Management of Systemic Inflammatory Response Syndrome after Cardiovascular Interventions. Diagnostic, Prognostic and Therapeutic Implications

A substantial number of patients may experience a systemic inflammatory response syndrome (SIRS) and related adverse events after transcatheter aortic valve implantation and endovascular aortic aneurysm repair. Although a clear etiology has not been established, endothelial disruption and tissue-ischemic response secondary to the foreign material may represent the trigger events. A latency period (0-48 hours) may occur between the initial injury and onset of symptoms mirroring an initial local response followed by a systemic response. Clinical presentation can be mild or severe depending on external triggers and patient's characteristics. Diagnosis is challenging because it simulates an infection, but lack of response to antibiotics, negative cultures are supportive of SIRS. Increased in-hospital stay, readmissions, major cardiovascular events, and reduced durability of the device used are the main complications. Treatment includes non-steroidal anti-inflammatory drugs or corticosteroids. In conclusion, further studies are warranted to fully explore pathophysiologic mechanisms underpinning SIRS as well as the possibility to enhance device material immune compatibility in order to reduce the host tissue's inflammatory reaction.

Repair of an ascending aortic aneurysm associated with an anomalous right coronary artery origin

BACKGROUND

Anomalous right coronary artery (RCA) origin off the ascending aorta, above the level of the sinus of Valsalva, is rare and can be associated with altered hemodynamics, decreased coronary perfusion, and presents unique considerations during intraoperative management in the surgical treatment of concomitant ascending aneurysmal disease.

CASE PRESENTATION

A 58-year-old female with prior symptomatic visceral aneurysmal rupture and cerebrovascular disease presented with a 5 cm ascending aortic aneurysm, elevated aortic index, and increased rupture risk factors. She was preoperatively diagnosed with an anomalous, high RCA origin off the ascending aorta 15 mm above the sinotubular junction. She underwent successful ascending aortic repair using a 28 mm Dacron hemiarch graft with reimplantation of an RCA button.

CONCLUSION

Our successful reconstructive surgical repair using an RCA button is effective management for high anomalous RCA take-offs from the ascending aorta and presents the first documented case of this rare coronary anomaly in the context of ascending aortic aneurysmal disease.

Percutaneous Drainage for Aortic Graft Infection Post-aneurysm Repair: A Viable Option?

Purpose

Non-operative management of aortic graft infection is usually only considered in a palliative context. We describe the safety, efficacy, and clinical outcomes of percutaneous drainage of aortic graft infections (AGI) following either open or endovascular repair of aneurysmal disease.

Methods

Twelve consecutive patients (11 males, 1 female, mean age 72.7 ± 10.3 years, age range 52-88 years) between January 2010-July 2020 who underwent percutaneous drain insertion in either an infected aortic sac or periaortic abscess cavity following endovascular or open surgical graft repair were identified. Patient and procedural characteristics as well as clinical outcomes were determined.

Results

Of the 12 patients who underwent percutaneous drain insertion, five (41.7%) had undergone open abdominal aneurysm repair, one (8.3%) open thoracoabdominal aneurysmal repair, and six (50%) endovascular abdominal aneurysm repairs. Drain size ranged from 10-20 French. All were inserted under ultrasound (US), computed tomography (CT), and/or fluoroscopic guidance. Median duration of drain placement was 55.2 days (range 3-174). Five patients (41.7%) had the drain in place as a stabilizing bridge until or after definitive surgical explantation and aortic reconstruction. Seven patients (58.3%) were managed with drain placement and antibiotic therapy without surgical intervention. Six (50%) were alive at the most recent time of follow-up (median, 732 days, range 166-1650 days). Three patients (25%) died during follow-up with causes including erosion of aortic reconstruction into sigmoid colon, unrelated chronic obstructive pulmonary disease exacerbation, and severe clostridium difficile colitis and pseudomonal pneumonia (median 1244 days, range 992-1597 days). Three (25%) patients were lost to follow-up. No drain-related complications were noted.

Conclusion

Percutaneous drainage of AGI following endovascular or open aneurysm repair is a safe and viable management option either as a temporizing measure as a bridge to surgical graft explantation or as a non-surgical therapy for long term management.

The Impact of Endograft Selection on Mid-Term Outcomes in Female Patients Following Endovascular Aortic Aneurysm Repair (EVAR) for Abdominal Aortic Aneurysm (AAA)

Background Abdominal aortic aneurysms (AAA) are far more common in male than female gender, although they appear to have a more aggressive pathophysiology in females. Given the lower incidence of AAA in females, it has been difficult to assess the impact of graft selection for endovascular aortic aneurysm repair (EVAR) in this cohort. Purpose To identify whether graft selection influences outcomes following AAA endoluminal repair in female patients. Methodology A retrospective analysis of published data for 711 female patients was conducted, collating data from three cohorts - Endurant Stent Graft Natural Selection Global post-market registry (ENGAGE), Global Registry for Endovascular Aortic Treatment (GREAT) and U.S. Zenith multicenter trial in combination with the Zenith female registry. Patients were recruited into the ENGAGE registry between 2009 and 2011, the GREAT registry between August 2010 and October 2016, and into the Zenith registry between 2000 and 2003. Patients from ENGAGE received the Medtronic Endurant stent graft for infrarenal AAA repair, patients analysed in GREAT received the Gore Excluder stent graft and the Zenith group received the Cook Zenith stent graft. Analyses were performed to evaluate all-cause mortality, aorta-related mortality, endoleak occurrence and surgical reintervention rates between the three cohorts. Results Of the 711 females, 133 were from ENGAGE (mean age 76 years), 538 were from GREAT (mean age 75 years) and 40 were from Zenith (mean age 74 years). The rates of co-morbidities between the three groups were broadly similar except for atherosclerotic disease which was more commonly observed in those treated with the GORE Excluder. The rate of endoleaks was lower when the Excluder stent was utilised as compared to the other two stents (Excluder 6.7% vs. Zenith 12.5% vs. Endurant 35.3%) even considering the limited follow-up of the Zenith group to two years as compared to five years for both ENGAGE and GREAT. All-cause mortality was similar in all three groups across the period examined while aorta-related mortality was uncommon. Reintervention rate was 15% at two years following the utilisation of the Zenith aortic graft while the rate of intervention at five years was broadly similar between ENGAGE and GREAT. Conclusion The newer generation, lower profile aortic endografts appear to have provided a safe and successful tool in the management of AAA in female patients, despite more complex aortic anatomy with shorter infrarenal neck length and larger aortic neck angulation.

Right Sinus of Valsalva Aneurysm Mimicking Right Coronary Artery Ischemia

An aneurysm of a single sinus of Valsalva is rare. It is usually asymptomatic and rarely discovered, unless it compresses the adjacent cardiac structures, or it presents in association with other pathology. We herein describe a case of a male, with known ischemic heart disease, collapsing after sudden back pain. A computed tomography scan demonstrated an aneurysm of the right sinus of Valsalva. The surgical repair aimed to exclude the aneurysm, preserving and reconstructing the aortic root.

Abdominal Aortic Aneurysm Repair in Renal and Liver Transplant Recipients

BACKGROUND

Abdominal aortic aneurysm (AAA) repair in patients with organ transplant remains a challenge. We looked at AAA repair in patients with organ transplants at our tertiary liver and kidney transplant unit.

METHODS

A retrospective analysis of a prospectively maintained database was undertaken from January 2008 to July 2018. We looked at patient demographics, type of repair, and technical success including reinterventions, perioperative transplant organ function, and 30-day and 1-year survival rate. Eight of 662 patients who underwent AAA repair had a solid organ transplant. Of these, 5 were kidney transplants, 2 liver transplants, and 1 had kidney and liver transplant; 75% were male; and average age was 63.4 (range: 49-83). All patients had asymptomatic AAAs, and 6 were treated with standard endovascular repair, 1 standard repair with iliac branch device, and 1 open repair. Adjunctive techniques such as CO₂ angiograms, deployment of main body through contralateral iliac, low-profile sheaths, custom-made stent grafts, and temporary axillo-femoral shunting were used to protect transplant organs. Thirty-day survival was 100% with 1 death at 5 months from liver failure, and 1 patient has a persistent type-2 endoleak 3 years after the procedure.

CONCLUSION

Abdominal aortic aneurysm repair in patients with organ transplants can be undertaken using adjunctive endovascular and open surgical techniques.

Selective Spleen Embolization of Splenomegaly to Improve Thrombocytopenia Facilitating Open Aortic Aneurysm Repair: A Staged Approach

We present an 82-year-old man with a history of hairy cell leukemia, having an 11-cm abdominal aortic aneurysm, who also had severe thrombocytopenia (about 20 000 platelets/μL) and splenomegaly at presentation. The patient had unfavorable anatomy for endovascular aneurysm repair, and therefore, an open procedure was planned. To reduce risk for perioperative bleeding and optimize patient preoperative status, a staged approach was employed. Initially, several sessions of embolization of 2 splenic artery branches were performed with the intent to decrease spleen size and to increase platelet count thus decreasing the perioperative bleeding risk. Then, after successfully increasing platelet count (280 000 PLT/μL), open repair of the aneurysm was conducted. This case demonstrates that selective splenic embolization in patients with hypersplenism and subsequent thrombocytopenia who are in need for major surgery may achieve a significant rise in platelet count and optimize patient's preoperative status in order to avoid bleeding complications.

Sonographic Changes in Optic Nerve Sheath Diameter Associated with Supra- versus Infrarenal Aortic Aneurysm Repair

BACKGROUND AND PURPOSE

Quantification of changes in optic nerve sheath diameter (ONSD) using ocular sonography (OS) constitutes an elegant technique for estimating intracranial and intraspinal pressure. Aortic aneurysm repair (AAR) is associated with a reasonable risk of increased spinal fluid pressure, which is largely dependent on the extent of aneurysm repair (supra- vs. infrarenal). The aim of this study was to compare ONSD measurements in patients with suprarenal AAR (sAAR) or infrarenal AAR (iAAR).

METHODS

Thirty patients who underwent elective endovascular repair of infrarenal aortic aneurysms (Group iAAR) were included in the study; the characteristics in these cases were prospectively analyzed and compared with those in a previously investigated group of 28 patients treated for suprarenal aortic aneurysms (Group sAAR). Six measurements of ONSDs were performed in each patient at five consecutive time points. Statistical analysis was performed using the Wilcoxon test. A P value < .05 was considered statistically significant.

RESULTS

A highly significant difference between pre- and postinterventional values could be detected in both patient groups (P < .01). In Group sAAR, there was a mean .3-mm increase of the ONSD, whereas in Group iAAR, a mean .2-mm decrease could be detected. Both groups roughly reached baseline values by the end of their inpatient stay.

CONCLUSIONS

ONSD changes seem to be a reliable marker to estimate spinal perfusion. Since OS provides a suitable bedside tool for rapid reevaluation, it may guide physicians in the identification and treatment of patients at high risk for spinal cord ischemia.

Chylous Ascites after Abdominal Aortic Aneurysm Repair

A 73-year-old man was transferred for treatment of abdominal aortic aneurysm. He had no history of abdominal surgeries. Grafting between the infra-renal abdominal aorta and the bilateral common iliac arteries was performed. Proximal and distal cross clamps were applied for grafting. He developed chylous ascites on the 5th post-operative day, 2 days after initiation of oral intake. Fortunately, he responded to treatment with total parenteral hyper-alimentation for 10 days, followed by a low-fat diet. There was no recurrence of ascites.

Progressive supranuclear palsy-like syndrome after aortic aneurysm repair: a case series

The syndrome of progressive supranuclear palsy-like syndrome is a rare complication of ascending aortic aneurysm repair. We report two patients with videos and present a table of prior reported cases. To our knowledge there is no previously published video of this syndrome. The suspected mechanism is brainstem injury though neuroimaging is often negative for an associated infarct. We hope our report will increase recognition of this syndrome after aortic surgery, especially in patients with visual complaints.