Salma El Batti

Type II endoleaks after endovascular repair of abdominal aortic aneurysm are not always a benign condition

OBJECTIVE The aim of the study was to determine whether type II endoleak (T2E) after endovascular repair of abdominal aorta (EVAR) is a benign condition (ie, not associated with growth, reintervention, rupture, or death). METHODS Data from patients who underwent EVAR for atherosclerotic infrarenal aortic aneurysms between June 1995 and May 2010 in the Vascular Surgery Department of Henri Mondor Hospital were prospectively collected. Data from patients presenting with at least one T2E on computed tomography scan during their follow-up were compared with those with no T2E. Three subcategories of T2E were studied according to time of occurrence (early or late), persistence (persistent or transient), and recurrence (recurrent or not recurrent). RESULTS Seven hundred patients were included with follow-up ranging from 1 month to 15 years (median, 31.3 months; range, 12.4-61.4); 201 (28.9%) had at least one T2E. Patients with T2Es were significantly older (P < .001), female (P = .015), had larger aneurysms (P = .019), and patent lumbar arteries (P = .003). Patients without T2Es had a higher incidence of current smoking (P < .001) and chronic obstructive pulmonary disease (P < .005). Multivariate analysis showed risk of T2E was increased in older patients (odds ratio [OR], 1.04; confidence interval [CI], 95% 1.02-1.06; P < .001) and in those with patent lumbar arteries (OR, 1.70; CI, 95% 1.16-2.50; P = .007), and was reduced in active smokers (OR, 0.16 CI, 95% 0.04-0.71; P = .015) or patients with coronary artery disease (OR, 0.65; CI, 95% 0.45-0.92; P = .016). Patients with T2Es had more complications (death, rupture, reintervention, or conversion) (P < .001) and greater aneurysm sac enlargement (>5 mm upon follow-up) (P < .001). Multivariate analysis showed T2E was a risk factor for aneurysm diameter growth >5 mm; this risk was increased if T2E persisted more than 6 months (hazard ratio [HR], 3.16; CI, 95% 2.55-6.03; P < .001), was recurrent (HR, 1.88; CI, 95% 1.18-3.01; P = .008), or associated with a type I or III endoleak (HR, 1.96; CI, 95% 1.41-2.73; P < .001). Recurrent T2E was associated with a higher rate of reintervention (P = .04) and conversion to open surgery (P = .028). CONCLUSIONS Not all T2Es are benign. Recurrent as well as persistent T2Es are prone to life-threatening complications.

Experience of the Zenith Dissection Endovascular System in the emergency setting of malperfusion in acute type B dissections

OBJECTIVE This study evaluated the safety and effectiveness of the Zenith Dissection Endovascular System (Cook Medical, Bloomington, Ind) in the urgent treatment of acute type B aortic dissections complicated by organ malperfusion. METHODS Between June 2011 and June 2013, we prospectively enrolled all patients with acute type B dissection (<14 days) complicated by visceral malperfusion and treated by the Zenith Dissection Endovascular System, including a proximal covered stent and a distal noncovered stent. Organ malperfusion was diagnosed during the clinical, biological, and morphologic follow-up of patients admitted to a dedicated intensive care unit (SOS Aorta). End points were 30-day mortality and morbidity, and reoperation rate, survival, and remodelling of the dissected aorta during follow-up. RESULTS Fifteen patients (11 men; mean age, 60 ± 12 years) were treated in emergency procedures with a median delay of 36 hours. Malperfusions included renal ischemia in all patients, intestinal ischemia in nine, and lower limb ischemia in six. The proximal entry tear in each patient was covered by a stent Zenith TX2 graft (mean diameter, 36 mm; mean length, 170 mm; Cook Medical), supplemented by a noncovered aortic stent (diameter, 36 or 46 mm; length, 164 mm) with a technical success rate of 100%. The left subclavian artery in 10 patients was covered without revascularization. One chimney was necessary to revascularize the left common carotid artery. Six patients required complementary arterial branch stenting for persistent static malperfusion, using eight peripheral stents (five iliacs, three renals). No deaths were recorded during the 30-day postoperative period. Major adverse events were reported in three patients (20%): 1 paraparesis with complete recovery, 1 colonic resection, 1 stroke, and 2 transient renal failures. The mean hospital stay was 14 ± 6 days. During a mean follow-up of 8 ± 3 months, one sudden death, no aortic-related complications, and no reoperations or conversions were recorded. Remodelling with healing of the thoracic false lumen was obtained in 10 patients (67%), and five others had a partially thrombosed false lumen without remodelling. CONCLUSIONS Used as a treatment for organ malperfusion complicating acute type B dissections, the Zenith Dissection Endovascular System achieved safely and effectively satisfactory clinical results in the short term. The long-term effect of this composite treatment on aortic remodelling remains to be determined.

A rare case of leiomyosarcoma arising from a femoral vein tributary: a case report

Abstract Primary vascular tumours are very rare. Most cases are leiomyosarcomas usually arising from large veins such as the inferior vena cava. Involvement of major veins in the limbs is uncommon and of small veins or tributaries extremely uncommon. We report a case of leiomyosarcoma originating from a tributary of the femoral vein in a 55-year-old woman.

Age-related changes of thoracic aorta geometry used to predict the risk for acute type B dissection.

AIMS Risk models that use a single aortic diameter threshold have failed to successfully predict acute type B aortic dissection (TBAD). We sought to identify meaningful age-indexed anatomical variables to predict TBAD risk. METHODS AND RESULTS A geometric deformable model, consisting of virtual elastic balloons that inflate inside a vessel lumen, was developed to quantify thoracic aorta geometry. In the presence of TBAD, true and total artery lumen morphology were assessed. A stepwise logistic model was built to predict TBAD risk. Initial covariates included age, gender, body mass index and all anatomic variables not directly related to the dissected segment. Patients with acute TBAD (n=34, 62±12years old, 57% male gender) were compared with subjects with symptoms of dissection, but with a subsequent negative diagnosis (n=51, 62±12years old, 76% male gender). Patient risk factors did not differ between groups. Most aortic anatomical variables were age-dependent. Aortic size was larger in every segment of the dissected with respect to non-dissected aortas (p<0.001). Variables entering the TBAD risk prediction model were aortic arch diameter, thoracic aorta length and age (predictability=0.9764, r=0.85), confirmed by a bootstrap internal validation. In dissected aortas, the true lumen volume was correlated to age (r=0.72). CONCLUSIONS TBAD probability increases with a larger aortic arch diameter and a longer thoracic aorta, whereas threshold values increase with age. The aortic morphology was age-dependent. After dissection, true lumen volume correlated to age. The use of threshold values indexed to age should be encouraged to better prevent and eventually treat TBAD.

Association Between Thoracic Aorta Calcium and Thoracic Aorta Geometry in a Cohort of Asymptomatic Participants at Increased Cardiovascular Risk

INTRODUCTION AND OBJECTIVES Thoracic aorta calcium detection is known to improve cardiovascular risk prediction for cardiac and noncardiac events beyond traditional risk factors. We investigated the influence of thoracic aorta morphometry on the presence and extent of aortic calcifications. METHODS Nonenhanced computed tomography heart scans were performed in 970 asymptomatic participants at increased cardiovascular risk. An automated algorithm estimated the geometry of the entire thoracic aorta and quantified the aortic calcium Agatston score. A nonparametric model was used to analyze the percentiles of calcium score by age. Logistic regression models were calculated to identify anatomical associations with calcium levels. RESULTS Calcifications were concentrated in the aortic arch and descending portions. Higher amounts of calcium were associated with an enlarged, unfolded, less tapered and more tortuous aorta. The size of the ascending aorta was not correlated with aortic calcium score, whereas enlargement of the descending aorta had the strongest association: the risk of having a global calcium score > 90th percentile was 3.62 times higher (confidence interval, 2.30-5.91; P < .001) for each 2.5-mm increase in descending aorta diameter. Vessel taper, tortuosity, unfolding and aortic arch and descending volumes were also correlated with higher amounts of calcium. CONCLUSIONS Thoracic aorta calcium was predominantly found at the arch and descending aorta and was positively associated with the size of the descending aorta and the aortic arch, but not with the size of the ascending aorta. These findings suggest that aortic dilatation may have different mechanisms and may consequently require different preventive strategies according to the considered segments.

Stent-assisted, balloon-induced intimal disruption and relamination of aortic dissection in patients with Marfan syndrome: Midterm outcomes and aortic remodeling

Objective The study objective was to assess the midterm outcomes and aortic remodeling in patients with Marfan syndrome with complicated acute type B aortic dissection treated with stent‐assisted, balloon‐induced intimal disruption and relamination. Methods We reviewed all patients treated with stent‐assisted, balloon‐induced intimal disruption and relamination for a complicated acute type B aortic dissection associated with Marfan syndrome according to the revised Ghent criteria. Results Between 2015 and November 2017, 7 patients with Marfan syndrome underwent stent‐assisted, balloon‐induced intimal disruption and relamination for a complicated acute type B aortic dissection. The median age of patients was 47 years (range, 23‐70). Four patients had a history of aortic root replacement. Technical success was achieved in 100%. Three patients required an adjunctive procedure for renal artery stenting (n = 2) and iliac artery stenting (n = 1). There was no in‐hospital death, 30‐day postoperative stroke, spinal cord ischemia, ischemic colitis, or renal failure requiring dialysis. At a median follow‐up of 15 months (range, 7‐28), 1 patient required aortic arch replacement for aneurysmal degeneration associated with a type Ia endoleak at 2 years, giving a late reintervention rate of 14%. There was no other secondary endoleak. The primary visceral patency rate was 100%. There were no all‐cause deaths reported. At last computed tomography scan, all patients had complete aortic remodeling of the treated thoracoabdominal aorta. Distally, at the nonstented infrarenal aortoiliac level, 6 patients had persistent false lumen flow with stable aorto‐iliac diameter in 5. One patient had iliac diameter growth (27 mm diameter at last computed tomography scan). Conclusions Stent‐assisted, balloon‐induced intimal disruption and relamination of aortic dissection in patients with Marfan syndrome is feasible, safe, and associated with an immediate and midterm persisting thoracoabdominal aortic remodeling.

Improved Survival After Implementation of a Large-Scale Regional Dedicated Aortic Network

Acute aortic diseases (AADs) include mainly abdominal or thoracic aortic aneurysms and acute aortic syndromes. Referring patients with AAD to specialized centers is particularly relevant considering the well-established volume–outcome relationship for cardiovascular surgery [(1)][1]. A regional

Aortic Non Covered Stents to Treat Complicated Acute Type B Aortic Dissections: Lessons Learned from Seven Years from S.O.S Aorta

preoperative. Four patients (33%) had a preliminary replacement of the aortic arch. The average maximum diameter of the aorta was 62 + 10 mm. The procedure of embolization was possible in 100% of the cases. The thrombosis of the false lumen at the level of the thoracic dilation was obtained in 75% of the cases after the first embolization. One patient required two sessions of embolization and two patients required three sessions. No patient presented postoperative spinal cord ischemia. One patient presented a retrograde type A dissection due to the erosion of the arterial wall by the non-covered stent of a stentgraft and was operated with uneventful course. Finally two patients had a scheduled replacement of the aorta downstream from the stentgraft for a preexistent thoraco-abdominal dilatation. The average follow-up was 3.4±2 months. Conclusion: The embolization of the false lumen of the chronic aortic dissections is feasible technically and seems not very risky. It makes it possible to treat simply some symptomatic dissections. The result on aortic remodeling requires a longer follow-up. This technique could perhaps make it possible to improve the results of the thoracic stentgrafts in chronic dissections.

First Experiment of Thoracic Stentgrafts with a Proximal Notch

was observed in 54.5% of the cases (n1⁄412) when they were perfused by the false channel, and in 7.9% of the cases (n1⁄43) when they were perfused by the true channel. Conclusion: The extensive deployment of a bare stent in this model of type B acute dissection allowed a re-expansion of the true channel in all the cases but involved a significant fall of the systolic pressure in the digestive and renal arteries in 54.5% of the cases when they originated from the false channel.