Case series of seven women with uterine fibroids associated with venous thromboembolism and chronic thromboembolic disease.

Uterine fibroids have been described as an associate to acute venous thromboembolism (VTE), with case reports showing an association between large uterine fibroids, acute deep venous thrombosis (DVT), and acute pulmonary embolism (PE). However, there is little known about the association or causation between uterine fibroids, chronic thromboembolic disease (CTED), and chronic thromboembolic pulmonary hypertension (CTEPH). We report on six women with uterine fibroids and CTEPH, as well as one woman with CTED, all of whom presented with exertional dyspnea, lower extremity swelling, and in the cases of CTEPH, clinical, echocardiographic, and hemodynamic evidence of pulmonary hypertension and right heart failure. Compression of the pelvic veins by fibroids was directly observed with invasive venography or contrast-enhanced computed tomography in five cases. All seven women underwent pulmonary thromboendarterectomy (PTE) followed by marked improvement in functional, clinical, and hemodynamic status.

Right Axillary Artery Cannulation for Endovascular Repair of an Acute Type A Aortic Dissection.

We present the case of a 48-year-old woman with an acute type A aortic dissection that was treated with thoracic endovascular aortic repair at our institution. The patient was found to have a focal type A dissection with pericardial effusion but no tamponade physiology and no involvement of the aortic valve or root. We elected to treat the patient's type A aortic dissection with an endovascular stent because of the patient's favorable anatomy and no evidence of neurologic deficits or signs of distal malperfusion. The patient was successfully treated with an abdominal aortic cuff deployed through the axillary artery. An axillary approach was necessary because of the short length of the delivery sheath preventing a transfemoral delivery. At 2-year follow-up, the patient remains free of complications with computed tomography scan revealing complete false lumen thrombosis and a stable endovascular repair. This report demonstrates a case of acute type A aortic dissection successfully treated using thoracic endovascular aortic repair and illustrates the utility of axillary cannulation for precise deployment of stent grafts in the ascending aorta.

Anterior Leaflet Augmentation With CorMatrix Porcine Extracellular Matrix in Twenty-Five Patients: Unexpected Patch Failures and Histologic Analysis.

BACKGROUND: This study reported on the treatment of Carpentier type IIIa and type IIIb mitral regurgitation (MR) with a large patch anterior mitral valve leaflet augmentation technique using CorMatrix (CorMatrix Cardiovascular Inc, Alpharetta, GA) extracellular matrix (ECM). METHODS: A single-site chart review was conducted on patients who underwent anterior leaflet augmentation performed with the Da Vinci surgical robot (Intuitive Surgical, Sunnyvale, CA) or through a median sternotomy. Only patients who had anterior leaflet augmentation with porcine intestine ECM or autologous pericardium were included. Follow-up echocardiography was performed on all patients. Histologic specimens were available on ECM patches from a subset of patients who required reoperation. RESULTS: Between August 2011 and April 2014, 44 patients (mean age, 62.6 ± 12.2 years) underwent anterior leaflet augmentation with either porcine intestinal ECM or autologous pericardium at the Temple University Hospital in Philadelphia. Two (4%) late deaths occurred, one in each group. One patient who underwent ECM augmentation died of non-cardiac-related causes 7 months after discharge as a result of complications of chronic renal failure. The second late death occurred 5 months after discharge because of complications of a stroke in a patient in the pericardial augmentation group. Eight (32%) of the patients with ECM had recurrence of severe MR on echocardiography at an average time of 201 ± 98 days. Seven (28%) patients required reoperation because of failure of the ECM patch including perforation (4%), excessive patch dilation (20%), and suture line dehiscence (4%). In contrast, none of the patients with pericardial augmentation developed severe MR or required operation. Statistical analysis of the patients with ECM augmentation demonstrated no correlation of the following: age; sex; comorbid conditions such as diabetes, chronic obstructive pulmonary disease, and hypertension; left ventricular ejection fraction; surgical approach; annuloplasty size; or type of MR with patch failure. A lower body mass index was the only factor associated with recurrent severe regurgitation on univariate analysis (p = 0.039). Histologic study of the four available explants demonstrated intense inflammation without evidence of host integration. The remaining 15 (60%) patients had normal mitral leaflet structure and function on follow-up echocardiograms out to 12 months. CONCLUSIONS: For type III MR, a large anterior leaflet patch technique with porcine ECM was associated with a 32% recurrence rate of severe MR related directly to patch failure. Further research and development should be performed on the use of ECM materials with a goal to decrease the failure rate experienced in this study.

Ascending Aortic Endoballoon Occlusion Feasible Despite Moderately Enlarged Aorta to Facilitate Robotic Mitral Valve Surgery.

OBJECTIVE: Aortic occlusion with an endoballoon is a well-established technique to facilitate robotic and minimally invasive mitral valve surgery. Use of the endoballoon has several relative contraindications including ascending aortic dilatation greater than 38 mm in size. We sought to review our experience using the endoballoon in cases of totally endoscopic mitral valve surgery with aortic diameters greater than 38 mm. METHODS: A retrospective review of our single-site database was conducted to identify patients undergoing totally endoscopic mitral valve surgery by a single surgeon using an endoballoon and who had ascending aortic dilation. We defined aortic dilation as greater than 38 mm. Computed tomography was done preoperatively on all patients to evaluate the aortic anatomy as well as iliofemoral access vessels. Femoral artery cannulation was done in a standardized fashion to advance and position the endoballoon, to occlude the ascending aorta, and to deliver cardioplegia. RESULTS: From October 2011 through June 2015, 196 patients underwent totally endoscopic mitral valve surgery using an endoballoon at our institution. Twenty-two patients (11.2%) had ascending aortic diameters greater than 38 mm (range, 38.1-46.6 mm; mean, 40.5 ± 2.5 mm). In these cases, there were no instances of aortic dissection or other injury due to balloon rupture, balloon migration, device movement leading to loss of occlusion, or inability to complete planned surgery due to occlusion failure. CONCLUSIONS: Our experience suggests that it is possible to successfully use endoaortic balloon occlusion in patients with ascending aortic dilation with proper preoperative imaging and planning.

Cardiac catheterization in patients with ascending aortic aneurysms: safety, success, and prevalence of coronary artery disease.

BACKGROUND: Evaluation for coronary artery disease (CAD) is recommended prior to surgery for ascending aortic aneurysms. Concerns regarding the use of coronary angiography in this population include safety and the ability to successfully selectively engage the coronary arteries. Additionally, the prevalence of CAD is not well described. METHODS: We retrospectively reviewed all patients referred for cardiac catheterization prior to elective surgery for an ascending aortic aneurysm at our institution over a 4-year period. Catheter selection was based on knowledge of the aneurysm size. Images were screened for whether selective coronary engagement was achieved and for the presence of significant coronary disease. RESULTS: A total of 205 patients met the inclusion criteria. The mean age was 61 years and 63% were male. There were no adverse events related to catheterization. The left coronary artery was selectively engaged in 98% of patients, and the right coronary in 92%. On average, 3.1 catheters were used for angiography per patient. Coronary artery disease was present in 19% of patients (n = 39). Increasing age was the only risk factor significantly associated with the presence of disease. Coronary bypass was required in 15% of patients at the time of aortic aneurysm surgery. CONCLUSIONS: Coronary angiography can be performed safely and the coronary arteries can be successfully selectively engaged in patients with ascending aortic aneurysms. The findings frequently impact the surgical approach. We believe that coronary angiography should be part of the routine preoperative evaluation in appropriate patients.

Reintervention for endograft failures after thoracic endovascular aortic repair.

OBJECTIVE: Thoracic endovascular aortic repair has emerged as an effective therapy for a variety of thoracic aortic pathologic entities. However, endograft failure remains a concern, and its treatment is often challenging. We examined our experience with endograft failure and its treatment by endovascular and open repair. METHODS: From January 2000 to January 2012, 680 patients underwent thoracic endovascular aortic repair at the University of Pennsylvania, and their charts were reviewed for the late outcomes and follow-up data. RESULTS: Of the 680 patients, 73 underwent 80 reinterventions (11.7%) during follow-up. The indications for index thoracic endovascular aortic repair were thoracic aortic aneurysms in 381, type A dissection with frozen elephant trunk in 52, type B dissection in 111, hybrid arch repair in 46, traumatic transection in 37, infection in 10, penetrating atherosclerotic ulcer in 25, and others in 18. The median interval from index thoracic endovascular aortic repair to reintervention was 210 days. Endograft failures included endoleak in 45, proximal aortic events in 11, distal aortic events in 15, endograft infection in 3, and others in 6. Endovascular reintervention (n = 80) was performed in 60 patients. In 20 patients, open aortic reconstructive procedures were performed. The overall 30-day mortality was 8.7% (7/80). During follow-up, 10 late deaths occurred. The overall survival in all patients was 81%, 60%, and 52% at 1, 5, and 7 years, respectively. The late survival for patients after reintervention for endograft failure was similar that for the patients who did not require reintervention (P = .31). CONCLUSIONS: Reintervention for endograft failure can be performed with acceptable early outcomes. The mid-term survival for patients requiring reintervention for endograft failure was similar to that of the patients without endograft failure. Thus, reintervention for endograft failure should be aggressively considered when indicated.

Thoracic endovascular aortic repair: evolution of therapy, patterns of use, and results in a 10-year experience.

OBJECTIVE: The introduction of aortic stent grafting in the treatment of thoracic aortic disease has pioneered unique treatment options and gained rapid clinical adoption despite a paucity of long-term outcome data. The purpose of this analysis is to examine all operations performed using thoracic aortic stent grafts at the University of Pennsylvania Health System. METHODS: A total of 502 operations involving thoracic aortic stent grafting were performed between April 1999 and April 2009. Patients were followed in a prospectively collected clinical perioperative registry, and long-term outcomes were determined from administrative data sources. Aortic pathologies included aortic aneurysm, acute aortic dissection (types A and B), hybrid arch repairs, reinterventions with additional stents, pseudoaneurysm, chronic type B dissection, traumatic transection, penetrating aortic ulcer, and other unique indications. RESULTS: Patients' mean age at the time of thoracic endovascular aortic repair was 70.1 ± 12.4 years, and 51% of the patients were aged more than 70 years. Some 41% of patients were female, and the majority of patients (87%) were hypertensive. Overall 30-day mortality was 10.1%. Multivariable risk factors for 30-day mortality included urgent/emergency, Stanford type A aortic dissection, perioperative spinal ischemia, type C aortic coverage, hybrid arch operation, aortic transection, chronic renal failure, and age. Neurologic complications included permanent complete or incomplete paraplegia in 17 patients (3.4%), reversible spinal cord ischemia in 26 patients (5.1%), transient stroke in 16 patients (3.2%), and permanent stroke in 23 patients (4.6%). Greater extent of aortic coverage was not associated with risk of spinal cord ischemia. Access complications, stroke, and endoleaks diminished with increased operative experience over time. Risk factors for late mortality included urgent/emergency indications, hybrid procedures, traumatic aortic transection, age, perioperative paralysis, and chronic renal failure. Patients undergoing stent grafting for type B dissection were more likely to survive than patients undergoing stent grafting for aneurysms or other indications. CONCLUSIONS: Thoracic aortic stent grafting has evolved to be a viable option to complement, augment, or even replace traditional treatments for aortic disease. These data illustrate the applicability of this evolving technology in the establishment of new treatment paradigms for complex aortic pathologies.

Have hybrid procedures replaced open aortic arch reconstruction in high-risk patients? A comparative study of elective open arch debranching with endovascular stent graft placement and conventional elective open total and distal aortic arch reconstruction.

OBJECTIVE: Open total arch procedures have been associated with significant morbidity and mortality in patients with multiple comorbidities. Aortic arch debranching with endovascular graft placement, the hybrid arch procedure, has emerged as a surgical option in this patient population. This study evaluates the outcomes of a contemporary comparative series from one institution of open total arch and hybrid arch procedures for extensive aortic arch pathology. METHODS: From July 2000 to March 2009, 1196 open arch procedures were performed, including 45 elective and 7 emergency open total arch procedures. From 2005 to 2009, 64 hybrid arch procedures were performed: 37 emergency type A dissections and 27 elective open arch debranchings. Hemiarch procedures were excluded. RESULTS: The hybrid arch cohort was significantly older (P = .008) and had greater predominance of atherosclerotic pathophysiology (P < .001). The incidence of permanent cerebral neurologic deficit was similar at 4% (1/27) for the hybrid arch cohort and 9% (4/45) for the open aortic arch cohort. In-hospital mortality was similar at 11% (3/27) for the hybrid arch cohort and 16% (7/45) for the open aortic arch cohort. However, in the open arch group, there was a significant difference in mortality between patients aged less than 75 years at 9% (3/34) and patients aged more than 75 years at 36% (4/11) (P = .05). CONCLUSIONS: Hybrid arch procedures provide a safe alternative to open repair. This study suggests the hybrid arch approach has a lower mortality for high-risk patients aged more than 75 years. This extends the indication for the hybrid arch approach in patients with complex aortic arch pathology previously considered prohibitively high risk for conventional open total arch repair.

Thoracic endografting is a viable option for the octogenarian.

BACKGROUND: The objective of our study is to determine the feasibility of thoracic aortic endografting in octogenarians. METHODS: Between 2000 and 2006 a total of 504 consecutive patients from two high-volume institutions underwent thoracic endoluminal graft repair for various thoracic aortic pathologies. The following devices were used: Gore TAG (W.L. Gore, Flagstaff, AZ); Talent (Medtronic, Minneapolis, MN); and Zenith (Cook, Inc, Bloomington, IN). One hundred one (101 of 504; 20%) patients were octogenarians; 60 males (1.5:1, M:F) with a mean age of 83.7 years. Indications for intervention included the following: atherosclerotic aneurysms, 75 (75 of 101, 74%); acute and chronic dissections, 11(11 of 101, 11%); penetrating aortic ulcers, 9 (9 of 101, 9%); contained ruptures, 5 (5 of 101, 5%); and 1 transection (1 of 101, 1%). Mean length of follow-up was 3.4 +/- 2.1 years. RESULTS: No intraoperative deaths were noted. Thirty-day mortality was 10% (10 of 101 patients) with an overall late mortality of 26.7% (27 of 101 patients). Mean hospital stay was 6.3 days. A total of 12 neurologic events were noticed: 2 paraplegia (2 of 101, 2%); 4 paraparesis (4 of 101, 4%), 3 with full recovery; and 6 (6 of 101, 6%) cerebrovascular accidents with full recovery in half. A total of 15 endoleaks (15 of 101, 15%) were seen and, in 11, interventions were required. CONCLUSIONS: Our data suggest that technical success is high and age-specific outcomes in this group of patients are favorable. Further studies are warranted.

Retrograde and antegrade cerebral perfusion: results in short elective arch reconstructive times.

BACKGROUND: Debate remains regarding optimal cerebral circulatory management during relatively noncomplex, short arch reconstructive times. Both retrograde cerebral perfusion with deep hypothermic circulatory arrest (RCP/DHCA) and antegrade cerebral perfusion with moderate hypothermic circulatory arrest (ACP/MHCA) have emerged as established techniques. The aim of the study was to evaluate perioperative outcomes between antegrade and retrograde cerebral perfusion techniques for elective arch reconstruction times less than 45 minutes. METHODS: Between 1997 and September 2008, 776 cases from two institutions were reviewed to compare RCP/DHCA and ACP/MHCA perfusion techniques. At the University of Pennsylvania, 682 were treated utilizing RCP/DHCA cerebral protection. At the University of Bologna, 94 were treated with ACP/MHCA and bilateral cerebral perfusion. RESULTS: Mean cerebral ischemic time and visceral ischemic time differed between RCP/DHCA and ACP/MHCA (p < 0.001). Multivariate analysis showed age more than 65 years, atherosclerotic aneurysm, and cross-clamp time as predictors of the composite endpoint of mortality, neurologic event, and acute myocardial infarction. There was no significant difference in permanent neurologic deficit, temporary neurologic dysfunction, or renal failure, between RCP/DHCA and ACP/MHCA. Mortality was comparable across both techniques. CONCLUSIONS: Both RCP/DHCA and ACP/MHCA have emerged as effective techniques for selected aortic arch operations with low morbidity and mortality. Univariate analysis revealed no statistically significant differences in primary or secondary outcomes between techniques for aortic reconstruction times less than 45 minutes. Data from this study demonstrate that selective use of either RCP/DHCA or ACP/MHCA provides excellent cerebral and visceral outcomes for elective open aortic surgery with short arch reconstructive times.

Results of a new surgical paradigm: endovascular repair for acute complicated type B aortic dissection.

BACKGROUND: Conventional open repair of acute complicated type B aortic dissection is associated with significant morbidity and mortality. This study examined the results of thoracic endovascular aortic repair (TEVAR) in acute type B aortic dissection complicated with rupture or malperfusion syndrome. METHODS: From 2004 through 2007, 35 patients (22 men) with acute complicated type B aortic dissection were treated with TEVAR. Indications included rupture in 18 (51.4%) and malperfusion syndrome in 17 (48.6%; mesenteric or renal, 5;lower extremities, 3; both, 9). Three types of endograft devices were used (mean per patient, 1.9 devices). Intravascular ultrasound imaging was used in 15 patients (42.8%). In patients with malperfusion syndrome, distal adjunct procedures to expand the true lumen included infrarenal aortic stents in 4, mesenteric/renal stents in 4, and iliofemoral stents in 7. Follow-up was 93.9% during a period of 18.3 months (range, 3 to 47 months). RESULTS: The mean age was 58.6 +/- 13.4 years. Technical success (coverage of the primary tear site) was achieved in 34 patients (97.1%). Coverage of the left subclavian artery was required in 25 patients (71.4%). Thirty-day mortality was 2.8%. One-year survival was 93.4% +/- 4.6%. Complications included permanent renal failure (2.8%), stroke (2.8%), spinal cord ischemia (transient [5.7%], permanent [(2.8%]), and vascular access (14.2%). The mean intensive care unit and hospital stay were 4.7 +/- 2.6 and 16.7 +/- 12.0 days, respectively. CONCLUSIONS: Endovascular repair of acute complicated type B aortic dissection is associated with low morbidity and mortality and has emerged as the surgical therapy of choice.

Anatomic exclusion from endovascular repair of thoracic aortic aneurysm.

OBJECTIVES: We sought to define the current anatomic barriers to thoracic aortic aneurysm (TAA) stent grafting to guide future device development. METHODS: All patients presenting with TAA requiring repair were evaluated for endovascular repair during a 4-year period (2000 to 2004). The TAAs evaluated were those beginning distal to the left common carotid artery (LCCA) and ending proximal to the celiac artery. All patients in whom endovascular repair was indicated underwent cross-sectional imaging by computed tomography angiography and three-dimensional modeling of their thoracic and abdominal arterial anatomy. Patients were evaluated for endovascular TAA repair in the context of the inclusion/exclusion criteria of pivotal United States Food and Drug Administration trials of the Gore TAG and Medtronic Talent devices. Anatomic requirements included >or=20 mm of suitable proximal and distal neck length, and proximal and distal neck diameters of 20 to 42 mm. These trials allowed the use of femoral or iliac access, including the use of conduits, and permitted stent graft coverage of the left subclavian artery (LSA) after preliminary carotid-subclavian bypass. Patients rejected for medical reasons or who died during evaluation were not included in the review. RESULTS: A total of 126 patients (73 men, 53 women) with TAA located between the LCCA and celiac artery were screened for endovascular repair, and 33 (26%) were rejected for anatomic reasons. The remaining 93 patients underwent endografting (59 Talent, 34 TAG). Rejection was not significantly different by gender (16/73 men, 17/53 women, P = .22, NS). Most patients (28/33) were rejected for more than one criterion. Hostile proximal neck characteristics were the most prevalent reason for disqualification, despite the ability to cover the LSA to extend the proximal seal zone. Many of these patients (16/28) also had distal neck anatomy unsuitable for grafting. Overall, 19 patients had hostile distal necks. Difficulties with vascular access (diseased or tortuous iliac arteries, or a small caliber aorta) that could not be overcome even by use of conduits occurred in a significant fraction of patients (10/33). CONCLUSIONS: Most patients with a TAA located between the LCCA and the celiac artery can be treated by endovascular repair. Patients excluded from TAA stent graft protocols for anatomic reasons most commonly have hostile proximal neck features that preclude endovascular repair with currently available devices. Transposition of arch vessels to facilitate greater use of existing stent grafts or development of new stent graft designs are needed to expand the applicability of TAA endovascular repair.

Endoleaks after endovascular repair of thoracic aortic aneurysms.

OBJECTIVE: Endoleaks are one of the unique complications seen after endovascular repair of thoracic aortic aneurysms (TEVAR). This investigation was performed to evaluate the incidence and determinants of endoleaks, as well as the outcomes of secondary interventions in patients with endoleaks, after TEVAR. METHODS: Over a 6-year period, 105 patients underwent TEVAR in the context of pivotal Food and Drug Administration trials with the Medtronic Talent (n = 64) and Gore TAG (n = 41) devices. The medical and radiology records of these patients were reviewed for this retrospective study. Of these, 69 patients (30 women and 39 men) had follow-up longer than 1 month and were used for this analysis. The patients were evaluated for the presence of an endoleak, endoleak type, aneurysm expansion, and endoleak intervention. RESULTS: The mean follow-up in this patient cohort was 17.3 +/- 14.7 months (range, 3-71 months). Endoleaks were detected in 29% (20/69) of patients, of which 40% (8/20) were type I, 35% (7/20) were type II, 20% (4/20) were type III, and 5% (1/20) had more than one type of endoleak. Patients without endoleaks experienced greater aneurysm sac regression than those with endoleaks (-2.89 +/- 9.1 mm vs -0.13 +/- 7.2 mm), although this difference was not statistically significant (P = .232). All but 2 endoleaks (90%; 18/20) were detected on the initial postoperative computed tomographic scan at 30 days. Two endoleaks (10%; 2/20) developed late. The endoleak group had more extensive aneurysms with significantly larger aneurysms at the time of intervention (69.4 +/- 10.5 mm vs 60.6 +/- 11.0 mm; P = .003). Factors predictive of endoleak included male sex (P = .016), larger aneurysm size (P = .003), the length of aorta treated by stent grafts (P = .0004), and an increasing number of stents used (P < .0001). No open conversions were performed for treatment of endoleaks. Four (50%) of the eight type I endoleaks were successfully repaired by using endovascular techniques. None of the type II endoleaks was treated by secondary intervention. During follow-up, the maximum aneurysm diameter in the type II endoleak patients increased a mean of 2.94 +/- 7.2 mm (range, -4.4 to 17 mm). Spontaneous thrombosis has occurred in 29% (2/7) of the type II endoleaks. Patients with type III endoleaks experienced a decrease in mean maximal aneurysm diameter of 0.78 +/- 3.1 mm during follow-up. CONCLUSIONS: Endoleaks are not uncommon after TEVAR. Many type I endoleaks may be treated successfully by endovascular means. Short-term follow-up suggests that observational management of type II endoleaks is associated with continued sac expansion, and these patients should be monitored closely.