Staging reinterventions for remodeling of residual aortic dissection: a single-center retrospective study

Objective

Inadequate remodeling of residual aortic dissection (RAD) following repair of Stanford A or B aortic dissections has been identified as a significant predictor of patient mortality. This study evaluates the short- to mid-term outcomes of staged reinterventions for RAD at a single center with prospective follow-up.

Methods

Data were retrospectively collected from patients with RAD who underwent staged reinterventions or received none-surgery treatment in the Cardiovascular Surgery Department of our hospital between July 2019 and December 2021. The cohort included 54 patients with residual distal aortic dissection post-primary surgery, comprising 28 who underwent open surgery and 26 who received thoracic endovascular aortic repair (TEVAR). Patients were divided into two groups: those who underwent staged stent interventions for distal dissection [staged reintervention (SR) group] and those who did not undergo surgery (non-surgery group). For the SR group, second or third staged stent interventions were performed. The study assessed distal remodeling of aortic dissection between the groups, focusing on endpoints such as mortality (both general and aortic-specific), occurrences of visceral branch occlusion, necessity for further interventions, and significant adverse events. Morphological changes were analyzed to determine the therapeutic impact.

Results

The study encompassed 54 participants, with 33 in the SR group and 21 in the non-surgical control group. Baseline demographics and clinical characteristics were statistically comparable across both groups. During an average follow-up of 31.5 ± 7.0 months, aortic-related mortality was 0% in both groups; all-cause mortality was 3% (one case) and 5% (one case) in the SR and control groups, respectively, with no statistically significant difference noted. In the SR group, a single patient experienced complications, including renal artery thrombosis, leading to diminished blood flow. An increased true lumen (TL) area and a decreased false lumen area at various aortic planes were observed in the SR group compared to the control group.

Conclusion

The staged reintervention strategy for treating RAD is safe and provides promising early results.

False lumen-dependent segmental arteries are associated with spinal cord injury in frozen elephant trunk procedure for acute type I aortic dissection

Objective

To investigate the association between false lumen (FL) dependency of segmental arteries (SAs) at T9-L3 levels and the risk of spinal cord injury (SCI) following total arch replacement and frozen elephant trunk (FET) implantation in the setting of acute DeBakey type I aortic dissection (AAD).

Methods

The study involved consecutive patients with AAD who underwent total arch replacement and FET implantation between 2020 and 2022. Primary outcome was postoperative SCI. The inverse probability of treatment weighting (IPTW) method was employed to minimize the impact of no-randomization bias. Antegrade placement of FET was followed by end-to-end anastomosis of a 4-branch arch graft at the proximal landing site of FET.

Results

A total of 146 patients were included (age, 50.5 ± 11.7 years, 115 male), of whom 35 (24%) had SAs at T9-L3 levels completely dependent on FL (FL-dependency group). There was no significant difference in early (30-day or in-hospital) mortality rates between FL-dependency (14.3%) and FL-independency (18.0%) groups (P = .80), however, the rate of SCI was significantly higher in the FL-Dependency group (34.3% vs 2.7%, P < .001). After adjustments, FL dependency was associated with a significantly increased risk of SCI (odds ratio, 13.1; 95% confidence interval, 4.2-41.0; P < .001), whereas it was not significantly associated with risks of early mortality or other major complications (P = .16-.98).

Conclusions

FL dependency of SAs at the T9-L3 levels was significantly associated with the development of SCI following FET implantation in AAD, warning against its uses on patients presenting with FL dependency of SAs at critical segments.

Comparison of Landmark-Guided Versus Fluoroscopy-Guided Cerebrospinal Fluid Drain-Related Complications After Aortic Repairs

OBJECTIVE

Cerebrospinal fluid drains (CSFDs) are efficacious in preventing spinal cord injury after thoracic or thoracoabdominal aortic repair with extensive coverage. Increasingly, fluoroscopy is used to guide placement instead of the traditional landmark-based approach, but it is unknown which approach is associated with fewer complications.

DESIGN

A retrospective cohort study.

SETTING

In the operating room.

PARTICIPANTS

Patients having undergone thoracic or thoracoabdominal aortic repair with a CSFD over a 7-year period at a single center.

INTERVENTIONS

No intervention.

MEASUREMENTS AND MAIN RESULTS

Groups were reviewed and statistically compared with respect to baseline characteristics, ease of CSFD placement, and major and minor complications directly related to placement. A total of 150 CSFDs were placed with landmark guidance as opposed to 95 with fluoroscopy guidance. Compared to the landmark group, patients with fluoroscopy-guided CSFDs were older (p < 0.008), had lower American Society of Anesthesiologists physical status scores (p = 0.008), required fewer CSFD placement attempts (p = 0.011), had the CSFD in place for longer duration (p < 0.001), and had a similar incidence of CSFD-related complications (p > 0.999). Composites of both major (4.5% of cases) and minor CSFD-related complications (6.1% of cases), the primary outcomes of the study, occurred with similar incidences between the 2 groups (p > 0.999 for both comparisons) after adjusting potential confounders.

CONCLUSIONS

In patients undergoing thoracic or thoracoabdominal aortic repairs, there were no significant differences in the risk of major and minor CSFD-related complications between fluoroscopic guidance and the landmark approach. Although the authors' institution is a high-volume center for this type of procedure, the study was limited by a small sample size. Hence, regardless of the technique used for the placement of CSFD, the risks related to the placement should be balanced carefully against the potential benefits resulting from spinal cord injury prevention. Fluoroscopy-aided insertion of CSFD requires fewer attempts and, hence, may be better tolerated by patients.

Outcomes of Secondary Endovascular Aortic Repair After Frozen Elephant Trunk

OBJECTIVE

The aim of this study was to evaluate the midterm outcomes of secondary extension of frozen elephant trunk (FET) by means of thoracic endovascular aortic repair (TEVAR).

METHODS

This single-center prospective study was conducted in a tertiary aortic center on consecutive patients having undergone TEVAR with an endograft covering most of the 10 cm FET module with 2 to 4 mm oversizing. All patients were monitored by computerized tomography angiography (CTA) at sixth month and yearly thereafter.

RESULTS

From January 2015 to July 2022, among 159 patients who received FET, 30 patients (18.8%) underwent a TEVAR procedure (13 for a thoracoabdominal aneurysm, 11 for a chronic aortic dissection and 6 for an emergency procedure). All connections were successfully achieved with 2 postoperative deaths (6.6%) and 1 paraplegia (3.3%). At a median follow-up of 21 months (interquartile range [IQR], 4.2-34.7), 5 patients (25%) required a fenestrated-branched endovascular aortic repair (F-BEVAR) extension followed by 4 patients with 5 reinterventions, 3 for a Type 3 endoleak due to disconnection between FET and TEVAR endograft, and 2 unrelated to the FET for a secondary Type 1C endoleak. All reinterventions were successful, without mortality or morbidity.

CONCLUSIONS

In this series, FET connection with a TEVAR endograft was effective with low postoperative morbidity but with a risk of aortic reintervention related to disconnection between the FET and TEVAR endograft. These results suggest the need for annual CTA monitoring with no time limit in patients following connection of the FET with a TEVAR endograft.

CLINICAL IMPACT

In this series of 30 patients, midterm outcomes of secondary extension of frozen elephant trunk (FET) by thoracic endovascular repair (TEVAR) showed 3 disconnections (10%) with a Type 3 endoleak between FET and TEVAR. These findings suggest the need for annual CTA monitoring with no time limit. But so far, only a few studies provide some information after one year while the risk of disconnection increases over time and becomes a concern after 3 years. This is the new message brought by our study.

[Intensive care management of acute diseases of the aorta]

Acute aortic diseases represent a group of complex severe and often fatal medical conditions. Although they are significantly rarer than cardiac or thromboembolic events, they are an important differential diagnosis to be ruled out, e.g., in the clinical work-up of acute chest pain.Treatment, especially surgical interventions, depends on the progression, extent and size of the pathology and whenever possible should be performed in specialized centers with the appropriate experience.Intensive care monitoring is advisable as a range of peracute complications can occur even in initially stable patients. Depending on the clinical presentation and affected structures, a number of severe complications need to be anticipated by critical care physicians. Additionally, a notable symptom is severe and refractory hypertension, especially in the acute phase. This article provides a summary of the most frequent clinical pictures and corresponding treatment options. Furthermore, the principles of initial patient stabilization and treatment as well as the perioperative management of complex surgical procedures on the aorta are discussed.

Cerebrospinal Fluid Drainage in Thoracic and Thoracoabdominal Endovascular Aortic Repair: A Survey of Current Clinical Practice in European Medical Centers

OBJECTIVES

The aim of this survey was to evaluate the daily clinical practice in European hospitals regarding the modalities to prevent spinal cord ischemia, with an emphasis on cerebrospinal fluid drainage (CSFD), in patients undergoing thoracic and thoracoabdominal endovascular repair.

DESIGN

A 21-item online survey on current practice of spinal cord protection with an emphasis on CSFD.

SETTING

Online service using Castor EDC software.

PARTICIPANTS

Members of the European Association of Cardiothoracic Anaesthesiology and Intensive Care and European Society of Vascular Surgeons.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

One hundred eighty invitations were sent and 104 were used for analysis. A majority of respondents used a written protocol for spinal cord protection during endovascular thoracic and thoracoabdominal repair (81/104 = 78%). The most common protective measures used were CSFD (79/81 = 98%), controlled hypertension (59/81 = 73%), drugs (11/81 = 14%), and hypothermia (6/81 = 7%). The two most common indications for placement of a spinal catheter were the length of the stent (83/104 = 80%) and location of aneurysm (71/104 = 68%). Preventive placement of the spinal drain (96/104) is the most common approach. In the subgroup of high-volume centers, 86% (12/14) of the respondents used a written protocol and all protocols include CSFD. Ninety-two percent (11/12) had included controlled arterial hypertension in the protocol compared with 70% (48/69) of the non-high-volume centers respondents.

CONCLUSIONS

The majority of European centers use a written protocol that includes CSFD. This survey showed the similarities and differences in the management of CSFD in patients undergoing endovascular thoracic and thoracoabdominal repair.

Short Term Outcomes of Distal Extended EndoVascular Aortic Repair (DEEVAR) Petticoat in Acute and Subacute Complicated Type B Aortic Dissection

OBJECTIVE

The aim of this study was to evaluate the peri-operative and short term results of institutional experience with the Distal Extended EndoVascular Aortic Repair PETTICOAT (DEEVAR PETTICOAT) procedure.

METHODS

This was a single centre, observational study. From January 2015 to December 2019, 53 patients were admitted to the institution for treatment of acute and subacute complicated type B aortic dissection. Among them, data on 16 patients deemed suitable for a PETTICOAT procedure extended at infrarenal and iliac level by means of a bifurcated endograft were prospectively collected. Patients with persistent pain, visceral or lower limb malperfusion, true lumen collapse, and distal extension with computed tomography angiography (CTA) evidence of entry tears in the infrarenal or iliac zone were included. A CTA scan was performed in all patients at the baseline, before hospital discharge and then at six and 12 months post-operatively to assess aortic remodelling. Complete aortic remodelling was defined as stable aortic size (maximum enlargement < 5 mm) with complete true lumen re-expansion and complete false lumen exclusion or disappearance.

RESULTS

Technical success was obtained in all patients. One patient (7%) had intra-operative infrarenal aortic rupture during balloon dilation of the distal end of the bare stent, successfully treated by deployment of a bifurcated endograft. Additional covered stenting of the visceral arteries was necessary in nine patients (56%) and malperfusion resolved immediately in all cases. There were no spinal cord ischaemia or other peri-procedural complications, and no post-operative death, stroke, paraplegia/paraparesis, or acute renal failure was observed. Follow up ranged from one month to 24 months (median 7.5 months). One patient (7%) with a history of drug abuse died from sepsis. At the last CTA check, all patients showed complete remodelling of the thoraco-abdominal aorta and iliac arteries without vessel enlargement.

CONCLUSION

The present findings suggest that the DEEVAR PETTICOAT procedure provides effective sealing of all distal tears without increased risk of major peri-procedural complications. Further studies with larger number of patients and longer follow up are needed to confirm the safety and durability of this technique.

Spinal drainage complications after aortic surgery

OBJECTIVE/BACKGROUND

Spinal drain (SD) placement is an adjunct used in open and endovascular aortic surgery to mitigate the risk of spinal cord injury. SD placement can lead to subdural hematoma and intracranial hemorrhage (SDH/ICH). Previous studies have highlighted a correlation between incidence of SDH/ICH and amount of cerebrospinal fluid (CSF) drained. We have two philosophies of SD management in our institution. One protocol allows fluid removal for pressure >10 cm H₂O with no volume restriction. A second, similar protocol restricts CSF drainage to <25 mL/h. We examined SD complications and the influence of volume restriction.

METHODS

Patients were identified according to the Current Procedure Terminology codes for SD placement, thoracic endovascular aortic repair, fenestrated/branched endovascular aortic repair, endovascular abdominal aortic repair, and open thoracic or thoracoabdominal aortic repair between January 1, 2012, and December 31, 2015. Patients' demographics included age, gender, race, body mass index, and comorbidities such as hypertension, chronic obstructive pulmonary disease, stroke, transient ischemic attack, diabetes mellitus, bleeding disorder, and connective tissue disorders. Management protocol was classified as volume independent (VI) or volume dependent (VD) by physician order. Postoperative complications related to the SD were noted.

RESULTS

We identified 948 patients who had an SD placed during the study period; 473 were done before aortic surgeries. A total of 364 patients (77%) underwent endovascular aortic surgery. The mean age at the time of procedure was 67.2 years, and 66% of patients were male. Thirty-nine patients (8.3%) were noted to have connective tissue disorders. Bloody SD placement occurred in 14 patients (3.1%) requiring rescheduling of the operation. SDH/ICH occurred in 11 patients (2.3%), postoperative blood tinged SD output in 94 patients (19.9 %), and 22 patients (4.7 %) had a CSF leak after SD removal. The incidence of SDH/ICH was not affected by the management protocol (2.6% VI vs 2.0% VD, P = .66), whereas the incidence of postoperative blood tinged SD output was significantly higher in the VI group (25.1% VI vs 15.0% VD, P = .006). Perioperative low-dose aspirin (81 mg) and prophylactic subcutaneous heparin did not increase the incidence of SDH/ICH. Postoperative thrombocytopenia was found to be associated with higher incidence of SDH/ICH (median 86,000 vs 113,000, P = .002).

CONCLUSIONS

Severe complications of SD placement (SDH/ICH) occur in 2.3% of SD patients undergoing aortic surgery, and the risk is higher in the setting of postoperative thrombocytopenia. SD volume limitation, blood tinged drainage, antiplatelet medication, and low-dose heparin do not affect the risk of SDH/ICH. The risks of spinal drains for aortic surgery should be balanced against potential benefits.

Measuring CMAPs in addition to MEPs can distinguish peripheral ischemia from spinal cord ischemia during endovascular aortic repair

•

MEP amplitude decreases occur frequently during endovascular aortic aneurysm repair.

•

They are usually caused by peripheral ischemia due to femoral artery sheaths.

•

Peripheral and central ischemia can be distinguished by measuring CMAP amplitudes.

Objective

Spinal cord injury is a devastating complication after endovascular thoracic and thoracoabdominal aneurysm repair (EVAR). Motor evoked potentials (MEPs) can be monitored to detect spinal cord injury, but may also be affected by peripheral ischemia caused by femoral artery sheaths. We aimed to determine the incidence of peripheral ischemia during EVAR, and whether central and peripheral ischemia can be distinguished using compound muscle action potentials (CMAPs).

Methods

We retrospectively analyzed all EVAR procedures between March 1st 2015 and January 1st 2020 during which MEPs were monitored. Peripheral ischemia was defined as both a reduction in MEP amplitudes reversed by removing the femoral sheaths and no clinical signs of immediate post-procedural paraparesis. All other MEP decreases were defined as central ischemia.

Results

A significant MEP decrease occurred in 14/27 (52%) of all procedures. Simultaneous CMAP amplitude reduction was observed in 7/8 (88%) of procedures where peripheral ischemia occurred, and never in procedures with central ischemia.

Conclusions

MEP reductions due to peripheral ischemia are common during EVAR. A MEP-reduction without a CMAP decrease indicates central ischemia.

Significance

CMAP measurements can help to distinguish central from peripheral ischemia, potentially reducing the chance of misinterpreting of MEP amplitude declines as centrally mediated, without affecting sensitivity.

Aneurysms and dissections - What is new in the literature of 2019/2020 - a European Society of Vascular Medicine annual review

More than 6,000 publications were found in PubMed concerning aneurysms and dissections, including those Epub ahead of print in 2019, printed in 2020. Among those publications 327 were selected and considered of particular interest.

Spinal Subdural Hematoma owing to the Removal of Cerebrospinal Fluid Drainage Tube During Thoracic Endovascular Aortic Repair

BACKGROUND

Cerebrospinal fluid (CSF) drainage during the treatment of aortic disease is commonly performed to prevent spinal cord ischemia. Spinal subdural hematoma (SDH) has never been reported after CSF drainage during thoracic endovascular aortic repair (TEVAR). We present a case of concurrent intracranial subarachnoid hemorrhage (SAH) and spinal SDH after CSF drainage tube removal in a patient with TEVAR.

CASE DESCRIPTION

A 73-year-old man was hospitalized to undergo TEVAR. The day before the procedure, a lumbar CSF drainage tube was inserted. Continuous CSF drainage was performed only during the procedure, and the tube was removed the following day. The patient complained of mild back pain on postoperative day 2; headache, bilateral lower limb paresis, and bladder and rectal disturbances developed on postoperative day 5. Brain and spinal magnetic resonance imaging revealed spinal subdural or subarachnoid hematoma and intracranial SAH. Lumbar laminectomies for spinal SDH removal were performed; lower limb strength improved immediately after surgery. At postoperative 2 years, the patient returned to his preoperative activity level; only mild right lower limb numbness persisted.

CONCLUSIONS

We present a rare case of intracranial SAH and spinal SDH that developed after CSF drainage tube removal in a patient with TEVAR. CSF drainage should be carefully considered in patients undergoing aortic procedures, as SAH and spinal SDH may occur in addition to spinal cord ischemia.