Andrzej Juraszek

Long-term results of thoracic endovascular aortic repair in atherosclerotic aneurysms involving the descending aorta

OBJECTIVE This study evaluated long-term results of thoracic endovascular aortic repair for atherosclerotic aneurysms involving descending aorta. METHODS One hundred thirteen patients underwent thoracic endovascular aortic repair for this indication from 1996 to 2009. Mean follow-up was 54 ± 38 months (5-144 months). In-hospital mortality, neurologic injury, need for rerouting, occurrence of endoleaks and their treatment, and survival were recorded. RESULTS In-hospital mortality was 5.3%. Transient neurologic injury rate was 2.6%. Previous rerouting was performed in 51%. Assisted early and late type I and III endoleak rates were 7.9% and 5.7%, respectively. Five percent of patients required late surgical conversion. Actuarial survivals were 86%, 60%, and 42% at 1, 5, and 10 years, respectively. Aorta-related actuarial survivals were 94%, 90%, and 83% at 1, 5, and 10 years, respectively. Cox regression analysis revealed higher number of prostheses as independent risk factor for early (hazard ratio, 5.38; 95% confidence interval, 1.68-42.37) and late (hazard ratio, 8.49; 95% confidence interval, 1.09-66.06) endoleak formation. Female sex (hazard ratio, 0.35; 95% confidence interval, 0.13-0.99), no arch involvement (hazard ratio, 0.21; 95% confidence interval, 0.05-0.08), and higher number of prostheses (hazard ratio, 7.95; 95% confidence interval, 1.36-46.58) affected survival. CONCLUSIONS Aorta-related survival is excellent among patients undergoing thoracic endovascular aortic repair for atherosclerotic aneurysms involving the descending aorta. Life-long surveillance remains mandatory, with early and late failure uncommon but still needing consideration. Thoracic endovascular aortic repair in this group of patients remains attractive and has now proven durability.

Midterm Results of Thoracic Endovascular Aortic Repair in Patients With Aneurysms Involving the Descending Aorta Originating From Chronic Type B Dissections

BACKGROUND Midterm results of TEVAR (thoracic endovascular aortic repair) in patients with aneurysms involving the descending aorta originating from chronic type B dissections are not known. METHODS Between 2004 and 2009, 14 patients with a median age of 63 years (79% male) with this pathology were treated. Seven patients underwent supraaortic transpositions in various extents prior to TEVAR in order to gain a sufficient proximal landing zone. RESULTS Median time from dissection to treatment was 19 months (4 to 84 months). All patients had an uneventful in-hospital course. The median covered length of the aortic arch and descending aorta was 190 mm (100 to 250 mm). Primary success rate defined as absence of type Ia endoleakage was 86%. No patient, where visceral or renal vessels originated from the false or from both lumina sustained ischemic injury by TEVAR. The median follow-up period is 34 months to date (6 to 64 months). Aortic-related morbidity and mortality during follow-up was low (14%). CONCLUSIONS Midterm results of TEVAR in patients with aneurysms involving the descending aorta originating from chronic type B dissections are good. The self-expanding capability of the stent grafts is sufficient over time. However, extensive coverage of the descending aorta is warranted to achieve success. Further studies are needed to extend our knowledge in this particular subgroup of patients.

Experimental Acute Type B Aortic Dissection: Different Sites of Primary Entry Tears Cause Different Ways of Propagation

BACKGROUND Many dissections seem to also have a retrograde component. The aim of the study was to evaluate different sites of primary entry tears and the propagation of the dissecting membrane, antegrade and retrograde, in an experimental model of acute type B aortic dissection. METHODS The entire thoracic aortic aorta including the supraaortic branches was harvested from 26 adult pigs. An intimal tear of 15 mm was created by contralateral incisions sites 20 mm downstream the origin of the left subclavian artery. In 13 cases the dissection was created at the concavity and in 13 cases at the convexity. The aortic annulus was then sewn into a silicon ring of a driving chamber. The distal aorta was connected to a tubing with adjustable resistance elements. The circulation was driven by the pneumatically driven Vienna heart to mimic aortic flow and pressure. RESULTS Mean circulation time was 64 ± 45 minutes. A mean pressure of 152 ± 43 mm Hg and a mean flow of 4.5 ± 1.0 L/minute were reached. The median antegrade propagation length of the dissecting membrane was 65 mm. The median retrograde propagation length in primary entry tears at the convexity was 20 mm and was stopped by the left subclavian artery. In aortas with the primary entry tear at the concavity, median retrograde propagation length was 21 mm extending up to the ascending aorta in 16%. CONCLUSIONS In this experimental model of acute type B aortic dissection, we confirmed that many type B dissections do also have a retrograde component. At the convexity, this component is stopped by the left subclavian artery as an anatomic barrier. At the concavity, the propagation of the dissecting membrane may extend up to the ascending aorta and may therefore cause retrograde type A dissection. These findings may substantiate clinical need for treatment of type B dissections with a primary entry tear at the concavity.

Results After Thoracic Endovascular Aortic Repair in Penetrating Atherosclerotic Ulcers

BACKGROUND Results after thoracic endovascular aortic repair in penetrating atherosclerotic ulcers are uncertain. METHODS From 1997 to 2010, 72 patients (median age, 67 years) presented with penetrating atherosclerotic ulcers (symptomatic, 58%; rupture, 36%). Median logistic EuroSCORE (European System for Cardiac Operative Risk Evaluation) was 32. Mean follow-up was 42 months (range, 19 to 56 months). In-hospital mortality, occurrence of endoleaks, reinterventions, and survival were recorded. RESULTS In hospital mortality was 4%. The primary success rate was 100%. Actuarial survival rates at 1, 5, and 10 years were 93%, 72%, and 60%. The early type I and III endoleak rate was 2.7%. The late type I and III endoleak rate was 4%. One late surgical conversion was performed. Aortic-related actuarial survival was 100% at 1 year and 98.6% at 5 and 10 years. Age older than 75 years (odds ratio, 8.928; 95% confidence interval, 2.05 to 38.93) was an independent predictor of survival. During follow-up, 21% of patients underwent a cardiovascular intervention. CONCLUSIONS Results after thoracic endovascular aortic repair in patients with penetrating atherosclerotic ulcers are excellent for early and late type I and III endoleak formation and aortic-related survival. Patients are mainly limited by age and by the aggressive underlying obliterative atherosclerotic process.

Sustained cognitive benefit 5 years after carotid endarterectomy

OBJECTIVES This study investigated the long-term effect of carotid endarterectomy (CEA) on cognitive brain function by means of P300 evoked potentials. METHODS Twenty-five consecutive patients (36% women) with a median age of 68 years underwent CEA with a median degree of stenosis of 90%. Cognitive brain function was objectively measured by means of P300 auditory evoked potentials (peak latencies in milliseconds [ms]) before CEA, at discharge, and at 1 and 5 years. Values were compared with 25 age- and sex-matched healthy individuals. RESULTS Cognitive P300 evoked potentials were prolonged (ie, impaired) in patients before CEA compared with controls (vertex [Cz], 384 +/- 52 vs 357 +/- 16 ms, P = .020]. At 1 year, P300 evoked potentials were significantly shortened (ie, improved) in patients after CEA compared with baseline values [Cz, 371 +/- 38 vs 384 +/- 52 ms, P = .010]. Furthermore, no difference between patients after CEA and controls was observed [Cz, 371 +/- 38 vs 360 +/- 14 ms, P = .21]. This effect was sustained at 5 years, and P300 evoked potentials continued to be significantly shortened (ie, improved) in patients after CEA compared with baseline values [Cz, 367 +/- 39 vs 384 +/- 52 ms, P = .040]. Continuing, no difference between patients after CEA and controls could be observed [Cz, 367 +/- 39 vs 362 +/- 17 ms, P = .58]. These results could be confirmed in repeated measures analysis of variance for Cz (P = .025) and frontal (Fz) results (P = .018). CONCLUSIONS CEA improves previously impaired cognitive brain function as shown by P300 measurements similar to normal cognitive brain function of age- and sex-matched healthy individuals. This beneficial effect is sustained up to 5 years after treatment.

Effect on false-lumen status of a combined vascular and endovascular approach for the treatment of acute type A aortic dissection

OBJECTIVE The aim of the study is to evaluate midterm results with regard to false-lumen status of a combined vascular and endovascular approach for the treatment of acute type A aortic dissection. METHODS We performed ascending/hemiarch replacement during hypothermic circulatory arrest with additional open implantation of the Djumbodis Dissection System (non-self-expanding bare metal stent) to readapt the dissected layers in the arch and the proximal descending aorta in a consecutive series of 15 patients (mean age 61 years, 20% female) suffering from acute type A aortic dissections. The primary end point was the status of the false lumen at the level of the stent. RESULTS We observed three in-hospital deaths (20%). Complete thrombosis of the false lumen was observed in one patient (8%). In 25% of patients, partial thrombosis of the false lumen was observed. The remaining patients had continuing antegrade perfusion. Surgical conversion during a mean follow-up of 37 months was required in two patients (16%) due to continuing enlargement of the distal arch and the proximal descending aorta. No late deaths were observed. CONCLUSION Additional implantation of the Djumbodis Dissection System to readapt the dissected layers in the arch and the proximal descending aorta does not seem to have additive value as an adjunct to standard ascending/hemiarch replacement with regard to closure of the false lumen in the arch and the proximal descending aorta. The most limiting factor seems to be the non-self-expanding capability of the device.

Endovascular and Conventional Treatment of Thoracic Aortic Aneurysms: A Comparison of Costs

BACKGROUND The purpose of this study is to compare costs of conventional surgical therapy with costs of endovascular stent-graft placement in patients with thoracic aortic aneurysms. METHODS Fifteen patients undergoing either conventional surgical therapy or endovascular stent-graft placement of thoracic aortic aneurysms were analyzed. A catalog of costs was then created for both procedures and this catalog was applied individually to each patient. RESULTS Total costs of the service provision of endovascular stent-graft placement including anesthesia were 38.220.98 euros considering 1.7 stent-grafts per patient and including 5900.00 euros (Euros) for days of care. In conventional surgical therapy, adding the costs of the service provision of left heart catheterization, conventional surgical therapy including anesthesia, as well as intraoperative echocardiography a sum of 19.534.12 euros was calculated. Days of care accounted for 31.230.00 euros and total costs of 50.764.12 euros were calculated. The difference between total costs of the two procedures was 12.543.14 euros. CONCLUSIONS Costs of endovascular stent-graft placement in patients with thoracic aortic aneurysms compare favorably with conventional surgical therapy, revealing a cost benefit of 24.7%. Higher procedural costs are outweighed by a lower number of days of care. Nevertheless, aneurysm-related secondary endovascular or surgical procedures may balance the benefit of endovascular therapy. Which strategy to choose, conventional or endovascular, should remain to be based on age, comorbidity, and technical feasibility.

The influence of bicuspid aortic valves on the dynamic pressure distribution in the ascending aorta: a porcine ex vivo model

OBJECTIVES The aim of the study was to simulate the effect of different bicuspid aortic valve configurations on the dynamic pressure distribution in the ascending aorta. METHODS Aortic specimens were harvested from adult domestic pigs. In Group 1, bicuspidalization was created by a running suture between the left and the right coronary leaflets (n = 6) and in Group 2 by a running suture between the left and the non-coronary leaflets (n = 6). Eleven tricuspid specimens served as controls. Two intraluminal pressure catheters were positioned at the concavity and the convexity of the ascending aorta. The specimens were connected to a mock circulation (heart rate: 60 bpm, target pressure: 95 mmHg). A comparison of the different conditions was also done in a numerical simulation. RESULTS At a distal mean aortic pressure of 94 ± 10 mmHg, a mean flow rate of 5.2 ± 0.3 l/min was achieved. The difference of maximal dynamic pressure values (which occurred in systole) between locations at the convexity and the concavity was 7.8 ± 2.9 mmHg for the bicuspid and 1.0 ± 0.9 mmHg for the tricuspid specimens (P < 0.001). The numerical simulation revealed an even higher pressure difference between convexity and concavity for bicuspid formation. CONCLUSIONS In this hydrodynamic mock circulation model, we were able to demonstrate that bicuspid aortic valves are associated with significant pressure differences in different locations within the ascending aorta compared with tricuspid aortic valves. These altered pressure distributions and flow patterns may further add to the understanding of aneurismal development in patients with bicuspid aortic valves and might serve to anticipate adverse aortic events due to a better knowledge of the underlying mechanisms.

Evaluation of the intraoperative specimens of the thoracic and abdominal aorta

BackgroundLittle is known about the histological patterns of acute and chronic aortic pathology with regard to medial degeneration, atherosclerosis and aortitis as well as their distribution in different age groups. The aim of the study was to evaluate histopathological findings of intraoperatively gained aortic specimens with regard to the incidence of medial degeneration, atherosclerosis and aortitis.MethodsIntraoperatively gained aortic specimens were evaluated in 151 patients including 83 (55%) aortic aneurysms (65 thoracic, 18 abdominal) and 68 (45%) acute type A aortic dissections. Histological stainings used were hematoxylin and eosin, Van Gieson as well as alcian blue. Patients were stratified according to above and below 65 years of age. High grade medial degeneration represented pooling of mucoid material in the whole aortic wall. High grade atherosclerosis represented severe intimal fibrosis, massive accumulation of macrophages and foam cells or massive calcification of the aortic wall.ResultsMedial degeneration was diagnosed in 106 (70%) patients including 55 (52%) aortic aneurysms and 51 (48%) acute type A aortic dissections. High grade medial degeneration was found in 50% of patients with thoracic aortic aneurysms < 65 years of age vs. 44% in patients ≥ 65 years of age (p = 0.64) and in 36% of patients with thoracic aortic dissections < 65 years of age vs. 14% in patients ≥ 65 years of age (p = 0.07). Atherosclerosis was diagnosed in 71 (47%) patients including 46 (65%) aortic aneurysms and 25 (35%) aortic dissections. High grade atherosclerosis was found in 23% of patients with thoracic aneurysms < 65 years of age vs. 36% in patients ≥ 65 years of age (p = 0.24) and in 13% of patients with aortic dissections < 65 years of age vs. 52% in patients ≥ 65 years of age (p < 0.001). Aortitis was rare (n = 2).ConclusionsMedial degeneration was the most frequent diagnosis in this series of aortic specimens. Medial degeneration was equally common in patients above and below 65 years of age. However in cases with acute type A aortic dissections, high grade atherosclerosis was the leading histopathological diagnosis in patients older than 65 years. Acute type A aortic dissections seem to have different underlying pathologies in different age groups.

Case report on successful ‘bail out’ aortic homograft implantation in a 81-year old woman with aortic ring rupture after double TAVI procedure

A 81-year woman was admitted to our institution due to worsening chronic heart failure. The patient presented herself with severe aortic valve stenosis and mitral valve insufficiency. Due to estimated high operative risk a TAVI approach was chosen. Following the fist TAVI implantation (Sapien XT™ 26 mm) a big paravalvular leakage was diagnosed. Hence, in order to close the paravalular leakage, a second TAVI procedure with a Core Valve™ 26 mm was performed. A following CT scan showed signs of aortic ring rupture. We therefore decided to perform open heart surgery. After removal of both TAVI prosthesis, native valve excision a 21 mm sized aortic homograft was implanted. Additionally, a mitral valve annuloplasty with CE Physio™ 28 mm ring was performed. In the postoperative period the patient remained for three weeks in the ICU, followed by two weeks on general ward. The patient was discharged home in good condition, with good left ventricular function and regular homograft function in the aortic position. The open heart surgery should have had been performed primarily. Nevertheless, the decision on the treatment strategy is always difficult in case of borderline patients.