Rana O. Afifi

Outcomes of Patients With Acute Type B (DeBakey III) Aortic Dissection: A 13-Year, Single-Center Experience.

Background— Aortic dissection remains the most common aortic catastrophe. In the endovascular era, the management of acute type B aortic dissection (ATBAD) is undergoing dramatic changes. The aim of this study is to evaluate the long-term outcomes of patients with ATBAD who were treated at our center over a 13-year period. Methods and Results— We reviewed patients with ATBAD between 2001 and 2014, analyzing variables based on status (complicated [c] versus uncomplicated [u]) and treatment modalities. We defined cATBAD as rupture, expansion of diameter on imaging during the admission, persistent pain, or clinical malperfusion leading to a deficit in cerebral, spinal, visceral, renal, or peripheral vascular territories at presentation or during initial hospitalization. Postoperative outcomes were defined as deficits not present before the intervention. Outcomes were compared between the groups by use of Kaplan-Meier and descriptive statistics. We treated 442 patients with ATBAD. Of those 442, 60.6% had uATBAD and were treated medically, and 39.4% had cATBAD, of whom 39.0% were treated medically to 30.0% with open repair, 21.3% with thoracic endovascular aortic repair, and 9.7% with other open peripheral procedures. Intervention-free survival at 1 and 5 years was 84.8% and 62.7% for uATBAD, 61.8% and 44.0% for cATBAD-medical, 69.2% and 47.2% for cATBAD-open, and 68.0% and 42.5% for cATBAD–thoracic endovascular aortic repair, respectively (P=0.001). Overall survival was significantly related primarily to complicated presentation. Conclusions— In our experience, early and late outcomes of ATBAD were dependent on the presence of complications, with cATBAD faring worse. Although uATBAD was associated with favorable early survival, late complications still occurred, mandating radiographic surveillance and open or endovascular interventions. Prospective trials are required to better determine the optimal therapy for uATBAD.

A Quarter Century of Organ Protection in Open Thoracoabdominal Repair.

INTRODUCTION Thoracoabdominal aortic aneurysm (TAAA) remains a challenging problem. We sought to examine our experience with thoracic and thoracoabdominal aortic repairs over a 24-year period. METHODS Patient information was collected in a prospective database and analyzed retrospectively. Univariate and multivariable analysis was performed. RESULTS Between January 1991 and December 2014, we repaired 1896 descending thoracic (DTAA) or TAAA in 1795 patients. Mean age was 64.2 ± 13.8, and 702 (37%) were women. Of 1896 operations, 646 (34.1%) were DTAA, 316 (16.7%) TAAA extent I, 310 (16.4%) TAAA extent II, 187 (9.9%) TAAA extent III, 348 (18.4%) TAAA extent IV, and 112 (5.9%) TAAA extent V. Adjunct [cerebrospinal fluid drainage (CSFD) + distal aortic perfusion (DAP)] was used in 78.4%. Mean preoperative glomerular filtration rate (GFR) was 75.1 ± 14.9 mL/min/1.73 m. Renal dysfunction occurred in 461 (24.3%). Immediate neurodeficit (IND) occurred in 79 (4.2%) and delayed in 104 (5.5%). Of these, 47/104 (45%) recovered by discharge. Postoperative stroke was 95/1896 (5%). Early mortality was 302/1896 (15.9%). Mortality with GFR >95.3 was 28/457 (6.1%), and 131/432 (30.3%) was with GFR < 48.3 (P < 0.0001). Predictors of early mortality were age (P < 0.02), GFR (P < 0.0001), TAAA2 or 3 (P = 0.001), coronary artery disease (P = 0.001), and emergency (P < 0.0001). CONCLUSIONS Open DTAA and TAAA repair can be performed with acceptable early and late outcomes. This study provides important early- and long-term data on open repair, allowing for better risk stratification of patients with DTAA and TAAA. It is the high-risk subgroup that can now be targeted for endovascular techniques.

Intraoperative Adjunctive Stem Cell Treatment in Patients with Critical Limb Ischemia Using a Novel Point-of-Care Device

INTRODUCTION In a prospective trial we tested whether adjunctive intraoperative stem cell treatment in patients with critical limb ischemia (CLI) can be performed safely in combination with bypass surgery and/or interventional treatment. The end point of our study was the safety and integrity of a novel point-of-care system used in patients with CLI. METHODS We included only patients with CLI and tissue loss according to Rutherford categories 4-6. The Harvest Bone Marrow Aspirate Concentrate System consists of an automated, microprocessor-controlled dedicated centrifuge with decanting capability and the accessory BMAC Pack for processing a patients bone marrow aspirate (BMA). The centrifuge is portable and enables BMA to be rapidly processed in the operating room to provide an autologous concentrate of nucleated cells for immediate injection. The surgeon aspirated 120 ml BMA from the iliac crest. RESULTS Eight consecutive patients were treated according to the study protocol. The mean follow-up period was 9.2 months (range 2-18). Stem cells were always injected during the final revascularization attempt. One minor amputation and two major amputations were required. In five of eight patients there was a discrete increase in the ankle-brachial index post-stem cell treatment. The dose of stem cells after centrifugation was 17.2 (range 13.8-54.2)x10E6 CD34-positive cells and 7.8 (range 1.8-35.9)x10E6 CD133-positive cells. The injected dose of VEGFR-2-coexpressing stem cells was 0.5-5.7x10E4. CONCLUSION We were able to show that the buffy coat preparation using a point-of-care system is a simple and fast method to enrich stem cells from BMAs. This automated system gives high recovery rates and good reproducibility.

Is Total Arch Replacement Associated With Worse Outcomes During Repair of Acute Type A Aortic Dissection

BACKGROUND As acute type A aortic dissection (ATAAD) remains a challenge, the extent of resection of the transverse arch remains debated during operative repair. The purpose of this study was to compare the outcomes of total arch repair versus ascending/proximal arch repair for ATAAD. METHODS We retrospectively reviewed our aortic database of ATAAD between October 1999 and December 2014. Patients were divided into two groups: total arch repair versus proximal arch repair (hemiarch). Indications for arch replacement during ATAAD include aneurysm greater than 5 cm, complex arch tear, and arch rupture. Inhospital and long-term outcomes were compared between the two groups using univariate analysis and multiple logistic regression analysis. Survival was analyzed using Kaplan-Meier and log rank statistics, and assessment of risk factors for survival was conducted by Cox proportional hazards regression analysis. RESULTS During the study period, we performed 489 repairs of ATAAD, 49 patients (10%) with total arch replacement and 440 patients (90%) with proximal arch replacement. Patients with total arch repair were older (62.4 ± 13.4 years versus 57.9 ± 14.8 years, p = 0.046) and had significantly increased retrograde aortic dissection, circulatory arrest, and retrograde cerebral perfusion times. The incidences of early mortality, stroke, and need for renal dialysis between the total arch and proximal arch group were not significantly different: 20.4% (10 of 49) versus 12.9% (57 of 440), 8.2% (4 of 49) versus 10.5% (46 of 440), and 27% (13 of 49) versus 17.6% (76 of 432), respectively. Late survival did not demonstrate a difference between groups. CONCLUSIONS Acute type A aortic dissection remains a challenge associated with significant mortality and morbidity. When compared with a less aggressive resection, total arch replacement performed in an individualized fashion can be associated with acceptable early and late outcomes for ATAAD and was not associated with worse outcomes.

Repair of extensive aortic aneurysms: a single-center experience using the elephant trunk technique over 20 years.

Objectives:We report the early and late outcomes after repair of extensive aortic aneurysms using the 2-stage elephant trunk (ET) technique. Background:Management of aneurysm involving the entire aorta is a significant challenge. Given the anatomical complexity, the staged ET procedure was devised. A paucity of long-term data of outcomes of this approach exists. Methods:A single-center retrospective analysis of a prospectively collected database of all patients undergoing repair for extensive aortic aneurysm was performed. Results:Between 1991 and 2013, we repaired 3012 aneurysms of the ascending or thoracoabdominal aorta. Of these, we performed 503 operations in 348 patients using the ET technique. Mean age was 62.4 ± 14.3 years, and 156/346 (45.1%) operations were in women; 288 patients underwent first-stage ET with 157 receiving a complete second-stage repair. Index repair early mortality was 29/317 (9.1%). Completion stage early mortality was 17/186 = 9.1%. Stroke after first-stage ET repair was 10/297 (3.4%) and immediate neurologic deficit after the second-stage ET repair was 6/206 (2.9%). In the 131 patients who did not receive a second-stage repair, 17.8% died in the interval between 31 and 45 days. Conclusions:Extensive aortic aneurysm is a complex problem, but it can be managed safely with a 2-stage open procedure. Those patients who could not complete the completion repair fared poorly. Better predictors for early outcome need to be determined. The use of ET technique remains a valuable approach for repair of extensive aortic aneurysm.

Redo Thoracoabdominal Aortic Aneurysm Repair: A Single-Center Experience Over 25 Years

BACKGROUND Aortic disease is a lifelong, progressive illness that may require repeated intervention over time. We reviewed our 25-year experience with open redo thoracoabdominal aortic aneurysm (TAAA) and descending thoracic aortic aneurysm (DTAA) repair. Our objectives were to determine patient outcomes after redo repair of DTAA/TAAA and compare them with nonredo repair. We also attempted to identify the risk factors for poor outcome. METHODS We reviewed all open redo TAAA and DTAA repairs between 1991 and 2014. Patient characteristics, preoperative, intraoperative variables, and postoperative outcomes were gathered. Data were analyzed by contingency table and by multiple logistic regression. RESULTS We performed 1,900 open DTAA/TAAA repairs, with 266 (14%) being redos. Redos were associated with younger age (62 ± 16.4 years vs 64.5 ± 13.4 years, p < 0.02). Reasons for redo DTAA/TAAA were extension of the disease (86.8%), intercostal patch expansion (6.8%), visceral patch expansion (10.9%), infection (4.5%), anastomotic pseudoaneurysm (8.3%), and previous endovascular aortic repair complications (6.4%). Extent IV TAAA was predominantly involved in redos (42.8% redo vs 14.6% nonredo, p < 0.0001). The early mortality rate was significantly higher in redo (61 of 266 [23%]). Long-term survival was significantly lower among redo compared with nonredo DTAA/TAAAs. A multivariable analysis using the significant risk factors for early death from the risk factors on univariate analysis found four preoperative variables were significant (age >70 years, glomerular filtration rate <48 mL/min per 1.73m2, extent III TAAA, and emergency presentation) for predicting early death. In the presence of all four risk factors in a redo patient, a maximal risk of 82% for early death was predicted. CONCLUSIONS The need for a redo operation in DTAA/TAAA repair is common and most often presents as an extension of the disease into an adjacent segment. A hybrid or completely endovascular treatment should be considered in high-risk patients.

Fluctuations in Spinal Cord Perfusion Pressure: A Harbinger of Delayed Paraplegia After Thoracoabdominal Aortic Repair

Delayed paraplegia (DP) following thoracoabdominal or descending thoracic aortic (TAA/DTA) repair is a dreaded complication. We reviewed our experience with the management of DP using our previously described COPS protocol (blood-pressure stabilization, cerebrospinal-fluid (CSP) draining and O2-delivery). Complete documentation of hourly CSP pressures and detailed hemodynamic variables were available since 2000. A case-control design was used to analyze the extensive hourly data in the perioperative period. Data were analyzed by contingency-tables, t test, and regression analysis, as appropriate. Between 2000 and 2011, we performed 1059 TAA/DTA repairs. Of these, 47 (4.4%) had DP and 31 (2.9%) had immediate neurologic deficit. Postoperatively, renal replacement therapy and drain complications were significantly associated with DP. Variation in systolic blood pressure (SBP) was also highly predictive. Similarly, spinal-cord perfusion pressure (SCPP = SBP ? SP) showed increased risk with greater variability closer to event day (OR 1.3, P = 0.009). Fluctuation of more than 15 mmHg in SBP in a 24-hour period was associated with 3.2-fold increased odds of DP (P = 0.004). In all, 8/47 (17%) made a full recovery, whereas 19 (40%) had partial recovery by discharge. The 30-day mortality was 18/47 (38%) in DP and 7/55 (13%) in controls (P < 0.001). Long-term survival was significantly lower among DP cases (5-year survival of 28% vs. 75%, P < 0.001). DP occurs infrequently and is predictably associated with intraoperative loss of MEP, postoperative renal replacement therapy, drain complications and unstable systolic and spinal-cord perfusion pressures. Increased vigilance is recommended for patients who experience any of these events.

Successful Multistaged Surgical Management of Secondary Aortoesophageal Fistula With Graft Infection.

Secondary aortoenteric fistula is a rare and dreaded complication of aortic graft replacement. This case demonstrates successful management of a patient with thoracic aortic graft infection resulting in aortoesophageal fistula and the feasibility of combined endovascular approach as a temporary measure to stabilize the patient in extremis, followed by a definitive surgical repair. The patient had a remote history of descending aortic repair and an emergent thoracic endovascular aortic repair for upper gastrointestinal bleeding 2 months ago. We performed a three-staged operation involving extraanatomic bypass, total infected aortic graft excision, and primary closure of the esophageal perforation with muscle flap coverage, from which he eventually recovered.

Outcomes and management of type A intramural hematoma

BACKGROUND Initial optimal management of acute type A aortic dissection (ATAAD) with intramural hematoma (ATAIMH) remains controversial, especially between centers in the Eastern vs. Western worlds. We examined the literature and our experience to report outcomes after repair of ATAIMH. METHODS We reviewed the hospital, follow-up clinic records and online mortality databases for all patients who presented to our center for open repair of ATAAD between 1999 and 2014. Preoperative characteristics, early and long-term outcomes were compared between classic ATAAD vs. ATAIMH. Survival was analyzed using Kaplan-Meier and log-rank statistics. RESULTS Of the 523 repaired ATAAD, 101 patients (19%) presented with IMH and 422 (81%) had classic dissection. ATAIMH were significantly older (64.8±12.9 vs. 56.8±14.6 years; P<0.001), more commonly females (39% vs. 26%; P=0.010), had poor baseline renal function (i.e., glomerular filtration rate) (P<0.017), more retrograde dissections (27% vs. 8.3%; P<0.001), and less distal malperfusion (5% vs. 15%; P<0.001). Age greater than 60 years, female sex, retrograde dissection, and Marfan syndrome were strongly correlated with ATAIMH. Time to repair for ATAIMH was longer (median, 55.3 vs. 9.8 hours; P<0.001) with one death in ATAIMH within three days of presentation (0.9% vs. 6%; P=0.040). In all, 30-day mortality in ATAIMH was not different from classic ATAAD (12% vs.16%; P=0.289). A significantly lower incidence of postoperative dialysis in ATAIMH was noted (10% vs. 19%; P=0.034). When adjusted for age and renal function, late survival was improved with IMH (P<0.039). CONCLUSIONS ATAIMH continues to be associated with significant morbidity and mortality, comparable to classic aortic dissection. A multidisciplinary management approach involving aggressive medical management and risk stratification for timely surgical intervention, along with genetic profiling, is recommended for optimal care. Long-term monitoring is mandatory to assess compliance to medical therapy and recognition of evolving complications.

Intercostal artery management in thoracoabdominal aortic surgery: To reattach or not to reattach?

Background: The need for intercostal artery (ICA) reattachment in surgery for descending thoracic aortic aneurysm (DTAA) or thoracoabdominal aortic aneurysm (TAAA) remains controversial. We reviewed our experience over a 14‐year period to assess the effects of ICA management on neurologic outcome after DTAA/TAAA repair. Methods: Intraoperative data were reviewed to ascertain the status of T3‐12 ICAs and L1‐4 ICAs. Arteries were classified as reattached, ligated, occluded, or not exposed. Temporality of reattachment or ligation in response to an intraoperative ischemic event (ie, loss of motor evoked potentials [MEPs]) was noted. Adjustment for other predictors of immediate or delayed paraplegia (DP) was performed by multiple logistic regression. The effects of specific artery level and type of reattachment technique were assessed using stratified contingency tables. Results: A total of 1096 DTAA/TAAAs were performed between 2001 and 2014. The mean patient age was 64 ± 15 years, and 37% were female. Spinal cord ischemia was identified in 10% of patients, including 35 (3%) immediate cases and 77 (7%) DP cases. Overall DP resolution was 47% at discharge. ICA ligation and intraoperative MEP changes were strong predictors of postoperative paraplegia. Multivariable analysis demonstrated that T8‐12 ICA ligation significantly increased the risk for paraplegia (odds ratio, 1.3/artery; P < .041) even after adjustment for age >65 years, glomerular filtration rate, extent of II/III aneurysm, increased operative time, and intraoperative MEP loss. Conclusions: Loss of intraoperative MEPs is serious, and increases the risk of paraplegia in any ICA management strategy. Even with intact MEP, ligation of T8‐12 ICAs is associated with increased risk. These findings support reattachment of T8‐12 ICAs whenever feasible.