included. Expression of cathepsins B, D, K, L, S, cystatin C, collagen I and III, their degraded products C-Telopeptide of type 1 and 3 collagen (CTX-I, CTX-III), cellular markers for leukocytes (CD45), T cells (CD3), macrophage scavenger receptor-1 (MSR-1), synthetic, and contractile smooth muscle cells (SMCs) (smoothelin: SMTH, collagen I and III, myosin heavy chain: MHC, embryonic smooth muscle myosin heavy chain: SMemb) were determined at messenger RNA (mRNA) level, using SYBRGreen-based quantitative PCR and at protein level using enzyme-linked immunosorbent assay (ELISA). RESULTS: Expression of cathepsins B, D, L, and S at mRNA level was significantly elevated in AAA compared to control aorta (1.7-fold, p = 0.025; 2.5-fold, p = 0.002; 2.6-fold, p = 0.034; and 7.0-fold, p = 0.003). Expression of cathepsin S correlated significantly with leukocytes and macrophages (ρ = 0.398, p = 0.033 and ρ = 0.422, p = 0.020), synthetic SMCs were significantly associated with cathepsins B, D, and L (ρ = 0.522, p = 0.003; ρ = 0.431, p = 0.015 and ρ = 0.467, p = 0.008). At protein level, cathepsins B and S were elevated in AAA compared to controls (5.4-fold, p = 0.001 and 7.3-fold, p < 0.001). Significant correlations were observed between collagen I, its degraded product, and cathepsin S (r = -0.350, p = 0.034 and r = +0.504, p < 0.001). Expression of cathepsin B was associated with SMCs, expression of cathepsin S with inflammatory cells. CONCLUSIONS: Particularly cathepsin S was associated with the degradation product of collagen I and thus might be involved in the progression of AAA. Furthermore, cathepsin S correlated with inflammatory cells.

Experts' Results in Blunt Thoracic Aortic Injury are Reproducible in Lower Volume Tertiary Institutions. Early and Mid-term Results of an Observational Study.

OBJECTIVES: The aim of this study was to evaluate the early and mid-term clinical results, the device performance, and the mid-term re-intervention rates of patients suffering blunt thoracic aortic injury (BTAI) managed by a multidisciplinary team in a low-volume BTAI centre. METHODS: This was a retrospective observational study in a tertiary hospital setting. From December 2005 to March 2016, all patients over 18 years old admitted with BTAI were included in the study. No exclusion criteria were applied. The study data were collected and analysed retrospectively. Follow-up of survivors included computed tomography imaging 3 and 9 months post-procedure, then annually. RESULTS: Twenty-eight patients were included in the study. Their mean age was 42 ± 16 years and 89% were male. A contained aortic rupture was diagnosed in 20 patients, a Stanford type B dissection in six, and intramural haematoma in two patients. Multidisciplinary evaluations were performed and an intervention was indicated in 25 patients (89%), four of whom died before the intervention. Nineteen patients underwent thoracic endovascular aortic repair of the descending thoracic aorta and two patients underwent a frozen elephant trunk procedure. The procedures were performed 0.7 ± 1.2 days after injury. All procedures were successful. There were no device related complications. The post-operative 30 day mortality was 5%, with one patient dying on the day of operation from other vascular injuries. The 30 day mortality of all patients was 18%. The median mid-term follow-up period was 786 days. All 30 day survivors survived the follow-up period. The mid-term imaging showed stable results in 19 patients. Two patients required frozen elephant trunk procedures after 240 and 681 days and both procedures were successful. CONCLUSIONS: In a low volume centre, a multidisciplinary team using a standardised protocol with the endovascular first approach demonstrated excellent outcomes, similar to those of large centres. If the aortic trauma is adequately managed, the patient's outcome is closely related to the additional trauma.

Bovine Pericardium as New Technical Option for In Situ Reconstruction of Aortic Graft Infection.

BACKGROUND: Alloplastic aortic graft infection is a devastating complication following aortic surgery. It is associated with excessively high mortality and morbidity caused by anastomotic rupture or septicemia. Many authors consider in situ replacement after complete surgical graft removal as the method of choice. However, there is an ongoing debate about the most suitable material for reconstruction. We present our first experiences with replacing the descending and infrarenal aorta using custom-made bovine pericardium grafts. MATERIAL AND METHODS: From January 2013 to 2015, 13 patients (10 male, median age 70 years, range 53-84) were treated for 5 early-graft infections after open reconstructions and 7 late graft infections (1 TEVAR, 2 EVAR, and 4 open reconstructions), and 1 patient was treated for mycotic aneurysm. Septicemia was evident in 8 patients, whereas 5 patients were presented with low-grade infection. In all cases, graft infection was proven by a synopsis of clinical findings, laboratory tests, imaging, and microbiologic tests (positive pathogen detection in 11 patients). Cutaneous and aortoenteric fistulae were present in 3 and 4 patients, respectively. All patients received an in situ replacement using a hand-sewn xenoprosthesis or patch made from a bovine pericardium sheet. Follow-up was routinely performed 3, 12, and 24 months after discharge. RESULTS: For reconstruction, 4 pericardium tubes, 7 bifurcated grafts, and 2 large patches were implanted in situ. Technical success was 100%. Median length of hospital stay was 44 days (range, 20-136 days), with an in-hospital mortality rate of 7.7% (n = 1). Major procedure- and disease-related complications were temporary (n = 2) and permanent dialysis (n = 1), limb loss (n = 1), and long-term ventilation (n = 5). Complete infection control and initial healing could be achieved in 75% (n = 10). During the follow-up (median 9 months, range: 1-27 months), primary graft patency was 100%, and mortality was 41.7%. We observed 2 secondary ruptures due to reinfection at 4 and 7 months. CONCLUSIONS: Custom-made bovine pericardium grafts provide a good option for in situ replacement following early or late aortic graft infection. Despite of its high biocompatibility, pericardium provides not an absolute protection against ongoing retroperitoneal infection. For the treatment, the principles of septic surgery need to be applied and close follow-up is mandatory.

3D non-contrast-enhanced ECG-gated MR angiography of the lower extremities with dual-source radiofrequency transmission at 3.0 T: Intraindividual comparison with contrast-enhanced MR angiography in PAOD patients.

OBJECTIVE: To compare prospectively image quality and diagnostic confidence of flow-sensitive 3D turbo spin echo (TSE)-based non-contrast-enhanced MR angiography (NE-MRA) at 3.0 T using dual-source radiofrequency (RF) transmission with contrast-enhanced MRA (CE-MRA) in patients with peripheral arterial occlusive disease (PAOD). METHODS: After consent was obtained, 35 patients (mean age 69.1 ± 10.6 years) with PAOD stage II-IV underwent NE-MRA followed by CE-MRA. Signal-to-noise ratio and contrast-to-noise ratio were calculated. Subjective image quality was independently assessed by two radiologists and stenosis scoring was performed in 875 arterial segments. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for stenosis classification were calculated using CE-MRA as a reference method. Diagnostic agreement with CE-MRA was evaluated with Cohen's kappa statistics. RESULTS: NE-MRA provided high objective and subjective image quality at all levels of the arterial tree. Sensitivity and specificity for the detection of relevant stenosis was 91 % and 89 %, respectively; the NPV was 96 % and the PPV 78 %. There was good concordance between CE-MRA and NE-MRA in stenosis scoring. CONCLUSIONS: 3D electrocardiography (ECG)-gated TSE NE-MRA with patient-adaptive dual-source RF transmission at 3.0 T is a promising alternative for PAOD patients with contraindications for gadolinium-based contrast agents. It offers high sensitivity and NPV values in the detection of clinically relevant arterial stenosis. KEY POINTS: • Flow-sensitive TSE NE-MRA is a promising technique for PAOD evaluation. • Diagnostic accuracy is comparable to contrast-enhanced MRA. • NE-MRA eliminates the risk of NSF in patients with renal insufficiency. • Costs arising from the use of contrast agents can be avoided.