Young Erben

Height alone, rather than body surface area, suffices for risk estimation in ascending aortic aneurysm

Background: In international guidelines, risk estimation for thoracic ascending aortic aneurysm (TAAA) is based on aortic diameter. We previously introduced the aortic size index (ASI), defined as aortic size/body surface area (BSA), as a predictor of aortic dissection, rupture, and death. However, weight might not contribute substantially to aortic size and growth. We seek to evaluate the height‐based aortic height index (AHI) versus ASI for risk estimation and revisit our natural history calculations. Methods: Aortic diameters and long‐term complications of 780 patients with TAAA were analyzed. Growth rate estimates, yearly complication rates, and survival were assessed. Risk stratification was performed using regression models. The predictive value of AHI and ASI was compared. Results: Patients were stratified into 4 categories of yearly risk of complications based on their ASI and AHI. ASIs (cm/m2) of ≤2.05, 2.08 to 2.95, 3.00 to 3.95 and ≥4, and AHIs (cm/m) of ≤2.43, 2.44 to 3.17, 3.21 to 4.06, and ≥4.1 were associated with a 4%, 7%, 12%, and 18% average yearly risk of complications, respectively. Five‐year complication‐free survival was progressively worse with increasing ASI and AHI. Both ASI and AHI were shown to be significant predictors of complications (P < .05). AHI categories 3.05 to 3.69, 3.70 to 4.34, and ≥4.35 cm/m were associated with a significantly increased risk of complications (P < .05). The overall fit of the model using AHI was modestly superior according to the concordance statistic. Conclusions: Compared with indices including weight, the simpler height‐based ratio (excluding weight and BSA calculations) yields satisfactory results for evaluating the risk of natural complications in patients with TAAA.

A systematic review on management of nutcracker syndrome

OBJECTIVE Although nutcracker syndrome (NS) is rare, patients presenting with symptoms or signs and anatomic compression of the left renal vein (LRV) can be considered for intervention. Open, laparoscopic, and endovascular techniques have been developed to decrease the venous outflow obstruction of the LRV. The paucity of data regarding the management of this uncommon disease process poses a challenge for adequate recommendations of the best treatment modality. Herein, we aim to present a systematic review for the management of NS. METHODS We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement standards to systematically search the electronic databases of MEDLINE from October 1982 to July 2017 for articles about the management of NS. Included were studies in English, Spanish, and German in all age groups. RESULTS The literature search provided 249 references. After abstract and full review screening for inclusion, 17 references were analyzed. Eight (47%) described the open surgical approach. The LRV transposition was the most commonly reported technique, followed by renal autotransplantation. Seven (41.11%) described the endovascular technique of stent implantation, and two (11.7%) described the minimally invasive laparoscopic extravascular stent implantation. CONCLUSIONS NS is a rare entity. Multiple techniques have been developed for the treatment of this condition. However, the rarity of this syndrome, the paucity of data, and the short-term follow-up of the existing evidence are the disadvantages that prevent recommendations for the best treatment strategy. Up to now, open surgical intervention, specifically LRV transposition, has been considered by some experts the mainstay for treatment of NS. The endovascular approach is gaining strength as more evidence has become available. However, the long-term patency and durability of this approach remain to be elucidated. Therefore, careful selection of patients is necessary in recommending this technique.

The Loop Technique: Addressing Celiac Artery Dissection in a Branched and Fenestrated Endograft for the Treatment of a Type III Thoracoabdominal Aneurysm.

Purpose: To describe a bailout technique for use during branched/fenestrated thoracoabdominal aortic aneurysm (TAAA) repair to address celiac artery (CA) dissection. Technique: The technique is demonstrated in a 69-year-old man who underwent fenestrated stent-graft repair of a 6-cm type III TAAA. The main fenestrated stent-graft was positioned without difficulty, and the renal and superior mesenteric arteries were stented. A stent-graft was placed in the CA, but angiography showed the vessel to be occluded by dissection beyond the stent-graft. Wire manipulations to regain access to the true lumen culminated in perforation. At this point, the gastroduodenal artery was catheterized with a 0.035-inch guidewire, which was advanced in retrograde fashion into the CA true lumen and then snared back to the left brachial artery forming a loop. After exchange for a 0.014-inch system, self-expanding stents were deployed into the hepatic artery. Postoperative recovery was uneventful, and the patient was discharged on day 6. At 1-year follow-up, the patient was doing very well. Imaging demonstrated no endoleak, no graft migration, and sac shrinkage to a diameter of 5.1 cm. Conclusion: The “loop technique” can be a very useful and effective bailout maneuver in regaining access to the true lumen of a dissected CA in patients undergoing branched/fenestrated thoracoabdominal aortic aneurysm repair.

Management of Isolated Atherosclerotic Stenosis of the Common Femoral Artery: A Review of the Literature

Objective: Common femoral endarterectomy (CFE) remains the standard of care for treatment of atherosclerotic stenosis of the common femoral artery (CFA). Endovascular interventions have become the first-line therapy for atherosclerotic disease of the aortoiliac and femoropopliteal systems. Recent reports have documented high rates of technical success and low rates of complications with endovascular management of CFA stenosis. This study is a contemporary review of the surgical and endovascular literature on the management CFA stenosis and compares the results of these methods. Methods: A search of OVID Medline identified all published reports of revascularization of isolated atherosclerotic CFA stenosis. For each study selected for review, the number of patients, number of limbs treated, percentage of patients with critical limb ischemia, and mean length of follow-up was recorded. Study end points included survival, primary patency, freedom from target lesion revascularization (TLR), freedom from amputation, and complications. Results: The review included 7 CFE studies and 4 endovascular studies. Survival was similar between the groups. Primary patency was consistently higher with CFE compared to endovascular therapy. Freedom from TLR was lower with CFE compared to endovascular therapy. Morbidity and mortality was also higher with CFE compared to endovascular therapy. Freedom from amputation was not consistently reported in the endovascular studies. Conclusion: There is limited data to support endovascular treatment of isolated CFA atherosclerosis. CFE has durable results, but there is significant morbidity and mortality resulting from this procedure. Endovascular interventions have low rates of complications, high rates of technical success, good short-term patency but increased need for repeat interventions when compared to surgery. Further trial data comparing CFE with endovascular therapy is needed to guide the management of CFA stenosis.

A novel hybrid left renal vein transposition and endovascular stenting technique for the treatment of posterior nutcracker syndrome

Posterior nutcracker syndrome occurs when a retroaortic left renal vein becomes compressed between the abdominal aorta and the lumbar spine. Although open surgical approaches remain the treatment of choice, endovascular stenting has been used successfully. We describe a case of a 28-year-old man who presented with microscopic hematuria, left-sided flank pain, and testicular swelling. Computed tomography findings were consistent with posterior nutcracker syndrome. He underwent a novel hybrid operation that included left renal vein transposition followed by endovascular stenting. Repeated imaging at 3 and 12 months revealed a patent stent with complete resolution of symptoms.

Natural history and management of renal artery aneurysms in a single tertiary referral center

Objective: Although renal artery aneurysms (RAAs) are uncommon, several large reports have been published indicating their benign natural history. The objective of our study was to review our single‐center experience managing this disease entity. Methods: A retrospective review of the Yale radiologic database from January 1999 to December 2016 was performed. Only patients with RAA and a computed tomography scan of the abdomen were selected for review. Demographics of the patients, aneurysm characteristics, management, postoperative complications, and follow‐up data were collected. Results: There were 241 patients with 259 RAAs identified, with a mean age of 69 years (range, 35‐100 years); 147 were female (61%). On computed tomography, aneurysms were solitary and right sided in 224 (86%) and 159 (61%), respectively; 64 (27%) patients had aneurysms elsewhere. The breakdown of RAAs by location was as follows: renal bifurcation in 84 (32%), renal pelvis in 77 (30%), distal renal artery in 58 (22%), mid renal artery in 34 (13%), and proximal renal artery in 6 (2%). Five patients had symptoms that were attributed to the RAA and underwent operative repair; all others were observed without an operation. Symptoms in the operative repair group included flank pain in four and uncontrolled hypertension in one. The mean overall diameter of the RAAs was 1.22 ± 0.49 cm. The diameter of operatively repaired and observed RAAs was 1.84 ± 0.55 cm and 1.21 ± 0.48 cm, respectively (P = .002). Operative repair included four coil embolizations and one open resection. There were no renal function changes in any of these patients after operation and no other complications. Mean follow‐up was 41 ± 35 months for patients in the group that was observed; 18 of these RAAs were >2 cm, and none ruptured. On multivariable regression analysis, female sex (P = .0001), smoking history (P = .00007), left‐sided RAA (P = .03), and main renal artery location (P = .03) were inversely related to growth, whereas a history of hypertension was directly related to growth rate (P = .01). The mean growth rate for RAAs was 0.017 ± 0.052 cm/y. Conclusions: RAAs tend to have a benign natural history. Although previous reports have not identified any factors that contribute to RAA growth, we observed that RAA location, sex, smoking history, and hypertension may have an impact on growth rates. No ruptures were observed. Operative repair at our institution was rare, with no morbidity or mortality. Observation of RAAs over time seems feasible in the asymptomatic patient with a small RAA.

Antithrombotic Therapy after Bioprosthetic Aortic Valve Replacement: A Therapeutic Morass

Valvular heart disease is a common pathologic condition that affects 6 million people in the United States and more than 100 million worldwide. The most common valvular disorder is aortic stenosis. Current American and European guidelines recommend surgical management for symptomatic aortic stenosis with low risk of perioperative complications and endovascular intervention for high-risk patients with multiple comorbidities. Considering the increasing volume of aortic valve replacement (AVR) with biological valves, it is very important to select the appropriate anticoagulant after surgical AVR. In this article, we review the impact of anticoagulation on immediate and remote complications after AVR.

Endovascular interventions decrease length of hospitalization and are cost-effective in acute mesenteric ischemia

Objective: Acute mesenteric ischemia (AMI) continues to be one of the most devastating diagnoses requiring emergent vascular intervention. There is a national trend toward increased use of endovascular procedures, with improved survival for the treatment of these patients. Our aim was to evaluate whether this trend has changed the treatment of AMI and the subsequent impact on length of hospitalization and hospitalization costs. Methods: We identified all patients admitted for AMI from the National Inpatient Sample from 2004 to 2014 who received open surgical revascularization (OPEN) or an endovascular intervention (ENDO). Primary end points included length of hospital stay and cost of hospitalization. Our secondary end points included acute kidney injury (AKI), in‐hospital mortality, and routine discharge. Results: Among 10,381 discharges identified in the data set, 3833 (37%; 97.5% confidence interval [CI], 35%‐39%) were male patients with a mean age of 69 years (range, 18‐98 years); 4543 (44%; 97.5% CI, 41%‐47%) patients were treated ENDO, and 5839 (56%; 97.5% CI, 53%‐59%) patients were treated OPEN. Although a higher proportion of patients in the ENDO group (28%; 97.5% CI, 24%‐31%) vs the OPEN group (14%; 97.5% CI, 11%‐16%) had a moderate to severe Charlson Comorbidity Index (P < .0001), ENDO was associated with a lower mortality rate (12.3% [97.5% CI, 9.8%‐14.8%] vs 33.1% [97.5% CI, 29.9%‐36.2%]; P < .0001) and a lower mean hospitalization cost (

Intraoperative descending aortic dissection during aortic root replacement: successful management

41,615 [97.5% CI,

Open Replacement of the Thoracoabdominal Aorta: Short- and Long-term Outcomes at a Single Institution

38,663‐