Drosos Kotelis

Operative and Midterm Outcomes of the Fenestrated Anaconda Stent-Graft in the Endovascular Treatment of Juxtarenal, Suprarenal, and Type IV Thoracoabdominal Aortic Aneurysms

Purpose: To report operative and midterm outcomes of fenestrated endovascular aneurysm repair (FEVAR) with the Anaconda device. Methods: A retrospective analysis was conducted of 39 consecutive patients (median age 74 years; 36 men) treated with the fenestrated Anaconda stent-graft between July 2011 and December 2015 at a single center. Indications for FEVAR were abdominal aortic aneurysms (AAAs) with neck anatomy unsuitable for a standard stent-graft. Median infrarenal neck length was 4 mm (range 0–9). Four (10%) patients presented with type IV thoracoabdominal aortic aneurysm (TAAA), 12 (31%) with suprarenal aneurysms, and 23 (59%) with juxtarenal aneurysms. Four (10%) patients had previous infrarenal aortic repair. Five (13%) patients had an infrarenal neck angulation >60°. A total of 106 fenestrations were incorporated into the stent-grafts (73 renal arteries, 25 superior mesenteric arteries, and 8 celiac trunks). Technical success, perioperative and midterm mortality and morbidity, target vessel patency, endoleaks, and reinterventions were documented. Results: Technical success was 95% (37/39). Three (8%) patients died in-hospital from mesenteric embolism in 2 and renal artery rupture with consequent multiorgan failure in 1. Two (5%) patients suffered an intraoperative embolic stroke. During a median follow-up of 33 months (range 4–55), adjunctive maneuvers were performed in 9 (23%) patients, including reintervention for type II endoleak with enlarged aneurysm sac in 2 (5%). Four additional patients died of causes unrelated to the aortic pathology (overall mortality 18%). In 34 (94%) of the 36 patients seen in follow-up, aneurysm sac size was stable or decreased. Target vessel stent patency was 99% (95/96). Conclusion: FEVAR with the Anaconda device delivers satisfactory short-term technical and clinical success rates in patients with juxtarenal, suprarenal, and type IV TAAA. Midterm efficacy and durability with respect to aneurysm sac regression and target vessel patency appear very good. Overall mortality and the need for reintervention were significant in this patient cohort.

Treatment of blunt thoracic aortic injury in Germany—Assessment of the TraumaRegister DGU®

Purpose Using the data delivered by the German Trauma Register DGU® from 2002 till 2013, the value of different therapies of blunt thoracic aortic injury (BTAI) in Germany was analyzed. Methods Prospectively collected data of patients suffering from BTAI were retrospectively analyzed with focus on the different treatment modalities for grade I–IV injuries. Results 821 patients suffering from BTAI were identified: 51.6% (424) grade I injury, 35.4% (291) grade II or III injury and 12.9% (106) grade IV injury (77.5% men [44.94 ± 20.6 years]). The main patterns of injury were high- speed accidents and falls (78.0% [n = 640], 21.8% [n = 171] respectively). Significant differences between grade I and grade II/III as well as IV injuries could be assessed for the incidence of cardiopulmonary resuscitation, a Glasgow Coma Scale score below 8 and a systolic blood pressure below 90 mmHg (p-value: <0.001). In the primary admission subgroup, 44.1% (197/447) of the patients received best medical treatment, 55.9% received surgical intervention (250/447): Thereof 37.2% (93/250) received open surgery and 62.8% (147/250) had been treated by endovascular means. Significantly lower 24-h- and in-hospital-mortality rates were encountered after endovascular treatment for all gradings of BTAI (p-value: <0.001). Yet this subgroup of patients showed the lowest incidence of further severe injuries and cardiac arrest. Conclusion Endovascular therapy became the treatment of choice for BTAI in Germany. Patients who have been treated by surgical means showed the highest survival rate, especially endovascular therapy showed a favorable low mortality rate.

Open Thoracic and Thoraco-abdominal Aortic Repair in Patients with Connective Tissue Disease

Retrospective cross-border, single centre study February 2000 to April 2016 72 aortic operations on 65 patients with CTD 41 male, median age 41 years [range 19–70 years] 56 patients (86%) with previous aortic repair (71 open, 4 endovascular) 33 patients (51%) operated before at the site of the procedure reported here Procedures: 8 emergency operations (11%) Aortic arch revision (n = 1; 1%) Descending thoracic aortic repair (n = 11; 15%) TAAA type I repair (n = 12; 17%), Type II repair (n = 29; 40%) Type III repair (n = 12; 17%) Type IV repair (n = 5; 7%). Ascending aorta and/or the aortic arch (n = 2; 3%) and (n = 8; 11%) 7 patients (10%) underwent staged procedures Median follow-up: 42 months (0.5–180 months)

Endovascular repair of the ascending aorta: the last frontier?

Starting at the infrarenal portion of the aorta, endovascular aortic repair with stent-grafts has evolved to the therapy of first choice for a variety of aortic pathologies and the majority of patients (1-3). The endovascular revolution has been galloping within two decades from the infrarenal aorta towards the thoracic and thoracoabdominal aorta, and has reached the aortic arch, with branched devices now enabling total endovascular solutions (4,5). The ascending aorta is anatomically the last frontier of the evolution of endovascular aortic therapies.

Comparison of urine and serum neutrophil gelatinase-associated lipocalin after open and endovascular thoraco-abdominal aortic surgery and their meaning as indicators of acute kidney injury

BACKGROUND Neutrophil gelatinase-associated lipocalin (NGAL) has been described as a potential biomarker of acute kidney injury (AKI) in different settings, but its behaviour under influence of open and endovascular repair of thoraco-abdominal aortic aneurysms (TAAA) has not been assessed yet. In this study, the course of NGAL was observed and differences of serum- (sNGAL) and urine-NGAL (uNGAL) levels following TAAA repair, especially with regard to AKI, were evaluated. PATIENTS AND METHODS In this retrospective single centre study, 52 patients (mean age 64.5 years, [43-85 years]), including 39 (75 %) men, were enrolled (2014-2015, 13.2 months mean follow-up). Levels of sNGAL and uNGAL were measured perioperatively for 48 hours on intensive care unit. Twenty-three patients were treated by endovascular and 29 by open TAAA-repair. RESULTS Logistic regression revealed an increase in NGAL (sNGAL p = 0.0263, uNGAL p = 0.0080) corresponding with an increase in serum creatinine within the first 48 hours. Fourteen patients (26.9 %) developed AKI and 11 (21.1 %) required dialysis. The course of NGAL differed significantly (uNGAL p < .0001, sNGAL p = 0.0002) between patients suffering from AKI requiring dialysis and patients without AKI. The predictive power of uNGAL was three times higher than that of sNGAL (estimate of the regression slope 0.1382 vs. 0.0460). No significant difference between patients undergoing open or endovascular TAAA repair regarding the perioperative course of sNGAL and uNGAL was observed. CONCLUSION serum-NGAL and urine-NGAL correlate with serum creatinine levels and AKI requiring dialysis. Furthermore, the postoperative course of sNGAL and uNGAL after open and endovascular TAAA repair is not significantly different. Taken together, the results indicate that uNGAL and, to a lesser extent, sNGAL could be considered biomarkers for early detection of perioperative AKI after open and endovascular TAAA surgery.

Recovery of lost motor evoked potentials in open thoracoabdominal aortic aneurysm repair using intercostal artery bypass

Ischemia of the spinal cord remains a disastrous complication in thoracoabdominal aortic aneurysm (TAAA) surgery. We report a case of open type I TAAA repair during which no motor evoked potentials were detectable for >1 hour after aortic cross-clamping. The creation of three intercostal artery bypasses restored spinal cord perfusion. As the patient showed only moderate clinical signs of spinal cord ischemia afterward, we underline the role of neuromonitoring to guide intercostal artery bypass implantation during TAAA surgery as the combined use of neuromonitoring and intercostal artery bypass implantation may prevent paraplegia in specific TAAA cases.