Adam J. Brownstein

Height alone, rather than body surface area, suffices for risk estimation in ascending aortic aneurysm

Background: In international guidelines, risk estimation for thoracic ascending aortic aneurysm (TAAA) is based on aortic diameter. We previously introduced the aortic size index (ASI), defined as aortic size/body surface area (BSA), as a predictor of aortic dissection, rupture, and death. However, weight might not contribute substantially to aortic size and growth. We seek to evaluate the height‐based aortic height index (AHI) versus ASI for risk estimation and revisit our natural history calculations. Methods: Aortic diameters and long‐term complications of 780 patients with TAAA were analyzed. Growth rate estimates, yearly complication rates, and survival were assessed. Risk stratification was performed using regression models. The predictive value of AHI and ASI was compared. Results: Patients were stratified into 4 categories of yearly risk of complications based on their ASI and AHI. ASIs (cm/m2) of ≤2.05, 2.08 to 2.95, 3.00 to 3.95 and ≥4, and AHIs (cm/m) of ≤2.43, 2.44 to 3.17, 3.21 to 4.06, and ≥4.1 were associated with a 4%, 7%, 12%, and 18% average yearly risk of complications, respectively. Five‐year complication‐free survival was progressively worse with increasing ASI and AHI. Both ASI and AHI were shown to be significant predictors of complications (P < .05). AHI categories 3.05 to 3.69, 3.70 to 4.34, and ≥4.35 cm/m were associated with a significantly increased risk of complications (P < .05). The overall fit of the model using AHI was modestly superior according to the concordance statistic. Conclusions: Compared with indices including weight, the simpler height‐based ratio (excluding weight and BSA calculations) yields satisfactory results for evaluating the risk of natural complications in patients with TAAA.

A systematic review on management of nutcracker syndrome

OBJECTIVE Although nutcracker syndrome (NS) is rare, patients presenting with symptoms or signs and anatomic compression of the left renal vein (LRV) can be considered for intervention. Open, laparoscopic, and endovascular techniques have been developed to decrease the venous outflow obstruction of the LRV. The paucity of data regarding the management of this uncommon disease process poses a challenge for adequate recommendations of the best treatment modality. Herein, we aim to present a systematic review for the management of NS. METHODS We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement standards to systematically search the electronic databases of MEDLINE from October 1982 to July 2017 for articles about the management of NS. Included were studies in English, Spanish, and German in all age groups. RESULTS The literature search provided 249 references. After abstract and full review screening for inclusion, 17 references were analyzed. Eight (47%) described the open surgical approach. The LRV transposition was the most commonly reported technique, followed by renal autotransplantation. Seven (41.11%) described the endovascular technique of stent implantation, and two (11.7%) described the minimally invasive laparoscopic extravascular stent implantation. CONCLUSIONS NS is a rare entity. Multiple techniques have been developed for the treatment of this condition. However, the rarity of this syndrome, the paucity of data, and the short-term follow-up of the existing evidence are the disadvantages that prevent recommendations for the best treatment strategy. Up to now, open surgical intervention, specifically LRV transposition, has been considered by some experts the mainstay for treatment of NS. The endovascular approach is gaining strength as more evidence has become available. However, the long-term patency and durability of this approach remain to be elucidated. Therefore, careful selection of patients is necessary in recommending this technique.

Natural history and management of renal artery aneurysms in a single tertiary referral center

Objective: Although renal artery aneurysms (RAAs) are uncommon, several large reports have been published indicating their benign natural history. The objective of our study was to review our single‐center experience managing this disease entity. Methods: A retrospective review of the Yale radiologic database from January 1999 to December 2016 was performed. Only patients with RAA and a computed tomography scan of the abdomen were selected for review. Demographics of the patients, aneurysm characteristics, management, postoperative complications, and follow‐up data were collected. Results: There were 241 patients with 259 RAAs identified, with a mean age of 69 years (range, 35‐100 years); 147 were female (61%). On computed tomography, aneurysms were solitary and right sided in 224 (86%) and 159 (61%), respectively; 64 (27%) patients had aneurysms elsewhere. The breakdown of RAAs by location was as follows: renal bifurcation in 84 (32%), renal pelvis in 77 (30%), distal renal artery in 58 (22%), mid renal artery in 34 (13%), and proximal renal artery in 6 (2%). Five patients had symptoms that were attributed to the RAA and underwent operative repair; all others were observed without an operation. Symptoms in the operative repair group included flank pain in four and uncontrolled hypertension in one. The mean overall diameter of the RAAs was 1.22 ± 0.49 cm. The diameter of operatively repaired and observed RAAs was 1.84 ± 0.55 cm and 1.21 ± 0.48 cm, respectively (P = .002). Operative repair included four coil embolizations and one open resection. There were no renal function changes in any of these patients after operation and no other complications. Mean follow‐up was 41 ± 35 months for patients in the group that was observed; 18 of these RAAs were >2 cm, and none ruptured. On multivariable regression analysis, female sex (P = .0001), smoking history (P = .00007), left‐sided RAA (P = .03), and main renal artery location (P = .03) were inversely related to growth, whereas a history of hypertension was directly related to growth rate (P = .01). The mean growth rate for RAAs was 0.017 ± 0.052 cm/y. Conclusions: RAAs tend to have a benign natural history. Although previous reports have not identified any factors that contribute to RAA growth, we observed that RAA location, sex, smoking history, and hypertension may have an impact on growth rates. No ruptures were observed. Operative repair at our institution was rare, with no morbidity or mortality. Observation of RAAs over time seems feasible in the asymptomatic patient with a small RAA.

Emergent pacemaker placement in a patient with Lyme carditis-induced complete heart block and ventricular asystole.

We report a case of a 31-year-old man who presented to the emergency department after four episodes of syncope within a 24 h time span. He was found to have symptomatic complete heart block associated with episodes of ventricular asystole lasting 5–6 s. He underwent emergent permanent pacemaker insertion during which he was found to have no underlying rhythm. He was later found to have positive serologies for Lyme disease despite no known exposure to ticks and neither signs nor symptoms of the disease. The pacemaker was ultimately removed due to resolution of his heart block with antibiotic therapy.

Open Replacement of the Thoracoabdominal Aorta: Short- and Long-term Outcomes at a Single Institution

Abstract Background Despite much progress in the surgical and endovascular treatment of thoracoabdominal aortic diseases (TAADs), there is no consensus regarding the optimal approach to minimize operative mortality and end‐organ dysfunction. We report our experience in the past 16 years treating TAAD by open surgery. Methods A retrospective review of all TAAD patients who underwent an open repair since January 2000 was performed. The primary endpoints included early morbidity and mortality, and the secondary endpoints were overall death and rate of aortic reintervention. Results There were 112 patients treated by open surgery for TAAD. Mean age was 66 ± 10 years and 61 (54%) were male. Seventy‐seven (69%) patients had aneurysmal degeneration without aortic dissection and the remaining 35 (31%) had a concomitant aortic dissection. There were 12 deaths (10.7%) and they were equally distributed between the aneurysm and dissection groups (p = 0.8). The mortality for elective surgery was 3.2% (2/61). The rate of permanent paraplegia and stroke were each 2.6% (3/112). The rate of cerebrovascular accident was significantly higher in the dissection group (8.5% vs. 1.2%, p = 0.05). The survival at 1, 5, and 10 years was 80.6, 56.1, and 32.7%, respectively. Conclusion Our data confirm that open replacement of the thoracoabdominal aorta can be performed in expert centers quite safely. Different aortic pathologies (degenerative aneurysm vs. dissection) do not influence the short‐ and long‐term outcomes. Open surgery should still be considered the standard in the management of TAAD.

Thoracic aortic aneurysm: unlocking the “silent killer” secrets

Thoracic aortic aneurysm (TAA) is an increasingly recognized condition that is often diagnosed incidentally. This review discusses ten of the most relevant epidemiological and clinical secrets of this disease; (1) the difference in pathogenesis between ascending and descending TAAs. TAAs at these two sites act as different diseases, which is related to the different embryologic origins of the ascending and descending aorta. (2) The familial pattern and genetics of thoracic aneurysms. Syndromic TAAs only explain 5% of the pattern of inheritance. (3) The effect of female sex on TAA growth and outcome. Females have been found to have worse outcomes compared to males. (4) Guilt by Association. TAAs are associated with abdominal aortic aneurysms, intracranial aneurysms, bicuspid aortic valve, and inflammatory disorders. (5) Natural history of TAAs. Important findings have been made regarding the expansion rate (in relation to familial pattern, location and size), and also regarding the risk of rupture or dissection. (6) The aortic size paradox. Size only is not a sufficient predictor of risk of dissection. (7) Biomarker void. Although many serum biomarkers have been studied, imaging remains the only reliable method for diagnosis and follow-up. (8) Indications for repair. Decisions are made depending on symptoms, location, size, and familial patterns. (9) Types of repair. Both open and endovascular repair options are available for certain TAAs. (10) Medical treatment. The efficacy of prescribing beta blockers, angiotensin converting enzyme inhibitors or angiotensin receptor blockers remains dubious.

The Effect of Blood Transfusion on Outcomes in Aortic Surgery

Abstract The use of blood transfusion in cardiac surgery varies widely. The beneficial effects of blood products are offset by an increase in morbidity and mortality. Despite multiple studies showing an association between blood product exposure and adverse short‐ and long‐term events, it is difficult to determine causality. Nevertheless, the implication is sufficient to warrant the search for alternative strategies to reduce the use of blood products while providing a standard of care that optimizes postoperative outcomes. Aortic surgery, in particular, is associated with an increased risk of bleeding requiring a blood transfusion. There is a paucity of evidence within aortic surgery regarding the deleterious effects of blood products. Here, we review the current evidence regarding patient outcomes after blood transfusion in cardiac surgery, with special emphasis on aortic surgery.

Precipitous Resolution of Type-A Intramural Hematoma with Medical Management in a Patient with Metastatic Stage 4 Renal Cell Carcinoma

Abstract Intramural hematoma (IMH) is a variant form of aortic dissection characterized by involvement of the aortic media without the presence of an overt intimal flap. Surgical extirpation is the standard of care for type‐A IMH in the Western world. However, a conservative approach with anti‐impulse therapy has been advocated especially in Japan as a viable alternative. Here, we report a case of an elderly male patient with a history of metastatic stage 4 renal cell carcinoma who was treated with anti‐impulse therapy for an acute type‐A IMH. Blood pressure stabilization and continuous monitoring resulted in complete resolution of the IMH within 6 days. This report illustrates how immediate medical management in patients with acute type‐A IMH who are not surgical candidates can alleviate the progression or even lead to regression as early as 1 week after initiating anti‐impulse therapy.