Jeko Metodiev Madjarov

Spontaneous splanchnic dissection: Application and timing of therapeutic options

BACKGROUND Spontaneous splanchnic dissection (SSD) occurs infrequently and has a poorly defined natural history. Few studies address the application, timing, and consequences of therapeutic options. Our goal was to apply conservative (non-operative) management in the care of each patient, reserving interventions for specific indications that may be predictive of adverse outcomes. METHODS Between 2003 and 2008, 10 consecutive patients (mean age 54.7-years-old, 70.0% male) presented with 11 SSDs involving either the celiac artery (n = 6), superior mesenteric artery (n = 3), or both (n = 1). Each patient had acute, spontaneous onset of persistent abdominal pain and was diagnosed with SSD following multidetector row computed tomographic angiography (CTA). Non-operative management (anticoagulation, anti-impulse therapy, analgesics, and serial CTA examinations) was initially used in 9 patients. Endovascular (n = 2) or operative (n = 2) intervention was performed either immediately (n = 1) or following failed medical management (n = 3) in 4 patients for specific indications that included persistent symptoms (n = 3), expansion of false lumen (n = 3), and/or radiologic malperfusion (n = 3). RESULTS All patients were asymptomatic after successful non-operative management or following intervention. No morbidity occurred. Upon complete follow-up (mean 13.4 months, range, 2 to 36 months), all patients remained asymptomatic. Preservation of distal perfusion with either thrombosis or ongoing regression of false lumen was achieved in 5 patients who received only non-operative management and in 4 patients following intervention. A stable chronic dissection was present in 1 patient who had only non-operative management. CONCLUSION Successful outcomes following SSD may be achieved with either non-operative therapy alone or intervention if persistent symptoms, expansion of false lumen, and/or malperfusion occur. The unpredictable response of the false lumen to conservative management mandates close, long-term follow-up. Endovascular and operative interventions produced similar outcomes in a small number of patients with limited follow-up. Although SSD is currently perceived as rare, the increasing use of CTA may prove that the true incidence has been underestimated.

Quality Improvement Program Increases Early Tracheal Extubation Rate and Decreases Pulmonary Complications and Resource Utilization After Cardiac Surgery

Abstract  Background: Early tracheal extubation is a common goal after cardiac surgery and may improve postoperative outcomes. Our study evaluates the impact of a quality improvement program (QIP) on early extubation, pulmonary complications, and resource utilization after cardiac surgery. Methods: Between 2002 and 2006, 980 patients underwent early tracheal extubation (<6 hours after surgery) and 1231 had conventional extubation (> 6 hours after surgery, conventional group). Outcomes compared between the two groups included: (1) pneumonia, (2) sepsis, (3) intensive care unit (ICU) length of stay, (4) hospital length of stay, (5) ICU readmission, and (6) reintubation. Logistic regression analysis and propensity score adjustment were used to adjust for imbalances in the patients’ preoperative characteristics. Results: Early extubation rates were significantly increased with QIP (QIP 53% vs. Non‐QIP 38%, p = 0.01). Early extubation was associated with a lower rate of (1) pneumonia (odds ratio [OR]= 0.35, 95% confidence intervals [CI]= 0.22–0.55, p <0.001), (2) sepsis (OR = 0.38, CI = 0.20–0.74, p <0.004), (3) prolonged ICU length of stay (OR = 0.42, CI = 0.35–0.50, p <0.001), (4) hospital length of stay (OR = 0.37, CI = 0.29–0.47, p <0.001), (5) ICU readmission (OR = 0.55, CI = 0.39–0.78, p <0.001), and (6) reintubation (OR = 0.53, CI = 0.34–0.81, p <0.003) both in multivariable logistic regression analysis and propensity score adjustment. Conclusions: QIP and early tracheal extubation reduce pulmonary complications and resource utilization after cardiac surgery.

PC034. Disparities in Outcomes between Genders in Patients With Type B Aortic Dissection Treated With Thoracic Endovascular Aortic Repair

reintervention had a greater renal stent distance (mean, 1.73 6 0.62 stents), as measured from the renal fenestration to the end of the stent, compared with those who did not need an additional renal procedure (2.84 6 0.96 cm vs 2.65 6 1.26 cm; P 1⁄4 .048). Other parameters including preoperative aortic diameter at the renal level, aortic stent graft diameter, and fenestration to renal ostium distance were similar between the two groups (P > .05). Conclusions: There is a trend observed for higher renal reintervention rates with a longer renal stent length. Other variables, such as preoperative aortic diameter, aortic stent graft size, and fenestration to renal ostium distance do not affect renal reinterventions.

Retrograde type A dissection after thoracic endovascular aortic repair for type B aortic dissection

Background: The purpose of this study was to evaluate clinical, anatomic, and procedural characteristics of patients who developed retrograde type A dissection (RTAD) after thoracic endovascular aortic repair (TEVAR) for type B aortic dissection (TBAD). Methods: Between January 2012 and January 2017, there were 186 patients who underwent TEVAR for TBAD at a multidisciplinary aortic center. Patients who developed RTAD after TEVAR (n = 15) were compared with those who did not (no‐RTAD group, n = 171). Primary outcomes were survival and need for reintervention. Results: The incidence of RTAD in our sample was 8% (n = 15). Kaplan‐Meier estimates found that no‐RTAD patients had better survival (P = .04). Survival rates at 30 days, 1 year, and 3 years were 93%, 60%, and 60% for RTAD patients and 94%, 87%, and 80% for no‐RTAD patients. One RTAD was diagnosed intraoperatively, 5 were diagnosed within 30 days of the index procedure, 6 were diagnosed within 1 year, and 3 were diagnosed after 1 year. Reintervention for RTAD was undertaken in 10 of 15 patients, with a 50% survival rate after reintervention. Partial or complete false lumen thrombosis was more frequently present in RTAD patients (P = .03). RTAD patients more frequently presented with renal ischemia (P = .04). Most RTAD patients (93%, RTAD patients; 64%, no‐RTAD patients; P = .02) had a proximal landing zone in zone 0, 1, or 2. Aortic diameter was more frequently ≥40 mm in the RTAD group (47%, RTAD patients; 21%, no‐RTAD patients; P = .05). Patients with RTAD had stent grafts placed in the renovisceral arteries for complicated dissections, and this approached significance (P = .05). Three RTAD patients had a type II arch (20%) compared with 53 no‐RTAD patients (31%; P = .6), but a comparison of type II arch with type I or type III found no statistical significance (P = .6). No correlations were found between ratio of descending to ascending diameters, average aortic sizing, graft size, or bare‐metal struts at proximal attachment zone and development of RTAD. We found no statistically significant differences in demographics, genetic disease, comorbidities, or previous repairs. Conclusions: The development of RTAD after TEVAR for TBAD does not appear to be correlated with any easily identifiable demographic feature but appears to be correlated with proximal landing zones in zone 1 and 2 and an ascending diameter >4 cm. Furthermore, the presence of partial or complete false lumen thrombosis as well as more complicated presentation with renal ischemia was significantly more frequent in patients with RTAD. TBAD patients should be observed long term, as type A dissections in our patients occurred even after 1 year.

Right Atrial Anomalous Muscle Bundle Presenting with Acute Superior Vena Cava Syndrome and Pulmonary Embolism: Surgical Management

BACKGROUND An anomalous muscle bundle (AMB) crossing the right atrial cavity represents a pathologic finding with unproved clinical significance. This congenital anomaly may be difficult to recognize via echocardiography and could be confused with other intracavitary lesions. METHODS We report the case of a 53-year-old woman presented to the cardiovascular service with acute superior vena cava (SVC) syndrome and submassive pulmonary embolism. RESULTS The patient underwent venography, confirming SVC stenosis. A ventilation/perfusion lung scan showed 2 sizable perfusion defects because of pulmonary embolism. Magnetic resonance imaging and echocardiography imaging demonstrated a right atrium (RA) mass. Surgery was then carried out using standard cardiopulmonary bypass; the right atrial muscle bundle was excised, and SVC reconstruction was performed. The patient was discharged uneventfully and remains symptom-free at 2-year follow-up. CONCLUSIONS In cases of nonmalignant pathology of SVC syndrome, appropriate studies should be conducted to exclude potential congenital abnormalities such as this AMB in the RA. Open-heart surgery is a viable treatment option in select cases.

Early Surgical Reconstruction of Sternum with Longitudinal Rigid Polymer Plating after Acute Chest Trauma

Purpose: The surgical management of the patients with traumatic sternal fractures remains controversial. The aim of this study was to evaluate the effectiveness of an early surgical reconstruction of a displaced sternal fracture utilizing longitudinal rigid polymer fixation in the settings of an acute chest trauma. Methods: To perform the sternal fixation, we utilized a longitudinal rigid plating system. The plate is made of polyether ether ketone (PEEK), an organic thermoplastic polymer. Results: We used the entire length of the plate on each side of the fracture, secured in multiple places with 6–8 screws. Once the plates have been fully secured we tighten all the screws with a screwdriver. We demonstrated that the method minimizes pain and prevents the development of pulmonary complications. Conclusion: This technique provides cosmetically acceptable results, minimizing risk of sternal nonunion, and decreases length of hospitalization.

Successful Repair of Acute Type B and Retrograde Type A Aortic Dissection With Kidney Ischemia

Acute dissection of thoracic aorta carries a risk of renal ischemia followed by the development of a kidney failure. The optimal surgical and nonsurgical management of these patients, timing of intervention, and the factors predicting renal recovery are not well delineated and remain controversial. We present a case of acute type B thoracic aortic dissection with left kidney ischemia. Evaluation of renal function was performed by the means of internationally accepted Risk, Injury, Failure, Loss of kidney function, End stage kidney disease and Acute Kidney Injury Network classifications for acute kidney injury, renal duplex sonography, and intravascular ultrasound that demonstrated left renal artery dissection with a flap completely compressing the true lumen. The patient underwent thoracic endovascular aortic repair and left renal artery stent and recovered well. Six months later, at the follow-up visit, retrograde type A aortic dissection was found, which was successfully repaired. Reversal of renal ischemia after aortic dissection depends on the precise assessment of renal function and prompt intervention.

An Extrapericardial Minimally Invasive Approach for Implantable Cardioverter Defibrillator

Abstract The indications for placement of an implantable cardioverter defibrillators (ICDs) have greatly expanded over the last years. However, standard transvenous approach is not suitable for a subset of patients who cannot benefit from ICD therapy. Here, we have demonstrated the feasibility and efficacy of extrapericardial ICD placement through a minimally invasive access in intact hearts as well as in postmyocardial infarction large animal models. Based on our data, we conclude that extrapericardial ICD placement is a feasible approach that may be a valuable alternative or adjunct to current defibrillator lead systems.

Endovascular repair of an innominate artery pseudoaneurysm using the Valiant Mona LSA branched graft device

A 60-year-old woman involved in a motor vehicle collision presented with a traumatic pseudoaneurysm of the innominate artery origin in addition to multiple concomitant injuries. She was classified as a high-risk candidate for open repair. An experimental thoracic branched graft device was used for coverage of the injury with the addition of a right carotid-to-left carotid-to-left subclavian artery bypass. Follow-up imaging showed resolution of the pseudoaneurysm and patency of her bypass grafts. This is the first described use of the Mona LSA Branch Thoracic Stent Graft System (Medtronic, Minneapolis, Minn) in the innominate artery.

Ethnic disparities in outcomes of patients with complicated type B aortic dissection

Objective: The objective of this study was to evaluate the difference in outcomes after endovascular intervention in patients with complicated type B aortic dissection (TBAD) based on ethnicity and blood pressure control. Methods: Between 2012 and 2016, there were 126 patients who underwent endovascular procedures for complicated TBAD at a single‐institution quaternary referral center. Patients self‐identified as African American (n = 53), white (n = 70), and Asian (n = 3). African American and white patients were compared on a number of variables, including age, ethnicity, insurance type, blood pressure, comorbidities, number of previous interventions, and number of antihypertension medications they were taking before intervention. Primary outcomes were survival and need for reintervention. Results: Kaplan‐Meier estimates for survival for African Americans vs whites were 94% vs 89%, 91% vs 83%, 89% vs 79%, and 89% vs 76% at 30 days, 1 year, 3 years, and 5 years, respectively (P = .05). African Americans were younger overall (52.5 ± 11 years) vs whites (63.7 ± 14.7 years; P < .0001). African Americans required a significantly greater number of reinterventions (P = .007). They also had higher rates of chronic kidney disease (P = .01), smoking (P = .03), and cocaine use (P = .02) and were more likely to be on Medicaid (P = .02). Hypertension was poorly controlled in both groups, with the percentage of patients with uncontrolled hypertension (systolic >140 mm Hg) preoperatively, postoperatively, and 30 days after intervention at 32%, 32%, and 39%. There was no significant difference between the cohorts in uncontrolled hypertension preoperatively (P = .39) or postoperatively (P = .63). However, more African Americans had uncontrolled hypertension at 30 days (African Americans, 49%; whites, 31%; odds ratio, 2.1; P = .09). African Americans were taking a greater number of antihypertension medications at presentation than whites (P = .01) and specifically had higher use rates of beta blockers (P = .02), diuretics (P = .02), and angiotensin‐converting enzyme inhibitors (P = .04). Conclusions: African Americans with TBAD present at a younger age than their white counterparts do and have a survival advantage up to at least 5 years. However, African Americans have a higher rate of reintervention that is probably associated with poor blood pressure control despite taking more antihypertension medications both before and after the repair. It appears that optimal medical therapy is difficult to achieve in all groups. More aggressive medical management is needed, particularly more so in African Americans, which may in turn decrease the number of interventions and potentially improve long‐term survival.