Contralateral Snare Cannulation vs. Retrograde Gate Cannulation during Endovascular Aortic Repair in Difficult Iliac Artery Anatomy: A Single Center Experience

OBJECTIVE

Endovascular aneurysm repair is well established as the gold standard in treating abdominal aortic aneurysms. Generally, endovascular repair is performed using a bi or trimodular stent graft, requiring placement of a contralateral iliac limb. Deployment of the contralateral iliac limb requires retrograde gate cannulation of the endograft main body contralateral limb. This step represents the crucial point of a standard endovascular repair procedure and can become challenging, especially in the case of high iliac tortuosity. This study compares the procedural times between the retrograde gate cannulation and the contralateral snare cannulation to demonstrate the possibility of directly performing the contralateral snare cannulation in the case of a complex iliac anatomy assessed by the iliac tortuosity index.

METHODS

One hundred and forty-eight patients with infrarenal abdominal aortic aneurysms who underwent endovascular aneurysm repair from 2017 to 2022 were analyzed retrospectively. Cannulation times between retrograde gate cannulation and contralateral snare cannulation were compared for each degree of iliac tortuosity. The degree of iliac tortuosity was assessed through the iliac tortuosity index. Cannulation times were detected from inserting the wire into the introducer to passing through the radio-opaque gate markers.

RESULTS

The cannulation times were 2.94 min for the retrograde gate cannulation group and 3.15 min for the contralateral snare cannulation group, respectively, with no statistically significant differences (p = 0.33). Overall cannulation times were 2.98 min. For the iliac tortuosity index grade 0, the cannulation times were 2.71 min for the retrograde gate cannulation group and 3.85 min for the contralateral snare cannulation group, respectively, with a significant difference in favor of the retrograde gate cannulation group (p < 0.0001). For the iliac tortuosity index grade 1, the cannulation times were 2.74 min for the retrograde gate cannulation group and 2.8 min for the contralateral snare cannulation group, respectively, with no statistically significant differences (p = 0.63). Regarding the iliac tortuosity index grades 2 and 3, the cannulation times were 3.01 and 4.93 min for the retrograde gate cannulation group and 2.71 and 3.28 min for the contralateral snare cannulation group, respectively. The first group's times were significantly higher than the second group's (p = 0.01 and p = 0.0001).

CONCLUSIONS

In patients with infrarenal abdominal aortic aneurysms undergoing endovascular aortic repair, the gate cannulation times were significantly shorter for the contralateral snare cannulation method than the retrograde gate cannulation method in the iliac tortuosity index grades 2 and 3. Therefore, performing the contralateral snare cannulation method would be appropriate.

Sex-Related Differences and Factors Associated with Peri-Procedural and 1 Year Mortality in Chronic Limb-Threatening Ischemia Patients from the CLIMATE Italian Registry

BACKGROUND

Identifying sex-related differences/variables associated with 30 day/1 year mortality in patients with chronic limb-threatening ischemia (CLTI).

METHODS

Multicenter/retrospective/observational study. A database was sent to all the Italian vascular surgeries to collect all the patients operated on for CLTI in 2019. Acute lower-limb ischemia and neuropathic-diabetic foot are not included.

FOLLOW-UP

One year. Data on demographics/comorbidities, treatments/outcomes, and 30 day/1 year mortality were investigated.

RESULTS

Information on 2399 cases (69.8% men) from 36/143 (25.2%) centers. Median (IQR) age: 73 (66-80) and 79 (71-85) years for men/women, respectively (p < 0.0001). Women were more likely to be over 75 (63.2% vs. 40.1%, p = 0.0001). More men smokers (73.7% vs. 42.2%, p < 0.0001), are on hemodialysis (10.1% vs. 6.7%, p = 0.006), affected by diabetes (61.9% vs. 52.8%, p < 0.0001), dyslipidemia (69.3% vs. 61.3%, p < 0.0001), hypertension (91.8% vs. 88.5%, p = 0.011), coronaropathy (43.9% vs. 29.4%, p < 0.0001), bronchopneumopathy (37.1% vs. 25.6%, p < 0.0001), underwent more open/hybrid surgeries (37.9% vs. 28.8%, p < 0.0001), and minor amputations (22% vs. 13.7%, p < 0.0001). More women underwent endovascular revascularizations (61.6% vs. 55.2%, p = 0.004), major amputations (9.6% vs. 6.9%, p = 0.024), and obtained limb-salvage if with limited gangrene (50.8% vs. 44.9%, p = 0.017). Age > 75 (HR = 3.63, p = 0.003) is associated with 30 day mortality. Age > 75 (HR = 2.14, p < 0.0001), nephropathy (HR = 1.54, p < 0.0001), coronaropathy (HR = 1.26, p = 0.036), and infection/necrosis of the foot (dry, HR = 1.42, p = 0.040; wet, HR = 2.04, p < 0.0001) are associated with 1 year mortality. No sex-linked difference in mortality statistics.

CONCLUSION

Women exhibit fewer comorbidities but are struck by CLTI when over 75, a factor associated with short- and mid-term mortality, explaining why mortality does not statistically differ between the sexes.

Single versus sequential saphenous vein grafting of the circumflex system: a flowmetric study

OBJECTIVE

We sought to evaluate if patients with proximal critical circumflex (CX) lesions did better with single SV-CABG on the best obtuse marginal (OM), or with sequential SV-CABG on two OM branches.

DESIGN

Ninety patients were prospectively randomised to single SV-CABG on the best OM (sSV-CABG-45 patients; Group A) or to sequential SV-CABG on 2 OM (seqSV-CABG 45 patients; Group B). Transit-time flowmetry (TTF), and graft flow reserve were evaluated. Recurrent angina, acute myocardial infarction, readmission for coronary reintervention were defined "treatment failure" during follow-up.

RESULTS

SeqSV-CABG showed better intraoperative maximum (119.1+/-57.5 ml/min vs. sSV-CABG 62.4+/-29.6; p=0.001), mean (56.3+/-31.5 ml/min vs. 30.8+/-12.8; p=0.0001), minimum flow (22.8+/-9.2 ml/min vs. 11.8+/-8.9; p=0.001) and P.I. (0.71+/-0.4 vs.1.46+/-0.9; p=0.006). Graft flow reserve also proved to be higher (95.4+/-29.7 ml/min mean flow vs. sSV-CABG 42.3+/-15.2 ml/min mean flow; p=0.0001; flow reserve 1.72+/-0.99 vs 1.32+/-1.09; p=0.001) as well as freedom from treatment failure (97.5+/-0.5% vs 88.7+/-0.4%; p=0.05).

CONCLUSIONS

SeqSV-CABG showed higher TTF flows, with no incremental risk for perioperative morbidity. Higher flows and graft flow reserve may allow lower treatment failure at mid-term follow-up.

Hypertension induces compensatory arterial remodeling following arteriotomy

BACKGROUND

Hypertension has been traditionally considered a risk factor for restenosis following carotid arteriotomy. Genetic and morphological response to carotid arteriotomy in normotensive Wystar-Kyoto (WKY), spontaneously hypertensive (SHR), and Milan hypertensive (MHS) rats were analyzed.

MATERIAL AND METHODS

C-myc, angiotensin II receptor-1 (AT1), angiotensin II receptor-2 (AT2), endothelin-1 receptor A (ET(A)), endothelin-1 receptor B (ET(B)), Bcl-2 family-members (Bcl-2/Bax, Bcl-X(L/S)) were analyzed in surgically injured as well as uninjured carotids of WKY and hypertensive strains (HS). Thirty-day histology and morphometry were accomplished on injured and uninjured carotids.

RESULTS

C-myc mRNA is activated earlier and/or to a greater extent in hypertensive strains than in WKY. AT1 mRNA increases in WKY after injury, while it decreases in SHR and MHS. AT2 shows the opposite, decreasing in WKY and increasing in hypertensive strains. ET(A) mRNA decreases in all strains although with different timing and levels, associated with a replacement by ET(B) mRNA. Bcl-2/Bax ratio gradually decreases in WKY, while it shows only a transient decrease in SHR and MHS 4 h after the injury. Negative remodeling is observed in all injured carotids, although neointima was detected in WKY only. Thirty days following arteriotomy, morphometry demonstrated a significant decrease of luminal area, with consistent gain in the medial area in WKY, whereas hypertensive strains showed significant increase of the luminal area, consistent with a contemporary decrease of the medial area.

CONCLUSIONS

Vaso-relaxant AT2 and ET(B) induced limited vasoconstriction in HS. Less apoptosis in hypertensive rats reduced cell proliferation, contrasting c-myc. These responses favorably modulated media/lumen area ratio following arteriotomy in HS.

A Randomized Trial of Pulsatile Perfusion Using an Intra-Aortic Balloon Pump Versus Nonpulsatile Perfusion on Short-Term Changes in Kidney Function During Cardiopulmonary Bypass During Myocardial Reperfusion

BACKGROUND

Nonpulsatile perfusion during cardiopulmonary bypass can induce renal damage. We evaluated whether pulsatile perfusion using an intra-aortic balloon pump preserves renal function in patients undergoing myocardial revascularization.

STUDY DESIGN

Randomized controlled trial, nonmasked parallel-group design.

SETTING & PARTICIPANTS

100 patients undergoing preoperative perfusion using an intra-aortic balloon pump; 64 with baseline estimated glomerular filtration rate (eGFR) of 60 mL/min/1.73 m(2) or greater (>or=1 mL/s/1.73 m(2); stage 1 or 2) and 36 with eGFR of 30 to 59 mL/min/1.73 m(2) (0.5 to 0.98 mL/s/1.73 m(2); stage 3).

INTERVENTION

Patients were randomly assigned to nonpulsatile perfusion during cardiopulmonary bypass (group A) or automatic intra-aortic balloon pump-induced pulsatile perfusion during cardiopulmonary bypass (group B).

OUTCOMES & MEASUREMENTS

Renal function, daily diuresis, complications, serum lactate levels, and other biochemical indices at 24 and 48 hours.

RESULTS

GFR, adjusted for baseline eGFR, was 16 mL/min/1.73 m(2) [0.27 mL/s/1.73 m(2)] less in group A (58.1 mL/min/1.73 m(2); 95% confidence interval [CI], 56.1 to 60.1 mL/min/1.73 m(2) [0.97 mL/s/1.73 m(2); 95% CI, 0.94 to 1.0 mL/s/1.73 m(2)]) than in group B (74.0 mL/min/1.73 m(2); 95% CI, 72.0 to 76.1 mL/min/1.73 m(2) [1.23 mL/s/1.73 m(2); 95% CI, 1.20 to 1.27 mL/s/1.73 m(2)]; P < 0.001). Plasma lactate levels were +3.9 mg/dL (+0.43 mmol/L) higher in group A (19.5 mg/dL; 95% CI, 18.4 to 20.5 mg/dL [2.16 mmol/L; 95% CI, 2.04 to 2.28 mmol/L]) than in group B (16.7 mg/dL; 95% CI, 14.4 to 16.7 mg/dL [1.73 mmol/L; 95% CI, 1.60 to 1.85 mmol/L]; P < 0.001). No significant difference between the 2 groups was observed for 24-hour diuresis. Patients with eGFR stage 3 had a greater decrease in GFR and daily diuresis and greater increase in lactate levels than those with eGFR stages 1 to 2.

LIMITATIONS

Short-term change in kidney function as a surrogate outcome for "hard" clinical outcomes of mortality, morbidity, and length of hospitalization. Other limitations are short-term follow-up and absence of measurement of hemodynamic parameters or inflammatory mediators.

CONCLUSIONS

Use of automatic pulsatile intra-aortic balloon pumps during cardiopulmonary bypass is associated with better renal function during myocardial reperfusion. More studies are needed to verify the effects of pulsatile intra-aortic balloon pumps.

Surgical treatment of coronary-to-pulmonary fistula: how and when?

Coronary arteriovenous fistulas (CAVF) are rare malformations. Opinions vary on which operation should be offered to these patients, particularly those asymptomatic. We report four patients operated on for CAVF referred to our institution over the course of a year. Three patients had associated cardiac lesions. In all of them CAVF was identified and closed with running sutures. There was no operative mortality or operative morbidity. All patients were asymptomatic at follow-up. In patients undergoing surgical treatment of cardiac disease, associated CAVF should always be treated. Although in patients with giant CAVF it is safer to patch the outflow of CAVF from the outflow chamber, in the majority of cases CAVF should be identified intraoperatively and closed with multiple running stitches.

Transbrachial insertion of a 7.5-Fr intra-aortic balloon pump in a severely atherosclerotic patient*

OBJECTIVE

Preoperative intra-aortic balloon pumping (IABP) improves the results of complex coronary surgery. However, its insertion may be harmful or contraindicated in cases of severe and diffuse atherosclerosis of the descending aorta and peripheral arteries. We sought to evaluate the efficacy and safety of transbrachial insertion of the new 7.5-Fr IABP to support a severely ill patient with eggshell distal aorta and femoro-iliac arteries undergoing coronary artery bypass grafting (CABG).

DESIGN

Case report.

SETTING

An 18-bed adult cardiac surgery unit at a university hospital.

PATIENT

A 68-yr-old man with ongoing unstable angina, left main disease, and eggshell calcification in the abdominal aorta and iliaco-femoral arteries, needing IABP for CABG.

INTERVENTION

Percutaneous sheathless right transbrachial insertion of 7.5-Fr IABP, followed by CABG.

MEASUREMENTS AND MAIN RESULTS

Fluoroscopy and chest radiograph were used to confirm the exact position of the IABP, in the preoperative and postoperative time, respectively. A digital pulse oximeter was applied to monitor distal perfusion. Anticoagulation consisted of nadroparin 4000 IU daily until the second postoperative day, followed by 150 mg of aspirin daily thereafter. Transbrachial IABP support allowed uneventful CABG and postoperative course, without IABP-related complications. Pulse oximetry demonstrated constant good values, the radial artery pulse was always present, and the hand appeared constantly warm. IABP was withdrawn 20 hrs following surgery, and the patient was discharged home on the ninth postoperative day.

CONCLUSIONS

The miniaturization of IABP, with the recent introduction of a 7.5-Fr balloon catheter, opens the door for the safe, effective transbrachial method of insertion in patients with severe peripheral atherosclerosis.

Intraaortic Balloon Pumping During Cardioplegic Arrest Preserves Lung Function in Patients With Chronic Obstructive Pulmonary Disease

BACKGROUND

Linear flow during cardiopulmonary bypass is considered a potential mechanism of lung damage in patients with chronic obstructive pulmonary disease (COPD). We evaluated differences in lung function of patients with COPD undergoing preoperative intraaortic balloon pumping (IABP), between linear flow during cardiopulmonary bypass (IABP-off) and maintenance of pulsatile flow (IABP-on at automatic 80 bpm) during cardioplegic arrest.

METHODS

Fifty patients with COPD undergoing preoperative IABP were randomized between January 2004 and July 2005 to receive nonpulsatile cardiopulmonary bypass with IABP discontinued during cardioplegic arrest (25 patients; group A), or IABP-induced pulsatile cardiopulmonary bypass (25 patients; group B). Hospital outcome, need for noninvasive ventilation, oxygenation (partial pressure of oxygen, arterial to fraction of inspired oxygen [Pao(2)/Fio(2])), respiratory system compliance, and scoring of chest radiographs were compared.

RESULTS

There were no hospital deaths, no IABP-related complications, and no differences in postoperative noninvasive ventilation (group A: 6 of 25, 24.0% vs group B: 5 of 25, 20%; p = not significant [NS]). One patient in both groups developed pneumonia (p = NS). Intensive care and hospital stay were comparable (p = NS). Group B showed lower intubation time (8.3 +/- 5.1 hours versus group A: 13.2 +/- 6.0; p = 0.001), better Pao(2)/Fio(2) at aortic declamping (369.5 +/- 93.7 mm Hg vs 225.7 +/- 99.3; p = 0.001) at admission in intensive care (321.3 +/- 96.9 vs 246.2 +/- 109.7; p = 0.003), and at 24 hours (349.8 +/- 100.4 vs 240.8 +/- 77.3; p = 0.003). The respiratory system compliance was better in group B at the end of surgery (56.4 +/- 8.2 mL/cm H(2)O vs 49.4 +/- 7.0; p = 0.004) and 8 hours postoperatively (76.4 +/- 8.2 vs 59.4 +/- 7.0; p = 0.0001), as well as scoring of chest radiograph at intensive care admission (0.20 +/- 0.41 vs 0.38 +/- 0.56; p = 0.05) and on the first day (0.26 +/- 0.45 vs 0.50 +/- 0.67; p = 0.025).

CONCLUSIONS

Automatic 80 bpm IABP during cardioplegic arrest preserves lung function in patients with COPD.

Determinants and prognosis of myocardial damage after coronary artery bypass grafting

BACKGROUND

Myocardial infarction remains a devastating complication after coronary revascularization. Although electrocardiography (ECG) and echocardiography suggest transmural infarction, myocardial damage and the quality of myocardial protection are not recognized unless troponin I (TnI) is assessed. Determinants and prognosis of TnI elevation after coronary artery bypass grafting (CABG) were evaluated.

METHODS

Data of 776 consecutive patients undergoing CABG between January 2002 and January 2004 were prospectively exposed to univariate and multivariate analysis. We evaluated the prognosis of patients with all the ECG, echocardiographic, and biochemical criteria for acute myocardial infarction and that of patients with only TnI elevation. Twelve-month follow-up survival and freedom from cardiac events (FCE) were accomplished.

RESULTS

Troponin I greater than 3.1 mug/L at 12 hours was detected in 6.9% of the population, and correlated with lower in-hospital (p < 0.001) and follow-up survival (p = 0.00001), and lower FCE (p = 0.0009). Twenty-one (38.8%) of these fulfilled ECG-echocardiographic criteria (p = 0.05), demonstrating higher TnI values at 12 (p = 0.001), 24 (p = 0.01), 48 (p = 0.01), and 72 (p = 0.04) hours, prolonged ventilation time (p = 0.001), higher in hospital mortality (p = 0.003), lower follow-up survival (p = 0.023), and lower FCE (p = 0.0084). A EuroSCORE greater than 6, ongoing unstable angina, aortic cross-clamp time greater than 90 minutes, cardiopulmonary bypass time greater than 180 minutes, incomplete revascularization, and intraoperative intraaortic balloon pump were independent predictors of myocardial damage (MD) at multivariate analysis. Combined antegrade and retrograde cardioplegia and postoperative enoximone infusion were associated with a lower TnI elevation.

CONCLUSIONS

Troponin I greater than 3.1 mug/L at 12 hours defines perioperative MD. Associated ECG-echocardiographic criteria indicate acute myocardial infarction and anticipate a worse outcome. Identification of predictors for MD is important to develop preventative strategies, as antegrade plus retrograde cardioplegia and enoximone infusion.