Fabio Ramponi

Transapical wire-assisted endovascular repair of thoracic aortic dissection.

Purpose To describe a technique for transapical wire–assisted endograft deployment under rapid ventricular pacing for a type B dissection involving the proximal left subclavian artery and extending to the aortic bifurcation. Case Report A 58-year-old man presented with a symptomatic thoracic aneurysm as a complication of a chronic type B dissection, with a short proximal neck in zone 1. After arch vessel debranching, the patient underwent endoluminal repair with deployment of a closed web, tapered Valiant thoracic endograft over a through-and-through wire from the left groin to the apex of the left ventricle, using rapid ventricular pacing to reduce cardiac output. The remaining dissected aorta was covered with a second Valiant endograft down to the distal third of the descending thoracic aorta and bare Z stents down to the aortic bifurcation to re-expand the true lumen. A freeflow Valiant endograft was deployed as a proximal extension to treat a proximal type I endoleak. The recovery was complicated by retrograde type A aortic dissection, considered secondary to the bare stent. The complication was repaired surgically; postoperative computed tomography after recovery was unremarkable. Conclusion Transapical wire–assisted deployment with rapid ventricular pacing is feasible and may provide improved stability for stenting within the aortic arch. The use of a stent-graft with a proximal bare stent is associated with a higher risk of retrograde extension of the dissection and warrants lifelong imaging follow-up.

Recurrent Aortic Dissection: Observations from the International Registry of Aortic Dissection (IRAD)

Background: Improved medical care after initial aortic dissection (AD) has led to increased survivorship and a population of individuals at risk for further cardiovascular events, including recurrent AD. Reports describing recurrent ADs have been restricted to small numbers of patients from single institutions. We used the IRAD (International Registry of Acute Aortic Dissection) database to examine the clinical profiles and outcomes of patients with recurrent AD. Methods: We identified 204 patients enrolled in IRAD with recurrent AD. For the primary analysis, patient characteristics, interventions, and outcomes were analyzed and compared with 3624 patients with initial AD. Iterative logistic modeling was performed to investigate variables associated with recurrent AD. Cox regression analyses were used to determine variables associated with 5-year survival. A subset of recurrent AD patients was analyzed for anatomic and demographic details of initial and recurrent ADs. Results: Patients with recurrent AD were more likely to have Marfan syndrome (21.5% versus 3.1%; P<0.001) but not bicuspid aortic valve (3.6% versus 3.2%; P=0.77). Descending aortic dimensions were greater in patients with recurrent AD than in patients with initial AD independently of sentinel dissection type (type A: 4.3 cm [3.5–5.6 cm] versus 3.3 cm [2.9–3.7 cm], P<0.001; type B: 5.0 cm [3.9–6.0 cm] versus 4.0 cm [3.5–4.8 cm], P<0.001), and this observation was accentuated among patients with Marfan syndrome. In multivariate analysis, the diagnosis of Marfan syndrome independently predicted recurrent AD (hazard ratio, 8.6; 95% confidence interval, 5.8–12.8; P<0.001). Patients with recurrent AD who presented with proximal followed by distal AD were younger than patients who experienced distal followed by proximal dissection AD (42.1±16.1 versus 54.3±14.8 years; P=0.004). Conclusions: Among those suffering acute aortic dissection, 5% have a history of a prior aortic dissection. Recurrent AD is strongly associated with Marfan syndrome.

Early diagnosis and resection of an asymptomatic leiomyosarcoma of the inferior vena cava prior to caval obstruction

Leiomyosarcoma of the inferior vena cava is a rare and aggressive tumor, characterized by a slow growth and usually late diagnosis. The mainstay of therapy is surgical resection with limited role for chemotherapy or radiotherapy; resection modalities and the need for caval reconstruction are still matters of debate. In this case report, we describe an asymptomatic intraluminal leiomyosarcoma of the inferior vena cava diagnosed incidentally prior to caval occlusion during a routine ultrasound examination of the upper abdomen.

Familial aortic aneurysm and dissection due to transforming growth factor-β receptor 2 mutation

This report describes the clinical course and management of a patient with Loeys-Dietz syndrome (LDS) type 2. In 2003, a 31-year-old male was diagnosed with acute aortic dissection type B; in the following six years he underwent multiple surgical and endovascular aortic procedures at different thoracic and abdominal levels secondary to progressive enlargement of both the non-dissected thoracic aorta and the false lumen distal to the left subclavian artery. LDS is characterized by arterial tortuosity and aneurysms as a result of heterozygous mutations in genes encoding transforming growth factor-β receptor 1 and 2. Further studies are required to establish the proper surgical management.

Total percutaneous cardiopulmonary bypass with Perclose ProGlide

Suture-mediated closure devices have been previously described as an interesting alternative to femoral cutdown during endovascular aortic procedures. The insertion of two or three devices before the cannulation (preclose technique) permits successful percutaneous access also with a large sheath up to 24 Fr diameter. The main benefit of percutaneous access is a lower rate of complication at the groin. The same technique can be applied to cardiac procedures where femoral cannulation for cardiopulmonary bypass (CPB) is required. We report a series of 12 patients in whom total percutaneous CPB was successfully established using a Perclose ProGlide for the arterial access.

Think differently: trans-apical platform for TEVAR.

The endovascular treatment of thoracic aortic disease (TEVAR) is an established treatment option and indications for endoluminal therapy are rapidly expanding (1-3). Advancements in imaging provide careful pre-operative evaluation of the anatomy, making the procedural planning very accurate (4). Nevertheless, despite design improvements in endograft delivery systems, inadequate arterial access (5) and limited landing zones still represent limitations. The apex of the left ventricle (LV) is the “front door” to the arterial vascular system and as such has gained popularity with the introduction of trans-catheter aortic valve implantation (TAVI) (6-9). In this paper we will discuss when and how trans-apical TEVAR (TaTEVAR) is a valid alternative to the conventional trans-arterial retrograde approach.

Robotically Assisted Minimally Invasive Off-pump Coronary Artery Bypass Surgery in a Patient With Permanent Tracheostomy

BACKGROUND Patients with a permanent tracheostomy requiring coronary surgery represent a unique challenge, being at increased risk of sternal wound complications, mediastinitis and stoma necrosis. Several techniques have been described including manubrium sparing sternotomy, thoracoscopic internal mammary harvest and hybrid revascularisation. METHODS We report a case of robotic assisted (daVinci®Xi™ Surgical System) total arterial off-pump revascularisation in a patient with previous laryngectomy and permanent tracheostomy. The main advantage of this approach was to minimise the risk of postoperative sternal complication and mediastinatis, whilst still providing the prognostic benefit of total arterial grafting and the neurological advantage of the aorta no-touch technique.

Bilateral Versus Single Internal Mammary Artery Use in Coronary Artery Bypass Grafting: A Propensity Matched Analysis

BACKGROUND Bilateral internal mammary artery (BIMA) grafts have demonstrated superior long-term outcomes compared with single internal mammary artery (SIMA) grafts. Despite this, BIMA remains widely underutilised due to perceived technical challenges and concerns regarding wound healing. We sought to examine the morbidity and mortality associated with BIMA use in a propensity-matched cohort of patients. METHODS From 2009 to 2016, 3,594 consecutive patients underwent coronary artery bypass surgery at three affiliated institutions. Thirty-day (30) mortality and morbidity data were collected prospectively. Propensity-score matched analyses were performed for BIMA versus SIMA use controlling for a number of preoperative characteristics. RESULTS Overall, 29% of procedures were performed off pump, with a greater proportion in the BIMA group (43% vs. 21%, p<0.001). In the propensity-score analysis consisting of 820 matched pairs, there were similar rates of 30-day mortality (1.3% BIMA vs. 0.9% SIMA, p=0.48) and deep sternal wound infection (1.1% BIMA vs. 0.9% SIMA, p=0.84). The rate of superficial sternal wound infection trended towards being higher in the BIMA group (2.6% vs. 1.3%, p=0.077). The rates of red blood cell transfusions (27.4% vs. 27%, p=0.217), other blood product transfusions (18% vs. 20%, p=0.217), and reoperation for bleeding (2.9% vs. 2.1%, p=0.349) were similar. CONCLUSIONS Bilateral internal mammary artery use was associated with similar rates of deep sternal wound infection compared to SIMA use, with a preponderance of superficial sternal wound infections that did not result in increased mortality or transfusion requirements. The use of BIMA should be more widely considered for coronary artery bypass surgery.

Management of aortic regurgitation and bilateral carotid occlusion in severe Takayasu arteritis

We present a patient with Takayasu arteritis and severe aortic valve regurgitation and bilateral carotid artery occlusions, who underwent aortic valve replacement and aorto‐bicarotid bypass. The management of the cardiovascular manifestations of Takayasu arteritis is reviewed.

Recurrent Aortic DissectionClinical Perspective: Observations From the International Registry of Aortic Dissection

Background: Improved medical care after initial aortic dissection (AD) has led to increased survivorship and a population of individuals at risk for further cardiovascular events, including recurrent AD. Reports describing recurrent ADs have been restricted to small numbers of patients from single institutions. We used the IRAD (International Registry of Acute Aortic Dissection) database to examine the clinical profiles and outcomes of patients with recurrent AD. Methods: We identified 204 patients enrolled in IRAD with recurrent AD. For the primary analysis, patient characteristics, interventions, and outcomes were analyzed and compared with 3624 patients with initial AD. Iterative logistic modeling was performed to investigate variables associated with recurrent AD. Cox regression analyses were used to determine variables associated with 5-year survival. A subset of recurrent AD patients was analyzed for anatomic and demographic details of initial and recurrent ADs. Results: Patients with recurrent AD were more likely to have Marfan syndrome (21.5% versus 3.1%; P<0.001) but not bicuspid aortic valve (3.6% versus 3.2%; P=0.77). Descending aortic dimensions were greater in patients with recurrent AD than in patients with initial AD independently of sentinel dissection type (type A: 4.3 cm [3.5–5.6 cm] versus 3.3 cm [2.9–3.7 cm], P<0.001; type B: 5.0 cm [3.9–6.0 cm] versus 4.0 cm [3.5–4.8 cm], P<0.001), and this observation was accentuated among patients with Marfan syndrome. In multivariate analysis, the diagnosis of Marfan syndrome independently predicted recurrent AD (hazard ratio, 8.6; 95% confidence interval, 5.8–12.8; P<0.001). Patients with recurrent AD who presented with proximal followed by distal AD were younger than patients who experienced distal followed by proximal dissection AD (42.1±16.1 versus 54.3±14.8 years; P=0.004). Conclusions: Among those suffering acute aortic dissection, 5% have a history of a prior aortic dissection. Recurrent AD is strongly associated with Marfan syndrome.