Paola De Rango

Interdisciplinary Expert Consensus Document on Management of Type B Aortic Dissection

An expert multidisciplinary panel in the treatment of type B aortic dissection reviewed available literature to develop treatment algorithms using a consensus method. Data from 63 studies published from 2006 to 2012 were retrieved for a total of 1,548 patients treated medically, 1,706 patients who underwent open surgery, and 3,457 patients who underwent thoracic endovascular repair (TEVAR). For acute (first 2 weeks) type B aortic dissection, the pooled early mortality rate was 6.4% with medical treatment and increased to 10.2% with TEVAR and 17.5% with open surgery, mostly for complicated cases. Limited data for treatment of subacute (2 to 6 weeks after onset) type B aortic dissection showed an early mortality rate of 2.8% with TEVAR. In chronic (after 6 weeks) type B aortic dissection, 5-year survival of 60% to 80% was expected with medical therapy because complications were likely. If interventional treatment was applied, the pooled early mortality rate was 6.6% with TEVAR and 8.0% with open surgery. Medical treatment of uncomplicated acute, subacute, and chronic type B aortic dissection is managed with close image monitoring. Hemodynamic instability, organ malperfusion, increasing periaortic hematoma, and hemorrhagic pleural effusion on imaging identify patients with complicated acute type B aortic dissection requiring urgent aortic repair. Recurrence of symptoms, aortic aneurysmal dilation (>55 mm), or a yearly increase of >4 mm after the acute phase are predictors of adverse outcome and need for delayed aortic repair (complicated chronic aortic dissections). The expert panel is aware that this consensus document provides proposal for strategies based on nonrobust evidence for management of type B aortic dissection, and that literature results were largely heterogeneous and should be interpreted cautiously.

Systematic review of clinical outcomes in hybrid procedures for aortic arch dissections and other arch diseases

OBJECTIVEnAvailable data on clinical outcomes of hybrid aortic arch repair are limited, especially for patients with aortic dissection. The objective of this review was to provide pooled analysis of periprocedural mortality and neurologic outcomes in hybrid procedures involving the aortic arch for dissection and other aortic diseases.nnnMETHODSnStudies involving hybrid aortic arch procedures (2002-2011) were systematically searched and reviewed. End points were periprocedural mortality, stroke, and spinal cord ischemia.nnnRESULTSnA total of 50 studies including 1886 patients were included. Perioperative mortality ranged from 1.6% to 25.0% with a pooled event ratio of 10.8% (95% confidence intervals [CI], 9.3-12.5). Perioperative stroke, regardless of severity, ranged from 0.8% to 25.0% (pooled ratio 6.9%; 95% CI, 5.7%-8.4), and spinal cord ischemia, including permanent and transitory events, ranged from 1.0% to 25.0% (pooled ratio, 6.8%; 95% CI, 5.6-8.2). Neurologic but no mortality risk was affected by timing and center volume with decreased rates in more recent and higher volume studies. In dissected aorta, perioperative mortality rate was 9.8% (95% CI, 7.7-12.4), stroke 4.3% (95% CI, 3.0-6.3), and spinal cord ischemia 5.8% (95% CI, 4.2-7.9). Perioperative mortality was higher in diseases that extended to the ascending aorta (15.1% vs 7.6%; odds ratio, 2.8; 95% CI, 1.17-6.7; P = .021), whereas there were no significant differences in the neurologic risks of stroke or spinal cord ischemia.nnnCONCLUSIONSnHybrid repair of the aortic arch carries not negligible risks of perioperative mortality and neurologic morbidity. Risk of neurologic complications has decreased with timing and center volume and may be limited in dissection repairs. However, contemporary information on aortic hybrid arch procedures is mainly provided by small case series or retrospective studies with wide range of results.

Acute Type A Intramural Hematoma Analysis of Current Management Strategy

Background— Management of acute type A intramural hematoma (IMH) remains controversial, varying from immediate surgery to medical management only. Conversion to typical dissection remains a concern. We analyzed our experience managing acute type A IMH. Methods and Results— Between October 1999 and May 2008, 251 patients with acute type A aortic dissection were treated, including 36 (14.3%) with type A IMH. Seven IMH patients (19%) were repaired immediately, 28 (80%) managed initially with optimal medical management and eventual repair and 1 (3%) with medical management only. End points analyzed were early mortality and conversion to typical dissection (flow in the false lumen of the ascending aorta). Time (hours) from onset of symptoms defined initiation of IMH. Early mortality for acute type A IMH was 8.3% (3/36): 14.3% (1/7) with immediate repair and 7.1% (2/28) when optimal medical management with eventual repair was undertaken (P=0.69). The 1 medically managed Asian patient survived with resolution of the IMH. Conversion to type A IMH to typical dissection occurred in 33% (12/36) of cases. No conversions were observed within 72 hours. Aortic diameter did not predict conversion. In actuarial analysis among the initially medically managed group with eventual repair, the hazard conversion to typical dissection increased significantly at 8 days from the onset of symptoms (P<0.05). Conclusions— Despite optimal medical management, conversion of type A IMH to typical dissection still remains a concern, with the most significant risk beyond 8 days. In our patient population, timely surgical repair is recommended.

Effect of statins on survival in patients undergoing dialysis access for end-stage renal disease

The benefit of statin therapy in patients with advanced chronic kidney disease remains uncertain. Randomized trials have questioned the efficacy of the drug in improving outcomes for on-dialysis populations, and many patients with end-stage renal disease are not currently taking statins. This study aimed to investigate the impact of statin use on survival of patients with vascular access performed at a vascular center for chronic dialysis. Consecutive end-stage renal disease patients admitted for vascular access surgery in 2006 to 2013 were reviewed. Information on therapy was retrieved and patients on statins were compared to those who were not on statins. Primary endpoint was 5-year survival. Independent predictors of mortality were assessed with Cox regression analysis adjusting for covariates (ie, age, sex, hyperlipidemia, hypertension, cardiac disease, cerebrovascular disease, chronic obstructive pulmonary disease, obesity, diabetes, and statins). Three hundred fifty-nine patients (230 males; mean age 68.9 ± 13.7 years) receiving 554 vascular accesses were analyzed: 127 (35.4%) were on statins. Use of statins was more frequent in patients with hypertension (89.8% v 81%; P = .034), hyperlipidemia (52.4% v 6.2%; P < .0001), coronary disease (54.1% v 42.6%; P = .043), diabetes (39.4% v 21.6%; P = .001), and obesity (11.6% v 2.0%; P < .0001). Mean follow-up was 35 months. Kaplan-Meier survival rates at 3 and 5 years were 84.4% and 75.9% for patients taking statins and 77.0% and 65.1% for those not taking statins (P = .18). Cox regression analysis selected statins therapy as the only independent negative predictor (odds ratio = 0.55; 95% confidence interval = 0.32-0.95; P = .032) of mortality, while age was an independent positive predictor (odds ratio = 1.05; 95% confidence interval = 1.03-1.08; P < .0001). Vascular access patency was comparable in statin takers and those not taking statins (P = .60). Use of statins might halve the risk of all-cause mortality at 5 years in adult patients with vascular access for chronic dialysis. Statins therapy should be considered in end-stage renal disease populations requiring dialysis access placement.

Results of Iliac Branch Stent-Grafts

The evolution of technology and introduction of new generation devices has resulted in increasing utilization of iliac branch graft (IBG) for endovascular treatment of iliac aneurysms. The indications of total endovascular repair have been expanded to more complex and bilateral iliac aneurysms. Technical success for IBGs is high, ranging from 86 to 100 % in most recent series. With the introduction of newer generation devices, the occlusion rates have declined and IBG patency of 81–100 % is achieved at variable follow-up lengths. Nevertheless, the risk of iliac occlusions, frequently associated with buttock claudication, and endoleak still remain possible concerns that require carefully pre-implant assessment and patient selection. This chapter summarizes the current results of IBGs.

Safety of Carotid Revascularization during the Acute Period of Neurological Symptom Onset in Women

BACKGROUNDnBenefit from carotid revascularization is supposed to be lower in women due to increased periprocedural risks. The aim of this study was to investigate the risk of stroke/death after carotid intervention in women treated within 15xa0days from last neurological event.nnnMETHODSnData from 282 consecutive patients treated during 2009-2015 by carotid endarterectomy or carotid stenting within 15xa0days from neurological symptoms were analyzed by sex and stratified according to treatment delay toward symptoms onset.nnnRESULTSnEighty women (28.4%) underwent carotid stenosis correction: in 37 treatment was performed within 7xa0days from symptoms (in 12 within 48xa0hr); the remaining underwent carotid disease correction between day 8 and day 15 after the index event. Baseline comorbidity profile, presenting symptoms (stroke, transient ischemic attack, and recurrent symptoms) and treatment delay were comparable between sexes. The 30-day stroke/death rate was 2.5% in women (2/80) and 3.5% (7/202) in men (Pxa0=xa01.00). There was no 30-day death or cerebral hemorrhage in women and in patients treated within the first 48xa0hours. In adjusted analyses, female sex was not associated with increased stroke/death risk. At 4 years, for women and men survival was 93.9% vs. 79.2% (Pxa0=xa00.047) and freedom from stroke 92.6% vs. 92.2% (Pxa0=xa00.76).nnnCONCLUSIONSnWomen with symptomatic carotid stenosis may benefit as men from intervention when performed within the acute (15xa0days) or hyperacute (48xa0hr) period after neurological event. Thirty-day stroke/death rate in this experience is lower or comparable to mens and treatment appears to be effective in preventing new strokes at midterm.

Pseudoaneurysm in chronic pancreatitis

A 50-year-old man with chronic pancreatitis was admitted to hospital with increasing midabdominal pain, vomiting and weakness. His history included alcohol abuse, gastric resection and pancreatic pseudocyst. His hemoglobin level was 73 (normal 130–170) g/L. Contrast-enhanced computed tomography (

Statins and Intracerebral HemorrhageClinical Perspective: Collaborative Systematic Review and Meta-Analysis

Background— A recent large, randomized trial suggested that statins may increase the risk of intracerebral hemorrhage. Accordingly, we systematically reviewed the association of statins with intracerebral hemorrhage in randomized and observational data. Methods and Results— We screened 17 electronic bibliographic databases to identify eligible studies and consulted with experts in the field. We used DerSimonian-Laird random-effects models to compute summary risk ratios with 95% confidence intervals. Randomized trials, cohort studies, and case-control studies were analyzed separately. Only adjusted risk estimates were used for pooling observational data. We included published and unpublished data from 23 randomized trials and 19 observational studies. The complete data set comprised 248 391 patients and 14 784 intracerebral hemorrhages. Statins were not associated with an increased risk of intracerebral hemorrhage in randomized trials (risk ratio, 1.10; 95% confidence interval, 0.86–1.41), cohort studies (risk ratio, 0.94; 95% confidence interval, 0.81–1.10), or case-control studies (risk ratio, 0.60; 95% confidence interval, 0.41–0.88). Substantial statistical heterogeneity was evident for the case-control studies (I2=66%, P=0.01), but not for the cohort studies (I2=0%, P=0.48) or randomized trials (I2=30%, P=0.09). Sensitivity analyses by study design features, patient characteristics, or magnitude of cholesterol lowering did not materially alter the results. Conclusions— We found no evidence that statins were associated with intracerebral hemorrhage; if such a risk is present, its absolute magnitude is likely to be small and outweighed by the other cardiovascular benefits of these drugs.Background— A recent large, randomized trial suggested that statins may increase the risk of intracerebral hemorrhage. Accordingly, we systematically reviewed the association of statins with intracerebral hemorrhage in randomized and observational data.nnMethods and Results— We screened 17 electronic bibliographic databases to identify eligible studies and consulted with experts in the field. We used DerSimonian-Laird random-effects models to compute summary risk ratios with 95% confidence intervals. Randomized trials, cohort studies, and case-control studies were analyzed separately. Only adjusted risk estimates were used for pooling observational data. We included published and unpublished data from 23 randomized trials and 19 observational studies. The complete data set comprised 248 391 patients and 14 784 intracerebral hemorrhages. Statins were not associated with an increased risk of intracerebral hemorrhage in randomized trials (risk ratio, 1.10; 95% confidence interval, 0.86–1.41), cohort studies (risk ratio, 0.94; 95% confidence interval, 0.81–1.10), or case-control studies (risk ratio, 0.60; 95% confidence interval, 0.41–0.88). Substantial statistical heterogeneity was evident for the case-control studies (I2=66%, P =0.01), but not for the cohort studies (I2=0%, P =0.48) or randomized trials (I2=30%, P =0.09). Sensitivity analyses by study design features, patient characteristics, or magnitude of cholesterol lowering did not materially alter the results.nnConclusions— We found no evidence that statins were associated with intracerebral hemorrhage; if such a risk is present, its absolute magnitude is likely to be small and outweighed by the other cardiovascular benefits of these drugs.nn# Clinical Perspective {#article-title-52}

Statins and Intracerebral HemorrhageClinical Perspective

Background— A recent large, randomized trial suggested that statins may increase the risk of intracerebral hemorrhage. Accordingly, we systematically reviewed the association of statins with intracerebral hemorrhage in randomized and observational data. Methods and Results— We screened 17 electronic bibliographic databases to identify eligible studies and consulted with experts in the field. We used DerSimonian-Laird random-effects models to compute summary risk ratios with 95% confidence intervals. Randomized trials, cohort studies, and case-control studies were analyzed separately. Only adjusted risk estimates were used for pooling observational data. We included published and unpublished data from 23 randomized trials and 19 observational studies. The complete data set comprised 248 391 patients and 14 784 intracerebral hemorrhages. Statins were not associated with an increased risk of intracerebral hemorrhage in randomized trials (risk ratio, 1.10; 95% confidence interval, 0.86–1.41), cohort studies (risk ratio, 0.94; 95% confidence interval, 0.81–1.10), or case-control studies (risk ratio, 0.60; 95% confidence interval, 0.41–0.88). Substantial statistical heterogeneity was evident for the case-control studies (I2=66%, P=0.01), but not for the cohort studies (I2=0%, P=0.48) or randomized trials (I2=30%, P=0.09). Sensitivity analyses by study design features, patient characteristics, or magnitude of cholesterol lowering did not materially alter the results. Conclusions— We found no evidence that statins were associated with intracerebral hemorrhage; if such a risk is present, its absolute magnitude is likely to be small and outweighed by the other cardiovascular benefits of these drugs.Background— A recent large, randomized trial suggested that statins may increase the risk of intracerebral hemorrhage. Accordingly, we systematically reviewed the association of statins with intracerebral hemorrhage in randomized and observational data.nnMethods and Results— We screened 17 electronic bibliographic databases to identify eligible studies and consulted with experts in the field. We used DerSimonian-Laird random-effects models to compute summary risk ratios with 95% confidence intervals. Randomized trials, cohort studies, and case-control studies were analyzed separately. Only adjusted risk estimates were used for pooling observational data. We included published and unpublished data from 23 randomized trials and 19 observational studies. The complete data set comprised 248 391 patients and 14 784 intracerebral hemorrhages. Statins were not associated with an increased risk of intracerebral hemorrhage in randomized trials (risk ratio, 1.10; 95% confidence interval, 0.86–1.41), cohort studies (risk ratio, 0.94; 95% confidence interval, 0.81–1.10), or case-control studies (risk ratio, 0.60; 95% confidence interval, 0.41–0.88). Substantial statistical heterogeneity was evident for the case-control studies (I2=66%, P =0.01), but not for the cohort studies (I2=0%, P =0.48) or randomized trials (I2=30%, P =0.09). Sensitivity analyses by study design features, patient characteristics, or magnitude of cholesterol lowering did not materially alter the results.nnConclusions— We found no evidence that statins were associated with intracerebral hemorrhage; if such a risk is present, its absolute magnitude is likely to be small and outweighed by the other cardiovascular benefits of these drugs.nn# Clinical Perspective {#article-title-52}