Endovascular repair of ascending aortic pathologies in patients unfit for open surgery: case series and literature review

The number of vascular centers performing endovascular repair of ascending aortic disease is constantly increasing. Accordingly to the guidelines, open surgical repair remains the gold standard for these pathologies. However, approximately one quarter of patients are deemed unfit for open surgery. In this study, we describe three cases of ascending thoracic endovascular aortic repair (TEVAR) performed at our center. All the patients were deemed unfit for open surgery by the aortic team. Two patients had an ascending aortic pseudoaneurysm, and the third had a focal type A aortic dissection. In two cases, we used two abdominal aortic cuffs deployed from zone 0B to zone 0C, with no need for supra-aortic trunk debranching. In one case, we performed a "reverse" extrathoracic debranching, and we deployed a thoracic endograft from zone 0B to zone 2. Complications included one minor stroke and one inguinal hematoma. In one patient with an infected pseudoaneurysm, we performed ascending TEVAR as a bridge strategy for open repair. This patient developed a type Ia endoleak; however, clinical stabilization and infection control were obtained, and he was able to undergo heart surgery successfully. He underwent a second reintervention to treat superior mesenteric embolic occlusion. At 2 years of follow-up, all three patients were alive. Our preliminary experience demonstrates the technical feasibility and clinical appropriateness of ascending TEVAR using standard, commercially available endografts. However, no consensus has been reached regarding some critical aspects, such as the development of a standardized technique or the efficacy of the currently available devices. The improvements in graft design and the adoption of the "aortic team" approach could help in the near future to standardize the procedure, establish appropriate indications, and ensure good clinical outcomes.

Volumetric analysis in primary and residual type B aortic dissection treated with stented-assisted balloon-induced intimal disruption and relamination (STABILISE) technique can predict aortic reintervention

OBJECTIVE

The aim of this study was to investigate the mid-term results of stented-assisted balloon-induced intimal disruption and relamination (STABILISE) in patients with aortic dissection with the implementation of volumetric analysis.

METHODS

This was a single-center retrospective analysis of prospectively collected data. From May 2017 to September 2022, 42 patients underwent STABILISE for acute complicated or subacute high-risk aortic dissection. STABILISE was completed with distal extended endovascular aortic repair in 24 patients. A computed tomography scan was performed at baseline, before hospital discharge, and at 1, 3, and 5 years. Perfused total aortic, true lumen, and false lumen volumes were assessed for thoracic, visceral, and aorto-iliac segment. The ratio between false lumen and total volume was named perfusion dissection index (PDI). Complete remodeling was defined as PDI = 0, and positive remodeling as PDI ≤0.1.

RESULTS

Technical success was 97.6%. No 30-day deaths, spinal cord injuries, or retrograde dissections were observed. Mean follow-up was 44 ± 19.4 months. Thoracic diameter was lower at last available computed tomography scan (36.7 vs 33.0 mm; P = .01). Aortic growth >5 mm was observed in 9.5% of the patients. Thoracic and visceral aortic complete remodeling were 92.8% and 83.3%, respectively, with no difference between acute and subacute group. Distal extended endovascular aortic repair significantly increased complete remodeling in the aorto-iliac segment, compared with STABILISE alone (69.6% vs 21.4%; P < .001). Freedom from vascular reinterventions at 3 years was 83.1% (95% confidence interval, 71.5%-96.6%). Total PDI ≤0.1 at first postoperative control was a predictor of vascular reinterventions (P < .0001).

CONCLUSIONS

STABILISE is a safe and feasible technique associated with high mid-term rates of complete remodeling in the thoracic and visceral aorta. Volumetric analysis allows the quantification of aortic remodeling and represents a predictor of aortic reinterventions.

"Octafen": A Noninvestigational Alternative Endograft Configuration for the Treatment of Thoracoabdominal Aortic Aneurysms

PURPOSE

To demonstrate the feasibility of Octafen technique, a novel endovascular configuration for the treatment of thoracoabdominal aortic aneurysms (TAAA).

TECHNIQUE

Two patients with complex TAAA and high surgical risk were treated with Octafen endograft configuration in a hybrid operating room with computed tomography (CT)-fluoroscopy image fusion guidance, using 3D-3D fusion techniques to facilitate procedural success. The procedure is a modification of the previously-described Octopus technique for endovascular repair of TAAA. The main advantage of this technique is the ability to use devices to repair a TAAA with the combination of off-the-shelf and noninvestigational custom-made devices. The devices used are readily available to most practicing vascular surgeons, which provides an alternative treatment in case of limited access to investigational devices, in time-sensitive cases, and in patients with limited functional capacity who cannot undergo open repair. In the modification described herein, we use a combination of standard bifurcated endovascular aneurysm repair (EVAR) devices (Excluder; W.L. Gore & Associates, Flagstaff, Arizona) in combination with a 2-vessel renal fenestrated device (Z-Fen; Cook Medical, Bloomington, Indiana). The article describes a step-by-step approach to this technique to elucidate pitfalls, benefits, and advantages.

CONCLUSION

The Octafen technique might offer an alternative option for thoracoabdominal aneurysm treatment circumventing the need for access to custom-made, investigational devices.

CLINICAL IMPACT

In this manuscript, we describe a technique for endovascular repair of thoraco-abdominal aortic aneurysms that involves the combination of off-the-shelf and non-investigational, custom-made devices. The 'Octafen' technique provides a treatment alternative in case of limited access to investigational devices and can be adjusted according to patient anatomy.

Sex-Specific Morphometric Analysis of Ascending Aorta and Aortic Arch for Planning Thoracic Endovascular Aortic Repair: A Retrospective Cohort Study

OBJECTIVE

In many studies on aortic disease, women are underrepresented. The present study aims to assess sex-specific morphometric differences and gain more insight into endovascular treatment of the ascending aorta (AA) and arch.

METHODS

Electrocardiogram-gated cardiac computed tomography scans of 116 consecutive patients who were evaluated for transcatheter aortic valve replacement were retrospectively reviewed. Measurements of the AA and aortic arch were made in multiplanar views, perpendicular to the semi-automatic centerline. Multiple linear regression analysis was performed to identify predictors affecting AA and aortic arch diameter in men and women. Propensity score matching was used to investigate whether sex influences aortic morphology.

RESULTS

In both sexes, body surface area (BSA) was identified as a positive predictor and diabetes as a negative predictor for aortic diameters. In men, age was identified as a positive predictor and smoking as a negative predictor for aortic diameters. Propensity score matching identified 40 pairs. Systolic and diastolic mean diameters and AA length were significantly wider in men. On average, male aortas were 7.4% wider than female aortas, both in systole and diastole.

CONCLUSIONS

The present analysis demonstrates that, in women, increased BSA is associated with increased aortic arch diameters, while diabetes is associated with decreased AA and arch diameters. In men, increased BSA and age are associated with increased AA and arch diameters, while smoking and diabetes are associated with decreased AA and arch diameters. Men were confirmed to have 7.4% greater AA and arch diameters than women.

CLINICAL IMPACT

Men had 7.4% greater ascending aorta and arch diameters than women in a retrospective cohort, gated computed tomography-based study of 116 patients. Sex-specific differences in ascending aortic and arch size should be considered by aortic endovascular device manufacturers and physicians when developing ascending and arch endografts and planning aortic interventions.

Experimental Analysis of Radiation Protection Offered by a Novel Exoskeleton-based Radiation Protection System Versus Conventional Lead Aprons

INTRODUCTION

The detrimental effects of radiation exposure to physicians have been well documented and are an active area of concern. The objective of this study was to evaluate the radiation protection offered by an exoskeleton-based radiation protection system (StemRad MD, StemRad Ltd, Israel).

METHODS

The experimental setup involved two anthropomorphic phantoms, an operator and a patient, and a C-arm as the X-ray radiation source. Thermo-luminescent detectors were used to measure radiation doses to different radiosensitive body parts on the operator phantom both with the StemRad MD and conventional lead apron (LA), at the left radial and right femoral positions. Detected radiation doses for the StemRad MD and LA for different body parts and positions were compared.

RESULTS

At the left radial position, mean radiation dose (mGy) reduction by the StemRad MD compared to the LA was above 90% for the left eye lens (0.22±0.13 vs 5.18±0.08, p<.0001), right eye lens (0.23±0.13 vs 4.98±0.10, p<.0001), left head (0.11±0.16 vs 3.53±0.07, p<.0001) , right head (0.27±0.09 vs 3.12±0.10, p<.0001), and left brain (0.04±0.08 vs 0.46±0.07, p<.0001). At the right femoral position, radiation reduction was above 90% for the left eye lens (0.14±0.10 vs 4.16±0.09, p<.0001), right eye lens (0.06±0.08 vs 1.90±0.11, p<.0001) , left head (0.10±0.08 vs 4.39±0.08, p<.0001), left brain (0.03±0.07 vs 1.44±0.08, p<.0001), right brain (0.00±0.14 vs 0.11±0.13, p=.06), and thyroid (0.04±0.07 vs 0.27±0.09, p<.0001).

CONCLUSIONS

The StemRad MD system provides superior radiation protection to the physician compared to conventional LAs. The effects are particularly impactful for the brain, eye lens, and head areas.

StemRad MD, An Exoskeleton-Based Radiation Protection System, Reduces Ergonomic Posture Risk Based on a Prospective Observational Study

OBJECTIVE

Poor ergonomic posture during interventional procedures might lead to increased physical discomfort and work-related musculoskeletal disorders. Adjunctive equipment such as lead aprons (LAs) has been shown to increase ergonomic posture risk (EPR). The objective of this study was to evaluate the effectiveness of StemRad MD (StemRad Ltd., Tel Aviv, Israel), a weightless exoskeleton-based radiation protective ensemble, in reducing EPR on the operator using wearable inertial measurement unit (IMU) sensors.

METHODS

A prospective, observational study was conducted at an academic hospital. Inertial measurement unit sensors were affixed to the upper back of 9 interventionalists to assess ergonomic risk posture during endovascular procedures while wearing a traditional LA or the StemRad MD radiation protection system. Total fluoroscopy time, procedure type, and ergonomic risk postures were recorded and analyzed.

RESULTS

Twenty-one cases were performed with StemRad MD and 30 with LAs. Mean procedure time for the StemRad MD procedures was 48.4±23.3 minutes (range: 24-106 min), and for LA procedures, it was 34.66±25.83 minutes (range: 6-100 min) (p=.060). The operators assumed low-risk ergonomic positions in 96.1% of StemRad MD cases and in 62.9% of LA cases (p=.001), and high-risk ergonomic positions in 0% and 6.2%, respectively (p=.80). Mean EPR score for StemRad MD was 1.16, and for the LA, it was 1.49 (p=.001).

CONCLUSIONS

StemRad MD significantly reduces the EPR to the torso compared with a LA-based radiation protection system.

CLINICAL IMPACT

Poor ergonomic posture during interventional procedures might leas to work-related musculoskeletal disorders for healthcare workers. StemRad MD, a weightless, exoskeleton-based radiation protection system was shown to significantly reduce ergonomic posture risk to the torso compared to conventional lead aprons. This might lead to reduced physical discomfort for procedure-based specialists.

Single-Center Experience With Aortic Coarctation Stenting in Adult Patients

OBJECTIVE

Endovascular repair of aortic coarctation (CoA) has become an important tool in the treatment of an expanding patient population. In this study, we present our 10-year experience with endovascular repair of CoA.

METHODS

Between January 2012 and January 2022, a total of 15 patients were treated at our Institution for CoA with catheter-based techniques. Demographics, intraprocedural data, and follow-up data were retrospectively collected from institutional databases and analyzed. The primary endpoint was technical success and secondary endpoints were intraoperative complications and short-, mid-, and long-term follow-up.

RESULTS

Mean age was 44.87 ± 15.52 years (range, 15-64) and 12 patients (80%) were male. Fourteen patients (93.3%) were hypertensive, and 4 patients (26.7%) had a bicuspid aortic valve. Three patients (20%) had undergone open repair in the pediatric age. Fourteen patients (93.3%) received stenting of CoA and 1 patient (6.7%) received thoracic endovascular aortic repair and left subclavian artery stenting for proximal pseudoaneurysmatic dilation and symptomatic restenosis. Mean pretreatment trans-stenotic gradient was 23.25 ± 11.16 mm Hg and posttreatment trans-stenotic gradient was 1.3 ± 1.33 mm Hg. Primary technical success was achieved in 15 cases (100%). One right inguinal hematoma (6.7%) was observed. One patient (6.7%) had an aortic rupture at the left subclavian artery origin after poststent dilation. Mean follow-up time was 34.75 ± 34.38 months. A total of 2 patients had an increased trans-stenotic gradient at long-term follow-up, and 1 reintervention (6.7%) for somatic growth was performed.

CONCLUSIONS

Endovascular repair of CoA is effective and safe, with excellent mid-term and long-term success rates.

Abstract 346: Mri Guided Experimental Study To Determine The Mechanistic Performance Of Vessel Prep V. Poba In Infrapopliteal Lesions

Objective: To present initial results of an ongoing ex-vivo experimental study to compare vessel preparation with intravascular lithotripsy (IVL) or orbital atherectomy (OA) versus plain old balloon angioplasty (POBA) in tibial arteries.

Method: We will study amputated limbs that have concentric calcification, in three arms, 1. POBA, 2. IVL, and 3. OA. Amputated limbs are first scanned on 7T MRI using UTE (Ultra-short echo time) and T2 weighted sequences to characterize target lesions with concentric calcium at high resolution. The diameter of balloon is sized based on diameter of the vessel proximal and distal to target lesion and confirmed with intravascular ultrasound (IVUS). A through-and-through wire is placed and angiography and IVUS are performed. POBA, IVL or OA is performed. In lesions with vessel prep, angioplasty is performed. All angioplasties are performed at minimum pressure required for the balloon to reach profile diameter. Finally, the ex-vivo harvested specimens are imaged in 9.4T MRI for 3-D plaque analysis prior to histologic sectioning and staining.

Results: We have 7 experiments, 3 BKA and 4 AKA. Balloon angioplasty without vessel prep was performed in 3/7, OA in 2/7 and IVL in 2/7. Lesions angioplastied without vessel prep required higher than burst pressure to reach profile. Lesions treated with OA and IVL required pressures between nominal and burst to reach profile. POBA samples demonstrated plaque disruption and dissections with more luminal gain compared with lesions that underwent vessel prep prior to angioplasty.

Conclusion: This study elucidates the mechanism of vessel prep and how it assists POBA in protecting the vessel wall. Vessel prep did not “debulk” or improve luminal gain substantially but required lower inflation pressures and had less uncontrolled dissections and disruptions of the vessel wall. Initial results demonstrate a compelling indication for vessel preparation in select tibial lesions with 360-degree concentric calcium.

Thermodynamic destabilization and aggregation propensity as the mechanism behind the association of apoE3 mutants and lipoprotein glomerulopathy

Lipoprotein glomerulopathy (LPG) is a rare renal disease, characterized by lipoprotein thrombi in glomerular capillaries. A series of apoE mutations have been associated with LPG development. We previously showed that three mutants based on apoE3 sequence, in which an arginine was substituted by proline, are thermodynamically destabilized and aggregation-prone. To examine whether other LPG-associated apoE3 mutations induce similar effects, we characterized three nonproline LPG-associated apoE3 mutations, namely, R25C (apoEKyoto), R114C (apoETsukuba), and A152D (apoELasVegas). All three apoE3 variants are found to have significantly reduced helical content and to be thermodynamically destabilized, both in lipid-free and lipoprotein-associated form, and to expose a larger portion of hydrophobic surface to the solvent compared with WT apoE3. Furthermore, all three apoE3 variants are aggregation-prone, as shown by dynamic light-scattering measurements and by their enhanced capacity to bind the amyloid probe thioflavin T. Overall, our data suggest that the LPG-associated apoE3 mutations R25C, R114C, and A152D induce protein misfolding, which may contribute to protein aggregation in glomerular capillaries. The similar effects of both LPG-associated proline and nonproline mutations on apoE3 structure suggest that the thermodynamic destabilization and enhanced aggregation of apoE3 may constitute a common underlying mechanism behind the pathogenesis of LPG.

Neutral and cationic mononuclear copper(II) complexes with enrofloxacin: structure and biological activity

The mononuclear copper complexes with the quinolone antibacterial drug enrofloxacin (=Herx) in the presence or not of a nitrogen donor heterocyclic ligand 1,10-phenanthroline (=phen) and 2,2'-bipyridine (=bipy) have been prepared and characterized. Interaction of copper(II) with deprotonated enrofloxacin leads to the formation of the neutral complex Cu(erx)2(H2O), 1, while the presence of phen or bipy leads to the formation of a neutral or a cationic mononuclear complex, respectively. The crystal structures of (chloro)(1,10-phenanthroline)(enrofloxacinato)copper(II), 2, and (aqua)(2,2'-bipyridine)(enrofloxacinato)copper(II) chloride, 3, have been determined with X-ray crystallography. The complexes have been studied with X-band electron paramagnetic resonance in aqueous solutions at liquid helium temperature. The study of the interaction of the complexes with calf-thymus DNA has been performed with diverse spectroscopic techniques and has showed that all complexes are bound to DNA by the intercalative mode. The antimicrobial efficiency of the complexes has been tested on three different microorganisms and the available evidence supports that the best inhibition is provided by Cu(erx)2(H2O) (minimum inhibitory concentration=0.125 microg mL(-1)) against Escherichia coli and Pseudomonas aeruginosa.

Mononuclear metal complexes with Piroxicam: Synthesis, structure and biological activity

Piroxicam (=Hpir) is a non-steroidal anti-inflammatory and an anti-arthritic drug. VO(2+), Mn(2+), Fe(3+), MoO(2)(2+) and UO(2)(2+) complexes with deprotonated piroxicam have been prepared and characterized with the use of infrared, UV-Vis, nuclear magnetic resonance and electron paramagnetic resonance spectroscopies. The experimental data suggest that piroxicam acts as a deprotonated bidentate ligand in all complexes and is coordinated to the metal ion through the pyridine nitrogen and the amide oxygen. Molecular mechanics calculations in the gas state have been performed in order to propose a model for the Fe(3+), VO(2+) and MoO(2)(2+) complexes. Potential anticancer cytostatic and cytotoxic effects of piroxicam complexes with VO(2+), Mn(2+) and MoO(2)(2+) on human promyelocytic leukemia HL-60 cells have been investigated. Among all complexes, only VO(pir)(2)(H(2)O) clearly induces apoptosis after 24-h incubation, whereas piroxicam induces apoptosis after 57-h incubation.