Narasimham L. Dasika

Operative delay for peripheral malperfusion syndrome in acute type A aortic dissection: a long-term analysis.

BACKGROUND We previously reported an improvement in early mortality for patients presenting with acute type A dissection with malperfusion using a strategy of initial percutaneous intervention to restore end-organ perfusion and delayed operative repair after resolution of the malperfusion syndrome. This study evaluates the late outcomes with this approach. METHODS A total of 196 patients were admitted with acute type A dissection (1997-2007). Seventy patients with ischemic end-organ dysfunction underwent percutaneous fenestration or branch vessel stenting. Operative therapy was planned after resolution of the reperfusion injury. Outcomes were compared for patients with (MP) and without (UC) dissection with ischemic end-organ dysfunction. RESULTS The mean age of the patients was 57.1 years, and 173 patients underwent operative repair (n = 126 UC group; n = 47 MP group). The remaining 23 patients in the MP group died before repair from complications of malperfusion (11) or aortic rupture (12) while awaiting resolution of the malperfusion syndrome. Operative mortality was seen in 9.2% of all patients (9.5% in UC group vs 8.5% in MP group; P = 1.0). On analysis of the entire cohort (n = 196), the mean survival was higher for the uncomplicated group (95.9 months for UC group vs 53.7 months for MP group; P < .001). A subgroup analysis of patients who underwent operation (n = 173) revealed similar mean survival (95.9 months for UC group vs 80.5 months for MP group; P = .45). CONCLUSION A strategy of immediate reperfusion, stabilization, and planned operative repair for acute type A dissection with malperfusion still carries a significant risk for early and late mortality. However, those patients who survive the initial malperfusion and undergo repair have a similar operative and late survival when compared with those patients presenting with uncomplicated dissection.

Intravascular Ultrasound in the Diagnosis and Treatment of Iliac Vein Compression (May-Thurner) Syndrome

Intravascular ultrasound (IVUS) imaging and venography of the left common femoral and iliac veins were performed in 16 patients. The studies were evaluated for the anatomic cause of obstruction and how IVUS influenced endovascular management. IVUS demonstrated the cause of vessel compression in all 16 patients. Other findings, such as associated thrombus and guide wire localization within the residual vessel lumen, can modify the approach to intervention in as many as 50% of patients. IVUS is a useful adjunct in the diagnosis and endovascular management of iliac vein compression syndrome.

Long-term results of percutaneous management of malperfusion in acute type B aortic dissection: Implications for thoracic aortic endovascular repair

OBJECTIVE Open repair for acute type B dissection with malperfusion is associated with significant morbidity. Thoracic aortic endovascular repair has been proposed as a less-invasive therapy for acute type B dissection with malperfusion. Benefits of thoracic aortic endovascular repair include the potential for false lumen thrombosis. Its risks include both early morbidity and mortality, and uncertain late results with potentially unstable landing zones. We present the first long-term analysis of an alternative endovascular approach consisting of percutaneous flap fenestration with true lumen and branch vessel stenting to restore end-organ perfusion. METHODS Outcomes were analyzed for 69 patients presenting with acute type B dissection with malperfusion from 1997 to 2008. All patients were evaluated with angiography and treated with a combination of flap fenestration, true lumen, or branch vessel stenting where appropriate. RESULTS Mean age was 57.3 years. Identified malperfused vascular beds included spinal cord (5), mesenteric (40), renal (51), and lower extremity (47). Major morbidity included dialysis need (11), stroke (3), paralysis (2), and 30-day mortality (n = 12, 17.4%). Mean Kaplan-Meier survival was 84.3 months. Although late mortality was associated with age (P < .0001), neither the type nor the number of malperfused vascular beds correlated with vital status at last follow-up (P > .4). Freedom from aortic rupture or open repair at 1, 5, and 8 years was 80.2%, 67.7%, and 54.2%, respectively. CONCLUSION Presentation with acute type B dissection with malperfusion carries a significant risk for both early and late mortality. Percutaneous approaches allow for rapid restoration of end-organ perfusion with acceptable results. These long-term results can serve as comparative data by which to evaluate newer therapies for acute type B dissection with malperfusion, such as thoracic aortic endovascular repair.

A comparative analysis of open and endovascular repair for the ruptured descending thoracic aorta

BACKGROUND Successful repair of the ruptured (non-traumatic) descending thoracic aorta (rTA) remains a formidable clinical challenge. Although effective for rTA, traditional open repair (DTAR) has significant associated morbidity. With expanding indications for thoracic endovascular aortic repair (TEVAR), we describe our experience with TEVAR and DTAR in this high-risk setting to elucidate their evolving roles. METHODS Since the inception of our thoracic aortic endovascular program in 1993, 69 patients underwent DTAR (34) or TEVAR (35) for rTA. Patients underwent TEVAR if they were considered nonoperative candidates because of extensive comorbidities (n = 31; 88.6%) or had extremely favorable anatomy for endovascular repair (eg, mid-descending saccular aneurysm, n = 4). Aortic pathology causing rupture was fusiform aneurysm (18), saccular aneurysm/ulcer (22), and dissection (29). Associated aortobronchial fistulae (12) and aortoesophageal (1) fistulae were also present in 18.8%. Arch repair was needed in 46; total descending repair was needed in 33. Follow-up was 100% complete (mean 37.4 months). RESULTS Mean age was 65.9 years (DTAR 60.3 year vs TEVAR 71.3 years, P = .005). In-hospital or 30-day mortality was seen in 13 patients (TEVAR n = 4; 11.4% vs DTAR n = 9; 26.5%, P = .13). Median length of stay was shorter after TEVAR (8 days vs DTAR 15 days, P = .02). Mean Kaplan-Meier survival was similar between groups (TEVAR 67.4 months vs DTAR 65.0 months, P = .7). By multivariate analysis, independent predictors of a composite outcome of early mortality, stroke, permanent spinal cord ischemia, or need for dialysis or tracheostomy included the presentation with hemodynamic instability (P < .001) and treatment with conventional open repair (P = .02). CONCLUSION An endovascular approach for the ruptured (non-traumatic) descending thoracic aorta reduces early morbidity, mortality, and duration of hospitalization, while providing equivalent late outcomes even in an older group largely considered high risk for open repair. These data support a paradigm shift, with TEVAR emerging as the preferred therapy for all patients presenting with descending aortic rupture.

Long-term follow-up of percutaneous transhepatic balloon cholangioplasty in the management of biliary strictures after liver transplantation.

Background. This study evaluated the efficacy of a protocol of initial balloon dilation for biliary strictures after liver transplantation. Methods. Complete records from 96 patients with biliary strictures were retrospectively reviewed. Seventy-six patients received percutaneous transhepatic balloon cholangioplasty (PTBC) after initial placement of biliary drainage (percutaneous transluminal cholangiography [PTC]) tube. In most cases, three dilations were performed with a 4 to 8 week interval between procedures. Follow-up ranged from 6 months to 10 years. Results. PTBC successfully treated strictures in 39 of 76 (51.3%) cases. Factors favoring successful PTBC included older age at transplant, shorter cold ischemic time, and single strictures. There were nine recurrent strictures after PTBC, all of which were successfully treated by nonoperative measures. The number of dilations performed affected both the likelihood of success and the long-term risk of stricture recurrence. Of the 37 PTBC failures, 14 underwent subsequent surgical revision. When both angiographic and surgical modalities were considered, treatment success was associated with first transplants, shorter cold ischemic time and operative time, and less intraoperative transfusion requirements. Factors associated with treatment failure included multiple, central hepatic duct, and intrahepatic strictures. PTC-tube independence was achieved in 51 of 76 (67%) patients using the combined approach of PTBC and surgery for PTBC failures. Conclusions. PTBC is an effective initial modality for treating posttransplant biliary strictures. Prolonged cold ischemic and operative times and multiple or peripheral strictures predispose to treatment failure. Solitary extrahepatic strictures that fail PTBC are salvageable with surgical revision with excellent results.

A Comparison of Open and Endovascular Descending Thoracic Aortic Repair in Patients Older Than 75 Years of Age

BACKGROUND Thoracic aortic endovascular repair (TEVAR) holds great promise in the elderly population. We conducted a concurrent comparison of TEVAR with open descending thoracic aneurysm repair (DTAR) in elderly patients to determine the more appropriate therapeutic option. METHODS Since 1993, 93 patients aged 75 years and older have undergone open (n = 41) or endovascular (n = 52) descending aortic repair. Intervention indications included aneurysms, dissection, or traumatic injury. Mean maximum aortic diameter was 6.1 cm. Contained rupture was more frequent in TEVAR (p = 0.005); 52 needed arch repair, and 46 needed total descending repair. RESULTS The mean age was 78.9 years (TEVAR, 80.6 vs DTAR, 76.9; p < 0.0001). The TEVAR patients had more significant comorbidities; 42 (80.8%) were prospectively identified as nonoperative candidates. Thirty-day mortality was higher in DTAR at 7 (17.1%) vs TEVAR at 3 (5.7%, p = 0.1). The composite end point of 30-day death, stroke, permanent paralysis, or dialysis requirement was similar (TEVAR, 9; DTAR, 10; p = 0.45). Median postoperative length of stay was shorter in TEVAR (6 days) vs DTAR (13 days; p = 0.003). Endoleaks were observed in 12. Actuarial survival at 48 months was similar (mean survival: TEVAR, 30.2 months vs DTAR, 33.7 months; p = 0.49). CONCLUSIONS Despite more complex preoperative comorbidities, the TEVAR group had shorter hospitalization, a trend towards a reduction in early mortality, and similar late outcomes. This comparative analysis suggests that thoracic endovascular repair may be a more suitable therapeutic option in this complex elderly group.

A single-center experience treating renal malperfusion after aortic dissection with central aortic fenestration and renal artery stenting.

OBJECTIVE Patients with aortic dissection were studied to define (1) anatomic and physiologic derangements in renal artery blood flow, (2) differences in clinically suspected renal malperfusion and true functional malperfusion, and (3) variations in endovascular interventions for the treatment of renal malperfusion. METHODS The cohort comprised 165 patients (mean age, 58 years) with dissections who were thought to have malperfusion sufficient to require arteriography. They were treated from 1996 to 2004 for acute (n = 115) or chronic (n = 50) aortic dissections (75 had type A, 90 had type B lesions). All patients had suspected peripheral vascular malperfusion (ie, cerebral, spinal, mesenteric, renal, or lower extremity vascular beds). Renal malperfusion was suspected in 88 patients secondary to worsening hypertension (n = 34), evolving renal insufficiency (n = 37), computed tomography evidence of impaired renal blood flow (n = 13), or a combination of factors (n = 4). Patients underwent angiographic and intravascular ultrasound studies. Renal malperfusion was confirmed with a systolic gradient between the aortic root and renal hilum (average, 44 mm Hg). RESULTS Right renal arteries arose exclusively from the true lumen in 115 patients (70%), the false lumen in 11 (7%), and both lumens in 37 (23%). Left renal arteries arose exclusively from the true lumen in 69 patients (42%), the false lumen in 32 (20%), and both lumens in 62 (38%). Angiographic confirmation of malperfusion existed in 59 patients (67%) of the 88 suspected of such, and in 31 patients (39%) of the 79 with suspected malperfusion of nonrenal tissues. Of the 90 patients with confirmed renal malperfusion, 71 underwent endovascular therapy, including isolated renal artery stenting (n = 31), as well as proximal aortic fenestration with or without aortic stenting (n = 24), or both renal and aortic intervention (n = 16). Residual pressure gradients averaged 8.1 mm Hg after these interventions. Five procedure-related complications (7%) occurred. The periprocedural postintervention mortality rate was 21% (n = 15), including multisystem organ failure (n = 7), false lumen rupture (n = 3), reperfusion injury (n = 2), cerebral ischemia (n = 1), cardiac arrest (n = 1), and unknown (n = 1). CONCLUSIONS Percutaneous aortic fenestration and renal artery stenting are both technically feasible and associated with an acceptable complication rate. Most patients respond well symptomatically, obviating the need for immediate surgical relief of renal artery obstruction and allowing for renal malperfusion recovery.

Cirrhotic patients with a transjugular intrahepatic portosystemic shunt undergoing major extrahepatic surgery

Background A transjugular intrahepatic portosystemic shunt (TIPS) can potentially reduce the risk of perioperative complications in cirrhotic patients undergoing surgery but experience is limited. The aim of our study was to assess the clinical outcomes in consecutive cirrhotic patients with a patent TIPS undergoing major extrahepatic surgery. Methods Between July 1992 and January 2007, 25 cirrhotic patients with a patent TIPS underwent abdominal or cardiothoracic surgery at a single center. Preoperative laboratory and clinical features and postoperative outcomes were reviewed. Results Mean subject age was 49±12 years. The TIPS was placed at a median of 20 days before surgery (range, 1 to 2338 d). In 19 patients, the TIPS had been previously placed for management of refractory ascites or bleeding varices whereas in 6 patients, the TIPS was specifically placed for portal decompression before planned surgery. The mean hepatic venous pressure gradient was significantly reduced from 19.6±5.5 to 8.7±2.9 mm Hg post-TIPS (P<0.001). The mean preoperative Model for End Stage Liver Disease (MELD) score was 15±7.6 and Child-Turcotte-Pugh scores were A (8%), B (64%), and C (28%). Nineteen abdominal and 6 cardiothoracic surgeries were performed under emergent (32%) or urgent (24%) circumstances. Postoperatively, severe ascites developed in 29% and encephalopathy in 17%. The median postoperative intensive care unit and hospital stay were 1 day (range, 0 to 26 d) and 7 days (0 to 32 d), respectively. During a median follow-up of 33 months, actuarial 1-year patient survival was 74%. The 3 patients (12%) who died during their hospitalization all had MELD scores ≥25 and required emergency surgery. Conclusions Portal decompression via TIPS may allow selected cirrhotic patients to safely undergo major surgery with an acceptable rate of short-term morbidity and mortality.

Early Open and Endovascular Thoracic Aortic Repair for Complicated Type B Aortic Dissection

BACKGROUND Aortic repair for acute (<2 weeks) or subacute (2 to 8 weeks) type B dissection is performed for rupture, impending rupture, or malperfusion. Thoracic aortic endovascular repair (TEVAR) has been suggested as a more suitable, less invasive alternative to open descending aortic repair for type B dissection, but a comparative analysis is warranted. METHODS Seventy-three patients with type B dissection (1995 to 2012) underwent early open descending aortic repair (n = 24) or TEVAR (n = 49). Mean age was 66.3 years. Intervention occurred in the acute (n = 53) or subacute (n = 20) period for malperfusion (n = 8), rupture (n = 22), or factors portending rupture, including rapid expansion (n = 26), uncontrolled pain (n = 18), aortic size greater than 5.0 cm (n = 26), or refractory hypertension (n = 2). Twenty-six had multiple indications. Patients undergoing TEVAR were older and had an increased incidence of coronary artery disease and renal impairment (all p < 0.05). RESULTS Thirty-day mortality was 12% (n = 9). Morbidity included stroke (n = 7), dialysis (n = 6), paralysis (n = 4), and tracheostomy (n = 7). A composite outcome of mortality and these morbidities independently correlated with presentation with frank rupture (p < 0.01) or limb ischemia (p = 0.03), but not treatment strategy (p = 0.3). Ten-year Kaplan-Meier survival was 57.5% and similar between groups (p = 0.74). Independent predictors of late mortality included perioperative stroke and presentation with rupture during late follow-up (both p < 0.02). Five-year freedom from aortic reintervention or rupture was similar between TEVAR (80.0%) and open descending aortic repair (82.8%; p = 0.45). CONCLUSIONS Early aortic repair for complicated type B dissection is associated with high rates of morbidity, late mortality, and reintervention. Despite its use in a higher risk group, outcomes seen with TEVAR were similar to open repair, thus supporting the recent paradigm shift toward an endovascular approach.

Aortic Branch Artery Pseudoaneurysms Accompanying Aortic Dissection. Part I. Pseudoaneurysm Anatomy

PURPOSE Small areas of blood flow are sometimes seen within an otherwise thrombosed false lumen on computed tomography (CT) scans of intramural hematomas of the aorta. These are blood-filled spaces that, although they have no apparent communication with the true lumen, appear isodense with the aorta on contrast-enhanced CT scans. The purpose of this report is to describe angiographic and autopsy studies that establish the nature of this entity and describe the principal CT features distinguishing it from a penetrating ulcer. MATERIALS AND METHODS Conventional angiographic and CT aorta findings in two cases with small collections of contrast material within an otherwise thrombosed false lumen of an aortic dissection are discussed. Also examined is another case with pathologic and histologic findings in addition to those of small collections of contrast material within an otherwise thrombosed false lumen of an aortic dissection, which illustrate the pathoanatomy of these lesions. RESULTS Angiographic and necropsy evidence shows that some of these lesions represent branch artery pseudoaneurysms and, as such, are secondary to an intramural hematoma, not the primary cause of it. CONCLUSIONS Difficulty in demonstrating communication between these collections of contrast material and the adjacent true lumen of the aorta on helical CT examinations and the characteristic location of these lesions along the nonpleural portion of the aortic circumference distinguish them from penetrating ulcers and should suggest the diagnosis of branch artery pseudoaneurysm. Demonstration of a branch artery originating from the contrast collection confirms the diagnosis. These branch artery pseudoaneurysms should be distinguished from penetrating atherosclerotic ulcers.