Carlo Sassi

Axillary artery cannulation in type a aortic dissection operations

BACKGROUND Femoral arteries are the preferred site of peripheral cannulation for arterial inflow in type A aortic dissection operations. The presence of aortoiliac aneurysms, severe peripheral occlusive disease, atherosclerosis of the femoral vessels, and distal extension of the aortic dissection may preclude their utilization. Axillary artery cannulation may represent a valid alternative in these circumstances. METHODS Between January 15, 1989, and August 20, 1998, in our institution, 22 of 152 operations (14.4%) for acute type A aortic dissection were performed with the use of the axillary artery for the arterial inflow. Axillary artery cannulation was undertaken in the presence of femoral arteries bilaterally compromised by dissection in 12 patients (54.5%), abdominal aorta and peripheral aneurysm in 5 patients (22.7%), severe atherosclerosis of both femoral arteries in 3 patients (13. 6%), and aortoiliac occlusive disease in 2 patients (9.1%). In all patients, distal anastomosis was performed with an open technique after deep hypothermic circulatory arrest. Retrograde cerebral perfusion was used in 9 patients (40.9%). RESULTS Axillary artery cannulation was successful in all patients. The left axillary artery was cannulated in 20 patients (90.9%), and the right axillary artery was cannulated in 2 patients (9.1%). Axillary artery cannulation followed an attempt of femoral artery cannulation in 15 patients (68. 2%). All patients survived the operation, and no patient had a cerebrovascular accident. No axillary artery thrombosis, no brachial plexus injury, and no intraoperative malperfusion were recorded in this series. Two patients (9.1%) died in the hospital of complications not related to axillary artery cannulation. CONCLUSIONS In patients with type A aortic dissection in whom femoral arteries are acutely or chronically diseased, axillary artery cannulation represents a safe and effective means of providing arterial inflow during cardiopulmonary bypass.

Evolution toward dissection of an intramural hematoma of the ascending aorta

Intramural hematoma of the aorta is a condition increasingly observed in clinical practice. Uncertainty exists whether such lesions represent a different pathology or simply the precursors of classic dissecting aneurysm. The patient was a 76-year-old woman with intramural hematoma of the ascending aorta. Clinical course, progression of the lesion to type A aortic dissection, and surgical treatment are described. Although natural history of intramural hematoma of the ascending aorta is not clearly elucidated, the case presented confirms that the evolution toward intimal flap formation is possible and that we cannot foresee the stabilization of these lesions. We stress that intramural hematoma of the ascending aorta has to be managed as an aortic type A dissection and that aggressive treatment is advisable.

Cerebral autoregulation after hypothermic circulatory arrest in operations on the aortic arch.

BACKGROUND The purpose of this study was to determine whether patients who undergo thoracic aorta repairs with the aid of hypothermic circulatory arrest experience impairments in cerebral autoregulation, and to ascertain the influence of three different techniques of cerebral protection on autoregulatory function. METHODS Sixty-seven patients undergoing elective aortic arch procedures with hypothermic circulatory arrest were tested for cerebral dynamic autoregulation using continuous transcranial Doppler velocity and blood pressure recordings. Twenty-three patients were treated using hypothermic circulatory arrest without adjuncts (group 1), 25 using antegrade cerebral perfusion (group 2), and 19 using retrograde cerebral perfusion (group 3). RESULTS There were no hospital deaths. Two major strokes occurred in this series; 9 patients experienced temporary neurologic dysfunction: in all these patients severe impairment of cerebral autoregulation was observed. Cerebral autoregulation in the immediate postoperative period was preserved only in patients treated with antegrade cerebral perfusion. Severe impairments were observed in the other two groups in which the degree of autoregulatory response was inversely correlated to the duration of the cerebral protection time during hypothermic circulatory arrest. Postoperative improvement of autoregulatory function was observed in the majority of patients. Our data suggest the exposure to brain damage in the presence of autoregulation impairment, thus indicating that postoperative hypotensive phases may further contribute to neurologic impairment. CONCLUSIONS The status of cerebral autoregulation in the postoperative period after hypothermic circulatory arrest procedures is profoundly altered. The degree of impairment is influenced by the cerebral protection technique. This study indicates the beneficial role of antegrade perfusion during hypothermic circulatory arrest for the preservation of this function and suggests that postoperative cerebral autoregulation impairment can be regarded as an expression of central nervous system injury.

Biological features (inflammation and neoangiogenesis) and atherosclerotic risk factors in carotid plaques and calcified aortic valve stenosis: two different sites of the same disease?

Neoangiogenesis and inflammation have a pivotal role in atherosclerosis. Observations support the hypothesis that calcified aortic valve stenosis is an inflammatory process, similar to atherosclerosis in tissue features and risk factors. We studied 2 groups of cases: 47 were affected by hemodynamic atherosclerotic carotid plaque (group 1) and 35 by severe calcified aortic valve stenosis (group 2). We compared the groups for atherosclerosis risk factors, morphologic features, and immunohistochemical phenotypes. In both groups, men, smokers, and hypertensive subjects prevailed, and histologic analysis showed an elevated score for T-lymphocyte infiltrates, neoangiogenesis, calcium, and sclerosis. Adhesion molecule expression was present in both lesions. Expression of intercellular adhesion molecule 1 correlated with inflammatory infiltrates (group 1, P = .0007; group 2, P = .06). Neoangiogenesis also correlated with inflammatory infiltrates (group 1, P = .035; group 2, P = .045). In valves, neoangiogenesis correlated with calcium (P = .048). Carotid plaque and calcified valve stenosis showed common risk factors and biologic hallmarks of a chronic inflammatory process. Inflammation and neoangiogenesis have a crucial role in plaque evolution and in the progression of aortic valve stenosis.

Prevalence of risk factors, coronary and systemic atherosclerosis in abdominal aortic aneurysm: comparison with high cardiovascular risk population.

Background: Abdominal aortic aneurysm (AAA) is considered a manifestation of atherosclerosis, however there are epidemiologic, biochemical, and structural differences between occlusive atherosclerosis and AAA. The pathogenesis of AAA involves several factors, first of all destruction of collagen and elastin in the aortic wall. Classical risk factors may influence the evolution and development of AAA, though no consistent association has been found. Aims of the study were to evaluate associations between risk factors and to establish the prevalence of carotid, peripheral vascular and coronary atherosclerosis in patients with AAA. Methods: We studied 98 patients with AAA (Group 1) awaiting surgery compared with high cardiovascular risk population having two or more risk factors (n = 82 Group 2). We evaluated traditional risk factors and we studied by eco-doppler and echocardiography the presence of carotid peripheral and coronaric atherosclerosis in two groups. Results: We found a higher incidence of AAA in males (p < 0.01). The prevalence of infrarenal AAA was significantly higher than suprarenal AAA (81 vs 17 p < 0.001). No differences in total cholesterol (199 ± 20 vs. 197 ± 25 mg/dl), low-density lipoprotein (142 ± 16 vs. 140 ± 18 mg/dl), triglycerides (138 ± 45 vs. 144 ± 56 mg/dl), glycemia (119 ± 15 vs. 122 ± 20 mg/dl), and fibrinogen (388 ± 154 vs. 362 ± 92 mg/dl) were found between groups. We demonstrated significant differences for cigarette smoking (p < 0.002), systolic and diastolic blood pressure (150 ± 15 vs. 143 ± 14 mmHg and 88 ± 6 vs. 85 ± 7 mmHg, p < 0.0001 and p < 0.05, respectively) and high sensititivity C reactive protein (2.8 ± 1.3 vs. 1.3 ± 0.7 mg/dl, p < 0.001). High-density lipoprotein (HDL) cholesterol levels were significant greater in Group 1 than Group 2 (p < 0.003). Subgroups of patients with AAA and luminal thrombus showed higher fibrinogen levels (564 ± 235 vs. 341 ± 83 mg/dl, p < 0.001) and lower HDL than in controls (46.6 ± 6.5 vs. 52.1 ± 7.8 mg/dl, p < 0.01). We did not find any difference in body mass index, or prevalence of coronary and peripheral atherosclerosis between groups. Conversely, we found higher prevalence of carotid atherosclerosis in Group 2 (9% vs. 25%, p < 0.004). Conclusion: Our AAA patients had fewer and different risk factors respect to patients with atherosclerosis. Only elevated blood pressure, C reactive protein, and smoking showed a significant association with AAA. Atherosclerosis in other arterial districts did not differ respect to subjects with high cardiovascular risk. Our results confirm the hypothesis that AAA and atherosclerosis are two different pathological entities with different risk profiles.

Endovascular treatment of patients with types A and B thoracic aortic dissection using Relay thoracic stent-grafts: results from the RESTORE Patient Registry.

Purpose To evaluate the safety and performance of Relay stent-grafts in patients with acute or chronic aortic dissections. Methods Patients with types A or B aortic dissections suitable for treatment with Relay stent-grafts and followed for 2 years after thoracic endovascular aortic repair (TEVAR) were identified from a company-sponsored registry database established in January 2006. Ninety-one consecutive patients (69 men; mean age 65 years) underwent TEVAR with Relay stent-grafts for dissection. Most patients (76, 84%) had type B dissections; 61 of all patients were classified as chronic and 30 as acute. Results The technical success rate was 95% (97% in acute, 95% in chronic, and 93% in type B dissections). The type I endoleak rate was 7% (7% in acute and 8% in chronic dissections); all occurred in patients with type B dissections. Paraplegia, paraparesis, and stroke occurred in 4, 1, and 2 patients, respectively; 2 cases of paraplegia occurred in patients with acute type B dissections. Thirty-day mortality was 8% (13% in acute and 5% in chronic dissections); all deaths occurred in patients with type B dissections. The 2-year survival rate was 82% in the overall population and 84% in patients with type B dissections. Conclusion The combination of Relays features, such as stent conformability, radial force, atraumatic design, and controlled deployment and fixation, may contribute to the safety of the Relay stent-grafts for the treatment of thoracic aortic dissections, including acute and chronic type B dissections.

Final operative and midterm results of the European experience in the RELAY Endovascular Registry for Thoracic Disease (RESTORE) study

PURPOSE Thoracic endovascular aortic repair is increasingly becoming the standard treatment of many thoracic aortic pathologies. New reliable and accurate stent grafts are emerging to widen the endovascular treatment options. We report the results of RELAY (Bolton Medical, Barcelona, Spain) in the large RELAY Endovascular Registry for Thoracic Disease (RESTORE) European registry. METHODS RESTORE is a multicenter, prospective European registry involving 22 centers in seven European countries. The RELAY device is composed of a stent graft (self-expanding nitinol stents and a polyester vascular graft) and a delivery device specifically designed for the thoracic aorta. Included were acute and elective patients presenting with a variety of pathologies (aneurysms, dissections, ulcerations, intramural hematomas, pseudoaneurysms) and lesions in different aortic and anatomic locations (ascending, arch, descending and thoracoabdominal). RESULTS The registry enrolled 304 patients from April 2005 to January 2009. All-cause mortality at 30 days was 7.2%. Freedom from all cause mortality and freedom from device- and procedure-related mortality at 2 years were 78.5% and 95.9%, respectively. An average of 1.26 graft components were used per patient, with a technical success of 97.7% irrespective of the etiology. Early endoleak rate was 4.6%. Perioperatively, stroke and paraplegia were registered in 1.6% and 2.0%, respectively. CONCLUSIONS The results of RESTORE support the safety of thoracic endovascular aortic repair with the RELAY stent graft, even in acute and complicated situations. The device was highly efficient in angulated aortic anatomies, with acceptable mortality and a low rate of neurologic complications.

Dramatic improvement of LV function after coronary sinus thromboembolectomy

We present the case of a 79-year-old man suffering from chronic atrial fibrillation, severe left ventricular dysfunction, massive right atrial thrombosis, and pulmonary hypertension. Complete coronary sinus thrombosis was found incidentally during preoperative screening. Successful coronary sinus, right atrial, and pulmonary operative embolectomy was followed soon after by a dramatic improvement of cardiac performance; the patients left ventricular function recovery, in particular, suggests that cardiac venous system played an important role in the genesis of myocardial impairment.

Endovascular repair of traumatic thoracic aortic injury: final results from the relay endovascular registry for thoracic disease.

BACKGROUND In blunt thoracic aortic injury, thoracic endovascular aortic repair (TEVAR) offers a less invasive alternative to open chest surgery. New reliable and accurate stent grafts have widened the endovascular treatment options. We report our experience with the Relay stent graft Bolton Medical, Sunrise, FL; Barcelona, Spain) for treatment of this injury. METHODS Relay Endovascular Registry for Thoracic Disease (RESTORE) is a multicenter, prospective European registry, which enrolled patients treated with the Relay stent graft for thoracic aortic diseases from April 2005 to January 2009. Regular follow-up examinations were conducted for up to 24 months. This paper analyzes the cohort of patients treated for traumatic aortic injury. RESULTS Forty adult trauma patients from 12 European centers underwent TEVAR. Mean age was 40 years and 34 patients were male. The proximal landing zone involved aortic arch zones 1 to 2 in 40% and zone 3 in 55% of procedures. Technical success was achieved in all cases. One (2.5%) patient suffered a rupture of the iliac artery. No patient developed procedure-related paraplegia or required conversion to open surgery. Follow-up imaging demonstrated complete exclusion of the traumatic tear and regression of the false aneurysms without endoleak or graft infolding. One late device-related complication was reported; penetration of the distal end of the stent graft treated by stent-graft extension. Thirty-day mortality was 2.5 % (n = 1), and late mortality 2.5% due to a secondary accident. Actuarial 2-year survival was 93.7%. CONCLUSIONS Thoracic endovascular aortic repair with the Relay stent graft is a safe and effective treatment for patients with traumatic aortic injury.

Glue containment and anastomosis reinforcement in repair of aortic dissection

In operations for aortic dissection anastomotic bleeding or secondary anastomosis dehiscence are common problems. The advent of Gelatin-resorcin-formaldehyde-glutaraldehyde (GRF) biologic glue has ameliorated type A dissection operative management. Glue containment is mandatory since detrimental effects of glue migration are described. We herein present a simple technique of anastomosis reinforcement and glue containment that helps in overcoming these complications.