Inferior Vena Cava (IVC) Resections without Reconstruction in Renal Tumors: Two Case Reports.

(1) Background: We aim to present our experience with resection of the inferior vena cava (IVC) without reconstruction in two patients diagnosed with renal tumors. (2) Case Report: The first case was diagnosed with right renal vein sarcoma and the second case was diagnosed with clear cell renal carcinoma; both presented signs of invasion and thrombosis of the IVC at infrarenal and cruoric levels, along with the development of collateral circulation with the help of the paravertebral plexus. In both patients, en bloc right nephrectomy was performed along with the resection of the thrombosed IVC without further reconstruction. In the case of the patient with right vein sarcoma, preservation of the left renal and caval intrahepatic vein was possible, whilst in the second case diagnosed with clear cell renal carcinoma, the associated left renal thrombosis also enforced the resection of the left renal vein. (3) Discussion: Postoperative evolution was favorable in both cases and did not exhibit major complications. Antibiotic therapy, analgesics, and anticoagulant medication were administered at therapeutic doses after surgery in both cases. The histopathological examination of the surgical specimen confirmed the diagnoses of renal vein sarcoma in the first case and clear cell renal carcinoma in the second case. Surgical treatment and adjuvant chemotherapy prolonged survival for two years for the first case and for two months, up until this moment, for the second case. The survival of clear cell renal carcinoma is currently at two months. (4) Conclusions: The resection of the inferior vena cava, without subsequent reconstruction in cases presenting diffused distal thrombosis, can represent an alternative to IVC reconstruction, which might lead to a major ulterior risk of thrombosis. In some cases, this can result in long-term survival.

One-Year Single-Center Results of the Multilayer Flow Modulator Stents for the Treatment of Type B Aortic Dissection.

PURPOSE: To report a single-center series of patients with type B aortic dissection treated with the Multilayer Flow Modulator (MFM). MATERIALS AND METHODS: Over a 36-month period, 23 patients (median age 53 years; 20 men) with complicated type B aortic dissections (2 acute, 5 subacute, and 16 chronic) were treated with the MFM. Primary endpoints of rupture or dissection-related death, overall mortality, and reintervention were evaluated using the Kaplan-Meier method; estimates for freedom from the endpoints are reported with the 95% confidence interval (CI). Secondary outcomes included technical success, adverse events, and aortic remodeling. Clinical and imaging data were collected preoperatively, directly postoperatively, and annually to 36 months for analysis using computational fluid dynamics (CFD). RESULTS: Initial technical success was 91.3%. The estimates of the endpoints at 12 months were 100% for freedom from rupture or aortic-related death, 95.7% for freedom from overall mortality, and 91.3% for freedom from reintervention. No device-related neurological or systemic complications occurred, and no additional reinterventions were needed during follow-up. A total of 144 branches overstented by the MFM remained patent. Morphologic analysis of the aortic dissection showed progressive true lumen volume increase (75.9%, p<0.001) with concomitant false lumen volume decrease (42.8%, p<0.001); the CFD analyses showed increased laminar flow. CONCLUSION: In the current series, the MFM provided a safe and feasible treatment option for complicated acute, subacute, and chronic type B aortic dissections, with high technical success, low mortality, and active aortic remodeling. Further studies should elucidate the long-term safety of the MFM and its effectiveness in a larger patient cohort.

Geometric Analysis of Type B Aortic Dissections Shows Aortic Remodeling After Intervention Using Multilayer Stents.

Recently, multilayer stents for type B aortic dissections (TBAD) have been proposed to decrease false lumen flow, increase and streamline true lumen flow, and retain branch vessel patency. We aimed to provide a protocol with standardized techniques to investigate aortic remodeling of TBAD by multilayer flow modulators (MFM) in static geometric and hemodynamic analyses. Combining existing literature and new insights, a standardized protocol was designed. Using pre- and postoperative CT scans, geometric models were constructed, lumen dimensions were calculated, computational fluid dynamics (CFD) models were composed, and velocity and pressures were calculated. Sixteen TBAD cases treated with MFM were included for analysis. For each case, aortic remodeling was analyzed using post-processing medical imaging software. After 3D models were created, geometrical anatomical measurements were performed, and meshes for finite element analysis were generated. MFM cases were compared pre- and postoperatively; true lumen volumes increased (p < 0.001), false lumen volumes decreased (p = 0.001), true lumen diameter at the plane of maximum compression (PMC) increased (p < 0.001), and false lumen index decreased (p = 0.008). True lumen flow was streamlined, and the overall fluid velocity and pressures decreased (p < 0.001 and p = 0.006, respectively). This protocol provided a standardized method to evaluate the effects of MFM treatments in TBAD on geometric analyses, PMC, and CFD outcomes.

A multilayer micromechanical elastic modulus measuring method in ex vivo human aneurysmal abdominal aortas.

Abdominal aortic aneurysms (AAA) are common and potentially life-threatening aortic dilatations, due to the effect of hemodynamic changes on the aortic wall. Previous research has shown a potential pathophysiological role for increased macroscopic aneurysmal wall stiffness; however, not investigating micromechanical stiffness. We aimed to compile a new protocol to examine micromechanical live aortic stiffness (elastic moduli), correlated to histological findings with quantitative immunofluorescence (QIF). Live AAA biopsies (n = 7) and non-dilated aortas (controls; n = 3) were sectioned. Local elastic moduli of aortic intima, media and adventitia were analysed in the direction towards the lumen and vice versa with nanoindentation. Smooth muscle cells (SMC), collagen and fibroblasts were examined using QIF. Nanoindentation of AAA vs. controls demonstrated a 4-fold decrease in elastic moduli (p = 0.022) for layers combined and a 26-fold decrease (p = 0.017) for media-to-intima direction. QIF of AAA vs. controls revealed a 4-, 3- and 6-fold decrease of SMC, collagen and fibroblasts, respectively (p = 0.036). Correlations were found between bidirectional intima and media measurements (ρ = 0.661, p = 0.038) and all QIF analyses (ρ = 0.857-0.905, p = 0.002-0.007). We present a novel protocol to analyse microscopic elastic moduli in live aortic tissues using nanoindentation. Hence, our preliminary findings of decreased elastic moduli and altered wall composition warrant further microscopic stiffness investigation to potentially clarify AAA pathophysiology and to explore potential treatment by wall strengthening. STATEMENT OF SIGNIFICANCE: Although extensive research on the pathophysiology of dilated abdominal aortas (aneurysms) has been performed, the exact underlying pathways are still largely unclear. Previously, the macroscopic stiffness of the pathologic and healthy aortic wall has been studied. This study however, for the first time, studied the microscopic stiffness changes in live tissue of dilated and non-dilated abdominal aortas. This new protocol provides a device to analyse the alterations on cellular level within their microenvironment, whereas previous studies studied the aorta as a whole. Outcomes of these measurements might help to better understand the underlying origin of the incidence and progression of aneurysms and other aortic diseases.

Aortic Remodeling After Total Endovascular Aortic Repair With Multilayer Stents: Computational Fluid Dynamics Analysis of Aortic Remodeling Over 3 Years of Follow-up.

PURPOSE: To report Multilayer Flow Modulator (MFM) implantation from the sinotubular junction to the distal infrarenal aorta in the treatment of type B aortic dissection (TBAD) and demonstrate aortic remodeling using computational fluid dynamics (CFD) analysis over the course of 3-year follow-up. CASE REPORT: A hypertensive patient with complicated TBAD required thoracic endovascular aortic repair due to severe thoracic pain associated with rapid progression of the false lumen aneurysm toward the distal aortic arch. Under general anesthesia, 2 aortic multilayer stents were placed over a 0.035-inch stiff guidewire in the compressed true lumen. The aorta was covered with 2 MFM stents between the sinotubular junction and the distal infrarenal aorta. Serial computed tomography scans showed progressive remodeling of the entire dissected aortic wall, with an excellent result at 24 months. Morphological and CFD vascular analysis confirmed the aortic remodeling, with a false lumen index drop from a preoperative 4.04 to 0.01 at 36 months. CONCLUSION: Endovascular aortic repair with multilayer stents is a promising treatment for complicated TBAD due to the unique ability of these devices to stabilize the entire aortic wall without compromising the flow in the major aortic side branches.

Aortic valve surgery of the 21st century: sutureless AVR versus TAVI.

Surgical aortic valve replacement (sAVR) has been a safe, effective and time-proven technique and is still the standard of care all over the world for aortic valve treatment. The vast majority of centers perform this procedure by doing a median sternotomy with several disadvantages. While many others specialties went minimally invasive decades ago, in cardiovascular field transcatheter valve implantation was the first minimally invasive valvular procedure that gained rapid worldwide acceptance. Transcatheter valve replacement (TAVR) is now marketed as a procedure that should be performed under local anesthesia, by an interventional cardiologist via trans femoral route with no other healthcare professional invited to the patient selection or case planning. An increasing number of surgeons are promoting minimally invasive aortic valve replacement, which is gaining grounds, especially with the help of the new sutureless valve technology. With these two new technologies emerging, legitimate questions arise and need to be answered - which has the longest durability, lower complication rate and lower overall mortality.

Three-Year Outcomes With the Multilayer Flow Modulator for Repair of Thoracoabdominal Aneurysms: A Follow-up Report From the STRATO Trial.

PURPOSE: To evaluate midterm outcomes of endovascular repair of types II and III thoracoabdominal aortic aneurysms (TAAA) using the Multilayer Flow Modulator (MFM) in patients unsuitable for open surgery or fenestrated stent-grafts. METHODS: In the prospective, multicenter, nonrandomized STRATO trial (EudraCT registration: 2009-013678-42; ClinicalTrials.gov identifier NCT01756911), 23 patients (mean age 75.8 years; 19 men) with Crawford type II and III TAAA (mean diameter 6.5 cm) were implanted between April 2010 and February 2011. Outcomes included all-cause mortality and stable aneurysm thrombosis with associated branch vessel patency. RESULTS: Through 36 months, there were 7 deaths (none confirmed as aneurysm-related), and no cases of spinal cord injury, device migration or fracture, or respiratory, renal, or peripheral complications. Three patients were lost to follow-up and 2 devices were explanted. The device was patent in the 11 remaining patients at 3 years. Stable aneurysm thrombosis was achieved for 15 of 20 patients at 12 months, 12 of 13 at 24 months, and 10 of 11 at 36 months. The rate of branch patency was 96% at 12 months (primary patency), 100% at 24 months, and 97% at 36 months. Nine patients suffered from endoleaks (attachment site or device overlap); 9 patients underwent 11 reinterventions (3 surgical). Maximum aneurysm diameter was stable for 18 of 20 patients at 12 months, 11 of 13 at 24 months, and 9 of 11 at 36 months. For 10 patients with computed tomography at 36 months, the mean ratio of aneurysm flow volume to total volume had decreased by 83%; the mean ratio of thrombus volume to total volume increased by 159%. CONCLUSION: Through 3 years, endovascular repair with the MFM appears to be safe and effective while successfully maintaining branch vessel patency.

One-year outcomes following repair of thoracoabdominal aneurysms with the multilayer flow modulator: report from the STRATO trial.

PURPOSE: To evaluate endovascular repair of type II and III thoracoabdominal aortic aneurysms (TAAA) using the Multilayer Flow Modulator (MFM) in patients with contraindications for open surgery and fenestrated stent-grafts. METHODS: In this prospective, multicenter, nonrandomized trial (EudraCT registration: 2009-013678-42; ClinicalTrials.gov identifier NCT01756911), 23 patients (19 men; mean age 75.8 years) with Crawford type II (43.5%) and III (56.5%) TAAA (mean diameter 6.5 cm) were treated with the MFM between April 2010 and February 2011. The primary efficacy outcome measure was stable aneurysm thrombosis with associated branch vessel patency at 12 months; the primary safety endpoint was 30-day and 12-month all-cause mortality. RESULTS: The rate of technical success was 100%. In 20 patients with computed tomography scans at 12 months, the primary efficacy outcome was met in 15 patients. The rate of primary patency of covered branch vessels was 96% (53/55); 1 patient with 2 occluded visceral branches underwent successful surgical reintervention. Endoleaks were identified in 5 patients (3 attachment site and 2 at device overlap), 4 of whom underwent reintervention (3 additional MFMs and 1 stent-graft implanted). At 12 months, aneurysm diameter was stable in 18 of 20 patients; the mean ratio of residual aneurysm flow volume to total volume had decreased by 28.9%, and the mean ratio of thrombus volume to total lumen volume had increased by 21.3% (n=17). There were no cases of device migration, loss of device integrity, spinal cord ischemia, or aneurysm rupture. CONCLUSION: At 1 year, endovascular repair with the MFM appears to be safe and effective while successfully maintaining branch vessel patency. Follow-up is ongoing.

Giant intracardiac neoplasic thrombus of a large cell neuroendocrine carcinoma of the lung.

Cardiac invasion by lung cancer is associated with a poor prognosis. We describe the case of a large cell neuroendocrine carcinoma of the lung with left intra-atrial extension in a patient presenting with a catastrophic nutritional status.

Early Amplatzer occluder closure of a postinfarct ventricular septal defect as a bridge to surgical procedure.

The management of postinfarction ventricular septal defects represents a challenge to both cardiologists and surgeons due to the high morbidity and mortality rate. We report the case of a 79-year-old patient who developed an apical rupture of the ventricular septum, nine days after an anterior myocardial infarction. As the patient was in cardiogenic shock and developed acute pulmonary edema we chose to perform a percutaneous closure of the septal defect using an Amplatzer occluder (AO). Despite the incomplete closure, the placement of the device greatly improved the patient's clinical condition allowing the delay of the surgical procedure, which could be performed ten days later with an excellent result.

Complete tracheal rupture after a failed suicide attempt.

Tracheal rupture is life-threatening and its management poses a considerable challenge to both anesthesiologists and surgeons. We report the case of a 44-year-old patient with a complete tracheal rupture after a failed suicide attempt by hanging. A rare bilateral injury of the laryngeal nerves was associated. An original tracheal intubation was performed using the video unit for thoracoscopy. The severity of the lesions required the placement of a tracheostomy cannula after the tracheal repair. The postoperative course was uneventful. The patient was discharged on the 12th day, with a remaining moderate dysphonia.