Giovanni Nano

Surgical excision of cardiac myxomas: Twenty years experience at a single institution

BACKGROUND Primary cardiac tumors are quite uncommon and myxomas constitute the major proportion among these masses. The present study summarizes our 20-year clinical experience with surgical resection of intracardiac myxomas. METHODS Between January 1990 and December 2007, 98 patients (42 males, mean age 60.4±4.1 years) underwent complete excision of primary intracardiac myxoma. In 84 patients the origin site of the tumor was located in the left atrium, and the most common implant site was the interatrial septum. The most common symptom at admission was dyspnea, while systemic embolization was observed in 37 patients. Preoperative diagnosis was established in all patients by transthoracic echocardiography. All patients were operated through median sternotomy. RESULTS Ninety-five patients (97%) survived the operation. Mean tumor dimension was 2.7±1.3 cm in largest diameter. According to the St. John Sutton classification (St. John Sutton MG, Mercier LA, Giuliani ER, et al. Atrial myxomas: a review of clinical experience in 40 patients. Mayo Clin Pro 1980;55:371-6), solid tumors were detected in 43 patients (44%), while a papillary myxoma was found in 55 patients (56%). The follow-up was 100% complete, and the mean time to last follow-up was 98±60 months. Of the 95 survivors, 3 patients (3%) died at a mean follow-up of 72±45 months after surgery. Actuarial survival was 98%, 98%, and 89% at 5, 10, and 15 years, respectively. One patient operated for left atrial myxoma resection showed a recurrence 68 months after the first surgery. CONCLUSIONS Although cardiac myxomas carry the risk of severe systemic and cardiac symptoms, prompt surgical excision gives excellent early and long-term results.

Dual Antiplatelet Regime Versus Acetyl-acetic Acid for Carotid Artery Stenting

Carotid artery stenting has been proposed as an option treatment of carotid artery stenosis. The aim of this single-institution study is to compare the dual-antiplatelet treatment and heparin combined with acetyl-acetic acid, in patients who underwent carotid artery stenting. We compared 2 groups of 50 patents each who underwent carotid artery stenting for primary atherosclerotic disease. Group A received heparin for 24 h combined with 325 mg acetyl-acetic acid and group B received 250 mg ticlopidine twice a day combined with 325 mg acetyl-acetic acid. Outcome measurements included 30-day bleeding and neurological complications and 30-day thrombosis/occlusion rates. The neurological complications were 16% in group A and 2% in group B (p < 0.05). Bleeding complications occurred in 4% in group A and 2% in group B (p > 0.05). The 30-day thrombosis/occlusion rate was 2% in group A and 0% in group B (p > 0.05). Dual antiplatelet treatment is recommended in all patients undergoing carotid artery stenting.

Endovascular Techniques for the Treatment of Ruptured Abdominal Aortic Aneurysms: 7-year Intention-to-treat Results

ObjectivesThe purpose of this single-institution study was to describe our 7-year intention-to-treat results, obtained with the use of endovascular techniques for the treatment of ruptured abdominal aortic aneurysms (rAAA).Patients and MethodsFrom October 1998 until March 2005, a total of 28 patients were admitted or transferred to our department with an rAAA. They were all treated according to a management protocol of intention-to-treat with endovascular techniques. Twenty of the patients received endovascular treatment and the remaining 8 underwent an open surgery procedure.ResultsThe mortality rate of the endovascularly treated patients was 40% (8 in 20), whereas of the 8 surgical patients 3 survived (mortality = 62.5%). The overall mortality rate of the 28 patients admitted with an rAAA was 46.4% (13 of 28 patients).ConclusionsIn our experience the intension-to-treat protocol for rAAA offered acceptable results in terms of mortality rates. Multi-center studies are necessary to establish the role of endovascular treatment in patients with rAAA.

Twenty-Five Year Outcomes of Tricuspid Valve Replacement Comparing Mechanical and Biologic Prostheses

BACKGROUND Tricuspid valve replacement (TVR) has historically been associated with high mortality and morbidity, and current knowledge of long-term results of TVR is limited. This study reviewed our experience from a consecutive series at 2 institutions. METHODS Ninety patients (65 women [72%]; mean age, 53.8 ± 14.2 years; mean body surface area, 1.6 ± 0.2 m(2)) underwent TVR between January 1980 and December 2005. The etiology was secondary to left-heart valve disease in 56 patients (62%), degenerative disease in 16 (18%), Ebstein anomaly in 7 (8%), and endocarditis in 11 (12%). Seventy patients (78%) were in New York Heart Association class III or IV. Sixty patients (67%) underwent redo procedures. TVR was with a mechanical valve in 46 patients (51%) and a biologic prosthesis in 44 (49%). RESULTS The overall operative mortality was 17.7% (16 patients). During follow-up, 16 of the 74 survivors died. Kaplan-Meier survival at 5, 10, and 15 years was, respectively, 72%, 65%, and 63%. During follow-up, 16 patients (21.6%) underwent reoperation; among them, 8 with a mechanical valve underwent reoperation for tricuspid valve thrombosis and 6 with a biologic prosthesis for tricuspid valve deterioration. However, freedom from reoperation at 5 and 10 years was similar between mechanical (86% and 76%) and bioprostheses (97% and 83%). All 16 patients survived the reoperation. CONCLUSIONS The present experience suggests that the type of implanted prosthesis in the tricuspid position does not affect early and long-term outcomes or the reoperation rate. Timely referral before end-stage cardiac impairment develops could determine further outcomes improvement.

Aortic Neck Dilatation and Endograft Migration are Correlated with Self-Expanding Endografts:

Purpose: To compare self-expanding and balloon-expandable stent-grafts in terms of aortic neck dilatation and endograft migration. Method: Two-hundred and forty-two patients (178 men; mean age 68 years, range 56–91) underwent elective endovascular repair of abdominal aortic aneurysm. Two-hundred self-expanding (115 Excluder, 48 Endologix, 23 Vanguard, 10 Anaconda, and 4 Talent) and 42 balloon-expandable (Lifepath) endografts were used. All patients underwent contrast-enhanced computed tomography (CT) prior to the intervention, at 1, 3, and 6 months after the procedure, and annually thereafter. Comparison was made between the first and the last followup CT scans. Results: Fifty-five (27.5%) of the 200 patients treated with self-expanding endografts had aortic neck dilatation compared to only 3 (7.1%) of the 42 patients treated with balloon-expandable endografts (p=0.023). Forty-nine (24.5%) patients in the self-expanding group versus only 3 (7.1%) patients of the balloon-expandable group presented with endograft migration (p=0.034); all had dilated necks. The difference between the means of neck dilatation for the Lifepath balloon-expandable stent-graft and the Excluder self-expanding endoprosthesis was statistically significant (p=0.011, 95% CI 0.07 to 0.91). Conclusion: Aortic neck dilatation following endovascular AAA repair appears to be correlated with self-expanding endografts, which may contribute to a higher incidence of graft migration compared to that occurring with balloon-expandable endografts.

Randomized control study of the outback LTD reentry catheter versus manual reentry for the treatment of chronic total occlusions in the superficial femoral artery

To assess the efficacy and safety of the Outback device in patients with a chronic total occlusion (CTO) of the superficial femoral artery and evaluate its impact on fluoroscopy and procedural times.

Aortic neck evolution after endovascular repair with TriVascular Ovation stent graft

OBJECTIVE Aortic neck dilation has been reported after endovascular aneurysm repair (EVAR) with self-expanding devices. With a core laboratory analysis of morphologic changes, this study evaluated midterm results of aortic neck evolution after EVAR by endograft with no chronic outward force. METHODS This was a multicenter registry of all patients undergoing EVAR with the Ovation endograft (TriVascular, Santa Rosa, Calif). Inclusion criteria were at least 24 months of follow-up. Standard computed tomography (CT) scans were reviewed centrally using a dedicated software with multiplanar and volume reconstructions. Proximal aortic neck was segmented into zone A (suprarenal aorta/fixation area), zone B (infrarenal aorta, from lowest renal artery to the first polymer-filled ring), and zone C (infrarenal aorta, at level of the first polymer-filled ring/sealing zone). Images were analyzed for neck enlargement (≥2 mm), graft migration (≥3 mm), endoleak, barb detachment, neck bulging, and patency of the celiac trunk and superior mesenteric and renal arteries. RESULTS Inclusion criteria were met in 161 patients (mean age, 75.2 years; 92% male). During a mean follow-up period of 32 months (range, 24-50), 17 patients died (no abdominal aortic aneurysm-related death). Primary clinical success at 2 years was 95.1% (defined as absence of aneurysm-related death, type I or type III endoleak, graft infection or thrombosis, aneurysm expansion >5 mm, aneurysm rupture, or conversion to open repair). Assisted primary clinical success was 100%. CT scan images at a minimum follow-up of 2 years were available in 89 cases. Patency of visceral arteries at the level of suprarenal fixation (zone A) was 100%. Neither graft migration nor barb detachment or neck bulging was observed. None of the patients had significant neck enlargement. The mean change in the diameter was 0.18 ± 0.22 mm at zone A, -0.32 ± 0.87 mm at zone B, and -0.06 ± 0.97 mm at zone C. Changes at zone B correlated significantly with changes at zone C (correlation coefficient, 0.183; P = .05), whereas no correlation was found with zone A (correlation coefficient, 0.000; P = 1.0). CONCLUSIONS No aortic neck dilation occurred in this series at CT scan after a minimum 24-month follow-up. This may suggest that aortic neck evolution is not associated with EVAR at midterm follow-up when an endograft with no chronic outward radial force is implanted.

Endovascular repair of traumatic thoracic aortic injury: final results from the relay endovascular registry for thoracic disease.

BACKGROUND In blunt thoracic aortic injury, thoracic endovascular aortic repair (TEVAR) offers a less invasive alternative to open chest surgery. New reliable and accurate stent grafts have widened the endovascular treatment options. We report our experience with the Relay stent graft Bolton Medical, Sunrise, FL; Barcelona, Spain) for treatment of this injury. METHODS Relay Endovascular Registry for Thoracic Disease (RESTORE) is a multicenter, prospective European registry, which enrolled patients treated with the Relay stent graft for thoracic aortic diseases from April 2005 to January 2009. Regular follow-up examinations were conducted for up to 24 months. This paper analyzes the cohort of patients treated for traumatic aortic injury. RESULTS Forty adult trauma patients from 12 European centers underwent TEVAR. Mean age was 40 years and 34 patients were male. The proximal landing zone involved aortic arch zones 1 to 2 in 40% and zone 3 in 55% of procedures. Technical success was achieved in all cases. One (2.5%) patient suffered a rupture of the iliac artery. No patient developed procedure-related paraplegia or required conversion to open surgery. Follow-up imaging demonstrated complete exclusion of the traumatic tear and regression of the false aneurysms without endoleak or graft infolding. One late device-related complication was reported; penetration of the distal end of the stent graft treated by stent-graft extension. Thirty-day mortality was 2.5 % (n = 1), and late mortality 2.5% due to a secondary accident. Actuarial 2-year survival was 93.7%. CONCLUSIONS Thoracic endovascular aortic repair with the Relay stent graft is a safe and effective treatment for patients with traumatic aortic injury.

Late Gastrointestinal Bleeding After Infrarenal Aortic Grafting: A 16-Year Experience

PurposeTo review the manifestation and management of gastrointestinal (GI) bleeding caused by secondary aortoenteric fistula (AEF) after infrarenal aortic grafting.MethodsBetween 1991 and 2006, nine patients underwent emergency treatment for secondary AEF localized in the duodenum (78%), ileum (11%), or sigmoid colon (11%). Three (33%) patients suffered hypovolemic shock. There were two (22%) real fistulas and seven (78%) paraprosthetic fistulas. Graft infection was confirmed in four (45%) patients and four (45%) had proximal sterile pseudoaneurysms. Surgical management consisted of graft removal with (n = 5) or without simultaneous extra-anatomic bypass (n = 1), in situ Dacron graft interposition (n = 3), ileo-duodenorrhaphy (n = 8), sigmoidectomy with colostomy (n = 1), and segmentary ileectomy (n = 1). Endografting was used only as a temporary measure to control bleeding in two patients.ResultsThe mortality rate was 55% (n = 5). There were no intraoperative deaths, but 75% of the septic patients, 66% of those with preoperative hemodynamic instability, 50% of those with pseudoaneurysms, and 100% of those who required bowel resection died during the early postoperative period. Moreover, all of the surviving patients suffered early postoperative morbidity, resulting in prolonged intensive care unit stay and hospitalization.ConclusionsSecondary AEF is life-threatening, difficult to treat, and associated with high morbidity and mortality, especially in patients with sepsis or hemodynamic instability and those requiring bowel resection.

Endovascular Treatment of the Carotid Stump Syndrome

In patients with an occluded internal carotid artery, the carotid stump syndrome is a potential source of microemboli that pass through the ipsilateral external carotid artery and the ophthalmic artery to the territory of the middle cerebral artery. Thus, the syndrome is associated with carotid territory symptoms although the internal carotid artery is occluded. Surgical exclusion of the internal carotid artery associated with endarterectomy of the external carotid artery has been described as the gold standard of treatment by many authors. This report is the second case, to our knowledge, of endovascular treatment of the carotid stump syndrome with the use of a stent-graft.