Wael Ahmad

Impairment of erectile function after elective repair of abdominal aortic aneurysm.

The purpose of the present study was to compare the functional change of erectile dysfunction after endovascular repair (EVAR) and open repair (OR) of abdominal aortic aneurysm. Between April 2009 and December 2011, male patients admitted for elective treatment of an asymptomatic infrarenal abdominal aortic aneurysm were included. The erectile function was evaluated by using a validated KEED questionnaire. All patients filled out the questionnaire preoperatively and postoperatively after one year. The number of patients with an increase of erectile dysfunction was 8 (26.6%) to 16 (53.3%) in open repair group vs. 30 (42.6%) to 40 (58.8%) in endovascular aneurysm repair. There was no statistically significant difference between open repair and endovascular aneurysm repair groups in order of new incidence of erectile dysfunction (p = 0.412). The study showed an increase in the mean value of Erectile Dysfunction -Score postoperatively in both the groups as well. The present study showed an increase of erectile dysfunction postoperatively, but the difference between the two groups was not statistically significant.

Clinical outcome after surgical and endovascular treatment of symptomatic persistent sciatic artery with review of the literature and reporting of three cases.

A persistent sciatic artery is a very rare vascular anomaly with an estimated incidence of 0.025–0.06% and with less than 200 described cases in the literature. During early embryonic development, the sciatic artery delivers the major blood supply to the lower limb and usually disappears when the superficial femoral artery has developed properly. The usual form of presentation in adults is the aneurysmal degeneration of the sciatic artery or less frequently with another complication (thrombosis, embolism, neuralgia). We describe three cases of a complete sciatic artery (two cases are bilateral and one is unilateral) associated with lower limb ischemia caused by embolism from the aneurysmal degeneration of the sciatic artery at the buttock level in two cases and atherosclerotic degeneration of the lower limb arteries in the third case. We also describe two combined therapy methods consisted of limb revascularization with vein-graft bypass and endovascular embolization of the aneurysm with vascular plug in the first case, in the second case combination of localized thrombolysis therapy followed by a bypass and an ilio-pedal vein bypass in the third one. And we discuss later the reported clinical outcome after surgical and endovascular treatment of this anomaly in the literature.

Endovascular Aortoiliac Aneurysm Repair with Fenestrated Stent Graft and Iliac Side Branch Using Image Fusion without Iodinated Contrast Medium

BACKGROUND The endovascular aneurysm repair (EVAR) is becoming the preferred method to treat an aortic aneurysm with its better short-term postoperative mortality and morbidity rates in comparison with the open repair. A main drawback of this method is the need to use a nephrotoxic iodinated contrast medium to visualize the aorta and its side branches. CASE REPORT An 83-year-old man with an asymptomatic infrarenal aortic aneurysm of a 51-mm diameter accompanied by a 42-mm aneurysm of the left common iliac artery was treated with combined fenestrated EVAR (FEVAR) and iliac side branch stent graft (ISBG) under guidance of image fusion (IF) without the intraoperative use of iodinated contrast agent. CONCLUSIONS Complex EVAR (FEVAR and ISBG) using computed tomography angiography IF is feasible and together with the use of CO2 angiography may help to abstain from need to nephrotoxic contrast medium.

The Ascending Aorta as an Exit Site for a Through-and-Through Wire in TEVAR.

Purpose: To describe a technique for trans–ascending aorta through-and-through guidewire placement for thoracic endograft advancement and deployment. Case Report: A 55-year-old man presented with a symptomatic pseudoaneurysm of the distal aortic arch after aortic coarctation open repair. He had also undergone mechanical aortic valve replacement. Planned were a left-sided carotid-subclavian bypass and a thoracic endovascular aortic repair with a chimney graft to the left common carotid artery. After carotid-subclavian bypass, efforts to retrograde cannulate the aortic arch and advance the thoracic endograft were unsuccessful. Because of the mechanical heart valve, no transapical approach could be used. Access to the ascending aorta was gained through a midline sternotomy. A through-and-through wire was positioned from the ascending aorta to femoral artery, which provided the required stability for advancement of the thoracic endograft. Six-month computed tomography documented patent endografts and carotid-subclavian bypass and no evidence of endoleak. Conclusion: A trans–ascending aorta through-and-through guidewire is a feasible adjunct that can be added to the endovascular armamentarium when transcardiac or transbrachial approaches are impossible or ineffective.

Impact of meteorological conditions on the incidence of acute aortic dissection

Background: There is still much controversy about whether meteorological conditions influence the occurrence of acute aortic dissection (AAD). The aim of the present study was to investigate the possible correlation between atmospheric pressure, temperature, lunar cycle and the event of aortic dissection in our patient population. Methods: The clinical data for 348 patients with AAD (73% type Stanford A) were confronted with the meteorological data provided by the Cologne weather station over the same period. Results: There were no statistically significant differences between meteorological parameters on days of AAD events compared with control days. A logistic regression model showed that air pressure (odds ratio [OR] 1.004, 95% confidence interval [CI] 0.991–1.017, p = 0.542), air temperature (OR 0.978, 95% CI 0.949–1.008, p = 0.145), season (p = 0.918) and month of the event (p = 0.175) as well as presence of full moon (OR 1.579, 95% CI 0.763–3.270, p = 0.219) were not able to predict AAD events. Also, no predictive power of meteorological data and season was found on analysing their impact on different types of AAD events. Conclusions: Our study did not reveal any dependence of atmospheric pressure, air temperature or the presence of full moon on the incidence of different types of AAD.

Image fusion using the two-dimensional-three-dimensional registration method helps reduce contrast medium volume, fluoroscopy time, and procedure time in hybrid thoracic endovascular aortic repairs

Objective The objective of this study was to evaluate the effect of image fusion (IF) technology in thoracic endovascular aortic repair (TEVAR) on reducing radiation exposure (dose and time), amount of injected iodinated contrast medium needed, and procedure time. Methods We performed a review of our institutional endovascular aortic database of patients who had undergone TEVAR between 2008 and 2016 before and after the installation of a three‐dimensional (3D) IF computed tomography system in our hybrid operating room. All patients were operated on using the same radiologic equipment with or without IF. Results The 146 patients who had undergone elective or emergent TEVAR with preoperative computed tomography angiography done in 1‐mm‐thick slices were divided into two groups: the IF group (98 patients), in which TEVAR was performed using intraoperative IF with the two‐dimensional‐3D registration method; and 48 controls without the use of IF. The IF group received a significantly reduced dose of contrast material, with a median of 70 mL (interquartile range [IQR], 50‐101 mL) compared with controls receiving 104 mL (IQR, 69‐168 mL; P < .001).Patients who underwent hybrid TEVAR had a significantly reduced procedure time under IF guidance (n = 25) compared with controls (n = 11; median, 162 minutes [IQR, 139‐199 minutes] vs 213 minutes [IQR, 189‐298 minutes]; P = .015). In addition, the intraoperative fluoroscopy time was reduced to 9 minutes (IQR, 6‐13 minutes) vs 23 minutes (IQR, 12‐45 minutes; P < .005). However, the radiation dose (dose‐area product) was similar for the two groups (P = .37).In patients who underwent plain TEVAR (n = 74) without a carotid‐subclavian bypass, the IF group needed significantly less contrast material (median, 64 mL [IQR, 43‐81 mL]) compared with the control group (median, 98 mL [IQR, 60‐180 mL]; P = .003), whereas intraoperative radiation exposition, procedure time, and fluoroscopy time did not statistically significantly differ between the two groups. Conclusions The IF technology using the two‐dimensional‐3D registration method was associated with reduced intraoperative contrast material volume in performing TEVAR. IF seemed to shorten the operation and radiation times in the more complicated (hybrid) TEVAR cases. However, a prospective study is needed to look at the dose‐area product, fluoroscopy time, and procedure time in a larger cohort of patients.

Patients Older Than 80 Years Can Reach Their Normal Life Expectancy After Abdominal Aortic Aneurysm Repair: A Comparison Between Endovascular Aneurysm Repair and Open Surgery

Purpose: To investigate the long-term outcomes of endovascular aneurysm repair (EVAR) and open surgical repair (OSR) of infrarenal abdominal aortic aneurysm in octogenarian patients and to compare them with the overall expected survival based on a sex- and age-matched German population. Methods: A total of 177 patients (median age 82 years; 149 men) ≥80 years old (range 80–92) who underwent primary elective repair of an infrarenal aortic aneurysm (≥5 cm) between 1998 and 2015 were identified in a database search. Two groups of patients were formed based on the type of procedure: 131 EVAR patients (median age 83 years; 114 men) and 46 OSR patients (median age 82 years; 35 men). Results: The median follow-up was 5 years for the OSR group and 4.5 years for the EVAR group. Kaplan-Meier analysis showed no significant difference in survival between the EVAR and OSR groups at 78 months. The observed survival of all study patients was not statistically different from the expected survival of a sex- and age-matched German population, which was true separately for women and men. Conclusion: The patients in this study seemed to reach normal life expectancy in comparison to the age- and sex-matched general population with a similar cumulative survival in both study groups over 5 years of follow-up.

A current systematic evaluation and meta-analysis of chimney graft technology in aortic arch diseases

Objective The aim of this study was to provide a review of the literature on the use of chimney graft (CG) technique in treating arterial diseases of the aortic arch and to extrapolate conclusions by summarizing the reported outcomes in a meta‐analysis. Methods An extensive electronic search was made using PubMed/MEDLINE, Science Direct Databases, and the Cochrane Library. Included in this meta‐analysis were all papers published up to February 2016 on endovascular chimney technique in the arch vessels with or without adjunct extra‐anatomic debranching, in any language, providing data about at least one of the essential outcomes: early and late type I endoleak, 30‐day mortality rate, development of perioperative stroke, patency, and retrograde aortic dissection. Results Of the 478 reports yielded by the electronic search, a total of 11 publications (on 373 patients and 387 CGs) fulfilled the inclusion criteria and were included in this study. The overall estimated proportion of technical success was 91.3% (95% confidence interval [CI], 87.4%‐94.0%). Of the 373 patients, 26 (7%) experienced a type Ia endoleak in the perioperative period. The overall estimated proportion of early type Ia endoleak was 9.4% (95% CI, 6.5%‐13.4%). Among the 10 studies that provided data, a retrograde type A dissection was observed in 2 of 351 patients, resulting in an overall estimated proportion of 1.8% (95% CI, 0.8%‐4.0%). The pooled 30‐day mortality rate was 7.9% (95% CI, 4.6%‐13.2%). The pooled estimation for reintervention was 10.6% (95% CI, 5%‐21%); for major stroke, 2.6% (95% CI, 1.3%‐5.0%); for early patency, 97.9% (95% CI, 95.8%‐99%); and for late patency, 92.9% (95% CI, 87.3%‐96%). Conclusions Treatment of aortic diseases involving the aortic arch poses a great challenge. The CG technique has been applied as an alternative treatment option. This meta‐analysis shows that endovascular repair of aortic arch disease using a CG technique in the aortic arch vessels is technically feasible and effective but not without major risk of complications.

Gender-based 30-day and long-term outcomes after carotid endarterectomy

BACKGROUND We analyses the effect of gender on short and long-term morbidity and mortality in carotid endarterectomy (CEA) under loco-regional anesthesia. PATIENTS AND METHODS Patients who were entered into a prospectively compiled computerized database of unilateral, consecutive CEAs performed at our hospital from January 2000 to December 2010 were analysed. Endpoints were perioperative stroke and death, and overall long-term survival rates. Statistical analysis was used to determine the relationships between gender and outcomes after CEA. A Cox proportional hazard model was applied to determine independent risk factors for long term survival. RESULTS A total of 1880 CEA procedures were performed in the period between 2000 and 2010. Overall, there were 28 (1.48 %) neurological deficits according to the ipsilateral carotid supply territory, including minor and major strokes. 7 occurred in the female group (1.19 %), and 21 in the male group (1.62 %) with no significant difference between the genders (p = 0.60). No significant difference emerged between female and male patients when postoperative neurological events according to the ipsilateral carotid supply territory were stratified by linical presentation (asymptomatic ICA stenosis: p = 0.75; symptomatic ICA stenosis: p = 0.66). The late overall mortality rate was 4.1% (n = 78) and 26/78 of these late deaths occurred in the female group (33 %). Log rank analysis of Kaplan Meier curves showed no statistically significant difference in long-term survival between the groups (p = 0.74). The multivariate risk factor analysis with the Cox proportinal hazard model revealed age (p < 0.00), and smoking (p = 0,02) as independent risk factors for decreased long term survival. CONCLUSIONS When considering short and long-term outcomes in patients receiving carotid endarterectomy in local anaesthesia gender should not be regarded as a factor on decision-making for carotid interventions in both symptomatic and asymptomatic patients.

The presence of variant genotype of the mannose-binding lectin gene (MBL2) is not associated with increased restenosis rate in carotid surgery

BACKGROUND We investigated the role of mannose-binding lectin (MBL) variant genotypes in patients with significant carotid restenosis after carotid endarterectomy (CEA) and who underwent a revision CEA. METHODS This was a cross-sectional analysis of 97 patients enrolled between 2001 and 2013. Three groups were investigated: group A included patients with internal carotid artery restenosis, group B included patients without restenosis after CEA, and group C included patients with peripheral arterial disease but without any signs of a carotid stenosis. Venous blood samples were drawn for the genotyping for MBL2 by polymerase chain reaction and for the determination of the MBL serum concentration by enzyme-linked immunoabsorbent assay. RESULTS The serum concentration of MBL was higher in patients with the normal genotype than in those with the genotype variants of MBL (95% confidence interval, 272.8-1008.7 μg/L; P = .001). There was no statistically significant difference among groups A, B, or C with respect to the presence of a variant genotype. Similarly, there was no significant gender difference regarding the presence of a variant genotype (P = .325). CONCLUSIONS The presence of a variant genotype of the MBL2 gene (and the correspondingly lower serum concentration of this molecule) was not correlated with the development of carotid restenosis after CEA beyond a follow-up of 12 months.