Chiara Lomazzi

Complications after endovascular stent-grafting of thoracic aortic diseases

BackgroundTo update our experience with thoracic aortic stent-graft treatment over a 5-year period, with special consideration for the occurrence and management of complications.MethodsFrom December 2000 to June 2006, 52 patients with thoracic aortic pathologies underwent endovascular repair; there were 43 males (83%) and 9 females, mean age 63 ± 19 years (range 17–87). Fourteen patients (27%) were treated for degenerative thoracic aortic aneurysm, 12 patients (24%) for penetrating aortic ulcer, 8 patients (15%) for blunt traumatic injury, 7 patients (13%) for acute type B dissection, 6 patients (11%) for a type B dissecting aneurysm; 5 patients (10%) with thoraco-abdominal aortic aneurysms were excluded from the analyses. Fifteen patients (32%) underwent emergency treatment. Overall, mean EuroSCORE was 9 ± 3 (median 15, range 3–19). All procedures were performed in the theatre under general anesthesia. All complications occurring during hospitalisation were recorded. Follow-up protocol featured CT-A, and chest X-rays 1, 4 and 12 months after intervention, and annually thereafter.ResultsPrimary technical success was achieved in all patients; procedures never aborted because of access difficulty. Conversion to standard open repair was never required. Mean duration of the procedure was 119 ± 75 minutes (median 90, range 45–285). Mean blood loss was 254 mL (range 50–1200 mL). The mean length of the aorta covered by the SGs was 192 ± 21 mm (range 100–360). The LSA was over-stented in 17 cases (17/47, 36%). Overall 30-day operative mortality was 6.4% (3/47). Major complications included pneumonia (n = 9), cerebrovascular accidents (n = 4), arrhythmia (n = 4), acute renal failure (n = 3), and colic ischemia (n = 1). Overall, endoleak rate was 14%.ConclusionAlthough this report is a retrospective and not comparative analysis of thoracic aortic repair, the combined minor and major morbidity rate was lower than previous reported to results of either electively and emergency performed conventional repair.

Intentional coverage of the left subclavian artery during endovascular stent graft repair for thoracic aortic disease

BackgroundSurgical revascularization of the left subclavian artery (LSA) has been performed to warrant arm perfusion and to prevent paraplegia during thoracic stent graft (SG) procedures. We retrospectively investigated the outcome after intentional occlusion of the left subclavian artery during SG repair for thoracic aortic diseases.MethodsFrom December 2000 to June 2005, 11 patients (mean age, 57 ± 19 years) with a short (<1 cm) proximal aspect of a thoracic aortic lesion underwent intentional LSA coverage to expand the proximal landing zone for SG fixation. Three patients were treated in the emergency setting. We did not perform a prophylactic revascularization of the LSA prior to SG implantation. A preliminary balloon occlusion test of the LSA was not performed in this series. The SG was positioned so that its covering was immediately distal to the left common carotid artery.ResultsSG implantation was technically successful in all patients. Intraoperative mortality was not observed; no patient suffered any impairment of left carotid artery flow. Aortography after SG implantation showed no direct flow in the LSA and refilling of the LSA via the ipsilateral vertebral artery. After the intervention, mean systolic pressure in the left arm decreased by 38 ± 17 mmHg. The stented length of the aorta was 171 ± 73 (median, 150). During hospitalization, no patient showed any signs of left arm malperfusion. Paraplegia was not observed. One patient developed transient ischemic attack. During a mean follow-up of 19 ± 8 months (range, 3–36), all patients were completely asymptomatic and had no functional deficit or temperature differential between arms. No leakage was detected.ConclusionIntentional LSA occlusion seems to be well tolerated. Prophylactic surgical maneuvers may be relegated to an elective measure after an endovascular aortic intervention when intolerable signs or symptoms of ischemia occur.

Endovascular Therapy for Chronic Mesenteric Ischemia

PurposeThe purpose of this article is to report on the effectiveness and durability of endovascular therapy for obstructive disease of the superior mesenteric artery and celiac trunk.Patients and methodsOur retrospective study population included nine patients (five women, four men; mean age 64 years, range 34–83 years) with 15 lesions. The indication for endovascular therapy was chronic mesenteric ischemia. The technical and clinical success rates and the incidence of complications were determined. Follow-up parameters included maintained patency and sustained clinical benefit.ResultsTen vessels were treated. The primary technical and clinical success rates were both 100% with no perioperative mortality. Major complications occurred in two patients (pseudoaneurysms). During a mean follow-up of 31 ± 18 months (range 3–60 months), thrombosis occurred in two patients at 1 and 3 months after the procedures, respectively. Thrombosis was successfully treated by catheter-directed intraarterial thrombolysis followed by percutaneous transluminal angioplasty (PTA) (n = 1) or stenting (n = 1). At 2 and 5 years, the primary patency rate was 78%, whereas survival was estimated to be 85% and 68% at 2 and 5 years, respectively. At this follow-up, all patients had obtained relief of symptoms.ConclusionsOur experience suggests that endovascular treatment for chronic mesenteric arterial obstructive disease is feasible, with a low incidence of complications and acceptable midterm results.

Predictive factors for endoleaks after thoracic aortic aneurysm endograft repair

BACKGROUND Our prospective investigation aimed to determine and analyze the incidence and the determinants of endoleaks after thoracic stent graft. METHODS Sixty-one patients affected by thoracic aortic aneurysms were treated between January 2000 and March 2008. The study cohort contained 54 men, with a mean age of 63.6 +/- 17.9 years. The follow-up imaging protocol included chest radiographs and triple-phase computed tomographic angiography performed at 1, 4, and 12 postoperative months and annually thereafter. RESULTS Median follow-up was 32.4 months (range: 1-96 months). Endoleaks were detected in 9 (14.7%) patients, of which 7 were type 1. Five endoleaks were detected at 30 postoperative days, and the other 4 developed with a mean delay of 12 months. Endovascular or hybrid interventions were used to treat the endoleaks. Secondary technical success rate was 100%. Multivariate analysis demonstrated that the diameter of the aneurysmal aorta (odds ratio 1.75, 95% confidence interval 1.07-2.86) and the coverage of the left subclavian artery (odds ratio 12.05, 95% confidence interval 1.28-113.30) were independently associated with endoleak development. The percentages of patients in whom reinterventions were unnecessary were 94.6% +/- 3.0%, 88.3% +/- 4.5%, and 85.4% +/- 5.2%, at 1, 2, and 5 years, respectively. The actuarial survival estimates at 1, 2, and 5 years were 85.2% +/- 4.6%, 78.1% +/- 5.4%, and 70.6% +/- 6.4%, respectively. CONCLUSIONS The diameter of the aneurysmal aorta and the position of the landing zone are independent predictors of endoleak occurrence after thoracic stent-graft procedures. A careful follow-up program should be considered in patients in whom these indices are unfavorable, because most of the endoleaks may be successfully and promptly treated by additional endovascular procedures.

Mobile Thrombus of the Thoracic Aorta: Management and Treatment Review

Detection of mobile thrombus of the thoracic aorta has become increasingly higher after any embolic event. Although the indication for treatment remains controversial, there is a growing interest about the ethiopathogenesis of this rare entity, and to define proper diagnostic and therapeutic approaches. The purpose of this article was to review the current management strategies and follow-up results of this rare pathology.

Incidence of vascular injuries after use of the Angio-Seal closure device following endovascular procedures in a single center.

IntroductionPercutaneous closure devices have been used to obtain rapid hemostasis and early mobilization of the patient after arterial catheterization. However, we observed challenging problems with the sealing procedure that require further surgical intervention. The present report is a retrospective analysis of the patterns of injury and the final outcome of four cases of femoral artery injury following the use of Angio-Seal.MethodsDuring the last 24 months, in a group of 175 patients (131 men, 44 women; median age 68.4 years, range 47–81 years) underwent percutaneous closure after diagnostic (n = 53) or therapeutic (n = 122) endovascular procedures. Among them we observed four patients (three men, one woman; median age 65.2 ± 10.8 years, range 47–75 years) who developed severe limiting claudication and required vascular repair of an iatrogenic vascular injury following deployment of the Angio-Seal. They had a femoral thrombosis due to narrowing/severe intimal dissection.ResultsAll patients required operative intervention with removal of the device. We performed femoropopliteal thrombectomy and common femoral endarterectomy with patch angioplasty (n = 2), resection of the femoral bifurcation and reimplantation of the deep femoral artery (n = 1), and femoral bifurcation endarterectomy with direct arterial suture (n = 1). The median hospital stay was 6.5 ± 3.8 days (range 4–12 days). Limb salvage was achieved in all of the surviving patients at a mean follow-up of 7 months (range 1–12 months).ConclusionsVascular injuries are uncommon after use of the hemostasis closure device. When they occur, however, they are likely to require challenging surgical correction.

Catheter-Directed Thrombolysis for Acute Renal Artery Thrombosis : Report of 4 Cases

Acute renal artery occlusion is a rare but threatening problem; optimal therapeutic treatment remains a challenge, and ultimate outcomes are still to be defined. In the last decades, several reports or short-case experiences have been reported describing the use of selective infusion of lytic agents into renal artery to treat acute occlusion. We report 4 cases of acute renal artery occlusion treated by catheter-directed intraarterial thrombolysis.

Biomarkers in TAA—The Holy Grail

Thoracic aortic aneurysm (TAA) is a silent disease, often discovered at a time point that dramatic complications, as rupture and dissection, occur. For the detection of asymptomatic TAA and prevention of such complications, it is essential to have an adequate screening tool. Until now, routine laboratory blood tests have played only a minor role in the screening, diagnosis, tracking and prediction of the natural history of TAAs. However, the knowledge about biomarkers is rapidly expanding in the cardiovascular field, and there are several potential biomarkers that might be implemented into TAA clinical practice in the near future. The most important and promising markers for TAA will be discussed in this overview.

Surgical treatment of malignant involvement of the inferior vena cava

BackgroundResection and replacement of the inferior vena cava to remove malignant disease is a formidable procedure. The purpose of this review is to describe our experience with regard to patient selection, operative technique, and early and late outcome.MethodsThe authors retrospectively reviewed a 12-year series of 11 patients; there were 10 males, with a mean age 57 ± 13 years (range 27–72) who underwent caval thrombectomy and/or resection for primary (n = 9) or recurrent (n = 2) vena cava tumours. Tumour location and type, clinical presentation, the segment of vena cava treated, graft patency, and tumour recurrence and survival data were collected. Late follow-up data were available for all patients. Graft patency was determined before hospital discharge and in follow-up by CT scan or ultrasonography. More than 80% of patients had symptoms from their caval involvement. The most common pathologic diagnosis was renal cell carcinoma (n = 6), and hepatocarcinoma (n = 2). In all but 2 patients, inferior vena cava surgical treatment was associated with multivisceral resection, including extended nephrectomy (n = 5), resection of neoplastic mass (n = 3), major hepatic resection (n = 2), and adrenal gland resection (n = 1). Prosthetic repair was performed in 5 patients (45%).ResultsThere were no early deaths. Major complications occurred in 1 patient (9%). Mean length of stay was 16 days. Late graft thrombosis or infection did not occur. The mean follow-up was 22.7 months (range 6–60). There have been no other late graft-related complications. All late deaths were caused by the progression of malignant disease and the actuarial survival rate was 100% at 1 year. Mean survival was 31 months (median 15).ConclusionAggressive surgical management may offer the only chance for cure or palliation for patients with primary or secondary caval tumours. Our experience confirms that vena cava surgery for tumours may be performed safely with low graft-related morbidity and good patency in carefully selected patients.

Spinal cord ischemia after simultaneous and sequential treatment of multilevel aortic disease

OBJECTIVES The aim of the present study is to report a risk analysis for spinal cord injury in a recent cohort of patients with simultaneous and sequential treatment of multilevel aortic disease. METHODS We performed a multicenter study with a retrospective data analysis. Simultaneous treatment refers to descending thoracic and infrarenal aortic lesions treated during the same operation, and sequential treatment refers to separate operations. All descending replacements were managed with endovascular repair. RESULTS Of 4320 patients, multilevel aortic disease was detected in 77 (1.8%). Simultaneous repair was performed in 32 patients (41.5%), and a sequential repair was performed in 45 patients (58.4%). Postoperative spinal cord injury developed in 6 patients (7.8%). At multivariable analysis, the distance of the distal aortic neck from the celiac trunk was the only independent predictor of postoperative spinal cord injury (odds ratio, 0.75; 95% confidence interval, 0.56-0.99; P=.046); open surgical repair of the abdominal aortic disease was associated with a higher risk of spinal cord injury but did not reach statistical significance (odds ratio, 0.16; 95% confidence interval, 0.02-1.06; P=.057). Actuarial survival estimates at 1, 2, and 5 years after the procedure were 80%±5%, 68%±6%, and 63%±7%, respectively. Spinal cord injury did not impair survival (P=.885). CONCLUSIONS In our experience, the risk of spinal cord injury is still substantial at 8% in patients with multilevel aortic disease. The distance of the distal landing zone from the celiac trunk is a significant predictor of spinal cord ischemia.