Intra-aortic balloon pump inserted through the subclavian artery: A minimally invasive approach to mechanical support in the ambulatory end-stage heart failure patient

OBJECTIVE

Intra-aortic balloon pumps are traditionally inserted through the femoral artery, limiting the patient's mobility. We used alternate approaches of intra-aortic balloon pump insertion to provide temporary and minimally invasive support for patients with decompensating, end-stage heart failure. The present study describes the outcomes with closed-chest, transthoracic intra-aortic balloon pumps by way of the subclavian artery.

METHODS

During a 3-year period, 20 patients underwent subclavian artery-intra-aortic balloon pump in the setting of end-stage heart failure. The balloon was inserted through a polytetrafluoroethylene graft sutured to the right subclavian artery in 19 patients (95%) and to the left subclavian artery in 1 patient (5%). The goal of support was to bridge to transplantation in 17 patients (85%) and bridge to recovery in 3 patients (15%). The primary outcome measure was death during subclavian artery-intra-aortic balloon pump support. The secondary outcomes included survival to the intended endpoint of bridge to transplantation/bridge to recovery, complications during subclavian artery-intra-aortic balloon pump support (eg, stroke, limb ischemia, brachial plexus injury, dissection, bleeding requiring reoperation, and device-related infection), emergent surgery for worsening heart failure, and ambulation during intra-aortic balloon pump support.

RESULTS

The duration of balloon support ranged from 3 to 48 days (mean, 17.3 ± 13.1 days). No patients died during subclavian artery-intra-aortic balloon pump support. Of the 20 patients, 14 (70%) were successfully bridged to transplant or left ventricular-assist device. Two patients (10%) required emergent left ventricular-assist device for worsening heart failure.

CONCLUSIONS

An intra-aortic balloon pump inserted through the subclavian artery is a simple, minimally invasive approach to mechanical support and is associated with limited morbidity and facilitates ambulation in patients with end-stage heart failure.

Electromagnetic tracking for registration and navigation in endovascular aneurysm repair: a phantom study

OBJECTIVE

To assess the feasibility of using an electromagnetic tracking for both registration and navigation in endovascular aneurysm repair.

MATERIALS AND METHODS

A registration process was implemented to align computed tomography (CT) data and electromagnetic tracking data. Two abdominal aortic aneurysm (AAA) phantoms were used, a rigid plastic AAA model (phantom A) and a soft silicon AAA model (phantom B). A pre-procedural CT volume was acquired for each phantom. Intra-operative simulation was performed by placing each phantom in the magnetic field of the tracking device. Using a modified electromagnetic catheter, a set of three-dimensional positions was acquired in the phantom's aortic lumen. Pre-procedural CT images and intra-procedural tracked positions were registered. Four reference points were used to calculate the registration accuracy of phantom A. Three surgeons simulated catheterisation of the left renal artery with phantom B using only image-guided procedure software.

RESULTS

The mean registration error was 1.3 mm (range 0.88-1.89). The median time for left renal catheterisation was 22 s (range 15-59).

CONCLUSION

Registration of CT data and electromagnetic tracking data is feasible using catheter positions in the aorto-iliac structure as landmark. This navigation system could reduce X-ray exposure time and the use of contrast medium injections.

Unusual inflow sources and device introduction sites in aortic arch debranching

AIM

Aim of the study was to evaluate a single center experience on hybrid treatment for thoracic aortic diseases, including aortic arch and ascending aorta endografting needing a total debranching from descending thoracic aorta and an antegrade endograft deployment from left ventricle.

METHODS

Between January 2004 and December 2010 48 patients underwent thoracic aorta endografting, with coverage of at least one supra-aortic artery, because of atherosclerotic, dissecting and post-traumatic aneurysms or complications of previous aortic surgery. Supra-aortic trunks revascularization was obtained from ascending aorta, common carotid arteries and, in three cases, from descending thoracic aorta since the unavailability of common inflow sites. In three cases the antegrade endograft introduction through left ventricle (transapical approach, 2 cases) or ascending aorta (one case) was the only possibility for a safe deployment.

RESULTS

Three groups have been identified on the basis of the proximal landing zone. Group A (27 patients): zone 2; Group B (9 patients): zone 1; Group C (12 patients): zone 0. The 30 days mortality was respectively 7.4%, 0% and 16%. Post operative paraplegia occurred in the 7.4% of group A, respiratory insufficiency and infections were the main post-operative complications with an incidence reaching 30% in each group.

CONCLUSION

Hybrid procedures on aortic arch represent a possible treatment for cases unfit for open surgery despite the complication rates and mortality are not negligible. In selected cases, the endografting can be extended up to beyond the landing zone 0 where an antegrade transventricular endograft deployment and a supra-aortic perfusion from descending thoracic aorta represent a feasible option.

Does patency after a vein collar and PTFE-bypass depend on sex and age? Re-analysis of a randomised trial

AIM

Randomized studies evaluating the effect of a vein collar at the distal anastomosis of PTFE-grafts show conflicting results. The study of the Joint Vascular Research Group (JVRG) of UK found improved primary patency while the Scandinavian Miller Collar Study (SCAMICOS) found neither any effect on patency nor on limb salvage after bypass to below-knee arteries. However, the Scandinavian patients were a decade older and predominately female compared to the British patients. Can this explain the conflicting result?

METHODS

Primary patency with respect to sex, age and the use of vein collar were re-analysed in 345 patients from SCAMICOS with Kaplan-Meier life-table technique, log-rank test and Cox proportional hazards regression to evaluate any interaction between sex or age and the effect of a vein collar on the primary patency rate.

RESULTS

Females had better patency than males (log-rank test, χ2=9.4, df=1, P=0.002) but age had no influence on patency (log-rank test, χ2=3.3, df=3, P=0.35). However, 47% of the males compared to 23% of the females were smokers (P=0.00002). No interaction effect between sex and vein collar (P-value=0.224) or age and vein collar (P-value=0.527) was established.

CONCLUSION

The difference between the two randomised vein collar studies are unlikely to depend on the disparity in sex and age of the study populations.

Current role and future directions of hybrid repair of thoracoabdominal aortic aneurysms

Hybrid procedures were introduced as a less invasive alternative to open conventional repair, avoiding thoracotomy, single-lung ventilation, and in many patients, aortic cross-clamping. Despite these potential advantages over open repair, results of hybrid repair have varied in the literature, with several reports indicating high morbidity and mortality rates. It is likely that once fenestrated and branched endografts receive approval from the Food and Drug Administration for clinical use, indications for hybrid repair of complex aortic aneurysms will further diminish. This article summarizes the current state of the art on patient selection, techniques, and results of hybrid procedures for the treatment of thoracoabdominal aortic aneurysms.

Prosthetic graft infection, five years after ascending aortic replacement

Fifty-year-old male developed an infected perigraft collection five years following wrapping of a Dacron tube with residual aneurysmal ascending aortic tissue. Treatment consisted of excision of the graft, debridement of the infected surrounding tissues, and replacement using a rifampin-soaked Hemashield tube graft. This case demonstrates the potential risk of wrapping prosthetic grafts with native aneurysmal aortic tissue.

Modified "stent-graft sandwich" technique for treatment of isolated common iliac artery aneurysm in patient with Marfan syndrome

Isolated iliac artery aneurysms are rare in the general population (0.03%) and represent 2% of all abdominal aneurysms, and the association with Marfan syndrome is even rarer. We report a Marfan syndrome case with an isolated common iliac artery aneurysm treated by using a modified "stent-graft sandwich" technique, with preservation of the internal iliac artery perfusion. The modified "stent-graft sandwich" technique involves building an appropriate proximal neck just in the common iliac artery for fittingly housing two new stent-grafts inside, both deployed simultaneously and each one going to both distal iliac arteries (internal and external).

Role of aortic stent graft oversizing and barb characteristics on folding

OBJECTIVE

To evaluate folding in infrarenal stent grafts in relation to oversizing, barb angle, and barb length using computed tomography images of stent grafts deployed in explanted bovine aortas.

METHODS

Computed tomography data from an in vitro investigation on the effect of oversizing of 4% to 45% (n = 19), barb length of 2 to 7 mm (n = 11), and barb angle of 10° to 90° (n = 7) on device fixation were examined for instances of folding. Folding was classified as circumferential or longitudinal and quantified on an ordinal scale based on codified criteria. Cumulative fold ranking from 0 (no fold) to 6 (two severe folds) for each deployment was used as the measure of folding observed.

RESULTS

Of the 37 cases, cumulative mean ± standard deviation fold ranking for stent grafts oversized >30% (n = 5) was significantly greater than the rest (3.4 ± 1.7 vs 0.5 ± 1.2, respectively; Mann-Whitney U test; P < .005). When barb length was varied from 2 to 7 mm (oversizing held at 10%-20%), folding was noted in one of 11 cases. Similarly, when barb angle was varied from 0° (vertical) to 90° (horizontal), folding was not noted in any of the seven cases. The pullout force was not significantly different between stent grafts with and without folding (5.4 ± 1.95 vs 5.12 ± 1.89 N, respectively; P > .5). At least one instance of folding was noted in the seven of seven (100%) stent grafts with oversizing >23.5% and in only five of 30 (14%) stent grafts with oversizing <23.5%.

CONCLUSIONS

Stent graft folding was prevalent when oversized >30%. Large variations in barb length and angle did not aggravate folding risk when oversized within the recommended range of 10% to 20%.

Treatment of penetrating aortic ulcer by endoprosthesis: a single center experience

AIM

This is a retrospective study of a single center experience in the endovascular treatment of penetrating aortic ulcer (PAU).

METHODS

Sixteen consecutive patients aged 69.1±9.6 years presenting PAU (in the aortic arch in 2, the descending thoracic aorta in 11, and in the abdominal aorta in 3) undergone therapy. Nine patients presented symptomatic, while 7 were asymptomatic. All patients underwent computer tomography angiography (CTA) of the thoracic and the abdominal aorta. Endovascular therapy alone was carried out in 12 patients, while 4 received hybrid therapy.

RESULTS

One patient died of multiorgan failure after hybrid procedure. Complications consisted of type II endoleak from lumbar arteries in 1 case of endovascular procedure, and acute respiratory insufficiency in 1 patient treated by endovascular technique on the emergency basis for aortic rupture.

CONCLUSION

PAU involves more frequently the descending thoracic aorta. Endovascular treatment (alone or in hybrid therapy) can give good results in patients with severe concomitant diseases. Prognosis of these patients is not favourable in most cases (48-month survival rate 47.9%) due to severe concomitant diseases.

Experience and outcomes after a decade of endovascular abdominal aortic aneurysm repair: a retrospective study from a community-based single center

BACKGROUND

The purpose of this study is to report the results of endovascular abdominal aortic aneurysm treatment based on the Zenith stent-graft from a community-based single center over a period of 9 years.

METHODS

We retrospectively analyzed immediate technical and clinical results as well as long-term outcomes in patients treated with endovascular aneurysm repair between 2001 and 2010. The study was performed in accordance with the recommendations of the ad hoc committee for standardized reporting practice in vascular surgery.

RESULTS

A total of 106 patients were treated in a period of 9 years. A Zenith stent-graft was used in 95% of cases. No deaths occurred during the first 30 days postsurgery. The complication rate was 4.7% (n = 5). The overall clinical and technical success rate at 30 days was 93.4%. After a mean follow-up period of 52 months (range, 13-112 months), the overall mortality rate was 25.4%. Aneurysm-related mortality was 2.1%. Rupture of the aneurysm occurred in four cases (4.3%). The final clinical failure rate was 13.8%. During the follow-up period, the mean diameter of the aneurysm decreased from 58.0 to 52.3 mm. However, expansion of the aneurysm was registered in 10 cases. Eleven patients had a primary endoleak, and another 11 secondary endoleaks occurred during the follow-up. The reintervention rate was 16.3%. The main reasons for repeat interventions were iliac limb occlusion (n = 5) and type 3 endoleak/limb disconnection (n = 4). Graft migration occurred in 3% of cases. A negative impact on sexual function after endovascular repair was reported by 20% of patients.

CONCLUSION

Endovascular repair is the treatment of choice for high-risk patients. A small but significant number of clinical failures were observed during the long-term follow-up.

Endovascular repair of a traumatic arteriovenous fistula involving the iliac bifurcation using an iliac branch device

Endovascular techniques have shown to be useful in the management of vascular injuries because they transform a complex and potentially dangerous procedure into a safe one. We present the case of a 39-year-old man with congestive heart failure and abdominal bruit 11 years after an abdominal gunshot wound. Imaging studies revealed an arteriovenous fistula involving the left iliac artery bifurcation, and an iliac branch device was used to treat it. Symptoms resolved, and follow-up imaging showed patency of the graft and closure of the arteriovenous communication. To our knowledge, this is the first report of a nonaneurysmal disease treated with this device.

[Comparative analysis of arterial bioprostheses with various antithrombotic modification]

The present study was aimed at comparing the results of remote patency ol arterial bioprosthcses «KemAngioprosthesis» in infrainguinal position with various antithromhotic modifi cation. We analyzed the outcomes in a total of 133 patients who were subdivided into two groups: Group I (n=91) underwent implantation of hioprostheses with antithrombotic modifi calion by non-fractionated heparin. and Group II (n=42) received prostheses treated with low-molecular-weight heparin «Clexane». Patients of the both groups underwent comprehensive analysis of the haemostatic system, blood plasma lipid spectrum, as well as duplex scanning of the prosthesis. 39 (42.9%) Group I patients and 6 (13.6%) Group II patients were found to have developed thromboses. Besides, 14 (I5.4%) Group I patients were diagnosed as hawing restenosis of the anastomosis site, with this complication observed in 3 (7.3%) Group II patients. The results of the analysis demonstrated better remote patency of bioprostheses with antithromhotic modifi cation by low-molecular-weight heparin «Clexane». Dynamic follow up of the patients made it possible to carry out timely correction of medicamentous therapy, as well as at early stages to reveal restenosis of anastomoses followed by endovascular correction.

Aortic valve re-replacement after Bentall procedure with a biological valved conduit in a sheep model

BACKGROUND AND AIM OF THE STUDY

The Bentall procedure is the 'gold standard' for the repair of a combined pathology of ascending aorta and aortic valve. Because there is no need for long-term anticoagulation, biological-valved conduits have become increasingly popular; however, the possible need for reoperation due to valve degeneration is a major disadvantage. The aim of this animal-based study was to prove the feasibility of an isolated replacement of the aortic valve prosthesis six months after a previous implantation of a biological valved conduit (BioValsalva) in a sheep model. A total aortic root replacement, using the BioValsalva conduit, was performed in 10 juvenile sheep. After six months, the surviving sheep were reoperated on, and the stentless valve was replaced with a stented biological valve placed inside the previously implanted vascular conduit.

RESULTS

Five animals survived the initial implantation of a BioValsalva conduit. During reoperation, the triple-layered vascular graft with polytetrafluoroethylene on the outside showed only slight adhesions with the surrounding tissue. The stentless valve was removed in one piece, after which a new stented valve was implanted inside the conduit. An X-radiographic examination of the explanted valve showed moderate calcification of the leaflet, and severe calcification of the aortic wall.

CONCLUSION

The results of this animal study confirmed that a degenerated stentless biological valve inside the BioValsalva conduit could be replaced with a new valve, without having to remove the entire conduit.

First-in-man study of paclitaxel-eluting stent BiOSS (Bifurcation Optimisation Stent System) dedicated for coronary bifurcation stenoses: three months results

BACKGROUND

The best treatment strategy for coronary bifurcation stenosis is still unknown. Dedicated bifurcation stents are the most promising solution.

AIM

To evaluate the safety and short-term efficacy of a new stent dedicated for coronary bifurcation stenosis.

METHODS

A new bifurcation optimisation stent system (BiOSS, Balton, Poland) is made of 316L stainless steel and is coated with a mixture of biodegradable lactate polymer and paclitaxel (1 μg/mm(2)). The stent consists of two parts, with different diameters according to Murray law connected by two 1.5 mm long bridges. BiOSS is mounted on a dedicated bifurcation balloon (Bottle, Balton, Poland) with markers of the proximal and the distal stent edge, and a third marker at the mid part showing the proximal end of its smaller distal part. The stent delivery is a rapid exchange system. Provisional T-stenting is the obligatory strategy. In order to optimise the result, Bottle balloon (nominal pressure: 10 atm) is inflated with mid marker positioned at the side branch ostium. Double antiplatelet therapy was planned for 12 months. Forty five patients with non-left main bifurcation stenosis (the n-LMB group), as well as 15 patients with left main (LM) bifurcation stenosis (the LMB group), were included in the prospective, feasibility and safety assessment registry. An intravascular ultrasound control is obligatory for all LM patients and strongly recommended for the remaining patients. Patients with ST-elevation myocardial infarction (STEMI) and Medina type 001 bifurcation lesions were excluded from the registry. The primary end-points of the study were: death, MI, in-stent thrombosis and target lesion revascularisation (in-hospital and one, three, six, and 12 months after the intervention). An angiographic control is planned at nine months in all patients. Here, we present the results of a three-month follow-up.

RESULTS

The average age of the enrolled patients (63% males) was 67 ± 11 years. Thirty five (58%) patients had hypertension, and 16 (27%) were diabetic (five on insulin treatment). Almost half of the patients (29, 48%) had previous non-ST- -elevation acute coronary syndrome treated with percutaneous coronary intervention. Six (10%) patients had previous coronary artery bypass grafting. In the LMB group (n = 15), there were: six with Medina type 111; five with type 010; three with type 110; and one with type 011 bifurcation lesions. In the n-LMB group (n = 45), the dominant vessel was left anterior descending (n = 26, 58%), followed by left circumflex (n = 15, 33%) and right coronary artery (n = 4, 9%). Medina type 111 lesions were present in 48% of patients. Intravascular ultrasound was performed in 37 (62%) cases. All BiOSS stents were implanted successfully (avg. pressure 12 atm), without any periprocedural complications. There were only seven (14%) cases with a second stent implanted within a side branch. There were four periprocedural increases of troponin interpreted as MI. At one month and at three months, all patients were uneventful (out-of hospital MACE rate 0%).

CONCLUSIONS

The BiOSS bifurcation dedicated stent is a feasible device, with promising safety and short-term clinical effectiveness/profile.

[A rare case of surgical management of a patient with thoracic aortic aneurysm]

Described in the article is a clinical case of successful surgical management of a male patient diagnosed with a syphilitic-origin aneurysm of the thoracic aorta isthmus, complicated by an aortopulmonary fistula. Also presented herein are the clinical pattern, findings of examination, and treatment policy. This is followed by a detailed description of both the course of the surgical intervention and outcomes obtained.

Hybrid procedure for celiac trunk aneurysm repair via left reno-splenic bypass and stent-graft deployment

Celiac trunk aneurysm is one of the rarest forms of splanchnic artery aneurysm. Conventional open vascular surgery is associated with increased rates of morbidity and mortality and can require complex vascular reconstruction.We describe the case of a 42-year-old patient with celiac trunk aneurysm whom we treated by means of a hybrid surgical-endovascular procedure. We performed a left reno-splenic bypass, after which we used a direct splenic artery approach to deploy a self-expandable 6 × 50-mm stent-graft across the splenic and hepatic arteries. One year later, the stability of the repair was confirmed.

Minimally invasive hybrid treatment of acute type I aortic dissection: a single-stage technique without circulatory arrest

After traditional treatment of acute type I aortic dissection, the possible persistence of residual false lumen in the untouched distal aorta can increase the risk of death.This case report presents an example of single-stage complete hybrid repair of acute type I aortic dissection via surgical interposition of an ascending aortic tube-graft and reconstruction of the supra-aortic branches to enable circulatory inflow from the ascending aortic graft, which was followed by endovascular stenting of the arch and of the descending and thoracic aortic segments. This procedure was performed with partial sternotomy and without circulatory arrest, to improve early and late outcomes.Unfortunately, there is no extensive experience with application of the technique described here, and we are contributing a report of only a single case. Nevertheless, we hope that this description of a single-stage complete repair of aortic dissection might lead to further application and eventually to fewer deaths in patients with acute type I aortic dissection. We suggest this approach for use especially in high-risk patients.

The 37-year durability of a Björk-Shiley Delrin-disc aortic valve prosthesis

We report the exceptional longevity of a Björk-Shiley Delrin-disc prosthetic aortic valve that had been implanted in a man who underwent surgical correction of an ascending aortic aneurysm 37 years later. Upon explantation of the valve, the Delrin disc had only shallow abrasion on the ventricular surface, and none on the aortic surface. We discuss the soundness and durability of this valve in our patient, in contrast with its short functional prosthetic life in other patients. The 37-year lifespan of this patient's Björk-Shiley Delrin-disc valve is among the longest reported.

[Comparative characteristics of new PTFE vascular patches in experiment]

Presented herein are the findings of a comparative experimental study of 64 novel patches made of porous polytctrafluoroethylene (PTFE). The PTFE explants with various number of technological layers were examined both in vitro and in vivo. The authors performed plasty of the canine aorta with explants followed by morphological assessment of the tissues with PTFE at various terms of follow up. Based on the results obtained during intraoperative assessment of the patches' properties and histological examination thereof, we selected better patches for plasty of the aorta and major arteries to be implemented into clinical practice.

[A variant of surgical reconstruction in type I aortic dissection combined with dissection and thrombosis of brachiocephalic arteries]

Described herein is a variant of surgical treatment of a patient presenting with type A aortic dissection extending to the brachiocephalic branches accompanied by thrombosis of the false channel of the latter. In the rare cases in dissection and thrombosis of the brachiocephalic branches for adequate protection of the body (systemic protection) it is necessary to use bidirectional arterial perfusion under the conditions of moderate hyperthermia: through a preliminarily sewn into the carotid artery prosthesis - perfusion of the brain, through cannulated aortic arch or femoral artery - body perfusion.

Paradoxical emboli from left superior vena cava causing recurrent brain abscess

Persistent left superior vena cava is a rare but well-recognised condition. We describe a case of persistent left superior vena cava draining directly into the left atrium, with a fixed anatomical right-to-left shunt and paradoxical embolic events causing recurrent brain abscess. Surgical ligation was curative.