E. Sebastian Debus

Endovascular vs Open Repair of Renal Artery Aneurysms: Outcomes of Repair and Long-Term Renal Function

BACKGROUND Endovascular treatment (ER) of renal artery aneurysms (RAA) has been widely used recently due to its assumed lower morbidity and mortality compared with open surgery (OS). The purpose of this study was to investigate the outcomes of OS and ER, and compare long-term renal function. STUDY DESIGN Data from 2000 to 2012 were retrospectively collected to identify patients who were treated for RAA in a single institution. Morbidity, mortality, freedom from reinterventions, and renal function were compared between OS and ER for RAA. RESULTS Forty-four RAA repairs were identified in 40 patients (28 women, mean age ± SD 54 ± 13 years). Twenty RAA were repaired with OS (45%) and 24 RAA (55%) with ER. Mean aneurysm sizes were 2.5 ± 1.5 cm (OS) and 2.2 ± 2.2 cm (ER; p = 0.66). Endovascular repair included coil embolization with or without stent placement in 19 patients (79%) and stent grafts in 4 (17%). Open surgery included excision or aneurysmorrhaphy of the aneurysm in 11 kidneys (55%), graft interposition or bypass in 4 (20%), and 4 nephrectomies (20%). There was 1 technical failure in each group. Comorbidities were similar between the 2 groups (American Society of Anesthesiologists III-IV: OS, 40%; ER, 58%; p = 0.44). Endovascular repair and OR had equivalent perioperative morbidity (any complication OS, 15%, ER, 17%, p = 1.0) and no mortality (OS, 0%, ER, 0%). Endovascular repair was associated with shorter hospitalization (OS, 6.3 ± 2.5; ER, 2 ± 3.4 days, p < 0.001). Mean follow-ups were 21 ± 32 months (OS) and 27 ± 36 months (ER). A 30% reduction in glomerular filtration rate occurred in 12.5% of OS patients and 9.1% of ER patients (p = 1.00). Freedom from reintervention at 12 and 24 months were OS, 82%/82% and ER, 82%/74%, respectively (log-rank-test = 0.23). CONCLUSIONS Endovascular repair of RAA is as safe and effective as open repair in selected patients with appropriate anatomy. There was no difference in decline in renal function between OS and ER.

Acute Type A Aortic Dissection Treated Using a Tubular Stent-Graft in the Ascending Aorta and a Multibranched Stent-Graft in the Aortic Arch

Purpose: To describe the combined use of a tubular stent-graft for the ascending aorta and an inner-branched arch stent-graft for patients with acute type A aortic dissection. Technique: The technique to deploy these modular, custom-made stent-grafts is demonstrated in 2 patients with acute DeBakey type I aortic dissections and significant comorbidities precluding open surgery. Both emergent procedures were made possible by the availability of suitable devices manufactured for elective repair in other patients. After preliminary carotid-subclavian bypass, a long Lunderquist guidewire was introduced from the right femoral artery to the left ventricle for delivery of the Zenith Ascend and Zenith Branched Arch Endovascular Grafts under inflow occlusion. Bridging stent-grafts were delivered to the innominate and left common carotid arteries to connect to the 2 inner branches; the left subclavian artery was occluded. Both cases were technically successful and resulted in exclusion of the false lumen in the ascending aorta. The operating and fluoroscopy times did not exceed those of comparable elective procedures. The patients were rapidly extubated shortly after the procedure and without serious immediate complications. One patient survived 11 months with a satisfactory repair; the other succumbed to complications of recurrent pneumonia after 23 days. Conclusion: Endovascular treatment of patients with acute type A aortic dissection using a combination of tubular and branched stent-grafts in the ascending aorta is feasible and offers an alternative strategy to open surgery.

Outcome of Surgeon-Modified Fenestrated/Branched Stent-Grafts for Symptomatic Complex Aortic Pathologies or Contained Rupture

Purpose: To analyze the outcome of surgeon-modified fenestrated and branched stent-grafts (sm-FBSG) in high-risk patients with symptomatic complex aortic pathology or contained rupture. Methods: A single-center retrospective analysis was conducted of 21 consecutive patients (mean age 70 years, range 58–87; 16 men) treated with a sm-FBSG from April 2014 to September 2016. The indications included 11 thoracoabdominal and 10 pararenal aortic pathologies, which presented as symptomatic in 8 and as contained rupture in 13 patients. The mean aneurysm diameter was 7.4±2.3 cm. Results: Technical success was 100%. From 1 to 4 (mean 3) renovisceral branch vessels were targeted with fenestrations. The mean length of in-hospital stay was 19 days (range 1–78). There was 1 death within 30 days and 2 further in-hospital deaths. Two patients suffered permanent spinal cord injury, 2 developed respiratory failure, and 2 had renal failure requiring temporary or permanent dialysis. No myocardial infarction, stroke, or bowel ischemia occurred. Six early endoleaks (3 type II and 3 minor type III) were detected. Mean follow-up was 11.2 months (range 2–33) in 17 patients. One late aneurysm-related death occurred. All 13 follow-up imaging studies showed patent target renovisceral vessels, with 1 type I and 2 type II endoleaks. Conclusion: Sm-FBSG can be utilized for urgent treatment of complex abdominal and thoracoabdominal aortic pathologies in high-risk patients with anatomy unsuitable for commercially available stent-grafts.

A multi-institutional experience in adventitial cystic disease.

Background: Adventitial cystic disease (ACD) is an unusual arteriopathy; case reports and small series constitute the available literature regarding treatment. We sought to examine the presentation, contemporary management, and long‐term outcomes using a multi‐institutional database. Methods: Using a standardized database, 14 institutions retrospectively collected demographics, comorbidities, presentation/symptoms, imaging, treatment, and follow‐up data on consecutive patients treated for ACD during a 10‐year period, using Society for Vascular Surgery reporting standards for limb ischemia. Univariate and multivariate analyses were performed comparing treatment methods and factors associated with recurrent intervention. Life‐table analysis was performed to estimate the freedom from reintervention in comparing the various treatment modalities. Results: Forty‐seven patients (32 men, 15 women; mean age, 43 years) were identified with ACD involving the popliteal artery (n = 41), radial artery (n = 3), superficial/common femoral artery (n = 2), and common femoral vein (n = 1). Lower extremity claudication was seen in 93% of ACD of the leg arteries, whereas patients with upper extremity ACD had hand or arm pain. Preoperative diagnosis was made in 88% of patients, primarily using cross‐sectional imaging of the lower extremity; mean lower extremity ankle‐brachial index was 0.71 in the affected limb. Forty‐one patients with lower extremity ACD underwent operative repair (resection with interposition graft, 21 patients; cyst resection, 13 patients; cyst resection with bypass graft, 5 patients; cyst resection with patch, 2 patients). Two patients with upper extremity ACD underwent cyst drainage without resection or arterial reconstruction. Complications, including graft infection, thrombosis, hematoma, and wound dehiscence, occurred in 12% of patients. Mean lower extremity ankle‐brachial index at 3 months postoperatively improved to 1.07 (P < .001), with an overall mean follow‐up of 20 months (range, 0.33‐9 years). Eight patients (18%) with lower extremity arterial ACD required reintervention (redo cyst resection, one; thrombectomy, three; redo bypass, one; balloon angioplasty, three) after a mean of 70 days with symptom relief in 88%. Lower extremity patients who underwent cyst resection and interposition or bypass graft were less likely to require reintervention (P = .04). One patient with lower extremity ACD required an above‐knee amputation for extensive tissue loss. Conclusions: This multi‐institutional, contemporary experience of ACD examines the treatment and outcomes of ACD. The majority of patients can be identified preoperatively; surgical repair, consisting of cyst excision with arterial reconstruction or bypass alone, provides the best long‐term symptomatic relief and reduced need for intervention to maintain patency.

Air Embolism During TEVAR: Carbon Dioxide Flushing Decreases the Amount of Gas Released from Thoracic Stent-Grafts During Deployment

Purpose: To investigate the amount of gas released from Zenith thoracic stent-grafts using standard saline flushing vs the carbon dioxide flushing technique. Methods: In an experimental bench setting, 20 thoracic stent-grafts were separated into 2 groups of 10 endografts. One group of grafts was flushed with 60 mL saline and the other group was flushed with carbon dioxide for 5 minutes followed by 60 mL saline. All grafts were deployed into a water-filled container with a curved plastic pipe; the deployment was recorded and released gas was measured using a calibrated setup. Results: Gas was released from all grafts in both study groups during endograft deployment. The average amount of released gas per graft was significantly lower in the study group with carbon dioxide flushing (0.79 vs 0.51 mL, p=0.005). Conclusion: Thoracic endografts release significant amounts of air during deployment if flushed according to the instructions for use. Application of carbon dioxide for the flushing of thoracic stent-grafts prior to standard saline flush significantly reduces the amount of gas released during deployment. The additional use of carbon dioxide should be considered as a standard flush technique for aortic stent-grafts, especially in those implanted in proximal aortic segments, to reduce the risk of air embolism and stroke.

The role of the multidisciplinary health care team in the management of patients with Marfan syndrome.

Marfan syndrome (MFS) is a rare, severe, chronic, life-threatening disease with multiorgan involvement that requires optimal multidisciplinary care to normalize both prognosis and quality of life. In this article, each key team member of all the medical disciplines of a multidisciplinary health care team at the Hamburg Marfan center gives a personal account of his or her contribution in the management of patients with MFS. The authors show how, with the support of health care managers, key team members organize themselves in an organizational structure to create a common meaning, to maximize therapeutic success for patients with MFS. First, we show how the initiative and collaboration of patient representatives, scientists, and physicians resulted in the foundation of Marfan centers, initially in the US and later in Germany, and how and why such centers evolved over time. Then, we elucidate the three main structural elements; a team of coordinators, core disciplines, and auxiliary disciplines of health care. Moreover, we explain how a multidisciplinary health care team integrates into many other health care structures of a university medical center, including external quality assurance; quality management system; clinical risk management; center for rare diseases; aorta center; health care teams for pregnancy, for neonates, and for rehabilitation; and in structures for patient centeredness. We provide accounts of medical goals and standards for each core discipline, including pediatricians, pediatric cardiologists, cardiologists, human geneticists, heart surgeons, vascular surgeons, vascular interventionists, orthopedic surgeons, ophthalmologists, and nurses; and of auxiliary disciplines including forensic pathologists, radiologists, rhythmologists, pulmonologists, sleep specialists, orthodontists, dentists, neurologists, obstetric surgeons, psychiatrist/psychologist, and rehabilitation specialists. We conclude that a multidisciplinary health care team is a means to maximize therapeutic success.

First implantation of Gore Hybrid Vascular Graft in the right vertebral artery for cerebral debranching in a patient with Loeys-Dietz syndrome

A 53-year-old woman with Loeys-Dietz syndrome developed progressive subclavian artery aneurysm and common carotid artery dissection. She was treated successfully by plugging and coiling of the subclavian aneurysm and its side branches after combined cervical debranching using standard carotid-axillary bypass and Gore Hybrid Vascular Graft for vertebral revascularization. Follow-up control (4 weeks) documented patent debranching, and only minimal residual flow in the subclavian aneurysm. The described off-label use for sutureless cerebral revascularisation of the vertebral artery might be a fast, simple, and reliable solution for cervical debranching in selective challenging patients. Further studies are necessary to evaluate side effects and durability.

Few internal iliac artery aneurysms rupture under 4 cm

Objective: This study investigated the diameter of internal iliac artery (IIA) aneurysms (IIAAs) at the time of rupture to evaluate whether the current threshold diameter for elective repair of 3 cm is reasonable. The prevalence of concomitant aneurysms and results of surgical treatment were also investigated. Methods: This was a retrospective analysis of patients with ruptured IIAA from seven countries. The patients were collected from vascular registries and patient records of 28 vascular centers. Computed tomography images taken at the time of rupture were analyzed, and maximal diameters of the ruptured IIA and other aortoiliac arteries were measured. Data on the type of surgical treatment, mortality at 30 days, and follow‐up were collected. Results: Sixty‐three patients (55 men and 8 women) were identified, operated on from 2002 to 2015. The patients were a mean age of 76.6 years (standard deviation, 9.0; range 48‐93 years). A concomitant common iliac artery aneurysm was present in 65.0%, 41.7% had a concomitant abdominal aortic aneurysm, and 36.7% had both. IIAA was isolated in 30.0%. The mean maximal diameter of the ruptured artery was 68.4 mm (standard deviation, 20.5 mm; median, 67.0 mm; range, 25‐116 mm). One rupture occurred at <3 cm and four at <4 cm (6.3% of all ruptures). All patients were treated, 73.0% by open repair and 27.0% by endovascular repair. The 30‐day mortality was 12.7%. Median follow‐up was 18.3 months (interquartile range, 2.0‐48.3 months). The 1‐year Kaplan‐Meier estimate for survival was 74.5% (standard error, 5.7%). Conclusions: IIAA is an uncommon condition and mostly coexists with other aortoiliac aneurysms. Follow‐up until a diameter of 4 cm seems justified, at least in elderly men, although lack of surveillance data precludes firm conclusions. The mortality was low compared with previously published figures and lower than mortality in patients with ruptured abdominal aortic aneurysm.

Proximal thoracic endograft displacement rescued by balloon-assisted pull-back, external shunting, and in situ fenestration of the left carotid artery

Proximal displacement of thoracic aortic endografts is a catastrophic adverse event, which rarely occurs but is associated with extremely high morbidity and mortality. We describe herein the case of a patient with accidental proximal displacement of a thoracic endograft with occlusion of all supra-aortic branches, successfully rescued by the combination of three advanced endovascular techniques: (1) aggressive pull-back maneuver with a compliant balloon; (2) establishment of an arterio-arterial temporary shunt to the occluded carotid artery over sheaths; and (3) in-situ fenestration of the occluded carotid artery.

Physician-Modified Thoracic Stent-Graft With Low Distal Radial Force to Prevent Distal Stent-Graft–Induced New Entry Tears in Patients With Genetic Aortic Syndromes and Aortic Dissection:

Purpose: To describe a novel modification technique to lower the distal radial force of a thoracic stent-graft so as to avert stent-graft–induced new entry tears (SINE) in the fragile aorta of patients with genetic aortic disease and aortic dissection. Technique: A commercially available thoracic stent-graft is partially deployed on a back table. The most distal Z-stent is removed, the distal fabric is marked by vascular clips, and the modified stent-graft is reloaded and deployed in the true lumen of an aortic dissection. The technique is demonstrated in 3 patients with aortic dissection related to genetic aortic diseases. Conclusion: Creating a low distal radial force stent-graft is easy and can be done in a short time. Endovascular implantation appears feasible and safe.