Jeffrey P. Wood

Surgical versus endovascular treatment of acute thoracic aortic rupture: a single-center experience

BACKGROUND Surgical management of acute thoracic aortic ruptures is controversial, especially in patients with preexisting comorbidities; associated mortality and paraplegia rates remain high. It was our objective to evaluate whether treating these patients acutely with endovascular stent grafts would improve their outcome. METHODS From November 1999 to February 2002 a total of 54 patients, age 28 to 83 years, were admitted to our institution with an acute rupture of the thoracic aorta (24 ruptured aneurysms, 14 perforated type B dissections, 16 traumatic ruptures). Twenty-eight patients were managed surgically using cardiopulmonary bypass (group 1), and 26 patients were treated acutely with an endovascular stent graft (group 2). The resuscitation protocol and interval from onset of symptoms to treatment was comparable in both groups. Medical records were reviewed for prehospitalization and emergency department data, operative findings, and outcomes. RESULTS There were 5 of 28 deaths (17.8%) in the surgical group and 1 of 26 deaths (3.8%) in the endovascular group. In the surgical group 1 of 28 patients (3.6%) exhibited paraplegia; there were no cases of paraplegia in the endovascular group. There were 4 of 28 cases (14.3%) of renal failure in group 1 and 1 of 26 (3.8%) in group 2. In group 1, 8 patients (28.6%) required mechanical ventilation for more than 48 hours; there were 2 of 26 patients (7.7%) in group 2 with this ventilatory requirement. Three patients required a repeat thoracotomy for hemorrhage in the surgical group. There were two access failures in the endovascular group. CONCLUSIONS In the treatment of acute ruptures of the thoracic aorta, the immediate outcome of patients treated with endovascular stent grafts appears to be better than with management by conventional surgical repair.

Vacuum-assisted suction drainage versus conventional treatment in the management of poststernotomy osteomyelitis

OBJECTIVE The purpose of our study was to compare vacuum-assisted suction drainage (VASD) to conventional wound management, in the treatment of poststernotomy osteomyelitis (SOM). METHODS We included a total of 42 patients that developed poststernotomy osteomyelitis and required open wound management, between 1998 and 2000, in this study. Twenty of these patients were treated by VASD and the other 22 by conventional wound management. The patients were well comparable with regards to age, presenting postoperative day, infecting organism and risk factors for osteomyelitis. This was a retrospective study. RESULTS The patients treated by VASD had a significantly reduced treatment duration (mean 17.2+/-5.8 vs. 22.9+/-10.8 days, P=0.009) and total hospital stay (mean 27.2+/-6.5 vs. 33.0+/-11.0 days, P=0.03). Perioperative mortality was similar, with one early death in each group. CONCLUSION We conclude from our experience in the treatment of 42 patients with poststernotomy osteomyelitis that VASD shortened wound healing and hospital stay and thus proved to be an excellent alternative to conventional open management of these wounds.

The clamshell approach for the treatment of extensive thoracic aortic disease

OBJECTIVE Management of extensive thoracic aortic disease may present an immense technical challenge. The choice of surgical access and subsequent exposure determines whether a single-stage or a 2-stage approach can be adopted. METHODS Fifteen patients with extensive thoracic aortic disease underwent resection of the ascending aorta, the aortic arch, and varying segments of the descending aorta. Four patients had concomitant coronary artery bypass grafting and 3 patients had aortic valve reconstruction. All patients were treated with a single-stage approach via a bilateral anterior thoracosternotomy (clamshell incision). RESULTS There was 1 hospital death (6.6%). Two patients required reoperation for bleeding (13.3%). Two patients needed mechanical ventilation for more than 48 hours. Three patients suffered a stroke (20%). Two patients (13.3%) had transient neurologic dysfunction. None of the patients had renal failure. There were no wound infections in this group. CONCLUSION The single-stage approach, via a clamshell incision, is a safe and effective procedure for patients who require treatment of extensive thoracic aortic disease and concomitant cardiac lesions.

Emergent endovascular stent grafting for perforated acute type B dissections and ruptured thoracic aortic aneurysms

BACKGROUND The purpose of our study was to demonstrate the effectiveness of endovascular stent grafts in the treatment of acutely ruptured thoracic aortic aneurysms and type B dissections as an alternative to the conventional surgical approach in an emergency setting. METHODS From January 2001 to October 2001, we deployed 11 emergent endovascular stent grafts into the thoracic aorta. We treated seven ruptured aortic aneurysms and four acutely perforated type B dissections. Aortic rupture was confirmed preoperatively by spiral computed tomography. In all cases, hemothorax was present. The average interval from onset of symptoms to treatment was 28.5 hours. We used nine Talent and two Excluder stent grafts. RESULTS Deployment of the stent grafts was successful in nine cases. There were two cases of access failure due to small caliber of iliac arteries, and 1 of these patients died shortly after the procedure was abandoned, At 12 months of follow-up, there were no cases of paraplegia, stent migration, or endoleaks. There was, however, one temporary renal failure, and 2 patients required mechanical ventilation for more than 48 hours. CONCLUSIONS Our experiences with emergency endovascular stent grafting show that the procedure is technically feasible, with less morbidity and mortality than conventional open surgery, in high-risk patients.

Comparative evaluation of left ventricular mass regression after aortic valve replacement: a prospective randomized analysis

BackgroundWe assessed the hemodynamic performance of various prostheses and the clinical outcomes after aortic valve replacement, in different age groups.MethodsOne-hundred-and-twenty patients with isolated aortic valve stenosis were included in this prospective randomized randomised trial and allocated in three age-groups to receive either pulmonary autograft (PA, n = 20) or mechanical prosthesis (MP, Edwards Mira n = 20) in group 1 (age < 55 years), either stentless bioprosthesis (CE Prima Plus n = 20) or MP (Edwards Mira n = 20) in group 2 (age 55-75 years) and either stentless (CE Prima Plus n = 20) or stented bioprosthesis (CE Perimount n = 20) in group 3 (age > 75). Clinical outcomes and hemodynamic performance were evaluated at discharge, six months and one year.ResultsIn group 1, patients with PA had significantly lower mean gradients than the MP (2.6 vs. 10.9 mmHg, p = 0.0005) with comparable left ventricular mass regression (LVMR). Morbidity included 1 stroke in the PA population and 1 gastrointestinal bleeding in the MP subgroup. In group 2, mean gradients did not differ significantly between both populations (7.0 vs. 8.9 mmHg, p = 0.81). The rate of LVMR and EF were comparable at 12 months; each group with one mortality. Morbidity included 1 stroke and 1 gastrointestinal bleeding in the stentless and 3 bleeding complications in the MP group. In group 3, mean gradients did not differ significantly (7.8 vs 6.5 mmHg, p = 0.06). Postoperative EF and LVMR were comparable. There were 3 deaths in the stented group and no mortality in the stentless group. Morbidity included 1 endocarditis and 1 stroke in the stentless compared to 1 endocarditis, 1 stroke and one pulmonary embolism in the stented group.ConclusionsClinical outcomes justify valve replacement with either valve substitute in the respective age groups. The PA hemodynamically outperformed the MPs. Stentless valves however, did not demonstrate significantly superior hemodynamics or outcomes in comparison to stented bioprosthesis or MPs.

Endovaskuläre Interventionen der thorakalen Aorta descendens

ZusammenfassungEndovaskuläre Eingriffe an der deszendierenden thorakalen Aorta haben sich in den letzten 10 Jahren als Alternative zur offenen chirurgischen Therapie etabliert. Zunächst war der Einsatz von endovaskulären Stentgrafts auf elektive Patienten mit einem Hochrisikoprofil für eine offene Operation beschränkt. Doch die Indikation wurde bald auch auf den notfallmäßigen Einsatz ausgeweitet.Bei elektiven Eingriffen an der deszendierenden thorakalen Aorta führte die endovaskuläre Therapie zu einem deutlichen Absinken der perioperativen Mortalität und Morbidität (Tabellen 1 und 2). Diese hervorragenden perioperativen Ergebnisse konnten auch in der Notfallsituation reproduziert werden und waren daher der offenen chirurgischen Therapie deutlich überlegen (Tabelle 3). Es bleibt die Frage der Langzeithaltbarkeit endovaskulärer Prothesen. Während Patienten nach offener chirurgischer Therapie kaum mit Spätkomplikationen rechnen müssen, wird in der Literatur von Stentgraftversagen im späten Verlauf berichtet (Abbildungen 1 und 2). Das Auftreten von Endoleaks (Abbildungen 3 und 4), Rupturen des Aneurysmasacks, Graftmigration und Materialverschleiß an den Stentgrafts wirft Fragen bezüglich der Langzeithaltbarkeit auf. Im Lichte dieser Spätkomplikationen bleibt die regelmäßige Nachsorge dieser Patienten notwendig, um letztendlich eine valide Aussage über Vorteile und Risiken dieser innovativen Technologie machen zu können.AbstractEndovascular interventions of the descending thoracic aorta have been established as an alternative to conventional open surgery. Initially, they were limited to elective patients with a high risk profile for open surgery, but soon their use was extended to emergencies as well.In the elective setting, endovascular interventions significantly lowered short-term morbidity and mortality. These excellent perioperative results were reproducible in the emergency setting, thereby leading to superior outcomes for patients treated by endovascular stent grafts when compared to the conventional open surgical approach. However, some questions regarding long-term durability of these devices remain unanswered. Stent-graft failures at midand long-term follow-up have been reported in the literature. The progressive nature of stent graft-related mid- and long-term complications stresses the need for continued surveillance of these patients.

Endovascular interventions of the descending thoracic aorta

ZusammenfassungEndovaskuläre Eingriffe an der deszendierenden thorakalen Aorta haben sich in den letzten 10 Jahren als Alternative zur offenen chirurgischen Therapie etabliert. Zunächst war der Einsatz von endovaskulären Stentgrafts auf elektive Patienten mit einem Hochrisikoprofil für eine offene Operation beschränkt. Doch die Indikation wurde bald auch auf den notfallmäßigen Einsatz ausgeweitet.Bei elektiven Eingriffen an der deszendierenden thorakalen Aorta führte die endovaskuläre Therapie zu einem deutlichen Absinken der perioperativen Mortalität und Morbidität (Tabellen 1 und 2). Diese hervorragenden perioperativen Ergebnisse konnten auch in der Notfallsituation reproduziert werden und waren daher der offenen chirurgischen Therapie deutlich überlegen (Tabelle 3). Es bleibt die Frage der Langzeithaltbarkeit endovaskulärer Prothesen. Während Patienten nach offener chirurgischer Therapie kaum mit Spätkomplikationen rechnen müssen, wird in der Literatur von Stentgraftversagen im späten Verlauf berichtet (Abbildungen 1 und 2). Das Auftreten von Endoleaks (Abbildungen 3 und 4), Rupturen des Aneurysmasacks, Graftmigration und Materialverschleiß an den Stentgrafts wirft Fragen bezüglich der Langzeithaltbarkeit auf. Im Lichte dieser Spätkomplikationen bleibt die regelmäßige Nachsorge dieser Patienten notwendig, um letztendlich eine valide Aussage über Vorteile und Risiken dieser innovativen Technologie machen zu können.AbstractEndovascular interventions of the descending thoracic aorta have been established as an alternative to conventional open surgery. Initially, they were limited to elective patients with a high risk profile for open surgery, but soon their use was extended to emergencies as well.In the elective setting, endovascular interventions significantly lowered short-term morbidity and mortality. These excellent perioperative results were reproducible in the emergency setting, thereby leading to superior outcomes for patients treated by endovascular stent grafts when compared to the conventional open surgical approach. However, some questions regarding long-term durability of these devices remain unanswered. Stent-graft failures at midand long-term follow-up have been reported in the literature. The progressive nature of stent graft-related mid- and long-term complications stresses the need for continued surveillance of these patients.

Endovaskuläre Interventionen der thorakalen Aorta descendens@@@Endovascular Interventions of the Descending Thoracic Aorta

ZusammenfassungEndovaskuläre Eingriffe an der deszendierenden thorakalen Aorta haben sich in den letzten 10 Jahren als Alternative zur offenen chirurgischen Therapie etabliert. Zunächst war der Einsatz von endovaskulären Stentgrafts auf elektive Patienten mit einem Hochrisikoprofil für eine offene Operation beschränkt. Doch die Indikation wurde bald auch auf den notfallmäßigen Einsatz ausgeweitet.Bei elektiven Eingriffen an der deszendierenden thorakalen Aorta führte die endovaskuläre Therapie zu einem deutlichen Absinken der perioperativen Mortalität und Morbidität (Tabellen 1 und 2). Diese hervorragenden perioperativen Ergebnisse konnten auch in der Notfallsituation reproduziert werden und waren daher der offenen chirurgischen Therapie deutlich überlegen (Tabelle 3). Es bleibt die Frage der Langzeithaltbarkeit endovaskulärer Prothesen. Während Patienten nach offener chirurgischer Therapie kaum mit Spätkomplikationen rechnen müssen, wird in der Literatur von Stentgraftversagen im späten Verlauf berichtet (Abbildungen 1 und 2). Das Auftreten von Endoleaks (Abbildungen 3 und 4), Rupturen des Aneurysmasacks, Graftmigration und Materialverschleiß an den Stentgrafts wirft Fragen bezüglich der Langzeithaltbarkeit auf. Im Lichte dieser Spätkomplikationen bleibt die regelmäßige Nachsorge dieser Patienten notwendig, um letztendlich eine valide Aussage über Vorteile und Risiken dieser innovativen Technologie machen zu können.AbstractEndovascular interventions of the descending thoracic aorta have been established as an alternative to conventional open surgery. Initially, they were limited to elective patients with a high risk profile for open surgery, but soon their use was extended to emergencies as well.In the elective setting, endovascular interventions significantly lowered short-term morbidity and mortality. These excellent perioperative results were reproducible in the emergency setting, thereby leading to superior outcomes for patients treated by endovascular stent grafts when compared to the conventional open surgical approach. However, some questions regarding long-term durability of these devices remain unanswered. Stent-graft failures at midand long-term follow-up have been reported in the literature. The progressive nature of stent graft-related mid- and long-term complications stresses the need for continued surveillance of these patients.