Julio A. Rodriguez

Acute traumatic rupture of the thoracic aorta treated with endoluminal stent grafts.

BACKGROUND Endovascular technologies provide a new therapeutic option in the treatment for acute traumatic rupture of the thoracic aorta. We report our experience with endoluminal stent graft repair of thoracic aortic ruptures. METHODS Five patients underwent repair of the thoracic aorta with an endoluminal stent graft for acute traumatic rupture. Data from patient history, the procedure, hospital course, and follow-up were analyzed. RESULTS All patient were involved in motor vehicle crashes. The mean Injury Severity Score was 51.8 +/- 6.38. All procedures were technically successful. Mean operating room time was 111 minutes and mean estimated blood loss was 200 mL. There were no cases of postprocedural endoleaks or conversions. There were no procedural complications, paraplegia, or deaths. Average follow-up was 20.2 months. CONCLUSION Five cases of successful endograft repair of thoracic aortic rupture have been demonstrated. This should encourage future studies to determine whether endovascular repair of thoracic aortic ruptures is a safe and feasible alternative to conventional open repair.

Aortic remodeling after endografting of thoracoabdominal aortic dissection

PURPOSE This study assessed the clinical outcome, morphologic changes, and behavior of acute and chronic type B aortic dissections after endovascular repair and evaluated the extent of dissection and diameter changes in the true (TL), false (FL), and whole lumen (WL) during follow-up. METHODS From May 2000 to September 2006, preprocedural and follow-up computed tomography scans were evaluated in 106 patients. Indices of the TL (TLi) and FL (FLi) were calculated at the proximal (p), middle (m), and distal (d) third of the descending thoracic aorta by dividing the TL or FL diameter by the WL. Analyses were by paired t test and chi2. RESULTS Stent grafts were used to treat 106 patients (mean age, 55 years, 70% men) with acute 59 (55.7%) and chronic 47 (44.3%) lesions. The entry site was successfully covered in 100 patients. The incidences of paraplegia and paresis were 2.8% and 1.0%. Mortality was 7.5% (8 patients), including two intraoperative deaths of contained ruptures. Seven (6.6%) early endoleaks occurred. At a mean follow-up of 15.6 months, TLi improved from 0.45 to 0.88 in the proximal third (p/3), from 0.42 to 0.81 in the middle third (m/3), and from 0.44 to 0.74 in the distal third (d/3), demonstrating expansion of the TL. Two patients had decrease in TL due to endoleak needing reintervention. The FLi decreased from 0.41 to 0.06 in p/3, from 0.44 to 0.10 in the m/3, and from 0.42 to 0.21 in the d/3, indicating FL shrinkage. Changes in the TLi and FLi were statistically significant. The decrease in the WL after repair was statistically significant in the proximal and middle aorta. Fourteen patients (13.2%) had increase in WL; seven required a second intervention. FL thrombosis occurred in 69 (65.1%). During follow-up, 36 (36.9%) patients had no retrograde flow, with complete shrinkage of the FL. The FL completely shrank in 28 patients (26.4%) despite retrograde flow. The FL increased in eight patients (7.5%); five needed reintervention. Thrombosis of FL was statistically significant with acute dissections and when dissection remained above the diaphragm (type IIIA; P = .001 and P = .0133). CONCLUSION Remodeling changes were seen when the entry tear was covered. The fate of the FL was determined by persistent antegrade flow and the level of the retrograde flow. Endografting for thoracic type B dissection was successful and promoted positive aortic remodeling changes.

Endovascular therapy in prevention and management of coronary-subclavian steal ☆

BACKGROUND The optimal management of patients undergoing coronary artery bypass grafting (CABG) who have proximal subclavian artery stenosis (SAS) is not well established. SAS may lead to flow reversal through a patent in situ internal mammary artery graft, resulting in myocardial ischemia (coronary-subclavian steal). We review our experience in prevention and management of coronary-subclavian steal. METHODS The medical records of patients who received treatment of symptomatic coronary-subclavian steal were reviewed. Patients who underwent subclavian artery revascularization before CABG were also included in our review. Patient demographic data, findings at presentation, imaging and treatment methods, and short-term and intermediate-term results were analyzed. RESULTS Over 4 years, 14 patients with combined subclavian and coronary artery disease were identified. Nine patients had angina (n = 8) and/or congestive heart failure (n = 2) after CABG (post-CABG group). Four patients underwent treatment of SAS and one underwent treatment of recurrent stenosis before or during CABG (pre-CABG group). Among this pre-CABG group, one patient had symptoms of left arm claudication; the other four patients had no symptoms. A blood pressure gradient was commonly noted between both arms. An angiogram confirmed the proximal location of SAS in all patients, and established the presence of flow reversal in a patent internal mammary artery graft in the post-CABG group. Operative management consisted of percutaneous transluminal angioplasty (PTA) and stenting of the subclavian lesion in 11 patients, PTA only in 2 patients, and carotid-subclavian bypass grafting in 1 patient. No known perioperative complications or morbidity was encountered in either group. Mean follow-up was 29 months, during which stenosis recurred in two patients, along with associated cardiac symptoms. In both patients repeat angioplasty was successful, for an assisted primary patency rate of 100%. CONCLUSION PTA and stenting to treat SAS appears to provide effective protection from and treatment of coronary-subclavian steal over the short and intermediate terms. A surveillance program is essential because of the risk for recurrent stenosis. Continued follow-up is necessary to determine long-term efficacy of this treatment compared with more conventional surgical approaches.

DAMAGE CONTROL TECHNIQUES IN THE MANAGEMENT OF SEVERE LUNG TRAUMA

BACKGROUND Damage control (DC) has improved survival from severe abdominal and extremity injuries. The data on the surgical strategies and outcomes in patients managed with DC for severe thoracic injuries are scarce. METHODS This is a retrospective review of patients treated with DC for thoracic/pulmonary complex trauma at two Level I trauma centers from 2006 to 2010. Subjects 14 years and older were included. Demographics, trauma characteristics, surgical techniques, and resuscitation strategies were reviewed. RESULTS A total of 840 trauma thoracotomies were performed. DC thoracotomy (DCT) was performed in 31 patients (3.7%). Pulmonary trauma was found in 25 of them. The median age was 28 years (interquartile range [IQR], 20–34 years), Revised Trauma Score (RTS) was 7.11 (IQR, 5.44–7.55), and Injury Severity Score (ISS) was 26 (IQR, 25–41). Nineteen patients had gunshot wounds, four had stab wounds, and two had blunt trauma. Pulmonary trauma was managed by pneumorrhaphy in 3, tractotomy in 12, wedge resection in 1, and packing as primary treatment in 8 patients. Clamping of the pulmonary hilum was used as a last resource in seven patients. Five patients returned to the intensive care unit with the pulmonary hilum occluded by a vascular clamp or an en masse ligature. These patients underwent a deferred resection within 16 hours to 90 hours after the initial DCT. Four of them survived. Bleeding from other intrathoracic sources was found in 20 patients: major vessels in nine, heart in three, and thoracic wall in nine. DCT mortality in pulmonary trauma was 6 (24%) of 25 because of coagulopathy, or persistent bleeding in 5 patients and multiorgan failure in 1 patient. CONCLUSION This series describes our experience with DCT in severe lung trauma. We describe pulmonary hilum clamping and deferred lung resection as a viable surgical alternative for major pulmonary injuries and the use of packing as a definitive method for hemorrhage control. LEVEL OF EVIDENCE Epidemiologic study, level V.

The AneuRx stent-graft since FDA approval: single-center experience of 230 cases.

PURPOSE To compare a single-center experience with the AneuRx stent-graft system before and after FDA approval to results from the multicenter phase II clinical trial. METHODS The medical records of 230 consecutive patients (218 men; mean age 74 years) undergoing AneuRx stent-graft implantation for abdominal aortic aneurysm (AAA) exclusion since September 1999 were reviewed to collect patient characteristics, aneurysm morphology, procedure variables, perioperative morbidity, mortality, and short-term outcome. These data were compared to the 30 patients treated at our institution during the AneuRx phase II clinical trial and to the overall multicenter trial data. Stent-graft difficulty was categorized from 1 (straight neck and access of appropriate size) to 4 (proximal neck <10 mm long or angulated >60 degrees and/or difficult access) based on aneurysm morphology. RESULTS Data from the 30 patients enrolled in the phase II trial at our institution were comparable in terms of patient characteristics and procedure variables to patients treated after FDA approval and to the multicenter data. However, the proportion of cases involving aneurysms with a more complex morphology (levels 3 and 4) rose 22% after FDA approval, reflecting a change in referral patterns. Our postoperative endoleak and morbidity rates increased nonsignificantly with respect to our own phase II experience (17% versus 6%, 18% versus 11%, respectively); however, they were not significantly different from the multicenter data. Reintervention was performed in 15 of 38 endoleak cases, mostly type I. Only 5 (2.1%) cases had a persistent endoleak at the time of discharge. CONCLUSIONS Since FDA approval of the AneuRx device, our endovascular practice has changed toward the management of increasingly more complex AAAs. Although we are attempting more challenging cases, we are able to maintain similarly high short-term success rates while offering stent-grafting to an increasing number of patients. These results suggest that more patients may be candidates for endoluminal graft placement than determined by the clinical trial selection criteria, provided that strict surveillance and long-term follow-up is maintained.

Endovascular Management of Malperfusion in Acute Type B Aortic Dissections

Purpose: To examine the feasibility, efficacy, and midterm results of endovascular stent-graft management of acute type B aortic dissection complicated by renal, visceral, or lower limb malperfusion. Methods: A retrospective review was conducted to identify all patients with acute type B dissection treated endovascularly at a single center between 1998 and 2009. Of the 85 patients identified, 23 (27%) consecutive patients (20 men; mean age 60.9±11.6 years) presented with clinical and imaging evidence of end-organ malperfusion: 7 (30%) renal, 6 (26%) lower limb, 4 (17%) renal and lower limb, 3 (13%) visceral, and single cases of renal/visceral, renal/lower limb/spinal cord, and renal/visceral/spinal cord/lower limb. Results: All patients had stent-graft coverage of the proximal entry tear; 5 (22%) patients required additional branch vessel stenting, and 2 (9%) had femorofemoral bypass graft. Successful correction of malperfusion was achieved in 21 (91%) patients. In 1 patient, ischemia in the lower limb was resolved but not in the left kidney; the other patient had an ischemic but viable lower limb and did not require any additional intervention. Thirty-day mortality was 9% (2/23 patients). The incidences of postoperative stroke and paraplegia were 17% (4/23) and 9% (2/23), respectively. The 21 survivors were followed for 17.2±15 months; during this period, 1 patient died, 1 was lost to follow-up, and 5 patients underwent additional open or endovascular procedures. Conclusion: Endovascular coverage of the proximal entry tear in acute type B dissections complicated by end-organ malperfusion resulted in correction of malperfusion in the majority of patients. It is a reasonable first line of treatment, but its superiority must be assessed in comparison with other techniques, such as fenestration.

Thoracic aortic dissections: unpredictable lesions that may be treated using endovascular techniques.

Abstract  Advances in endoluminal technology have enabled interventionists to treat a variety of pathologies that traditionally would require open surgery. Although excluding descending thoracic aortic aneurysms seems feasible, thoracic aortic dissection and its complications are an area in which the appropriateness of endovascular therapy has yet to be defined. Five case reports are presented, each with varying pathologies associated with type III dissections. The follow‐up of the cases ranged from 6 to 18 months with a mean of 12.2 months. The endovascular approach and the technical aspect of the intervention have been emphasized in each case. (J Card Surg 2003; 18:334‐350)

Symptomatic Seroma after Open Abdominal Aortic Aneurysm Repair

Seroma following open abdominal aortic aneurysm repair has rarely been described. The majority of cases in the literature have been associated with use of polytetrafluoroethylene grafts. Here, we present a patient with a very large, symptomatic periaortic graft seroma 10 years after conventional (open) repair. The etiology of such seromas is of significant interest in endovascular aortic repair.

Malignant Fibrous Histiocytoma of the Aorta Complicated by Anuria

Tumors of the aorta have been reported infrequently in the literature. We report a case of a 63-year-old woman diagnosed with maligant aortic fibrous histiocytoma (also known as fibroxanthosarcoma). She was referred to us with suspected occlusion of the right renal artery in a single functioning kidney, with a clinical picture of anuria during the previous 48 hours. We also review 31 previously published cases in the literature.

Pseudoaneurysm of the Aortic Arch After Aortosubclavian Bypass Treated with Endoluminal Stent Grafting: A Case Report

This paper describes a case of aortic arch pseudoaneurysm treated with stent graft 2 years after aortosubclavian bypass repair of a subclavian artery aneurysm. An 84-year-old man presented with back pain. Two years before, he had had a left subclavian artery aneurysm repaired with aortosubclavian bypass. Upon examination by computed tomography (CT) scan and angiography he was found to have a bovine arch configuration, a 7-centimeter pseudoaneurysm arising from the stump of the native subclavian artery, a patent aortosubclavian bypass, and a left hemothorax. A 37 mm by 10 mm Gore Excluder thoracic graft was introduced into the right femoral artery cutdown and deployed across the arch, excluding the pseudoaneurysm and preserving the brachiocephalic vessels. Follow up CT scan at 1 year shows exclusion of the pseudoaneurysm. The patient continues to do well 1 year after implantation without evidence of endoleak. In the presence of unusual anatomical characteristics, endoluminal stent graft repair can be successfully performed across the aortic arch.