Thomas Kotsis

Management of complicated and uncomplicated acute type B dissection. A systematic review and meta-analysis

BACKGROUND The management of acute type B dissection represents a clinical challenge. We undertook a systematic review of the available literature regarding medical, surgical and endovascular treatments of acute type B aortic dissection and combined the eligible studies into a meta-analysis. METHODS An extensive electronic health database search was performed on all articles published from January 2006 up to November 2013 describing the management of acute type B aortic dissection. Studies including less than 15 patients were excluded. RESULTS ACUTE COMPLICATED TYPE B DISSECTION: overall, 2,531 patients were treated with endovascular repair (TEVAR) and the pooled rate for 30-day/in-hospital mortality was 7.3%. The pooled estimates for cerebrovascular events, spinal cord ischemia (SCI) and total neurologic events were 3.9%, 3.1% and 7.3%, respectively. A total of 1,276 patients underwent open surgical repair and the pooled rate for 30-day/in-hospital mortality was 19.0%. The pooled rate for cerebrovascular events was 6.8%, for SCI 3.3% and for total neurologic complications 9.8%. Acute uncomplicated type B dissection: outcome of 2,347 patients who underwent conservative medical management were analyzed. The pooled 30-day/in-hospital mortality rate was 2.4%. The pooled rate for cerebrovascular events was 1%, for SCI 0.8% and for overall neurologic complications 2%. CONCLUSIONS Endovascular repair provides a superior 30-day/in-hospital survival for acute complicated type B aortic dissection compared to surgical aortic reconstruction. However, open repair still has a significant role as endovascular repair is not applicable in all patients and there remains concerns regarding the durability of this technique. TEVAR seems to have a more favorable outcome regarding aortic remodeling and the aortic-specific survival rate when compared with medical therapy alone. Randomized controlled trials focusing on the prognostic factors of early and late complications in uncomplicated type B dissections are needed.

Endovascular Exclusion of Symptomatic Bilateral Common Iliac Artery Aneurysms with Preservation of an Aneurysmal Internal Iliac Artery via a Reverse-U Stent-Graft

Purpose: To report a technique to maintain flow to an aneurysmal internal iliac artery (IIA) when treating bilateral common iliac artery (CIA) aneurysms with an aortomonoiliac stent-graft and femorofemoral bypass. Technique: First, an external iliac artery (EIA) to IIA endograft is placed distal to the IIA aneurysm then the contralateral IIA is embolized with coils. An aortomonoiliac stent-graft extending to the contralateral EIA is placed, and the procedure is completed with a femorofemoral bypass. Conclusion: Endovascular treatment of bilateral CIA aneurysms and combined with a unilateral IIA aneurysm is a technically demanding procedure. An endovascular repair with retrograde (reverse-U stent-graft) hypogastric artery preservation can be considered a first choice until the use of branched iliac stent-grafts becomes more widespread.

Liver resection with repair of major hepatic veins.

BACKGROUND Liver resections for tumors adjacent to major hepatic veins often require reconstruction of venous wall defects. We describe a new operative approach that facilitates repair of major hepatic veins during hepatectomies. METHODS In 3 cases of liver tumors, the resection line had to include partially the wall of the right hepatic vein, middle hepatic vein and left hepatic vein of the preserved liver. The procedure was carried out by employing portal triad clamping combined with extrahepatic occlusion of the hepatic veins. Venous grafts for vascular repair were harvested from the inferior mesenteric vein. RESULTS In all 3 patients, histology showed tumor-free resection margins. Follow-up of 32 to 42 months revealed no recurrence and excellent liver function. CONCLUSIONS Combination of selective hepatic vascular exclusion with venous repair techniques, facilitates extensive liver resections in patients with tumors adjacent to the major hepatic veins and maximizes preservation of healthy liver tissue.

Atherosclerotic aneurysms of the superficial femoral artery: report of two ruptured cases and review of the literature

Isolated arteriosclerotic aneurysms of the superficial femoral artery are rare. In citing the literature a total of 30 cases in 28 patients in the last 25 years were found. In addition to the above cases, two aged patients with ruptured aneurysms of the superficial femoral artery are reported; these were managed successfully with partial aneurysmectomy and restoration of the circulation of the extremity with a synthetic graft. The prognosis for this type of aneurysm following surgical therapy is good, despite the advanced age of the patients, and amputation is relatively rare, occurring in only two out of the 30 aneurysms (6.6%) reported. The risk of rupture is 46.6% (14/30) and is greater than that found in peripheral aneurysms. This, in association with the possibility of the creation of thrombosis (5/30; 16.6%) or embolization (1/30; 3.3%), threatens the extremity itself as well as the life of the patient, increasing the risk of complications and even death at a rate of 66.6% (20/30). Timely diagnosis, immediate surgical reconstruction and prompt mobilization, however, can guarantee a good prognosis for these aged patients.

External Iliac Venous Aneurysm Treated With Tangential Aneurysmatectomy and Lateral Venorrhaphy: A Case Report and Review of the Literature

Venous aneurysms of the femoro-iliac axis are uncommon abnormalities of the vascular system with a potentially life-threatening course; they can be associated with the disastrous events of thromboembolism or rupture. Therefore, a focused imaging evaluation and prophylactic treatment is essential. The appropriate surgical approach is, however, dictated by the morphological parameters and the extent of the aneurysm. We present an external iliac venous aneurysm in a 31-year-old woman that was revealed incidentally and treated successfully by tangential aneurysmectomy and lateral venorrhaphy. The choice of surgical technique is discussed along with a review of the literature on venous aneurysms.

An Update of the Role of Endovascular Repair in Blunt Carotid Artery Trauma

Blunt carotid injury (BCAI) is an increasingly recognised entity in trauma patients. Without a prompt diagnosis and a proper treatment, they can result in devastating consequences with cerebral ischaemia rate of 40-80% and mortality rate of 25-60%. Several applied screening protocols and continuously improving diagnostic modalities have been developed to identify patients with BCAI. The appropriate treatment of BCAI still remains controversial and strictly individualised. Besides anti-thrombotic/anticoagulation therapy and surgical intervention, continuously evolving endovascular techniques emerge as an additional treatment option for patients with BCAI. We provide an update on blunt carotid trauma, emphasising the role of endovascular approaches.

The Effect of Perioperative Ischemia and Reperfusion on Multiorgan Dysfunction following Abdominal Aortic Aneurysm Repair

Abdominal aortic aneurysms (AAAs) are relatively common and are potentially life-threatening medical problems. The aim of this review is to provide an overview of the effect of I/R injury on multiorgan failure following AAA repair. The PubMed, CINAHL, EMBASE, Medline, Cochrane Review, and Scopus databases were comprehensively searched for articles concerning the pathophysiology of I/R and its systemic effects. Cross-referencing was performed using the bibliographies from the articles obtained. Articles retrieved were restricted to those published in English. One of the most prominent characteristics of AAA open repair is the double physiological phenomenon of ischemia-reperfusion (I/R) that happens either at the time of clamping or following the aortic clamp removal. Ischemia-reperfusion injury causes significant pathophysiological disturbances to distant organs, increasing the possibility for postoperative multiorgan failure. Although tissue injury is mediated by diverse mechanisms, microvascular dysfunction seems to be the final outcome of I/R.

The Influence of Total Plasma Homocysteine and Traditional Atherosclerotic Risk Factors on Degree of Abdominal Aortic Aneurysm Tissue Inflammation

Objective: Modulating effects of genetic and environmental risk factors on severity of human abdominal aortic aneurysm (AAA) tissue inflammation remain unclear. We investigated the influence of total plasma homocysteine (tHcy) and traditional atherosclerotic risk factors (ARF) on degree of AAA tissue inflammation. Methods: Aneurysm specimens were obtained from 89 male patients aged 52 to 83 years, underwent asymptomatic not ruptured AAA (mean diameter 5.5 cm) open repair and graded for degree of histologic inflammation. Multivariate analysis was used to determine the association of tHcy and ARF, with degree of inflammation. Results: Current cigarette smoking, odds ratio (OR) 4.4, 95% confidence interval 1.3 to 15.2, P = .01 and no other ARF, neither tHcy levels OR 0.9 (0.9-1.02), P = .2 were associated with high-grade tissue inflammation. Conclusion: These results provide evidence against a major effect of tHcy levels on AAA tissue inflammation, while current cigarette smoking is a significant modulating factor.

Comparative Results of Staged and Simultaneous Bilateral Carotid Endarterectomy: A Clinical Study and Surgical Treatment

OBJECTIVE Bilateral carotid stenoses are actually managed by staged endarterectomy. The present study compares the results of the above surgical procedure with simultaneous bilateral carotid endarterectomy. METHODS Sixty-four carotid endarterectomies were carried out on two groups of thirty-two patients with bilateral carotid stenoses. Fifteen patients (group A) were subjected to staged and 17 patients (group B) who were subjected to simultaneous bilateral carotid endarterectomies. RESULTS The mortality rate was zero in both groups; no statistically significant difference was found concerning complications related to the heart, neurological deficit and postoperative hypertension. CONCLUSIONS Simultaneous carotid endarterectomy is a challenging and technically demanding operation but with limited indications in strictly selected patients. The development of methods of more effective monitoring and protection of the cerebral cells might broaden the indications of such a surgical tactic in the future. Staged carotid endarterectomy, however, remains the method of choice for the management of bilateral carotid occlusive disease.

Abdominal Aortic Aneurysm With Ectopic Renal Artery Origins: A Case Report

The coexistense of an abdominal aortic aneurysm with ectopic main renal vasculature complicates aortic surgery and mandates a focused imaging evaluation and a carefully planned operation to minimize renal ischemia. We present the case of a 75-year-old man with an abdominal aortic aneurysm and a right kidney with two ectopic main renal arteries, one originating from the aneurysmal distal aorta and the other from the right common iliac artery; the patient underwent a surgical repair and followed an uneventful course with no deterioration of renal function. The preoperative and intraoperative details are reported, along with a review of the literature.