Shaggy and calcified aorta: surgical implications

The Predictive Value of Aortic Calcification on Computed Tomography for Major Cardiovascular Events

As the prevalence of cardiovascular disease continues to increase, early identification of patients at high risk of major adverse cardiovascular events (MACE) using reliable diagnostic modalities is important. Transcatheter aortic valve implantation (TAVI) is a minimally invasive percutaneous procedure used to replace the aortic valve with a bioprosthetic one, often without the need for surgery. Extra coronary calcification in the ascending and/or descending thoracic aorta, aortic arch, and abdominal aorta has recently been identified as a method to quantify the extent of atherosclerotic cardiovascular disease. However, its definitive role in the prediction of MACE remains unclear. We performed a comprehensive review to summarize the current literature on the diagnostic and predictive value of thoracic and abdominal aortic calcification, as quantified in computed tomography, for the association, risk stratification, and prediction of MACE and after TAVI procedures. Despite increasing evidence, the predictive role of thoracic calcification still remains unproven, with a need for carefully tailored studies to confirm these findings.

Anterolateral thoracotomy with partial sternotomy: a feasible approach for treating the complex pathology of the aortic arch

OBJECTIVES

Our goal was to review our surgical experiences in patients with complex pathologies of the aortic arch who have undergone anterolateral thoracotomy with a partial sternotomy (ALPS).

METHODS

From October 2019 to November 2023, a total of 23 patients underwent one-stage repairs of complex pathologies of the aortic arch through the ALPS approach. The mean age was 61.9 ± 16.7 years old. The aortic pathologies were as follows: aorta-related infection in 11 (aorto-oesophageal fistula: 4, graft infection: 6, native aortic infection: 1); aortic dissection in 9 including shaggy aorta in 2, non-dissecting aneurysm in 1, and coarctation of the aorta (CoA) in 2.

RESULTS

Eighteen patients underwent aortic replacement from either the sinotubular junction or the ascending aorta to the descending aorta; 1 patient underwent it from the aortic root to the descending aorta (redo Bentall procedure and extensive aortic arch replacement); 3 patients underwent it from the aortic arch between the left carotid artery and left subclavian artery to the descending aorta; and 1 patient underwent a descending aortic replacement. Ten patients underwent omentopexy, latissimus dorsi muscle flap installation or both procedures. The hospital mortality rate was 13.0% (3/23). The overall survival and freedom from aortic events were 73.3%±10.2% and 74.1%±10.2%, respectively, at the 3-year follow-up. There was an absence of aorta-related deaths, and no recurrent infections were identified.

CONCLUSIONS

The short-term outcomes using the ALPS approach for the treatment of complex pathologies of the aortic arch were acceptable. Further studies will be required to determine the long-term results.

Protruding Aortic Plaque and Coronary Plaque Vulnerability

BACKGROUND

Protruding aortic plaque is known to be associated with an increased risk for future cardiac and cerebrovascular events. However, the relationship between protruding aortic plaque and coronary plaque characteristics has not been systematically investigated.

METHODS AND RESULTS

A total of 615 patients who underwent computed tomography angiography, and preintervention optical coherence tomography imaging were included. Coronary plaque characteristics were compared to evaluate coronary plaque vulnerability in patients with protruding aortic plaque on computed tomography angiography. 615 patients, the 186 (30.2%) patients with protruding aortic plaque were older and had more comorbidities such as hypertension, chronic kidney disease, and a prior myocardial infarction than those without. They also had a higher prevalence of coronary plaques with vulnerable features such as thin-cap fibroatheroma (85 [45.7%] versus 120 [28.0%], P<0.001), lipid-rich plaque (165 [88.7%] versus 346 [80.7%], P=0.014), macrophages (147 [79.0%] versus 294 [68.5%], P=0.008), layered plaque (117 [62.9%] versus 213 [49.7%], P=0.002), and plaque rupture (96 [51.6%] versus 111 [25.9%], P<0.001). Patients with protruding aortic plaque experienced more major adverse cardiac and cerebrovascular events, including all-cause mortality, nonfatal acute coronary syndromes, and stroke (27 [14.7%] versus 21 [4.9%], P<0.001; 8 [4.3%] versus 1 [0.2%], P<0.001; 5 [2.7%] versus 3 [0.7%], P=0.030; and 5 [2.7%] versus 2 [0.5%], P=0.013, respectively).

CONCLUSIONS

The current study demonstrates that patients with protruding aortic plaque have more features of coronary plaque vulnerability and are at increased risk of future adverse events.

Shaggy aorta-An autopsy analysis

Aims

Shaggy aorta is defined as "very extensive atheromatous disease with diffuse ulcers associated with soft, loosely held debris and a paucity of actual thrombus" and often results in visceral or peripheral arterial embolization (shaggy aorta syndrome). Most of the studies are clinico-radiological with hardly any assessment of the pathological features. We present an autopsy analysis of shaggy aorta.

Materials and Methods

A retrospective study of autopsied cases of shaggy aorta over 15 years was conducted. The involvement of the various segments of the aorta (ascending, transverse, thoracic, and abdominal) was correlated with the clinical manifestations and cardiac/extra-cardiac findings at autopsy. The mortality was categorized as those related to shaggy aorta (Group I), related to cardiac diseases (Group II), and those unrelated to cardiovascular diseases (Group III).

Statistical Analysis

Nil.

Results

In a span of 15 years, there were 76 cases of shaggy aorta affecting predominantly males (85.5%) and patients in the sixth decades of life (mean age of 64.5 years). The important associated cardiovascular risk factors included hypertension, tobacco use, and diabetes mellitus. Predominant involvement of the entire aorta and arch + descending aorta was seen in 39.5% and 35.5% of the cases, respectively. Regardless of extreme severity, only half of the patients (37 cases, 48. 7%) had clinical presentation due to shaggy aorta.

Conclusions

The occurrence of shaggy aorta may be more common than expected, and it would be important to keep this possibility in mind even in asymptomatic elderly patients with cardiovascular risk factors since aorto-arterial manipulations and anti-coagulant therapy can prove detrimental in such patients.

A Case of Floating Aortic Arch Thrombosis in a Patient without Thrombophilia

Floating aortic arch thrombi-blood clots forming in an aorta without aneurysms or atherosclerosis-in a normal aorta are exceedingly rare. The etiology is unknown, and there are no guidelines for appropriate treatment strategies. We report a case of floating aortic arch thrombosis in a patient without coagulopathy that was treated surgically. As the mass could not be identified preoperatively as a tumor or thrombus, synthetic graft replacement was performed, allowing resection of the lesion site. Histopathological examination revealed erosion and fissures in the tunica intima of the aorta, which suggested vessel damage to the tunica intima as the cause.

MDCT Imaging of Non-Traumatic Thoracic Aortic Emergencies and Its Impact on Diagnosis and Management—A Reappraisal

Non-traumatic thoracic aorta emergencies are associated with significant morbidity and mortality. Diseases of the intimomedial layers (aortic dissection and variants) have been grouped under the common term of acute aortic syndrome because they are life-threatening conditions clinically indistinguishable on presentation. Patients with aortic dissection may present with a wide variety of symptoms secondary to the pattern of dissection and end organ malperfusion. Other conditions may be seen in patients with acute symptoms, including ruptured and unstable thoracic aortic aneurysm, iatrogenic or infective pseudoaneurysms, aortic fistula, acute aortic thrombus/occlusive disease, and vasculitis. Imaging plays a pivotal role in the patient’s management and care. In the emergency room, chest X-ray is the initial imaging test offering a screening evaluation for alternative common differential diagnoses and a preliminary assessment of the mediastinal dimensions. State-of-the-art multidetector computed tomography angiography (CTA) provides a widely available, rapid, replicable, noninvasive diagnostic imaging with sensitivity approaching 100%. It is an impressive tool in decision-making process with a deep impact on treatment including endovascular or open surgical or conservative treatment. Radiologists must be familiar with the spectrum of these entities to help triage patients appropriately and efficiently. Understanding the imaging findings and proper measurement techniques allow the radiologist to suggest the most appropriate next management step.

Retrospective observational study evaluating zinc plasma level in patients undergoing thoracoabdominal aortic aneurysm repair and its correlation with outcome

Thoracoabdominal aortic aneurysm (TAAA) repair is related to a relevant morbidity and in-hospital mortality rate. In this retrospective observational single-center study including serum zinc levels of 33 patients we investigated the relationship between zinc and patients’ outcome following TAAA repair. Six patients died during the hospital stay (18%). These patients showed significantly decreased zinc levels before the intervention (zinc levels before intervention: 60.09 µg/dl [survivors] vs. 45.92 µg/dl [non-survivors]). The post-interventional intensive care SOFA-score (Sepsis-related organ failure assessment) (at day 2) as well as the SAPS (Simplified Acute Physiology Score) (at day 2) showed higher score points in case of low pre-interventional zinc levels. No significant correlation between patient comorbidities and zinc level before intervention, except for peripheral arterial disease (PAD), which was significantly correlated to reduced baseline zinc levels, was observed. Septic shock, pneumonia and urinary tract infections were not associated to reduced zinc levels preoperatively as well as during therapy. Patients with adverse outcome after TAAA repair showed reduced pre-interventional zinc levels. We speculate that decreased zinc levels before intervention may be related to a poorer outcome because of poorer physical status as well as negatively altered perioperative inflammatory response.

Endovascular repair of ascending aortic diseases with custom-made endografts

OBJECTIVES

The aim of this article is to report the mid-term results of ascending thoracic endovascular aortic repair using a custom-made device (CMD).

METHODS

This was a retrospective study performed at tertiary centres. Nine patients considered unfit for open surgery received elective total endovascular repair of the ascending aorta with a Relay® (Terumo Aortic, Sunrise; FL, USA) CMD: pseudoaneurysn (n = 5), localized dissection (n =3) and contained rupture (n = 1).

RESULTS

Primary clinical success was achieved in all patients with no major complications and no early conversion to open surgery. All patients were discharged home and independent: median length of stay was 7 days (interquartile range, 6-18). No patient was lost to follow-up at a median 26 months (interquartile range, 12-36). Three patients died 2, 6 and 24 months after intervention; 1 was aorta related (late aorto-atrial fistula due to infection that required open surgery). At the last follow-up available, no endoleaks, migrations, fractures or ruptures were observed in the remaining 6 patients.

CONCLUSIONS

Ascending thoracic endovascular aortic repair with Terumo Aortic CMDs was technically feasible, effective and safe in very selected lesions. CMDs showed good ascending aorta conformability with different configurations and diameters, and satisfactory mid-term durability as shown by both structural integrity and aortic lesion exclusion.

Is Hybrid Repair for an Entire Shaggy Aorta Feasible?

OBJECTIVE

This paper reviewed clinical experiences to evaluate the feasibility of a surgical strategy for an entire shaggy aorta.

METHODS

Fifty-two (52) surgeries (47 men, average age 72±7 years) were performed for an entire shaggy aorta at the current institution from 2002-2017. Open surgery was performed in 30 cases, including total arch replacement in 12, extended aortic arch replacement via L-shaped thoracotomy in 10 and median sternotomy combined with left thoracotomy in two, and thoracoabdominal aortic replacement in six. Hybrid procedures were performed in 22 cases: type I hybrid arch repair in six, type II hybrid arch repair in seven and type III hybrid arch repair in nine.

RESULTS

Hospital mortality was significantly higher with a hybrid repair: surgical, one case (3%); hybrid, six cases (27%), (p=0.0125). Stroke occurred at relatively high rates in both groups: surgical, seven cases (23%); hybrid, six cases (27%) (p=0.75). Spinal cord injury was significantly higher in hybrid repair: surgical, one case (3%); hybrid, seven cases (32%), (p=0.004). Open surgery revealed a better long-term survival rate than the hybrid procedure at 5 and 10 years: surgical, 82%, 65.7%; hybrid, 53%, 35.1%, respectively (p=0.0452). The rate of freedom from aortic events was significantly better with open surgery than a hybrid procedure at 5 and 10 years: surgical, 96%, 85%; hybrid, 83%, 41.3%, respectively (p=0.0082).

CONCLUSIONS

Surgery for an entire shaggy aorta was frequently associated with embolic complications such as stroke, paraplegia, renal failure, and bowel necrosis. However, open surgical repair may produce better early and late outcomes and freedom from aortic events compared with hybrid repair.

Thoracic Endovascular Aortic Repair in "Shaggy Thoracic Aortic Aneurysms"

OBJECTIVES

To report the outcomes of thoracic endovascular aortic repair (TEVAR) for shaggy thoracic aortic aneurysms (STA).

METHODS

It is a single center, retrospective, observational, cohort study. Data were collected prospectively between January 2005 and May 2019. STA was defined, based on computed tomography angiography findings, as the presence of an irregular/ulcerated atheroma protruding and/or thrombus thickness ≥ 5 mm protruding into the aortic lumen, and/or occupying more than two thirds of the circumference of the aortic diameter axially. Primary outcomes were early (≤ 30 days) and late survival and freedom from major complication due to end-organ or peripheral ischemic embolization.

RESULTS

Nine (2.3%) of 391 patients met the inclusion criteria. Mean age was 71 years ± 10 (range 55-83). Mean aneurysm diameter was 68 mm ± 0.5 (range 60-75). Four patients presented symptomatic: rupture (n = 2), blue toe syndrome (n = 2). TEVAR was performed in 7 of the 9 patients. Operative-related embolization occurred in 1 patient (transient ischemic attack and acute kidney injury). In-hospital mortality was observed in 1 patient following spinal cord ischemia and multiple organ failure development. Median follow-up was 48 months (IQR 5-84). Freedom from major complication due to end-organ or peripheral ischemic embolization was achieved in all patients. No patient developed further localization of STA in the proximal or distal aorta, and did not experience reno-visceral or peripheral atheroembolization episodes.

CONCLUSIONS

Risk of atheroembolism in STA is still threatening but TEVAR proved to be an effective and durable treatment in this high-risk cohort.

The Shaggy Aorta Syndrome: An Updated Review

BACKGROUND

Shaggy aorta (SA) depicts the severe aortic surface degeneration, extremely friable, and likely to cause spontaneous peripheral and visceral embolization or during catheterization, aortic manipulation, surgery, or minimally invasive procedures. This study aims to provide the most accurate and up-to-date information on this disease.

METHODS

Potentially eligible studies to be included were identified by searching the following databases: CENTRAL Library, ClinicalTrials.gov, MEDLINE, and CINAHL, using a combination of subject headings and text words to identify relevant studies: (Shaggy aorta) OR (aortic embolization) OR (aortic embolism) OR (aortic thrombus) OR (aortic plaque). From a total of 29,111 abstracts, and after applying inclusion and exclusion criteria, we considered 60 studies for inclusion in this review.

RESULTS

Appropriate measurement and assessment of the aortic wall are pivotal in the modern era, in particular when percutaneous procedures are performed, as SA has been identified as an independent risk factor for spinal cord injury, mesenteric embolization, and cerebral infarction after endovascular aortic repair. Furthermore, SA increases the rate of cerebral complications during transcatheter aortic valve implantation.

CONCLUSIONS

In conclusion, prompt diagnosis of SA syndrome and appropriate guidelines on the management of these conditions may help physicians to better assess the patient risk and to minimize the dreadful-related complications.

Clinical evaluation of a new dispersive aortic cannula

INTRODUCTION

Cerebral injury is a serious complication in open-heart surgery. Once it occurs, it causes significant disability and death. We developed a novel dispersive aortic cannula named the Stealth Flow cannula and used it as a standard aortic cannula in cardiopulmonary bypass. The aim of this study was to evaluate the efficiency of this aortic cannula.

METHODS

A total of 182 consecutive patients undergoing cardiac surgery using cardiopulmonary bypass were studied. The patients were divided into two groups: the Soft-Flow cannula group (n = 89) and the Stealth Flow cannula group (n = 93). Patients with a shaggy aortic arch were excluded from this study because the cannulae were inserted at the ascending aorta with a cannula tip directed toward the aortic root in these cases. Patients with multiple arterial perfusion sites were also excluded. Complications including early mortality, perioperative stroke, and intraoperative aortic injury were compared between the two groups.

RESULTS

Age, operative procedure, cardiopulmonary bypass time, and the Japan SCORE were not significantly different between the groups. In comparisons between the Stealth Flow and Soft-Flow groups, the incidences of early mortality, perioperative stroke, intraoperative aortic dissection, and all complications were 1.08% versus 1.12% (p = 0.98), 1.1% versus 2.2% (p = 0.53), 0% versus 1.1% (p = 0.33), and 1.1% versus 3.4% (p = 0.29), respectively. The incidence of major cardiovascular events, including early death, perioperative stroke, and aortic dissection, was not different.

CONCLUSIONS

The Stealth Flow cannula, which was designed based on our previous experimental study, contributed to reducing cerebral and aortic events as much as the Soft-Flow cannula in the present clinical study.

Spinal cord injury following aortic arch replacement

PURPOSE

Postoperative spinal cord injury is a devastating complication after aortic arch replacement. The purpose of this study was to determine the predictors of this complication.

METHODS

A group of 254 consecutive patients undergoing aortic arch replacement via median sternotomy, with (n = 78) or without (n = 176) extended replacement of the upper descending aorta, were included in a risk analysis. The frozen elephant trunk technique was used in 46 patients. The patients' atherothrombotic lesions (extensive intimal thickening of > 4 mm) were identified from computed tomography images.

RESULTS

Complete paraplegia (n = 7) and incomplete paraparesis (n = 4) occurred immediately after the operation (permanent spinal cord injury rate, 1.97%; transient spinal cord injury rate, 2.36%). A multivariable logistic regression analysis identified the use of the frozen elephant trunk technique (odds ratio 36.3), previous repair of thoracoabdominal aorta or descending aorta (odds ratio 29.4), proximal atherothrombotic aorta (odds ratio 9.6), chronic obstructive lung disease (odds ratio 7.1) and old age (odds ratio 1.1) as predictors of spinal cord injury (p < 0.0001, area under curve 0.93).

CONCLUSIONS

Spinal cord injury occurs with a non-negligible incidence following aortic arch replacement. The full objective assessment of the morphology of the whole aorta and the recognition of the risk factors are mandatory.

Prevention of Back Bleeding During Carotid Endarterectomy: Analysis of Clamping Techniques

OBJECTIVE

Complete control of back bleeding during carotid endarterectomy (CEA) is important. We investigated the causes of back bleeding during CEA and techniques for the control of bleeding.

METHODS

A retrospective review was performed of 214 CEA procedures. We assessed the results of routine preoperative examinations, instruments used for arterial clamping (vessel loop and crude or bulldog clamps), and severity of carotid artery stenosis and arterial wall calcification. The study end point was incomplete control of back bleeding before arteriotomy. Factors associated with back bleeding were identified by univariate analysis. The culprit artery and intraoperative technique used in patients with back bleeding were also determined.

RESULTS

Transient back bleeding occurred in 19 CEA procedures (8.9%). Back bleeding was from the ascending pharyngeal artery in 9 cases, common carotid artery in 8 cases, and external carotid artery in 2 cases. Univariate analysis identified the following factors as being related to incomplete control of back bleeding: moderate carotid artery stenosis (20 mm thick) and use of bulldog clamps.

CONCLUSIONS

Transient back bleeding during CEA was uncommon, with the risk factors being severe carotid calcification and moderate carotid stenosis. Transient back bleeding was managed by clamping an undetected ascending pharyngeal artery or by additional clamping of the common carotid or external carotid artery. The vessel loop and crude were superior to the bulldog clamp for clamping the carotid artery.

Neurologic Deficit After Aortic Arch Replacement: The Influence of the Aortic Atherosclerosis

BACKGROUND

Postoperative neurologic deficits are associated with severe morbidity in aortic arch replacement.

METHODS

A group of 198 consecutive patients undergoing isolated total aortic arch replacement with the use of antegrade cerebral perfusion were analyzed for the risk factors for predicting neurologic deficit. With the use of computed tomography, atherothrombotic lesions (defined as extensive intimal thickening exceeding 4 mm) were identified in the proximal aorta (the ascending aorta or aortic arch) in 26.2% of cases and in the distal aorta in 34.9% of cases.

RESULTS

Permanent neurologic deficits occurred in 11.1% (including non-disabling stroke confirmed by imaging) and transient neurologic deficits in 8.1% of patients. A univariate analysis identified proximal atherothrombotic aorta (p = 0.0057), distal atherothrombotic aorta (p = 0.032), and retrograde systemic perfusion from the femoral artery in the presence of distal atherothrombotic aorta (p = 0.0022) as risk factors for neurologic deficits. A multivariate logistic regression analysis identified atherothrombotic proximal aorta (odds ratio 2.4, p = 0.033) as the independent risk factor. The presence of carotid stenosis did not affect the rate of neurologic deficit. Intracranial hemorrhagic lesions were found in 23% of permanent neurologic deficit cases.

CONCLUSIONS

Atherothrombotic lesions found by objectively graded computed tomography were predictors of neurologic deficit. Retrograde perfusion in the presence of a distal atherothrombotic lesion should be avoided whenever possible. Strategies based on the full assessment of the whole aortic morphologic characteristics appear to be mandatory. Anticoagulation therapy should be performed carefully to avoid intracranial hemorrhagic changes.

Sutureless aortic valve implantation in patient with porcelain aorta via unclamped aorta and deep hypothermic circulatory arrest

Severe atherosclerotic calcification of the ascending aorta, the so-called porcelain aorta, precludes cardiac surgeons from placing an aortic cross-clamp and direct aortic cannulation due to the increased risk of systemic embolism and stroke. In the present report, we support the option of sutureless valve implantation in a case of a porcelain ascending aorta, with deep hypothermic circulatory arrest and also without aortic cross-clamp.

Transapical aortic perfusion using a deep hypothermic procedure to prevent dissecting lung injury during re-do thoracoabdominal aortic aneurysm surgery

BACKGROUND

Avoiding various complications is a challenge during re-do thoracoabdominal aneurysm surgery.

CASE PRESENTATION

A 56-year-old man had undergone surgery for type I aortic dissection four times. The residual thoracoabdominal aortic aneurysm that had severe adhesions to lung parenchyma was resected. Since the proximal anastomotic site was buried in lung parenchyma, deep hypothermia was essential to avoid lung dissection and to protect the spinal cord during the proximal anastomosis. The deep hypothermia was induced with bilateral infusion of cardiopulmonary bypass by femoral artery cannulation for the lower body and by transapical cannulation for the upper body because of easy access. There was no hemorrhagic tendency after deep hypothermic bypass. The patient was discharged uneventfully.

CONCLUSIONS

For upper body perfusion, transapical aortic cannulation was a simple and effective procedure during left thoracotomy.

The perceval S aortic valve implantation in patients with porcelain aorta; is this ideal option?

We would like to present in this paper a patient with severe aortic valve stenosis referred to our department for surgical aortic valve replacement. In this patient, it was intraoperatively detected an unexpected heavily calcified porcelain ascending aorta. We present the treatment options in this situation, the difficulties affronted intraoperatively, the significance of the preoperative chest computed tomography scan and the use of the Perceval S aortic valve as ideal bioprosthesis implantation. This is a self-expanding, self-anchoring, and sutureless valve with a wide indication in all patients requiring aortic bioprosthesis.

Prevention of Embolization in Concomitant Endovascular Therapy for Thoracic and Abdominal Aneurysms with Severely Atheromatous Aorta

A 74-year-old man with multiple aortic aneurysms and shaggy aorta was simultaneously treated by conventional open repair for an abdominal aortic aneurysm and endoluminal stent grafting for a thoracic aortic aneurysm. We performed intermittent clamping of the visceral and carotid arteries under an extracorporeal circulation circuit without a blood flow pump, which lead to the avoidance of embolization in spite of the disadvantage of endoluminal stent grafting for atheromatous aorta.

Vascular diseases: aortitis, aortic aneurysms, and vascular calcification

Inflammatory diseases of the aorta broadly include noninfectious and infectious aortitis, periaortitis, atherosclerosis, and inflammatory atherosclerotic aneurysms. Aortitis is uncommon but is increasingly recognized as an important cause of aortic aneurysms and dissections. Abdominal (AAA) and thoracic aortic aneurysms (TAA) have different pathologies and etiologies. AAAs are the most common type of aortic aneurysm, and the vast majority of these are atherosclerotic. The causes of TAA vary depending on the site of involvement, but medial degeneration is a common pathologic substrate, regardless of etiology, and genetic influences play a prominent role in TAA expression. Standardized classification schemes for inflammatory and degenerative diseases of the aorta have only recently been added to the pathology literature. A brief overview of the new histopathologic classifications for aortic inflammatory and degenerative diseases has recently been published by the Society for Cardiovascular Pathology and the Association for European Cardiovascular Pathology as a consensus document on the surgical pathology of the aorta. Vascular calcification is a highly regulated biologic process, and the mechanisms leading to vascular calcification are under investigation. Calcification may occur in the intima (atherosclerotic) or in the media secondary to metabolic disease. Rarely, vascular calcification may be associated with genetic disorders.

Risk factors for early renal dysfunction following endovascular aortic aneurysm repair and its effect on the postoperative outcome

PURPOSE

Renal insufficiency is associated with increased morbidity and death after endovascular aortic aneurysm repair (EVAR). However, the effect of postoperative acute kidney dysfunction on patient outcome has not been fully determined. This study aimed to determine the risk factors of early postoperative renal function decline using chronic kidney disease (CKD) staging and its effect on the clinical outcome.

METHODS

A retrospective analysis was performed on a prospectively maintained EVAR database. Pre- and postoperative CKD stages were determined for all patients according to the estimated glomerular filtration rate values.

RESULTS

We identified 135 patients who were treated with elective EVAR. CKD stage decline was observed in 25 (19 %) of the patients. Freedom from aneurysm-related death was significantly lower in patients with postoperative CKD progression compared with those with unchanged CKD stage. A shaggy aorta without oral beta-blocker administration and higher preoperative serum creatinine levels (>1.4 mg/dL) were found to be independent predictors of an early postoperative CKD stage decline.

CONCLUSIONS

Patients with postoperative CKD progression have an increased frequency of aneurysm-related death. The presence of a shaggy aorta, absence of oral beta-blocker administration and an increased preoperative creatinine level are independent predictors of early postoperative CKD progression.

[An atypical presentation of atherosclerosis in psoriasis: "Porcelain aorta"]

BACKGROUND

Several recent epidemiological studies have shown an increase in cardiovascular morbidity and mortality in patients with psoriasis; such increase is greater in the event of severe and early psoriasis.

PATIENTS AND METHODS

We report the case of a 42-year-old patient with severe skin psoriasis ongoing since childhood and presenting with porcelain aorta, a little-known sign of atherosclerosis. This is the first publication reporting this association.

DISCUSSION

Porcelain aorta results from atherosclerotic calcification of the aortic arch. For long asymptomatic, it can manifest itself in various complications. This observation highlights the importance of cardiovascular risk assessment and of screening for complications thereof in patients presenting psoriasis.

Overcoming Challenges in the Management of Critical Events During Cardiopulmonary Bypass

Critical events during cardiopulmonary bypass (CPB) can challenge the most experienced perfusionists, anesthesiologists, and surgeons and can potentially lead to devastating outcomes. Much of the challenge of troubleshooting these events requires a key understanding of these situations and a well-defined strategy for early recognition and treatment. Adverse situations may be anticipated prior to going on CPB. Atherosclerosis is pervasive, and a high plaque burden may have implications in surgical technique modification and planning of CPB. Hematologic abnormalities such as cold agglutinins, antithrombin III deficiency, and hemoglobin S have been discussed with emphasis on managing complications arising from their altered pathophysiology. Jehovah’s witness patients require appropriate techniques for cell salvage to minimize blood loss. During initiation of CPB, devastating situations leading to acute hypoperfusion and multiorgan failure may be encountered in patients undergoing surgery for aortic dissection. Massive air emboli during CPB, though rare, necessitate an urgent diagnosis to detect the source and prompt management to contain catastrophic outcomes. Gaseous microemboli remain ubiquitous and continue to be a major concern for neurocognitive impairment despite our best efforts to improve techniques and refine the CPB circuit. During maintenance of CPB, adverse events reflect inability to provide optimal perfusion and can be ascribed to CPB machine malfunction or physiological aberrations. We also discuss critical events that can occur during perfusion and the need to monitor for organ perfusion in altered physiologic states emanating from hemodilution, hypothermia, and acid–base alterations.

Bad aorta

As its outcomes improve, cardiac surgery has been performed on more and more cases which were previously considered to be difficult to deal with. However, there are still a number of problems to be solved regarding surgery on patients with severe sclerotic lesions in the ascending aorta, which we collectively call "bad aorta". Concerning a preoperative assessment of the ascending aorta, our report revealed no relationship between the severity of calcification detected with a preoperative non-enhanced CT and the aortic lesion found during the surgery. Meanwhile, an intraoperative epiaortic ultrasound enables us to make high-quality evaluations of the aorta without imposing much burden on the patient. This modality may be essential for cardiac surgery. As for surgical management for bad aorta, quite a few methods have been reported to this point, but the overall operative mortality rate and cerebrovascular accident rate are relatively high, at a little <10 %, respectively. With the recent cross-clamping method under short-term total circulatory arrest (TCA), however, the results are much better; these rates total around 5 %. Further improvement is expected in the outcome of cardiac surgery on bad aorta cases by establishing a modality to evaluate sclerotic lesions in the ascending aorta with epiaortic ultrasound and by selecting a proper procedure for each case.

Aortic valve replacement within an unexpected porcelain aorta: the sutureless valve option

Four patients referred for surgical treatment of aortic stenosis presented an unexpected extremely calcified (porcelain) ascending aorta at the intraoperative epiaortic ultrasonography scanning. In each patient, replacement of the aortic valve was successfully performed using a sutureless implantable bioprosthesis during a short period of hypothermic circulatory arrest. In the era of transcatheter aortic valve implantation procedures, the sutureless valve may be a valuable option for surgical units that do not dispose of transcatheter technology or a hybrid operative theatre.