One stage hybrid repair of aortic arch aneurysms with antegrade endovascular graft deployment

Despite advances in surgical technique and intensive care medicine, the mortality and morbidity of standard single or two staged approaches for the management of arch aortic aneurysms remain extremely high. With the elephant trunk technique, some patients never proceed to completion of treatment either because of worsening co-morbidity or interim rupture. Retrograde thoracic endografting is not always feasible and its complications are well known. This study examines the use of a hybrid approach for treating arch aneurysms in one stage. The technique combines open aortic arch debranching with antegrade stent repair of these aneurysms. In this series three women and nine men with aneurysms involving the arch, ascending and descending thoracic aorta were treated. Their median age was 66 years. Most aneurysms were degenerative in aetiology [50%. The rest were either dissecting or secondary to Marfan's disease. One patient had the ascending aorta replaced prior to presenting with the arch problem. All other patients were put on cardiopulmonary bypass and had their ascending aorta replaced with or without further concomitant cardiac procedures. Cerebral perfusion was maintained antegrade at 24[degree sign] C through right axillary artery cannulation. This was followed by debranching of the arch of aorta and closure of the origins of the innominate, left common carotid and left sub-clavian arteries. The thoracic endografts were then introduced antegrade through a side arm connected to the body of the main aortic graft. No attempt was made to revascularise the left sublcavian artery. All patients were followed-up with CT scans. No patients was lost to follow-up. It was possible to complete the procedure in a single stage in all patients. The mean operative time was 5.7 hours. There was no intraoperative mortality. There were no intra or postoperative coagulation problems. Two patients had immediate type II endoleak that disappeared completely in one month. One patient died postoperatively having developed acute renal failure and chest infection. Acute renal failure requiring temporary dialysis occurred in three other patients. One patient developed delayed paraparesis that recovered with CSF drainage. One patient suffered with lower medial quadranopia in the right eye. There were no strokes or permanent spinal neurological deficits. Two patients with history of COPD required prolonged respiratory support. They were no long term complications secondary to occlusion of the left subclavian artery. The median length of ITU stay was 5.1 days. The mean length of hospital stay was 15.8 days. During a median follow-up duration of 8.8 months two patients were successfully treated for type II endoleak and one patient developed type 1 endoleak that required extension of the bottom end of the endografts. All aortic debranching grafts remain patent to last follow-up. One stage hybrid repair of aneurysms involving the aortic arch is a feasible technique. The preliminary results of this series show low mortality and complications rate. Larger series with longer follow-ups are underway

Hybrid reconstruction of thoracoabdominal aortic aneurysms: retrograde visceral revascularization with endovascular exclusion

Combined retrograde open visceral revascularization and endovascular exclusion for the treatment of thoracoabdominal aortic aneurysms [TAAA]. It is a retrospective review of a prospectively collected database of 11 consecutive patients [4 women], with a median patient age of 71 years [range 41 to 77 years]. All patients underwent hybrid reconstruction of thoracoabdominal aortic aneurysms [Crawford type II in 3 and type III in 8 patients] in the period between November 2006 and November 2007. Seven patients underwent elective repair, 3 patients were symptomatic and underwent urgent repair, and 1 patient had an emergency repair for rupture. Previous aortic surgery had been performed in 3 patients. One or more severe comorbidities were present in 82% of patients [9/11]; six patients had moderate to severe respiratory insufficiency, 4 patients had moderate to severe left ventricular dysfunction, and 5 patients had chronic renal impairment. One patient had Marfan's syndrome. A total of 40 visceral bypasses were performed; these included 11 to the superior mesenteric artery [SMA], 11 to the celiac trunk [CA] and 18 renal artery [RA] bypasses [bilateral in 7 patients and single in 4]. Aneurysm exclusion was achieved with a median of 2 stent-grafts per patient. Paraplegia did not occur in any patient. The 30-day mortality was 18% [2/11 patients]. Two patients [18%] required re-intubation and respiratory support following initial extubation, 4 patients [36.5%] required inotropic support, and 2 patients [18%] required temporary renal support for <5 days. The hybrid reconstruction was performed as a one stage operation in 7/11 patients. All operations were completed. Median operative time was 7 hours [5.5 to 9.5 hours]. Median lengths of ITU stay and total hospital stay were 9 days and 22 days respectively. Postoperative CT at 1 week revealed no type 1 endoleaks in any patients and 4 cases of type II endoleak and a 100% graft patency. During a median follow-up of 13 weeks [range, 1 to 54 weeks] there was no aneurysm expansion and all grafts remained patent. Preliminary results of hybrid reconstruction of Crawford types II and III thoracoabdominal aortic aneurysms show technical feasibility and low paraplegia rates. Until longer follow-up is available, in terms of stent durability and extra-anatomical bypass graft-related complications, the hybrid procedure should be reserved for high surgical risk patients unfit for open repair

Radiographic identification of age and gender from the degree and pattern of calcification of the costal cartilages

Accurate diagnosis of human age and gender has always been a problem for forensic scientists. This study aimed at the determination of the gender and approximate age using a simple, inexpensive and readily available technique, which requires little expertise, by utilizing radiological-determined pattern and degree of calcification of the costal cartilages. The study comprised [50] cases of both genders; their ages ranged from [15] to [80] years. The chest plate comprised of the sternum, costal cartilage and the last [2] cms of ribs, were exposed to radiological examination. The central and mixed patterns of calcification at the costochondral junction were characteristic and definitely identified female gender; while the peripheral pattern occurred in both genders, but was more in male gender. Independent of gender, there was a statistically significant association between age and degree of calcification. Degrees of calcification, which equal [2.5] up to [4], identify a male as having an age > 40 years. Linear regression equations were used to calculate age from the degree of calcification at the costochondral junction with low to moderate accuracy