Piero Trabattoni

Redo in aortic homograft replacement: Transcatheter aortic valve as a valid alternative to surgical replacement

CLINICAL SUMMARY A 48-year-old woman was referred to our hospital with symptoms of ingravescent severe dyspnea. Fifteen years earlier, she had undergone placement of a 21-mm aortic valve Bravo 400 stentless xenograft (Cryolife International, Atlanta, Ga). Four years later, she underwent a valve replacement with a 21-mm mechanical prosthesis (Carbomedics, Austin, Tex) for valve degeneration, and subsequently, she received a homograft for aortic valve endocarditis. The echocardiographic control, performed during the last 15 years, showed progressive calcific valve degeneration with a peak transvascular pressure gradient of 41 mm Hg and aortic valve area of 0.5 cm. Preoperative computed tomographic angiographic analysis showed diffuse aortic root

Cumulative radiation exposure during thoracic endovascular aneurysm repair and subsequent follow-up

OBJECTIVES Thoracic endovascular aneurysm repair (TEVAR) is an appealing alternative to the standard surgical approach, but requires rigorous radiological follow-up. The cumulative radiation exposure (RE) of patients undergoing TEVAR-including pre-operative workup, the procedure and subsequent follow-up computed tomography (CT) imaging-has not previously been investigated. METHODS From August 2003 to February 2011, 48 patients underwent TEVAR at our institution. Mean age was 66 ± 11 years, with 10 patients (21%) aged <60 years. Forty-one (85%) patients were male; 7 (15%) had urgent/emergent operation; 21 (44%) had undergone previous aortic surgery. Mean aortic diameter was 7.3 ± 2.1 cm. Intra-operative screening time and RE were reviewed, and typical institutional thoracic CT scan RE was calculated (17.8 mSv). Life expectancy of an age- and sex-matched population was estimated to assess the cumulative RE from recurrent CT follow-up. RESULTS The average screening time was 15.7 ± 11.4 min, with an RE of 11.3 ± 9 mSv. Obese patients had significantly higher RE during TEVAR (Pearsons coefficient = 0.388, P = 0.019). The RE dropped from 14.9 ± 9.4 mSv to 8.6 ± 7.9 mSv (P = 0.033) after a hybrid suite was established. Our institutional TEVAR protocol involves one pre-operative thoracoabdominal CT scan and three follow-up thoracic CT scans for the first year, with a yearly evaluation thereafter. The life expectancy of an age- and sex-matched population was 17 years. A patient adhering to our surveillance protocol would be subjected to an overall exposure of 89 mSv at 1 year and 161 mSv at 5 years, with a projected lifetime RE >350 mSv. CONCLUSIONS A 2-year RE exceeding the threshold of 100 mSv with a life expectancy >15 years can be estimated to lead to a lifetime risk increase in radiation-induced leukaemia and solid-tumour cancer >2.7%. The risks of cumulative RE especially in younger and/or obese patients must be balanced with the expected morbidity and mortality reduction in TEVAR versus traditional open repair, and the anticipated benefits of recurrent radiographic imaging.

Aortic Dissection Complicating Intraaortic Balloon Pumping: Percutaneous Management of Delayed Spinal Cord Ischemia

Iatrogenic acute type B dissection is a rare complication of intraaortic balloon pumping. Delayed visceral and spinal cord malperfusion can occur for distal progression of the dissection or relative hypotension. Cerebrospinal fluid drainage and percutaneous balloon fenestration provide a safe and effective method for managing ischemic complications.

Right Aortic Arch Related to Kommerell Diverticulum and Internal Carotid Artery Agenesis

A 31-year-old woman presented with blood pressure somewhat lower on the left compared with the right arm, hyposthenia, and left arm claudication. A vascular ultrasound examination demonstrated the absence of internal left carotid associated with left subclavian artery stenosis. A multidetector computed tomography using a 64-row scanner (Figure 1) confirmed the echographic results and revealed the …

Five-year echocardiographic follow-up after TAVI: structural and functional changes of a balloon-expandable prosthetic aortic valve

Aims Scarce data are available on the long-term structural and functional changes of prosthetic valves after transcatheter aortic valve implantation (TAVI). The objective was to evaluate with echocardiography the long-term structural and functional changes of prosthetic valves after TAVI. Methods and results Structural valve deterioration (SVD) was defined as leaflet thickening ≥3mm, presence of calcification and abnormal leaflet motion. Five-year echocardiographic follow-up was available in 96 out of 318 patients who underwent TAVI with a balloon-expandable device between April 2008 and December 2011. At 1-year follow-up, no patient showed SVD. At 5-year follow-up, SVD were observed in 29 (30%) patients who showed also a significant reduction of aortic valve area (AVA) together with an increase of mean and peak aortic pressure gradients at the latest echocardiography evaluation. Moreover, rate of central aortic valve regurgitation ≥2 was higher in SVD patients as compared to those without SVD, while there was no difference in terms of paravalvular regurgitation. Despite SVD, one patient only reached the criteria for severe stenosis and no reintervention was needed at 5-year follow-up. Variables independently associated with SVD were female sex, small body surface area, use of a 23 mm valve, and small AVA at pre-discharge echocardiogram. Conclusion At 5-year follow-up, 30% of patients who underwent TAVI with a balloon-expandable valve showed initial SVD. However, SVD was not associated with severe stenosis in most of the patients and had no significant impact on and clinical outcome.

TCT-695 Comparison of in-hospital and 1-year TAVR results between Sapien XT and Sapien 3 prosthetic valves

Transcatheter aortic valves are rapidly evolving in order to reduce procedural complications and to improve acute and long-term outcomes of aortic stenosis (AS) treatment. Aim of the study was to compare in a single-center experience in-hospital and 1-year results of severe AS treatment with Sapien

Superficial femoral artery access for transcatheter aortic valve replacement.

Different vascular accesses have been described for the delivery of a transcatheter aortic bioprosthesis. We report the use of the superficial femoral artery (SFA) as the arterial site of puncture with surgical cut-down. It may be a reasonable access alternative to the other classical routes, especially in the setting of either obese patients with elevated body mass index or in the presence of high femoral artery bifurcation. This route seems to be feasible with a low-profile risk.

A Short Report on Single Stage Transcatheter Aortic Valve Replacement and Carotid Stenting

No consensus exists on the timing, safety, and efficacy of treating severe symptomatic aortic and carotid stenosis. In the older population and in the presence of multiple comorbidities that arise during the surgery, a less invasive transcatheter treatment may be the only reasonable option. We discuss this topic by analyzing a case of an 84-year-old man who underwent a combined single-stage transcatheter procedure.

Comparison of SFA lesion treatment with Zilver PTX in diabetics vs. Non-diabetics: 2-year clinical and functional results

BACKGROUND Prospective single-arm study, aimed at evaluating safety and effectiveness at 12 and 24 months of the paclitaxel-eluting nitinol stent (Zilver PTX), and focused in particular on the treatment of complex lesions and/or diabetic patients. METHODS Between May 2010 and March 2012, 67 patients (78% males) were treated by Zilver PTX, because of stenosis or occlusions of the superficial femoral artery in one of two centers. The mean age of patients was 70.1±8 years. Thirty-two of 67 (48%) were diabetics, 14 (21%) active smokers and 11 (14.6%) had chronic renal failure (end stage renal disease). The average length of lesions was 104±60 mm. Occlusion was complete in 46.3% of cases, whereas severely calcified lesions were present in 30% of patients (18.8% in diabetics and 31.4% in non-diabetics). Twenty-six patients (39%) had type C or D lesions according to TASC 2. RESULTS One hundred-two stents were used (1.7±0.9 per patients); median 1 (range 1-4). All patients had successful stent placement. Primary patency, evaluated by Kaplan-Meier method was 88±0.06% at 12 months, and 68±0.1% at 24 months. In particular, the difference between diabetics (D) and non-diabetics (non-D) was not significant (P=0.07, Log-Rank). Patients turned from 4.2±1.3 to 1.6±1.3 Rutherford class. There were 5 deaths due to systemic comorbidities. There also were 3 major amputations, all of them also in the D group. Among the other patients, differences between D and non-D patients were not significant in terms of wound healing, bipedal stay and spontaneous ambulation. The mean follow-up length was 28±5 months (range 24-36 months). There was only one patient who had fracture and stent migration (1.5%). In 13 diabetic patients, tibial PTA was also associated. Additional treatment was required in 6 D and 1 non-D. CONCLUSIONS The use of Zilver PTX is safe and effective in the treatment of SFA lesions. In particular, both stent patency and functional results on the basis of both clinical and instrumental tools were similar in D and non-D, suggesting a particularly favorable activity of PTX in a subpopulation of diabetics. Further studies are required to confirm these results, which seem to be particularly promising in diabetic patients.

Vascular homograft use in a femoropopliteal rare bacterial infection bypass.

We report on a patient with a femoropopliteal bypass infected by Kytococcus sedentarius. Treatment consisted of resection of the infected prosthesis with homograft substitution and antibiotic therapy started postoperatively. At 6 months followup, the patient showed no signs of infection and results of laboratory findings were normal.