Martin Funovics

Repeatability and Reproducibility of Central Corneal Thickness Measurement With Pentacam, Orbscan, and Ultrasound

Purpose. The authors conducted a comparison of anterior chamber depth (ACD) measurement by 3 devices of EchoScan, Orbscan II, and IOLMaster to assess the validity of the latter 2 and its reliability with Orbscan II. Methods. Forty-four myopic patients, 56.8% female, were enrolled in this prospective study. In all 88 eyes, the ACD was first measured with Orbscan II, followed by IOLMaster and EchoScan U3300, both under cycloplegia. The mean (± standard deviation) age and spherical equivalent were 30.2 ± 8.5 years and −4.98 ± 2.67 D, respectively. The difference between ACD measurements by these 3 devices was analyzed using the repeated-measures analysis of variance. Agreement between each pair of devices was assessed by computing the 95% limits of agreement (LoA). Orbscan II reliability was also evaluated by using the 95% LoA between 2 consecutive measurements. P value adjustments for multiple comparisons were performed using the Bonferroni method. Results. There was a statistically significant difference between measurements made with the 3 devices (p < 0.001). The mean difference between Orbscan II and Echoscan ACD measurements was −0.03 ± 0.12 mm, with the 95% LoA from −0.25 to +0.20 mm, and between IOLMaster and Echoscan measurements, it was +0.09 ± 0.14 mm with the 95% LoA from −0.18 to +0.36 mm. On average, Orbscan II readings were lower and those of IOLMaster were higher than Echoscan readings. Both Orbscan II and IOLMaster agreed with Echoscan in measuring ACD. The 2 readings by Orbscan II had a 95% LoA of −0.05 and +0.07 mm that shows good reliability. Conclusion. ACD measurement differences with the 3 studied devices proved to be statistically significant; however, these minor differences may be clinically negligible depending on the use of the measurement. As an advantage, both Orbscan II and IOLMaster are noncontact, and with their ACD measurements being valid, they may be considered suitable devices for this purpose. In addition, Orbscan II produces highly repeatable ACD measurements.

Mechanisms of symptomatic spinal cord ischemia after TEVAR: insights from the European Registry of Endovascular Aortic Repair Complications (EuREC).

Purpose To test the hypothesis that simultaneous closure of at least 2 independent vascular territories supplying the spinal cord and/or prolonged hypotension may be associated with symptomatic spinal cord ischemia (SCI) after thoracic endovascular aortic repair (TEVAR). Methods A pattern matching algorithm was used to develop a risk model for symptomatic SCI using a prospective 63-patient single-center cohort to test the positive predictive value (PPV) of prolonged intraoperative hypotension and/or simultaneous closure of at least 2 of 4 the vascular territories supplying the spinal cord (left subclavian, intercostal, lumbar, and hypogastric arteries). This risk model was then applied to data extracted from the multicenter European Registry on Endovascular Aortic Repair Complications (EuREC). Between 2002 and 2010, the 19 centers participating in EuREC reported 38 (1.7%) cases of symptomatic spinal cord ischemia among the 2235 patients in the database. Results In the single-center cohort, direct correlations were seen between the occurrence of symptomatic SCI and both prolonged intraoperative hypotension (PPV 1.00, 95% CI 0.22 to 1.00, p=0.04) and simultaneous closure of at least 2 independent spinal cord vascular territories (PPV 0.67, 95% CI 0.24 to 0.91, p=0.005). Previous closure of a single vascular territory was not associated with an increased risk of symptomatic spinal cord ischemia (PPV 0.07, 95% CI 0.01 to 0.16, p=0.56). The combination of prolonged hypotension and simultaneous closure of at least 2 territories exhibited the strongest association (PPV 0.75, 95% CI 0.38 to 0.75, p<0.0001). Applying the model to the entire EuREC cohort found an almost perfect agreement between the predicted and observed risk factors (kappa 0.77, 95% CI 0.65 to 0.90). Conclusion Extensive coverage of intercostal arteries alone by a thoracic stent-graft is not associated with symptomatic SCI; however, simultaneous closure of at least 2 vascular territories supplying the spinal cord is highly relevant, especially in combination with prolonged intraoperative hypotension. As such, these results further emphasize the need to preserve the left subclavian artery during TEVAR.

A New Mechanism by Which an Acute Type B Aortic Dissection Is Primarily Complicated, Becomes Complicated, or Remains Uncomplicated

BACKGROUND This study is to evaluate if different locations of the primary entry tear result in primary complicated, secondary complicated, or uncomplicated acute type B aortic dissection. METHODS Sixty-five patients were analyzed. Patients were stratified according to the location of the primary entry tear. Primary entry tears in axial computed tomographic scans at the upper circumference (180°) of the distal aortic arch were defined as convex (group A) and the remaining as concave (group B). Detailed morphometry was done and the clinical outcome, including need for thoracic endovascular aortic repair, was evaluated. RESULTS Forty-two patients (group A) had the primary entry tear at the convexity and 23 patients (group B) had the primary entry tear at the concavity of the distal aortic arch. There was a significant difference with regard to the incidence of primary complicated type B aortic dissection (group A 21% vs group B 61%, p = 0.003) and with regard to the development of complications in group A (9 days; 9 to 37) versus group B (0 days; 0 to 13, p = 0.03). Cox regression analysis revealed a primary entry tear at the concavity to be the only independent predictor of primary or secondary development of a complicated acute type B aortic dissection (hazard ratio, 1.8; 95% confidence interval, 1.0 to 3.2). CONCLUSIONS A primary entry tear at the concavity of the distal aortic arch is associated with a significant increase of the occurrence of complicated acute type B aortic dissection. Due to low procedural risk and high success rates, closure of the primary entry tear with thoracic endovascular aortic repair is strongly recommended in this newly defined high-risk subgroup of patients.

Long-term results of thoracic endovascular aortic repair in atherosclerotic aneurysms involving the descending aorta

OBJECTIVE This study evaluated long-term results of thoracic endovascular aortic repair for atherosclerotic aneurysms involving descending aorta. METHODS One hundred thirteen patients underwent thoracic endovascular aortic repair for this indication from 1996 to 2009. Mean follow-up was 54 ± 38 months (5-144 months). In-hospital mortality, neurologic injury, need for rerouting, occurrence of endoleaks and their treatment, and survival were recorded. RESULTS In-hospital mortality was 5.3%. Transient neurologic injury rate was 2.6%. Previous rerouting was performed in 51%. Assisted early and late type I and III endoleak rates were 7.9% and 5.7%, respectively. Five percent of patients required late surgical conversion. Actuarial survivals were 86%, 60%, and 42% at 1, 5, and 10 years, respectively. Aorta-related actuarial survivals were 94%, 90%, and 83% at 1, 5, and 10 years, respectively. Cox regression analysis revealed higher number of prostheses as independent risk factor for early (hazard ratio, 5.38; 95% confidence interval, 1.68-42.37) and late (hazard ratio, 8.49; 95% confidence interval, 1.09-66.06) endoleak formation. Female sex (hazard ratio, 0.35; 95% confidence interval, 0.13-0.99), no arch involvement (hazard ratio, 0.21; 95% confidence interval, 0.05-0.08), and higher number of prostheses (hazard ratio, 7.95; 95% confidence interval, 1.36-46.58) affected survival. CONCLUSIONS Aorta-related survival is excellent among patients undergoing thoracic endovascular aortic repair for atherosclerotic aneurysms involving the descending aorta. Life-long surveillance remains mandatory, with early and late failure uncommon but still needing consideration. Thoracic endovascular aortic repair in this group of patients remains attractive and has now proven durability.

Type II endoleaks after endovascular repair of abdominal aortic aneurysms: fate of the aneurysm sac and neck changes during long-term follow-up.

Purpose To evaluate the frequency of type II endoleaks after endovascular aneurysm repair (EVAR) and to compare sac diameter and neck changes in patients with type II endoleak to endoleak-free patients with at least 3-year imaging follow-up. Methods Among 407 consecutive EVAR patients, 109 patients (101 men; mean age 72.1 years, range 55–86) had at least 3-year computed tomography (CT) data and no type I or III endoleak. In this cohort, 49 patients presented with a type II endoleak at some time and 60 patients had no endoleak. Patients with type II endoleaks were further divided into subgroups based on the vessel origin and the perfusion status (persistent or transient). The course of the perfusion status of type II endoleaks and changes in the aneurysm sac diameters, neck diameters, and renal to stent-graft distances (RSD) were evaluated in the defined groups. Reintervention and death rates were also reported. Results The mean follow-up was 68.1±23.8 months. Compared to the no endoleak group, overall sac diameter increased significantly in the type II endoleak group (p=0.007), but vessel origin did not have any influence. With regard to the perfusion status of type II endoleaks, aneurysm sac changes were significantly higher (p = 0.002) in the persistent endoleak group. During the study period, the increase in the proximal neck diameter was significantly higher in the no endoleak group compared to the type II endoleak group (p=0.025). No significant difference was found in RSD changes between the defined groups. Reinterventions were performed in 20 (18.3%) patients (13 for type II endoleak); 2 (1.8%) patients without type II endoleak died of ruptured aneurysm. Conclusion Persistent type II endoleaks led to significant aneurysm sac enlargement, but without increased mortality or rupture rates.

Midterm Results of Thoracic Endovascular Aortic Repair in Patients With Aneurysms Involving the Descending Aorta Originating From Chronic Type B Dissections

BACKGROUND Midterm results of TEVAR (thoracic endovascular aortic repair) in patients with aneurysms involving the descending aorta originating from chronic type B dissections are not known. METHODS Between 2004 and 2009, 14 patients with a median age of 63 years (79% male) with this pathology were treated. Seven patients underwent supraaortic transpositions in various extents prior to TEVAR in order to gain a sufficient proximal landing zone. RESULTS Median time from dissection to treatment was 19 months (4 to 84 months). All patients had an uneventful in-hospital course. The median covered length of the aortic arch and descending aorta was 190 mm (100 to 250 mm). Primary success rate defined as absence of type Ia endoleakage was 86%. No patient, where visceral or renal vessels originated from the false or from both lumina sustained ischemic injury by TEVAR. The median follow-up period is 34 months to date (6 to 64 months). Aortic-related morbidity and mortality during follow-up was low (14%). CONCLUSIONS Midterm results of TEVAR in patients with aneurysms involving the descending aorta originating from chronic type B dissections are good. The self-expanding capability of the stent grafts is sufficient over time. However, extensive coverage of the descending aorta is warranted to achieve success. Further studies are needed to extend our knowledge in this particular subgroup of patients.

Treatment of Symptomatic Coral Reef Aorta by Endovascular Stent-Graft Placement

We report 2 patients who were referred for treatment of hemodynamically significant symptomatic stenosis of the aorta at the thoracoabdominal transition (coral reef aorta) that was causing abdominal angina and intermittent claudication. Both patients underwent successful transfemoral endovascular stent-graft placement and are free of symptoms, with regular findings at 6-month follow-up completion computed tomography scan.

Results After Thoracic Endovascular Aortic Repair in Penetrating Atherosclerotic Ulcers

BACKGROUND Results after thoracic endovascular aortic repair in penetrating atherosclerotic ulcers are uncertain. METHODS From 1997 to 2010, 72 patients (median age, 67 years) presented with penetrating atherosclerotic ulcers (symptomatic, 58%; rupture, 36%). Median logistic EuroSCORE (European System for Cardiac Operative Risk Evaluation) was 32. Mean follow-up was 42 months (range, 19 to 56 months). In-hospital mortality, occurrence of endoleaks, reinterventions, and survival were recorded. RESULTS In hospital mortality was 4%. The primary success rate was 100%. Actuarial survival rates at 1, 5, and 10 years were 93%, 72%, and 60%. The early type I and III endoleak rate was 2.7%. The late type I and III endoleak rate was 4%. One late surgical conversion was performed. Aortic-related actuarial survival was 100% at 1 year and 98.6% at 5 and 10 years. Age older than 75 years (odds ratio, 8.928; 95% confidence interval, 2.05 to 38.93) was an independent predictor of survival. During follow-up, 21% of patients underwent a cardiovascular intervention. CONCLUSIONS Results after thoracic endovascular aortic repair in patients with penetrating atherosclerotic ulcers are excellent for early and late type I and III endoleak formation and aortic-related survival. Patients are mainly limited by age and by the aggressive underlying obliterative atherosclerotic process.

Endovascular Repair of the Descending Aorta and the Aortic Arch With the Relay Stent Graft

PURPOSE The aim of this study was to evaluate the efficacy and safety of thoracic endovascular aortic repair with a newly designed Relay thoracic stent graft (Bolton Medical, Sunrise, FL). DESCRIPTION Between 2005 and 2007, 22 patients (71.8 +/- 8.5) received 24 stent grafts. Indications were aneurysms (n = 13), penetrating atherosclerotic ulcers (n = 7), and dissections (n = 2). Due to the proximity of the lesions to the aortic arch, rerouting procedures (ie, subclavian transposition [n = 1], double transposition [n = 12], and total arch rerouting [n = 6] were performed pre-interventionally; three patients did not undergo rerouting). All patients were followed-up with a computed tomographic scan of the entire aorta at discharge, 3 months, 6 months, and annually thereafter (mean follow-up, 13 months). EVALUATION Primary technical success was obtained in 20 of 22 patients, with one persisting type I endoleak and one asymptomatic type II endoleak. One patient died due to malignant arrhythmia 3 days after stent-graft placement. During follow-up, 1 nonaortic related death was observed. No additional endoleaks were observed. Finally, all supra-aortic rerouting procedures remained patent. CONCLUSIONS In the treatment of degenerative disease of the descending aorta and the aortic arch, the Bolton Relay stent graft offers acceptable efficacy and safety in short-term follow-up.

Transposition of the supra-aortic vessels before stent grafting the aortic arch and descending aorta.

Thoracic endovascular aortic repair has broadened the spectrum of treatment options for various acute and chronic thoracic aortic diseases. In clinical practice, aneurysms of the descending aorta are rarely limited to 1 segment. Thus, various surgical and endovascular options have been developed to offer treatment to those patients with more extended descending thoracic aortic disease. We have summarized the most common methods of arch rerouting, depending on the aortic involvement, emphasizing that these techniques should be used very selectively by experienced cardiovascular surgery teams.