Nikolaos Tsilimparis

Global Burden of Hypertension and Systolic Blood Pressure of at Least 110 to 115 mm Hg, 1990-2015

Importance Elevated systolic blood (SBP) pressure is a leading global health risk. Quantifying the levels of SBP is important to guide prevention policies and interventions. Objective To estimate the association between SBP of at least 110 to 115 mm Hg and SBP of 140 mm Hg or higher and the burden of different causes of death and disability by age and sex for 195 countries and territories, 1990-2015. Design A comparative risk assessment of health loss related to SBP. Estimated distribution of SBP was based on 844 studies from 154 countries (published 1980-2015) of 8.69 million participants. Spatiotemporal Gaussian process regression was used to generate estimates of mean SBP and adjusted variance for each age, sex, country, and year. Diseases with sufficient evidence for a causal relationship with high SBP (eg, ischemic heart disease, ischemic stroke, and hemorrhagic stroke) were included in the primary analysis. Main Outcomes and Measures Mean SBP level, cause-specific deaths, and health burden related to SBP (≥110-115 mm Hg and also ≥140 mm Hg) by age, sex, country, and year. Results Between 1990-2015, the rate of SBP of at least 110 to 115 mm Hg increased from 73u2009119 (95% uncertainty interval [UI], 67u2009949-78u2009241) to 81u2009373 (95% UI, 76u2009814-85u2009770) per 100u2009000, and SBP of 140 mm Hg or higher increased from 17u2009307 (95% UI, 17u2009117-17u2009492) to 20u2009526 (95% UI, 20u2009283-20u2009746) per 100u2009000. The estimated annual death rate per 100u2009000 associated with SBP of at least 110 to 115 mm Hg increased from 135.6 (95% UI, 122.4-148.1) to 145.2 (95% UI 130.3-159.9) and the rate for SBP of 140 mm Hg or higher increased from 97.9 (95% UI, 87.5-108.1) to 106.3 (95% UI, 94.6-118.1). Loss of disability-adjusted life-years (DALYs) associated with SBP of at least 110 to 115 mm Hg increased from 148 million (95% UI, 134-162 million) to 211 million (95% UI, 193-231 million), and for SBP of 140 mm Hg or higher, the loss increased from 5.2 million (95% UI, 4.6-5.7 million) to 7.8 million (95% UI, 7.0-8.7 million). The largest numbers of SBP-related deaths were caused by ischemic heart disease (4.9 million [95% UI, 4.0-5.7 million]; 54.5%), hemorrhagic stroke (2.0 million [95% UI, 1.6-2.3 million]; 58.3%), and ischemic stroke (1.5 million [95% UI, 1.2-1.8 million]; 50.0%). In 2015, China, India, Russia, Indonesia, and the United States accounted for more than half of the global DALYs related to SBP of at least 110 to 115 mm Hg. Conclusions and Relevance In international surveys, although there is uncertainty in some estimates, the rate of elevated SBP (≥110-115 and ≥140 mm Hg) increased substantially between 1990 and 2015, and DALYs and deaths associated with elevated SBP also increased. Projections based on this sample suggest that in 2015, an estimated 3.5 billion adults had SBP of at least 110 to 115 mm Hg and 874 million adults had SBP of 140 mm Hg or higher.

Addressing Persistent False Lumen Flow in Chronic Aortic Dissection: The Knickerbocker Technique

Purpose To describe an innovative technique to occlude distal backflow into a false lumen aneurysm by controlled rupture of the dissection membrane after stent-graft implantation. Technique The “Knickerbocker technique” involves relining the true lumen in the descending aorta with an oversized thoracic tubular endograft, followed by controlled rupture of the dissection membrane using a large compliant balloon within the grafts midsection. This maneuver, which allows expansion of the stent-grafts midsection into the false lumen, was developed in order to occlude the large false lumen distally and thus prevent continued false lumen perfusion through distal abdominal entry tears. The technique has been successfully used in 3 patients with ruptured or symptomatic chronic false lumen aneurysm in type B aortic dissection. There was no short-term mortality associated with the procedure. After a mean follow-up of 8 months, the false lumen aneurysm remained thrombosed, with no mortality after a mean clinical follow-up of 22 months. Conclusion The Knickerbocker technique appears to be feasible and effective in inducing false lumen thrombosis in selected patients who undergo stent-grafting for chronic type B aortic dissection.

Branched versus fenestrated endografts for endovascular repair of aortic arch lesions

OBJECTIVEnEndovascular repair of the aortic arch represents a formidable challenge because of aortic diameter, angulation, elasticity, and greater distance to the femoral access vessels. Whereas both fenestrated and branched endografts have been customized to accommodate complex pathologic processes of the arch, no data comparing the techniques are available. The aim of this study was to compare the outcomes of custom-made fenestrated vs branched thoracic endovascular aortic repair (fTEVAR vs bTEVAR).nnnMETHODSnThis was a single-center, retrospective comparative study of all consecutive patients treated with fTEVAR and bTEVAR for aortic arch diseases. All patients were considered unsuitable for open surgical therapy and treated with customized stent grafts (Cook Medical, Bloomington, Ind).nnnRESULTSnWithin 42xa0months, 29 patients underwent fTEVAR and bTEVAR (66xa0± 9xa0years; nine female patients). The fTEVAR patients (nxa0= 15) had no differences in comorbidities compared with the bTEVAR patients (nxa0= 14). Dissection or postdissection aneurysm was the indication in 6 of 15 fTEVARs and 5 of 14 bTEVARs (40% vs 36%; Pxa0= NS); the remaining procedures were performed for aneurysms. Six (40%) fTEVAR patients underwent previous cervical debranching compared with all bTEVAR patients. In all patients with bTEVAR, two arch vessels were targeted (innominate, 13; left carotid artery, 14; left subclavian artery, 1), whereas fTEVAR targeted 1.6xa0± 0.5 arch vessels (bovine trunk, 4; innominate artery, 1; left carotid artery, 10; left subclavian artery, 9). Technical success was achieved in all but one case of a fenestrated endograft that was displaced, resulting in major stroke and death of the patient. Strokes occurred in two fTEVAR patients and one bTEVAR patient (Pxa0= NS). The 30-day mortality was 20% in the fTEVAR patients (nxa0= 3) vs 0% in the bTEVAR patients (Pxa0= NS). The causes of early mortality were major stroke (nxa0= 1), access complication (nxa0= 1), and myocardial infarction (nxa0= 1). Mean follow-up was 8 (1-35) and 10 (2-22) months for fTEVAR and bTEVAR, respectively. No branch occlusions occurred, and two patients underwent coil embolization for endoleaks (Pxa0= NS). One patient was readmitted with infected branched endograft 4xa0months after intervention and has so far been successfully treated with aneurysm sac drainage and antibiotics. There was one late nonaneurysm-related death in each group.nnnCONCLUSIONSnBoth fTEVAR and bTEVAR are feasible for the treatment of aortic arch diseases in high-risk patients. Results are promising, although fTEVAR was associated with higher mortality in this early experience. bTEVAR was more commonly used in Ishimaru zonexa00.

Carbon Dioxide Flushing Technique to Prevent Cerebral Arterial Air Embolism and Stroke During TEVAR.

Purpose: To describe the technique of carbon dioxide (CO2) flushing of thoracic stent-grafts to reduce the risk of cerebral air embolism. Technique: To remove room air, thoracic stent-grafts were preoperatively flushed 2 minutes with carbon dioxide from a cylinder connected to the flushing chamber of the captor valves of Zenith custom-made endografts; this was followed by the standard saline flush. Thirty-six patients undergoing thoracic endovascular aortic repairs (TEVAR) involving the ascending aorta and the aortic arch received CO2-flushed Zenith endografts. One patient with a highly calcified arch experienced a minor stroke. Conclusion: Arterial air embolism is a potentially underappreciated problem of aortic endografting, especially in the proximal segments of the aorta. CO2 flushing may have the potential to reduce air embolization during TEVAR.

Einführung des GermanVasc

ZusammenfassungDie zunehmende Ökonomisierung des Gesundheitswesens, anstehende gesetzliche Novellierungen und ein inhomogenes Patientenkollektiv verlangen nach leistungsfähigen Methoden der Qualitätssicherung und Versorgungsforschung in der Gefäßmedizin. Mehr als 12 etablierte internationale Registerprojekte zeigen bereits seit Jahren, wie wichtig klinische Register als komplementäre Methode zu den randomisierten kontrollierten Studien („randomized controlled trial“, RCT) sind. In Nordamerika beispielsweise konnte durch Ableitung von Behandlungsparametern die Rezidivstenoserate bei der Versorgung der extrakraniellen Karotisstenose signifikant gesenkt werden. In England führte die registerbasierte Qualitätssteigerung bei der elektiven Versorgung des Bauchaortenaneurysmas (BAA) zu einer Senkung der Mortalitätsrate von 7,5 auf etwa 2,4u2009% innerhalb von 4xa0Jahren. Im Gegensatz zu vielen Ländern im europäischen und außereuropäischen Ausland verfügt Deutschland derzeit noch über kein gemeinsames populationsbezogenes Register für alle vaskulären Behandlungen. Mit dem prospektiven BAA-Register wird derzeit nur ein kleiner Teil des vaskulären Versorgungsspektrums erfasst. Die verpflichtende sektorenübergreifende Qualitätssicherung zur Karotisrevaskularisation bietet mit jährlich etwa 33.000xa0Datensätzen zwar ein annähernd vollständiges Bild der deutschen Karotisversorgung, in die Auswertung gehen allerdings nur Sekundärdaten mit eingeschränkter Validität ein. Mit dem gemeinsamen Gefäßregister für Deutschland GermanVasc können die Versorgungsrealität des einwohnerreichsten europäischen Landes erfasst und bisher unbeantwortete Fragestellungen besser beantwortet werden.AbstractIncreasing economic aspects of the healthcare system, forthcoming legislative amendments and an inhomogeneous patient population call for advanced methods of quality improvement and research in vascular medicine. More than 12 established international registry projects have proven the importance of clinical registries as a complementary method for randomized clinical trials (RCT). In the USA the restenosis rate after carotid endarterectomy (CEA) could also be decreased due to the results of register data. In the United Kingdom the mortality rate of elective surgery in 8380 patients with abdominal aortic aneurysms (AAA) has been reduced from 7,5u2009% to 2.4u2009% from 2008 to 2012 by the use of register data. Unlike in many other countries, Germany currently has no common population-based registry for vascular treatments. The prospective registry for AAA currently only records a small proportion of treatments. The mandatory data collection and analysis of approximately 33,000 CEAs by the AQUA Institute is an important part of quality insurance but has limitations because of the limited validity. An interdisciplinary common vascular registry for Germany, GermanVasc, allows a better and more accurate description of the actual medical care situation. With GermanVasc it will be possible to answer some of the key questions in vascular medicine in Germany.

Polytetrafluoroethylene Excludes the False Lumen Expanding Material Options for the Candy-Plug Technique

False lumen perfusion via retrograde flow from distal entry tears and aneurysmal degeneration limit the response to endovascular treatment in patients with chronic aortic dissection. Occlusion of these connections between the true and false lumens by stent-graft coverage using fenestrated and branched endografts into the iliac arteries allows complete false lumen thrombosis throughout the dissected thoracoabdominal aorta. However, these advanced interventions are challenging and carry significant limitations and risks, especially for spinal cord ischemia, as all segmental arteries may be covered during treatment. The majority of patients with postdissection aneurysms have aneurysmal dilatation in the distal aortic arch and the proximal and mid descending thoracic aorta, while the abdominal segment remains relatively normal. This subset of patients may be treated with less invasiveness and a lower risk for spinal cord ischemia using standard endovascular repair to cover the proximal entry combined with techniques of direct false lumen occlusion, leaving the abdominal aorta and the iliac arteries untreated. In this issue of the JEVT, Ogawa and colleagues describe an alternative technique to create an extra-large occluding plug to achieve false lumen thrombosis in a patient with chronic type B aortic dissection and a 6-cm false lumen aneurysm in the proximal descending thoracic aorta. The authors used a 45-mm Excluder aortic extender (W.L. Gore & Associates, Flagstaff, AZ, USA) and modified this short thoracic endograft to an extra-large vascular plug with a remaining central opening to retrieve the nosecone of the delivery system. This technique, dubbed the candy-plug technique because of the resultant candy wrapper shape of the cuff, was originally used with a TX2 ProForm endograft (Cook Medical, Bloomington, IN, USA). The treatment strategy that was chosen in this case differs from the original idea mainly by the placement of the candy plug in an unsupported and unstented segment of the dissected 641672 JETXXX10.1177/1526602816641672Journal of Endovascular TherapyKölbel et al research-article2016

Early and midterm outcome of Multilayer Flow Modulator stent for complex aortic aneurysm treatment in Germany

Objective: The objective of this study was to assess the early and midterm outcomes of endovascular repair of complex aortic aneurysm cases using the Multilayer Flow Modulator (MFM; Cardiatis, Isnes, Belgium) endograft in Germany. Methods: A retrospective study including patients presenting with abdominal aortic aneurysm (AAA), thoracic aortic aneurysm, or thoracoabdominal aortic aneurysm treated with the MFM was conducted in Germany. Mortality and morbidity (in terms of spinal cord ischemia, visceral ischemia, and stroke) at 30 days postoperatively were evaluated. In addition, during follow‐up, freedom from reintervention, rupture, and failure mode were also assessed. Results: Between 2009 and 2014, a total of 61 patients with AAA, thoracoabdominal aortic aneurysm, or thoracic aortic aneurysm were treated with the MFM endograft in 29 hospitals around Germany. However, data of 40 patients with a mean age of 73.4 ± 11.2 years (72.5% male; 29/40) and mean aortic aneurysm diameter of 60.3 ± 16.6 mm from 14 hospitals were available for this retrospective study. Thirty‐seven (93%) patients were treated urgently. In 12 cases (12/40 [30%]), patients were treated outside instructions for use because of aortic aneurysm diameter >65 mm. A total of 69 MFM stents were used (1.7/patient). The technical success rate was 95% (38/40). Postoperatively, no patient presented with spinal cord ischemia, renal function deterioration, stroke, or intestinal ischemia, except for one patient who developed multiorgan failure because of early stent migration. The intraoperative and 30‐day mortality rate was 0% and 2.5%, respectively. The mean follow‐up was 12.9 months (±14.9 months), with a survival rate at 1 month, 6 months, and 12 months of 97%, 78%, and 70%, respectively. Freedom from failure mode (type I or II) at 1 month, 6 months, and 12 months was 97.5%, 88%, and 86%, respectively, and visceral vessel patency was 99.3% (155/156 available). During follow‐up, 4 patients (4/39 [10%]) had an aneurysm sac rupture and 10 (10/39 [25%]) underwent a reintervention. Freedom from rupture and freedom from reintervention at 1 month, 6 months, and 12 months were 97.5% and 100%, 96% and 84%, and 86% and 75%, respectively. Conclusions: The use of the MFM for endovascular treatment of complex aortic aneurysm in urgent cases appears to be technically feasible in terms of mortality and morbidity, with moderate 30‐day and acceptable midterm outcomes. Reinterventions may be needed to expand the utility of outcomes.

Combined Ascending Aortic Stent-Graft and Inner Branched Arch Device for Type A Aortic Dissection

Purpose: To report the use of the Zenith Ascend stent-graft in conjunction with the Zenith inner branched arch device to treat type A aortic dissection. Case Report: Five patients (mean age 66 years, range 52–78; 4 men) with type A aortic dissection (2 acute) and insufficient distal landing zones were treated with the Zenith Ascend stent-graft and inner branched arch devices to extend the distal landing zone. Left carotid–subclavian bypass was performed in a staged or simultaneous setting depending on the urgency of the condition. Technical success (no type I or III endoleak and successful revascularization of all supra-aortic vessels) was achieved in all patients. Median intensive care unit stay was 5 days (range 4–23) and the median hospital stay was 16 days (range 8–25). The 2 patients with acute dissection died in hospital and at 5 months, respectively. The 3 elective patients were followed for 7, 13, and 19 months, respectively. All had false lumen thrombosis with either a reduced or stable aneurysm diameter. Conclusion: This limited experience demonstrated the feasibility and safety of the combined use of the Ascend stent-graft and inner branched arch devices. This strategy may sometimes be more beneficial than either stent-graft used alone.

Use of a Steerable Sheath for Retrograde Access to Antegrade Branches in Branched Stent-Graft Repair of Complex Aortic Aneurysms

Purpose: To describe how to use a steerable sheath from a femoral access to catheterize antegrade branches in a branched aortic stent-graft. Technique: Following femoral cutdown, a stent-graft with antegrade branches destined for renovisceral target vessels was deployed in the desired position. A steerable sheath with a tip that rotates up to 180° was introduced from the common femoral artery and navigated to the antegrade branches for consecutive catheterization of the target vessels and deployment of one or more bridging stents per branch. The technique is demonstrated in 4 patients who underwent successful complex abdominal and thoracoabdominal branched endovascular repairs with 1, 2, and 4 antegrade branches. Conclusion: Retrograde access for complex aortic endografts with antegrade branches using a steerable sheath appears feasible and effective and may serve as an alternative to upper extremity access.

Transapical Access for Antegrade Catheterization of the Inner Branches of an Arch Stent-Graft Deployed Distal to an Ascending Arch Stent-Graft

Propose: To describe a technique for antegrade cannulation and bridging of the supra-aortic branches through a transapical access in the treatment of an arch aneurysm using combined ascending and branched arch stent-grafts. Technique: An 81-year-old man with a past history of open infrarenal aortic repair, emergent endovascular aortic repair for thoracic aortic rupture, and later perivisceral 4-vessel branched endovascular repair of type I thoracoabdominal aneurysm presented for repair of a concomitant 7.5-cm arch aneurysm. Because of a 44-mm ascending aorta, a tapered 50/44-mm ascending stent-graft was delivered through a transapical access to establish an adequate landing zone before implantation of a 46-mm inner branched arch device via a transfemoral route. Innominate and left subclavian arteries were antegradely cannulated and bridged through the existing transapical path. Conclusion: Our case demonstrates the feasibility of transapical access for cannulation of an arch branched device, while introducing the theoretical possibility of completing the entire procedure through a transapical access.