Domenico Baccellieri

Evaluation of a new disease-specific endovascular device for type B aortic dissection

OBJECTIVE The study objective was to evaluate the feasibility, safety, and early technical and clinical success rate of a new endovascular device specifically designed for aortic dissection that has recently become available in Europe. METHODS From June of 2005 to the present, the Zenith Dissection Endovascular System (William Cook Europe, Bjaerverskov, Denmark) was used in 11 selected patients (all male, with a median age of 58 years [range, 45-76 years]) with type B chronic aortic dissection with a compression or collapse of the true lumen. All procedures were performed under general anesthesia with preoperative cerebrospinal fluid drainage in 4 patients. One-step open surgical supra-aortic vessels re-routing was performed in 6 patients to obtain an adequate proximal landing zone: Left carotid-subclavian artery bypass was performed in 5 patients, and right-to-left common carotid artery bypass and left subclavian to common carotid artery transposition was performed in 1 patient. Clinical follow-up visits and computed tomography scans were obtained at 1, 6, and 12 months, and yearly thereafter. RESULTS A secondary technical success was obtained in all patients (100%), and 30-day clinical success was achieved in 10 patients (91%). A type IA entry flow was observed in 1 patient. No mortality was recorded. Occlusion of visceral/renal arteries, retrograde dissections, and device-induced tears in the intimal lamellae were not observed. Periprocedural morbidity included temporary renal failure in 1 patient and postimplantation syndrome with fever and leukocytosis for 23 days in 1 patient. No cases of paraplegia were recorded. At a median follow-up of 12 months (range, 2-30 months), we observed a clinical success rate of 91%. No migration of the device was observed. No late occlusion of the visceral or renal arteries was recorded at follow-up. CONCLUSION The perioperative and short-term follow-up results showed that the Zenith Dissection Endovascular System for the treatment of aortic dissection can be safely used without affecting the patency of the branches covered by the bare stent. However, these results need to be validated in a larger group of patients with a mid-term follow-up.

P2X7 receptor antagonism modulates IL-1β and MMP9 in human atherosclerotic vessels

In atherosclerosis, matrix metallopeptidases (MMPs) contribute to plaque rupture through weakening of the fibrous cap. Pleiotropic P2X purinoceptor 7 (P2X7), expressed in the carotid plaque (PL), is involved in interleukin 1 beta (IL-1β) release that may influence MMP9 generation, thus their possible modulation through acting on P2X7 was investigated. P2X7-related machinery was characterized and the effects of P2X7 antagonists (A740003, KN62) and MMPs inhibitors (Batimastat, Ro28-2653) were studied in ex-vivo tissue cultures of human PL’s vs. non-atherosclerotic internal mammary artery (IMA) by using molecular biology, immune-biochemical and microscopy methodologies. We highlighted atherosclerosis-related differences between PLs and IMAs molecular patterns, and their responsivity to P2X7 antagonism. High IL-1β tissue content was associated with PLs morphology and instability/vulnerability. We demonstrated that A740003, but not KN62, decreased IL-1β and MMP9 independently from NLR family pyrin domain containing 3, but in relationship with patient’s smoking status. Acting downstream P2X7 by MMPs inhibitors, diminished IL-1β mRNA without transcriptional effect at MMP9, possibly because the assumption of statin by patients. These data firstly demonstrated A740003 suitability as a specific tool to decrease inflammatory status in human vessels and might support the design of studies applying P2X7 antagonists for the local targeting and tailored therapy of atherosclerosis.

Possible graft-related complications in visceral debranching for hybrid B dissection repair.

BACKGROUND Hybrid repair (HR) of thoracoabdominal aortic aneurysm (TAAA) and dissection (TAAD), consisting of rerouting renovisceral branches followed by endograft aortic repair, has been shown to be a feasible option. It is especially appealing in patients unfit for both open and total endovascular repair. In order to determine the role of dissecting etiology and intraoperative variables as risk factors for graft-related complications in visceral debranching, we retrospectively analyzed the clinical outcomes, patency rate and hemodynamic alterations of the renovisceral debranching grafts in our series. METHODS We analyzed 55 consecutive patients who underwent thoracoabdominal aortic HR between 2001 and 2013 in our center. Forty-four procedures were performed for TAAA and 11 procedures for TAAD. In TAAD patients, dissection involved 9/44 (20.5%) renovisceral vessels. One hundred and fifty-nine visceral bypasses were made (156 retrograde; three anterograde). RESULTS Thirty-day mortality was 12.7% (n=7). Potential graft-related complications included four cases of pancreatitis (7.3%) and five of peri-operative renal failure (9.1%). At a mean follow-up of 36.1 months, the global rate of visceral graft occlusion was 9.4% (15/159), leading to fatal bowel infarction in two patients and kidney loss in seven patients. Actuarial primary patency in renovisceral grafts at 12, 24, and 36 months was 96.3%, 92.6%, and 90.2% respectively. At the level of the anastomosis of the graft to the superior mesenteric artery, significant flow alterations (systolic peak velocity >250 cm/s) were observed during computed flow dynamics analysis in 18.5% of cases. Overall, an additional procedure to ensure patency was required in 19 bypasses intraoperatively and three during follow-up. The presence of aortic dissection had no significant impact on debranching graft-related complications. During multivariate analysis, retropancreatic routing to CT was the only independent predictor of graft-related complications (P=0.006). CONCLUSIONS Specific visceral graft-related complications were not uncommon in our series and were often associated with clinical consequences. Hemodynamic alterations of debranching grafts were observed in particular at the level of the anastomosis with the superior mesenteric artery. Careful follow-up is mandatory in order to monitor visceral bypasses and facilitate patency when required.

Late patency of reconstructed visceral arteries after open repair of thoracoabdominal aortic aneurysm

Background: In the era of rising endovascular treatment of thoracoabdominal aortic aneurysms (TAAAs), the analysis of visceral vessel (VV) patency after open surgical repair is crucial to provide a future benchmark between these different approaches. This study reports the late outcomes of a single‐center experience with open TAAA repair, focusing on the results of different techniques adopted for renal and splanchnic revascularization. Methods: Data were analyzed for 382 consecutive open TAAA repairs performed between January 2009 and July 2015 (284 men; mean age, 66 ± 10 years). Follow‐up of surviving patients was carried out by computed tomography angiography and office checkups at 3 and 12 months and yearly afterward. Kaplan‐Meier analysis was performed for overall survival, patency of reconstructed VVs (celiac trunk, superior mesenteric artery, right renal artery, left renal artery), and reinterventions on visceral arteries. Furthermore, VV long‐term patency was analyzed in subgroups of patients according to the revascularization strategy (patch inclusion of all vessels, group 1; one‐vessel separate reattachment and patch inclusion of the remaining vessels, group 2; separate reattachment of all VVs, group 3). Results: In‐hospital mortality and paraparesis/paraplegia occurred in 7.6% and 8.1% of patients, respectively. Among the 353 survivors, 338 complied with the follow‐up protocol, and adequate computed tomography angiography images were available in 247 patients (952 VVs were analyzed). Overall follow‐up survival was 94%, 91%, and 70% at 1 year, 2 years, and 5 years, respectively. At the same time points, VV patency was 99%, 98%, and 98% for celiac trunk; 100%, 100%, and 100% for superior mesenteric artery; 100%, 96%, and 96% for right renal artery; and 91%, 87%, and 82% for left renal artery (log‐rank test, P < .0001). Estimates for reinterventions on VVs were 1.2%, 6.3%, and 17% at the same time points. Freedom from occlusion of any VV at 1 year and 3 years was 95% and 87% for group 1, 89% and 79% for group 2, and 92% and 92% for group 3, respectively (log‐rank test, P = .13). Conclusions: Long‐term patency of VVs after open TAAA repair performed in high‐volume centers is high, regardless of the technique employed for revascularization. The left renal artery appears to be most prone to occlusion over time.

Feasibility of Renal Artery Stenting Before, During, and After Endovascular Aneurysm Repair With Suprarenal Fixation Endograft

Suprarenal fixation by means of proximal bare stent may help prevent endograft migration and proximal endoleak. It seems not to compromise renal perfusion and function; however, it is still unclear whether its presence is in conflict with stenting of the renal arteries to treat associated renal stenosis. We report five cases of renal artery stenting performed before, at the same time, or after endovascular treatment of abdominal aortic aneurysm with a suprarenal fixation endograft (Zenith; Cook, Biaverskov, Denmark). Suprarenal fixation endograft seems to not affect renal artery stenting regardless the timing of the procedure.

Thoracic and Abdominal Aorta Percutaneous Treatment

Aortic disease is a potentially serious condition that in many cases can be diagnosed and treated before it becomes dangerous. The most appropriate management is related to the severity, extension, and site of disease and to the specific patient’s clinical characteristics and risk factors.

Comparison of Open and Endovascular Surgery for the Treatment of the Infections of the Thoracic Aorta

OMC. The patients were followed by CT-scan at 1, 3, 6, and 12 months, then annually. Results: Among the 90patients (63men,meanage59± 21 years) treated for a complicatedATBADover the seven years periodof thestudy, the totalmortalityatD30was6.7%.During the 25 ± 16 months average follow-up, an aneurysmal progression was observed in 21% of the patients, necessitating a secondary surgical operation in 17% of the cases; total post-operative mortality was 18%. The distribution of the patients among the groups, the rates of death at 30 days and of aneurysmal progression, reintervention and total mortality during the follow-up were respectively: group 1 (N1⁄450): 10%, 30%, 20%, 24%; group 2 (N1⁄416): 6%, 25%, 25%, 18%; group 3 (N1⁄424): 4%, 4%, 4%, 4%. After statistical analysis, only the belonging to group 3 appeared as a protective factor of aneurysmal progression (p1⁄4 0.013), and ofmortality during the follow-up (p1⁄40.042). Conclusion: Associated with the closure of the main tear with a covered stent, the use of a non-covered aortic stent proved to present a tendency to the improvement ofmortality at D30 in the patients treated for complicated ATBAD. The dilation of this stent with the balloon in order to obtain a re-apposition of the septum of dissection seems to prevent to a significant degree the aneurysmal progression of the dissected aorta and to decrease the mid-term total mortality.

Endotension after Abdominal Aortic Aneurysm Endovascular Repair in Cirrhotic Patients

BACKGROUND Endotension can present a real challenge for the long-term success of endovascular aortic repair (EVAR). Sometimes, it can be associated with liver dysfunction and consequent plasmatic alterations as in the 2 cases reported here. METHODS Significant and progressive abdominal aortic aneurysms (AAA) sac enlargement, without radiologic signs of endoleak, was observed in 2 patients during a 3-year follow-up after EVAR. The first was a 70-year-old man affected by viral liver cirrhosis and the second was a 71-year-old man with cirrhosis due to alcoholic liver disease. RESULTS Both patients underwent successful conversion to open AAA repair; intraoperative findings confirmed the diagnosis of endotension. CONCLUSIONS Cirrhosis-induced plasmatic alterations may affect long-term efficacy of EVAR and should be considered when weighing endovascular treatment against open AAA repair in these high-risk patients. Surgical conversion is feasible despite the high procedural risk associated with liver disease.

Late Retrograde Migration of a Left Subclavian Artery Chimney Stent-Graft Into the Innominate Artery.

Purpose: To report an uncommon case of chimney stent-graft migration in the aortic arch. Case Report: A 29-year-old man presented with chronic left arm hyposthenia after late displacement and thrombosis of a left subclavian artery (LSA) chimney graft that migrated retrogradely into the innominate artery 2 years after deployment. The self-expanding LSA chimney was placed during a redo procedure to repair a pseudoaneurysm and type I endoleak after an index emergency thoracic endovascular aortic repair for traumatic aortic rupture 1 year earlier. The patient was successfully treated in an elective procedure via a median sternotomy, with arch aortotomy under circulatory arrest to remove the proximal end of the thrombosed chimney graft from the ostium of the innominate trunk. Three months later, a left carotid-to-subclavian bypass was performed to restore flow to the left arm. Conclusion: Migration of the proximal end of an overly long chimney graft that moved freely in the aortic arch exposed the patient to a high risk of stroke and death. Because of the high-risk situation, open repair under circulatory arrest was elected to remove the proximal end of the chimney graft, with no major complications.