Clinical outcomes of endovascular treatment for ruptured thoracic aortic disease

Background/Aims@#Untreated rupture of the thoracic aorta is associated with a high mortality rate. We aimed to review the clinical results of endovascular treatment for ruptured thoracic aortic disease. @*Methods@#We retrospectively reviewed data on 37 patients (mean age, 67.0 ± 15.18 years) treated for ruptured thoracic aortic disease from January 2005 to May 2016. The median follow-up duration was 308 days (interquartile range, 61 to 1,036.5). The primary end-point of the study was the composite of death, secondary intervention, endoleak, and major stroke/paraplegia after endovascular treatment. @*Results@#The etiologies of ruptured thoracic aortic disease were aortic dissection (n = 11, 29.7%), intramural hematoma (n = 7, 18.9%), thoracic aortic aneurysm (n = 14, 37.8%), and traumatic aortic transection (n = 5, 13.5%). Three patients died within 24 hours of thoracic endovascular aortic repair, and one showed type I endoleak. The technical success rate was 89.2% (33/37). The in-hospital mortality rate was 13.5% (5/37); no deaths occurred during follow-up. The composite outcome rate during follow-up was 37.8% (14/37), comprising death (n = 5, 13.5%), secondary intervention (n = 5, 13.5%), endoleak (n = 5, 13.5%), and major stroke/paraplegia (n = 3, 8.1%). Left subclavian artery revascularization and proximal landing zone were not associated with the composite outcome. Low mean arterial pressure (MAP; ≤ 60 mmHg, [hazard ratio, 13.018; 95% confidence interval, 2.435 to 69.583, p = 0.003]) was the most significant predictor and high transfusion requirement in the first 24 hours was associated with event-free survival (log rank p = 0.018). @*Conclusions@#Endovascular treatment achieves high technical success rates and acceptable clinical outcome. High transfusion volume and low MAP were associated with poor clinical outcomes.

Safety and Efficacy of an Aortic Arch Stent Graft with Window-Shaped Fenestration for Supra-Aortic Arch Vessels: an Experimental Study in Swine

BACKGROUND AND OBJECTIVES: Thoracic endovascular aortic repair exhibits limitations in cases where the aortic pathology involves the aortic arch. We had already developed a fenestrated aortic stent graft (FASG) with a preloaded catheter for aortic pathology involving the aortic arch. FASG was suitable for elective cases. MATERIALS AND METHODS: An aortic arch stent graft with a window-shaped fenestration (FASG-W) for supra-aortic arch vessels is suitable for emergent cases. This study aims to test a FASG-W for supra-aortic arch vessels and to perform a preclinical study in swine to evaluate the safety and efficacy of this device. Six FASG-Ws with 1 preloaded catheter were advanced through the iliac artery in 6 swine. The presence of endoleak and the patency and deformity of the grafts were examined with computed tomography (CT) at 4 weeks postoperatively. A postmortem examination was performed at 8 weeks. The mean procedure time for FASG-W was 27.15±4.02 minutes. The mean time for the selection of the right carotid artery was 5.72±0.72 minutes. RESULTS: Major adverse events were not observed in any of the 6 pigs who survived for 8 weeks. For the FASG-W, no endoleaks, no disconnection, and no occlusion of the stent grafts were observed in the CT findings or the postmortem gross findings. CONCLUSION: The procedure with the FASG-W was able to be performed safely in a relatively short procedure time and involved an easy technique. The FASG-W was found to be safe and convenient for use in this preclinical study of swine.

Thoracic Endovascular Repair by Chimney Technique for Aortic Dissection with Malperfusion Syndrome / 대한내과학회지

A perfusion deficit of the aortic branch vessels in a patient with a type B aortic dissection is a challenging complication, as it leads to hemodynamic instability and doubles the mortality rate; however, the optimal management strategy in these cases remains controversial. Although surgical repair is still performed as the standard, endovascular approaches have been used recently as alternatives because of the high rate of perioperative complications. Herein, we report a patient with a type B aortic dissection and compromised renal and iliac arteries who was successfully treated by thoracic endovascular repair and insertion of a percutaneous stent. In addition, we adopted the chimney technique to preserve blood flow to the left subclavian artery due to the short proximal landing zone.

Successful Repair of Type I Endoleak Using the Frozen Elephant Trunk Technique

Thoracic endovascular aortic repair (TEVAR) has emerged as an effective therapy for a variety of thoracic aortic pathologies. However, various types of endoleak remain a major concern, and its treatment is often challenging. We report a case of type I endoleak occurring 19 months after zone II hybrid TEVAR. The endoleak was successfully repaired by the frozen elephant trunk technique, without removal of a previous stent graft, combined with ascending aorta and total arch replacement.

A Case of Microangiopathic Hemolytic Anemia after Myxoma Excision and Mitral Valve Repair Presenting as Hemolytic Uremic Syndrome

Microangiopathic hemolytic anemia occurs in a diverse group of disorders, including thrombotic thrombocytopenic purpura, hemolytic uremic syndrome, and prosthetic cardiac valves. Hemolytic anemia also occurs as a rare complication after mitral valve repair. In this report, we describe a case of microangiopathic hemolytic anemia following myxoma excision and mitral valve repair, which was presented as hemolytic uremic syndrome.

Type B Aortic Dissection with Malperfusion of Both Common Iliac Arteries That Underwent Stent Placement Using the Left Brachial Approach / 대한내과학회지

Malperfusion syndrome is a complication of acute descending aortic dissection (DAD) and it is associated with a poor clinical outcome. Surgical treatment for it has a high rate of mortality. Thoracic endovascular aortic repair (TEVAR) for DAD with malperfusion syndrome has resulted in good clinical outcomes. However, when both common iliac arteries are compromised by a false lumen, it is impossible to conduct TEVAR because there is no accessible artery. We successfully treated a case of DAD with malperfusion syndrome in which both common iliac arteries were compromised by placing stents in both arteries using the left brachial approach.

Effect of n-3 Polyunsaturated Fatty Acids on Regression of Coronary Atherosclerosis in Statin Treated Patients Undergoing Percutaneous Coronary Intervention

BACKGROUND AND OBJECTIVES: Statins remain the mainstay of secondary coronary artery disease (CAD) prevention, but n-3 polyunsaturated fatty acids (ω-3 PUFA) display biological effects that may also reduce the risk of atherosclerosis and CAD. However, data on the possible antiatherosclerotic benefits of adding ω-3 PUFA to statin therapy are limited. This study aimed to investigate the potential additive effects of ω-3 PUFA on regression of atherosclerosis in CAD patients receiving statin therapy and stent implantation. SUBJECTS AND METHODS: Seventy-four CAD patients undergoing percutaneous coronary intervention (PCI) with stent implantation were enrolled, prescribed statins, and randomly assigned to two groups: n-3 group (ω-3 PUFA 3 g/day, n=38) or placebo group (placebo, n=36). All patients completed the study follow-up consisting of an intravascular ultrasound at baseline and at 12 months. RESULTS: There was no difference in the baseline characteristics and distribution of other medications. No significant differences were observed in primary endpoints, including changes in atheroma volume index (-12.65% vs. -8.51%, p=0.768) and percent atheroma volume (-4.36% vs. -9.98%, p=0.526), and in secondary endpoints including a change in neointimal volume index (7.84 vs. 4.94 mm3/mm, p=0.087). CONCLUSION: ω-3 PUFA had no definite additional effect on the regression of coronary atherosclerosis when added to statin in CAD patients undergoing PCI.

Safety and Efficacy of a Novel, Fenestrated Aortic Arch Stent Graft with a Preloaded Catheter for Supraaortic Arch Vessels: An Experimental Study in Swine

Thoracic endovascular aortic repair (TEVAR) shows limitations in cases in which the aortic pathology involves the aortic arch. The study aims were to test a fenestrated aortic arch stent graft (FASG) with a preloaded catheter for the supraaortic arch vessels and to perform a preclinical study in swine to evaluate the safety and efficacy of this device. Six FASGs with 1 preloaded catheter and 5 FASGs with 2 preloaded catheters were advanced through the iliac artery in 11 swines. The presence of endoleaks and the patency and deformity of the grafts were examined with computed tomography (CT) at 4 weeks postoperatively. A postmortem examination was performed at 8 weeks. The mean procedure time for the one and two FASG groups was 30.2 (27.9-34.5) min and 43.1 (39.2-53.7) min. The mean time for the selection of the carotid artery was 4.8 (4.2-5.5) min and 6.2 (4.6-9.4) min. Major adverse event was observed in one of 11 pigs. One pig died at 4 weeks likely because of the effects of the high dose of ketamine, while the remaining 10 pigs survived 8-week. For both the one and two FASG groups, no endoleaks, no disconnection, no occlusion of the stent grafts were observed in the CT findings and the postmortem gross findings. The procedure with the FASG could be performed safely in a relatively short procedure time and involved an easy technique. The FASG is found to be safe and convenient in this preclinical study with swine.

Effects of Intracoronary Administration of Autologous Adipose Tissue-Derived Stem Cells on Acute Myocardial Infarction in a Porcine Model

PURPOSE: Adipose-derived stem cells (ADSCs) are known to be potentially effective in regeneration of damaged tissue. We aimed to assess the effectiveness of intracoronary administration of ADSCs in reducing the infarction area and improving function after acute transmural myocardial infarction (MI) in a porcine model. MATERIALS AND METHODS: ADSCs were obtained from each pig's abdominal subcutaneous fat tissue by simple liposuction. After 3 passages of 14-days culture, 2 million ADSCs were injected into the coronary artery 30 min after acute transmural MI. At baseline and 4 weeks after the ADSC injection, 99mTc methoxyisobutylisonitrile-single photon emission computed tomography (MIBISPECT) was performed to evaluate the left ventricular volume, left ventricular ejection fraction (LVEF; %), and perfusion defects as well as the myocardial salvage (%) and salvage index. At 4 weeks, each pig was sacrificed, and the heart was extracted and dissected. Gross and microscopic analyses with specific immunohistochemistry staining were then performed. RESULTS: Analysis showed improvement in the perfusion defect, but not in the LVEF in the ADSC group (n=14), compared with the control group (n=14) (perfusion defect, -13.0+/-10.0 vs. -2.6+/-12.0, p=0.019; LVEF, -8.0+/-15.4 vs. -15.9+/-14.8, p=0.181). There was a tendency of reducing left ventricular volume in ADSC group. The ADSCs identified by stromal cell-derived factor-1 (SDF-1) staining were well co-localized by von Willebrand factor and Troponin T staining. CONCLUSION: Intracoronary injection of cultured ADSCs improved myocardial perfusion in this porcine acute transmural MI model.

Upper Limb Ischemia: Clinical Experiences of Acute and Chronic Upper Limb Ischemia in a Single Center

BACKGROUND: Upper limb ischemia is less common than lower limb ischemia, and relatively few cases have been reported. This paper reviews the epidemiology, etiology, and clinical characteristics of upper limb ischemia and analyzes the factors affecting functional sequelae after treatment. METHODS: The records of 35 patients with acute and chronic upper limb ischemia who underwent treatment from January 2007 to December 2012 were retrospectively reviewed. RESULTS: The median age was 55.03 years, and the number of male patients was 24 (68.6%). The most common etiology was embolism of cardiac origin, followed by thrombosis with secondary trauma, and the brachial artery was the most common location for a lesion causing obstruction. Computed tomography angiography was the first-line diagnostic tool in our center. Twenty-eight operations were performed, and conservative therapy was implemented in seven cases. Five deaths (14.3%) occurred during follow-up. Twenty patients (57.1%) complained of functional sequelae after treatment. Functional sequelae were found to be more likely in patients with a longer duration of symptoms (odds ratio, 1.251; p=0.046) and higher lactate dehydrogenase (LDH) levels (odds ratio, 1.001; p=0.031). CONCLUSION: An increased duration of symptoms and higher initial serum LDH levels were associated with the more frequent occurrence of functional sequelae. The prognosis of upper limb ischemia is associated with prompt and proper treatment and can also be predicted by initial serum LDH levels.

Peptidoglycan Up-Regulates CXCL8 Expression via Multiple Pathways in Monocytes/Macrophages

Peptidoglycan (PG), the gram positive bacterial pathogen-associated molecular patterns (PAMP), is detected in a high proportion in macrophage-rich atheromatous regions, and expression of chemokine CXCL8, which triggers monocyte arrest on early atherosclerotic endothelium, is elevated in monocytes/macrophages in human atherosclerotic lesion. The aim of this study was to investigate whether PG induced CXCL8 expression in the cell type and to determine cellular signaling pathways involved in that process. Exposure of THP-1 cell, human monocyte/macrophage cell line, to PG not only enhanced CXCL8 release but also profoundly induced il8 gene transcription. PG-induced release of CXCL8 and induction of il8 gene transcription were blocked by OxPAPC, an inhibitor of TLR-2/4 and TLR4, but not by polymyxin B, an inhibitor of LPS. PG-mediated CXCL8 release was significantly attenuated by inhibitors of PI3K-Akt-mTOR pathways. PKC inhibitors, MAPK inhibitors, and ROS quenchers also significantly attenuated expression of CXCL8. The present study proposes that PG contributes to inflammatory reaction and progression of atherosclerosis by inducing CXCL8 expression in monocytes/macrophages, and that TLR-2, PI3K-Akt-mTOR, PKC, ROS, and MAPK are actively involved in the process.

Multiple Embolic Aortic Valve Endocarditis with Small Patent Ductus Arteriosus in Adult

A 50-year-old female was admitted to Pusan National University Hospital with complaints of fatigue and sweating. Echocardiography showed a small patent ductus arteriosus (PDA) and highly mobile vegetations on the aortic valve. Emergency operation was performed due to the high risk of embolization and severe aortic regurgitation. When the pulmonary artery opened, we found unexpected fresh vegetation. The tissue of the PDA was fragile and infected. We successfully removed the infected tissue, closed the PDA with a patch, and replaced the aortic valve with a mechanical prosthesis.

Hybrid Technique to Correct Cerebral Malperfusion Following Repair of a Type A Aortic Dissection

A 49-year-old man with drowsy mentality was diagnosed with acute type A aortic dissection; he underwent an emergency operation. When selective antegrade cerebral perfusion was initiated, the right regional cerebral oxygen saturation (rSO2) decreased as compared to the left one. Adequate blood flow was perfused through the branch of the artificial graft, after distal anastomosis, but the right rSO2 did not recover. Angiography revealed another intimal tear on the right common carotid artery. A stent was then inserted. The right rSO2 promptly increased to the same level as that of the left one. The patient was discharged without any neurologic complications.

Hybrid Treatment of an Aortic Arch Aneurysm with an Aberrant Right Subclavian Artery / 대한내과학회지

Aberrant right subclavian artery (ARSA) is a rare congenital anomaly but is the most common of the congenital vascular anomalies of the aortic arch. We report the case of a 68-year-old female undergoing chemotherapy for multiple myeloma who had a large thoracic aortic aneurysm (7.4 cm) with ARSA. She was treated with a hybrid procedure that combined a left common carotid-to-subclavian artery bypass with a "thoracic endovascular aortic repair (TEVAR)" because of the risk associated with a thoracotomy. A stent graft was deployed in the proximal part of the descending aorta to cover the thoracic aortic aneurysm after a left common carotid-to-subclavian bypass was made to restore blood flow in the left arm. There was no endoleak on digital subtraction angiography. Hybrid therapy can be performed successfully for the treatment of thoracic aortic aneurysm with ARSA.

Complicated Acute Aortic Dissection with Malperfusion of the Left Common Iliac Artery Treated with Thoracic Endovascular Aortic Repair / 대한내과학회지

Acute aortic dissection with malperfusion syndrome is associated with poor clinical outcomes, and surgical treatment for complicated descending aortic dissections is associated with a high risk of operative mortality. Endovascular repair is emerging as a good alternative to surgery. Endovascular repair for a descending aortic dissection with malperfusion syndrome offers good clinical outcomes because of technical and anatomical benefits. Here, we report a case of descending aortic dissection and malperfusion syndrome in the left common iliac artery that was successfully treated with an aortic stent graft and peripheral stent.

Endovascular Treatment of an Abdominal Aortic Pseudoaneurysm in a Patient with Behcet's Disease / 대한내과학회지

Behcet's disease shows systemic involvement, including mucocutaneus, ophthalmical, neurological, pulmonary, gastrointestinal, urogenital, mucoskeletal, and cardiovascular disorders. Aneurysmal changes develop in 65% of patients with arterial involvement and are associated with a poor prognosis. Although many attempts have been made to surgically manage these serious arterial lesions, several reports have shown a high recurrence rate and operation-related complications. Stent-graft placement has been indicated for the treatment of pseudoaneurysms and aneurysms in patients with a high surgical risk, including those with Behcet's disease. We herein describe an abdominal aortic pseudoaneurysm in a patient with Behcet's disease that was successfully treated with stent-graft insertion without an endoleak after 36 months of follow-up.

Effects of Low Dose Pioglitazone on Restenosis and Coronary Atherosclerosis in Diabetic Patients Undergoing Drug Eluting Stent Implantation

PURPOSE: Thiazolidinediones are insulin-sensitizing agents that reduce neointimal proliferation and the adverse clinical outcomes associated with percutaneous coronary intervention (PCI) in patients with diabetes mellitus (DM). There is little data on whether or not low dose pioglitazone reduces adverse clinical outcomes. MATERIALS AND METHODS: The study population included 121 DM patients with coronary artery disease and they were randomly assigned to 60 patients taking 15 mg of pioglitazone daily in addition to their diabetic medications and 61 patients with placebo after the index procedure with drug-eluting stents (DESs). The primary end points were rate of in-stent restenosis (ISR) and change in atheroma volume and in-stent neointimal volume. The secondary end points were all-cause death, myocardial infarction (MI), stent thrombosis and re-PCI. RESULTS: There were no statistical differences in the clinical outcomes and the rate of ISR between the two groups [all-cause death; n=0 (0%) in the pioglitazone group vs. n=1 (1.6%) in the control group, p=0.504, MI; n=2 (3.3%) vs. n=1 (1.6%), p=0.465, re-PCI; n=6 (10.0%) vs. n=6 (9.8%), p=0.652, ISR; n=4 (9.3%) vs. n=4 (7.5%), p=1.000, respectively]. There were no differences in changes in neointimal volume, percent neointimal volume, total plaque volume and percent plaque volume between the two groups on intravascular ultrasonography (IVUS) study. CONCLUSION: Our study demonstrated that low dose pioglitazone does not reduce rate of ISR, neointimal volume nor atheroma volume in DM patients who have undergone PCI with DESs, despite the limitations of the study.

Mid-Term Results of Endovascular Repair for Traumatic Aortic Injury / 대한내과학회지

BACKGROUND/AIMS: Traumatic aortic injury (TAI) is rarely seen clinically, but is highly fatal. In determining how to treat TAI, there are many factors to consider, due to the complexity of concomitant injuries. The Society of Vascular Surgery recommends that thoracic endovascular aortic repair (TEVAR) should be preferentially performed over open surgical repair. We evaluated the efficacy of TEVAR based on our experiences in TAI treatment. METHODS: Between July 2008 and August 2011, we conducted a retrospective analysis of the patients who underwent TEVAR following TAI and analyzed factors including TAI type and sites, time from injury to repair, Injury Severity Score, and complications. Seven patients with multiple injuries underwent TEVAR in the acute setting. Follow-up was accomplished regularly by computed tomographic angiography (CTA). RESULTS: Type III aortic injury, rib fractures, and hemothorax were found in all patients. TEVAR was successfully performed. Completion angiography demonstrated complete exclusion of pseudoaneurysm without endoleakage, and perfusion of aortic arch vessels was maintained. There was no in-hospital mortality or evidence of spinal cord ischemia. The average follow-up duration was 30.4 +/- 23.9 months, and regular CTA revealed good durability of the stent-graft without late complications such as endoleakage, stent migration, or pseudoaneurysm formation. CONCLUSIONS: Through this study, we were able to identify good mid-term results of TEVAR in our hospital. TEVAR is thought to be a good modality with which to treat acute traumatic aortic injury, especially given the consideration of bleeding risk in trauma patients with multiple injuries.

The Modified Chimney Technique With a Thoracic Aortic Stent Graft to Preserve the Blood Flow of the Left Common Carotid Artery for Treating Descending Thoracic Aortic Aneurysm and Dissection

While thoracic endovascular aortic repair is an effective treatment option for descending thoracic aorta pathology, it does have limitations. The main limitation is related to the anatomical difficulties when disease involves the aortic arch. A fenestrated, branched aortic stent graft and hybrid operation has been introduced to overcome this limitation, but it is a custom-made device and is time consuming to manufacture. Furthermore, these devices cannot be used in an emergency setting. We report two patients with massive descending thoracic aortic aneurysm and ruptured aortic dissection very near the aortic arch who underwent a procedure which we named the modified chimney technique. The modified chimney technique can be used as a treatment option in such an emergency situation or as a rescue procedure when aortic pathology is involved near the supra-aortic vessels.

Endovascular Management of Acute Total Occlusion of the Aorta

Acute total occlusion of the aorta is a rare and clinically critical condition requiring aggressive immediate diagnosis and treatment. A 73-year-old male was seen at our hospital complaining of pain sensation in both legs. Under the likely impression of an acute total occlusion of the aorta, emergency abdominal aortogram was done, which revealed total occlusion of the distal aorta and both iliac arteries. Intra-arterial thrombolysis with urokinase was attempted for 48 hours as intervention during the acute stage is highly related to distal thromboembolic events. Follow-up angiography showed improved arterial flow but residual stenosis at both the common iliac arteries. Self-expandable nitinol stents were inserted at both the iliac arteries by the v-kissing technique resulting in a satisfying outcome as seen on angiography without complications. The patient was discharged without additional medical problems. From our experience, we conclude that the use of intra-arterial thrombolysis with percutaneous transluminal angioplasty is an alternative to the conventional surgical approach in treating acute total occlusion of the aorta.