Accuracy and Sterilizability of In-House Printed Patient-Specific Aortic Model for Surgeon-Modified Stent Grafts-A Workflow Description for Emergency Aortic Endovascular Procedures.

Introduction: The use of 3D-printed aortic models for the creation of surgeon-modified endoprostheses represents a promising avenue in aortic surgery. By focusing on the potential impact of sterilization on model integrity and geometry, this report sheds light on the suitability of these models for creating customized endoprostheses. The study presented here aimed to investigate the safety and viability of 3D-printed aortic models in the context of sterilization processes and subsequent remodeling. Methods: The study involved the fabrication of 3D-printed aortic models using patient-specific imaging data and established additive manufacturing techniques. Five identical aortic models of the same patient were printed. Two models were subjected to sterilization and two to disinfection using commonly employed methods, and one model remained untreated. The models were checked by in-house quality control for deformation (heat map analyses) after the sterilization and disinfection processes. Three models (sterilized, disinfected, and untreated) were sent for ex-house (Lufthansa Technik, AG, Materials Technologies and Central Laboratory Services, Hamburg, Germany) evaluation and subsequent quantification of possible structural changes using advanced imaging and measurement technologies (macroscopic and SEM/EDX examinations). After sterilization and disinfection, each aortic model underwent sterility checks. Results: Based on macroscopic and SEM/EDX examinations, distinct evidence of material alterations attributed to a treatment process, such as a cleaning procedure, was not identified on the three implants. Comparative material analyses conducted via the EDX technique yield consistent results for all three implants. Disinfected and sterilized models tested negative for common pathogens. Conclusions: The evaluation of 3D-printed aortic models' safety after sterilization as well as their suitability for surgeon-modified endoprostheses is a critical step toward their clinical integration. By comprehensively assessing changes in model integrity and geometry after sterilization, this research has contributed to the broader understanding of the use of 3D-printed models for tailor-made endovascular solutions. As medical technologies continue to evolve, research endeavors such as this one can serve as a foundation for harnessing the full potential of 3D printing to advance patient-centered care in aortic surgery.

Open Surgical Therapy for Peripheral Artery Disease.

PURPOSE OF REVIEW: The surgical management of symptomatic peripheral artery disease (PAD) has changed in the last few decades. Improvement in endovascular technology has resulted in more complex lesion once reserved for open surgery being addressed in an endovascular fashion. Even with these advances, there are lesions and patients that are better managed with an open surgical procedure. The aim of this review is to describe the most commonly performed open surgical procedures for PAD. RECENT FINDINGS: The recently published Best Endovascular versus Best Surgical Therapy (BEST-CLI) trial was an international, prospective, randomized controlled trial that aimed to investigate which revascularization (endovascular vs. surgical bypass) approach was superior for limb salvage. The evidence supports an open surgical bypass as an initial approach. The advancements made in the surgical management of PAD have provided options for patients who were once deemed poor surgical candidates. The goal continues to be utilization of the best available tools to address patient disease. In this current era, it is important to be familiar with the open surgical therapies.

Chronic abdominal aortic occlusion in a patient with an underdeveloped, irradiated pelvis after childhood treatment of Ewing Sarcoma.

Chronic radiation-induced arterial injury is generally predictable by known tumor types and anatomic location. We present the first case of radiation-induced chronic aortic occlusion associated with a small pelvis secondary to the treatment of childhood Ewing sarcoma. The patient presented with profound claudication and accelerated atherosclerosis obliterans of the aortoiliac system and failed endovascular treatment. Successful aortic reconstruction was performed. This case highlights the long-term effects of chemoradiation to the aortoiliac segment and pelvic bones in a child, and the technical challenges of vascular reconstruction in an underdeveloped irradiated pelvis.

Computed tomography -defined sarcopenia is associated with long-term survival among patients undergoing open thoracic aortic reconstruction.

BACKGROUND AND OBJECTIVE: As markers of sarcopenia, psoas muscle areas and indexes measured from computed tomography images have been found to predict long-term mortality in cardiothoracic as well as other surgical cohorts. Our objective was to investigate the association between psoas muscle status, taking into account muscle density in addition to area, and survival among patients undergoing open thoracic aortic reconstruction. METHODS: This was a retrospective registry study of a total of 451 patients treated with open surgery for thoracic aortic pathology. Psoas muscle area and density were measured from preoperative computed tomography images at the L3 and L4 lumbar levels. In addition, lean psoas muscle area was calculated by averaging sex-specific values of psoas muscle area and density. The association between mortality and psoas muscle status was analyzed with adjusted Cox-regression analysis. RESULTS: The median age of the study population was 63 (interquartile range (IQR): 53-70) years. The majority were male (74.7%, n = 337) and underwent elective procedures (58.1% n = 262). Surgery of the ascending aorta was carried out in 90% of the patients, and 15% (n = 67) had concomitant coronary artery bypass surgery. Aortic dissection was present in 34.6% (n = 156) patients. Median follow-up time was 4.3 years (IQR: 2.2-7.4). During the follow-up, 106 patients (23.5%) died, with 55.7% of deaths occurring within the first four postoperative weeks. Psoas muscle parameters were not associated with perioperative mortality, but significant independent associations with long-term mortality were observed for psoas muscle area, density, and lean psoas muscle area with hazard ratios (HRs) of 0.63 (95% confidence interval (CI): 0.45-0.88), 0.62 (95% CI: 0.46-0.83), and 0.47 (95% CI: 0.32-0.69), respectively (all per 1-SD increase). CONCLUSIONS: Psoas muscle sarcopenia status is associated with long-term mortality after open thoracic aortic surgery.

Digestive hemorrhage and fever as a result of a double secondary aortoenteric fistula following the repair of a juxtarenal abdominal aortic aneurysm and an infection of the aortobifemoral bypass graft: a case report.

A double secondary aortoenteric fistula (AEF) occurs in a patient who has had significant aortic surgery and is characterized by a direct connection between the gastrointestinal (GI) tract and the aorta at two separate sites. Importance: During aortoc reconstructive surgery, the patient may present with a variety of unusual complaints, including fever and GI bleeding. These symptoms are indicative of problems, including the development of an aortoentric fistula, particularly when there is a double secondary fistula. Case presentation: The patient was admitted to the hospital due to hematemesis, melena, and high-grade fever after undergoing synthetic grafting aortobifemoral bypass (anatomical reconstruction) and partial resection of the juxtarenal abdominal aortic aneurysm. Pus discharge and a double aortoenteric fistula in unusual sites such as the second-third portion of the duodenum and caecum are visible in upper GI endoscopy and computed tomography angiography. The patient underwent a two-stage open surgery, the first stage involving aortic limb graft exclusion and extra anatomical reconstruction, and the second stage involving graft removal, fistula management, and bowel repair. Then the patient spent a few days in the surgical intensive care unit before being discharged. Clinical discussion: Primary and secondary AEF are the two categories of AEF. In patients who underwent aortic reconstruction surgery, the frequency of secondary AEF ranges from 0.36 to 1.6%. Due to the 8:1 injury ratio in the secondery AEF, men suffer more injuries than women.There are two types of fistula depending on whether or not the suture line is involved. The first form is graft enteric erosion, which excludes the suture line, while the second type is entric graft fistula, where the suture line is included. Most common site fistula is third and fourth part of duodenum and least common site is fistula formation in large bowel. Conclusions: An uncommon complication is double secondary AEF following aortic reconstruction surgery. Since one of the most significant presentations an AEF patient can present with is major GI bleeding and sepsis, A delay in seeking immediate medical treatment could result in the patient's death. It should be emphasized that one of the mechanisms for AEF formation and a frequent cause of sepsis in patients is recurrent aortic graft infection following aortic reconstruction surgery.

Innominate artery patency after direct cannulation in neonates.

Objective: The study objective was to determine the short-term incidence of innominate artery stenosis for neonates who underwent direct innominate artery cannulation during the Norwood procedure. Methods: This is a retrospective, single-institution review of 92 patients who underwent the Norwood procedure with direct innominate artery cannulation from 2006 to 2017. The primary outcome was angiographic evidence of patency at pre-Glenn cardiac catheterization. Patient characteristics, intraoperative surgical and hemodynamic measurements, and postoperative neurologic findings were recorded. Results: At a median age of 5.0 days, 92 neonates underwent the Norwood procedure with direct innominate artery cannulation. These patients underwent cardiac catheterization at a median of 3.0 months after the index operation. In 5 of 92 patients with catheterization images available for review, there was angiographic evidence of mild innominate artery stenosis, and none had moderate or severe stenosis. Review of follow-up records did not reveal evidence of clinically significant stenosis or innominate artery reintervention. Conclusions: In neonates undergoing the Norwood procedure with direct innominate cannulation, innominate artery stenosis was uncommon and clinically significant stenosis did not occur.

Therapeutic effectiveness of tuberculous aneurysm and risk factors for mortality: a systematic review.

OBJECTIVE: This study aimed to determine the therapeutic effectiveness of tuberculous aortic aneurysms (TBAAs) and the risk factors for mortality. METHODS: We reviewed all case reports of TBAAs treated with open surgery or endovascular aneurysm repair (EVAR) from online database in 1996-2021. Only thoracic and abdominal aortic aneurysms were included. RESULTS: Eighty cases of open surgery and 42 cases of EVAR were included. The 2-year mortality and perioperative mortality rates of open surgery were 11.3% and 10.0%, respectively. Emergent open surgery had a significantly higher mortality (25.0%) than non-emergent open surgery (6.7%). In the EVAR group, 2-year mortality, perioperative mortality, and TBAA-related mortality were 16.7%, 4.8%, and 10.0%, respectively. Patients with typical tuberculosis (TB) symptoms before EVAR had a significantly higher TBAA-related mortality (35.0%) than patients with no typical TB symptoms before EVAR (0%). In the open surgery group, the rate of TB recurrence (2.7% vs 2.4%) and aneurysm recurrence (8.1% vs 7.3%) were quite close between preoperative anti-TB-treated and postoperative anti-TB-treated cases. However, in the EVAR group, TB recurrence (8.7% vs 0%) and aneurysm recurrence (12.5% vs 6.25%) were more common in postoperative anti-TB-treated cases. CONCLUSION: Open surgery was accompanied by higher perioperative mortality, whereas EVAR was followed with higher TBAA-related mortality. Emergent surgical choices of open surgery may be associated with high perioperative mortality. Typical TB symptoms before EVAR are a significant risk factor for mortality after EVAR. Early anti-TB treatment should be administered if EVAR is the surgical option.

Six-month preclinical results of novel vascular anastomosis device intended to facilitate open aortic and arch vessel reconstruction.

The surgical repair of type A aortic dissection often involves prosthetic proximal aortic and arch reconstruction. Hypothermic circulatory arrest is typically used in these complex surgeries given the required prolonged ischaemia and the associated morbidity and mortality. A novel vascular anastomoses device (Device) has been developed to rapidly connect a native vessel to a polyester graft. This study describes deployment of the Device in the ovine model (n = 3; 6 carotid arteries). Anastamoses were created rapidly, and brain ischaemia time was limited to 6 min in all but one vessel. All vessels remained fully patent with normal blood flow and thrombus-free transitions through 6 months. Results thus suggest that this Device has the potential to reduce anastomosis time versus conventional suturing techniques and thereby reduce hypothermic circulatory arrest time.

Ten-year experience with cryopreserved vascular allografts in the Croatian Cardiovascular Tissue Bank.

The Croatian Cardiovascular Tissue Bank (CTB) was established in June 2011. Activities managed by CTB are processing of heart valves and blood vessels, as well as quality control, storage, medical release and distribution of allografts. The aim of this report is to present CTB's vascular tissue activities and retrospectively evaluate the outcomes of their use in the University Hospital Centre Zagreb. Between June 2011 and July 2021, 90 vascular allografts (VAs) from 55 donors after brain death were referred to CTB. Only 54% of VAs met the tissue quality requirements while 46% of tissues were discarded. The most frequent reasons for discard were unacceptable morphology and initial microbiological contamination. Altogether 42 VAs were released for transplantation and 37 of them were used in 27 surgical procedures. The most common indication for surgery was prosthetic graft or stent infection. According to the anatomic position of vascular reconstruction, patients were divided in the aortic and peripheral reconstruction group. A total of 23 patients were treated. In the aortic reconstruction group 58% of patients did not experience any graft-related complications. In the group of patients who underwent peripheral reconstruction significant incidence of reinfection was observed highlighting it as a major graft-related complication. Despite the small patient groups and limited duration of follow-up, presented clinical outcomes provide valuable information on the efficacy of vascular allografts. Additional clinical results collected on a larger patient groups and comparison to other reconstructive treatment options are necessary.

Mycobacterium Bovis Causing Mycotic Aneurysm Secondary to Intravesical Treatment with Bacillus Calmette-Guérin: A Case Report.

BACKGROUND: Bacillus Calmette-Guerin (BCG) is a live, attenuated strain of Mycobacterium bovis that is used in the treatment of non-muscle invasive bladder cancer (NMIBC). Vascular complications, including mycotic aneurysms, after BCG therapy are exceedingly rare. In this patient population, the diagnosis of mycotic aneurysms can be delayed or missed due to their non-specific clinical and radiologic presentation. Literature review reveals management of mycotic aneurysms attributable to BCG therapy is widely varied.2,5-8,12,15 CASE REPORT: We report a patient who presented with mycotic aneurysm formation secondary to BCG treatment for bladder cancer that was repaired with in-line reconstruction utilizing cryoartery and buttressed with omental flap. We suggest this as an alternative treatment to in-line prosthetic graft or extra-anatomic reconstruction.

Left renal vein as a graft for aortic reconstruction in a patient with primary aortoenteric fistula secondary to a mycotic aneurysm.

Description of the use of the left renal vein for aortic reconstruction in primary aortoenteric fistula secondary to a mycotic aneurysm has not been found in the literature. We report here a case of primary aortoenteric fistula secondary to a mycotic aneurysm with gross retroperitoneal contamination that was successfully treated by using a left renal vein graft for aortic reconstruction.

Novel prefabricated bovine pericardial grafts as alternate conduit for septic aortoiliac reconstruction.

OBJECTIVE: Infection of prosthetic aortic grafts represents a serious complication with high morbidity and mortality. Replacement with autologous material is recommended; however, in its absence, biological material should be favored. In the present retrospective cohort study, we evaluated the short- and midterm results with the use of commercially available prefabricated bovine pericardium grafts (BPGs) used for the management of aortic graft infection or aortic reconstructive surgery in the presence of systemic infection. METHODS: We performed a retrospective analysis of patients in whom BPGs had been used for aortic reconstruction at two vascular centers. Prefabricated vascular pericardium grafts were preferred over other biological reconstruction techniques for selected cases. Comorbidities, procedure-related details, perioperative morbidity, clinical outcomes, and mortality were analyzed. RESULTS: From 2014 to 2019, 21 patients had received BPGs at two Austrian vascular centers. Their median age was 63 years (interquartile range [IQR], 55-71 years), the patients were predominantly male (76%), and the median body mass index was 25.3 kg/m2 (IQR, 21.7-27.3 kg/m2). The major comorbidities included arterial hypertension, peripheral artery disease, smoking, and chronic pulmonary disease. The indications for surgery were vascular graft or endograft infection in 62% and aortic reconstruction in the presence of systemic infection in 38%. Three patients (14%) had aortoenteric fistulas. Surgery was technically successful in all cases. The median follow-up was 21.6 months (IQR, 6.0-34.6 months). The 30-day mortality was 9.5%. The 1- and 2-year overall survival was 84% and 75%, respectively. Of the 21 patients, 89% had remained free of recurrent infection. One of the two reinfections had resolved after treatment of the underlying focus. At 2 years, the primary and assisted primary patency rates were 86% and 94%, respectively. No limbs were lost during follow-up. CONCLUSIONS: Prefabricated BPGs represent a promising alternative for the management of aortic graft infections and aortoiliac reconstruction in the presence of systemic infection.

Aortic Reconstruction by Cadaveric Graft After Radical Resection of Recurrent Retroperitoneal Leyomiosarcoma - A Case Report and Literature Review.

BACKGROUND/AIM: Retroperitoneal sarcomas represent very aggressive malignancies with high capacity of invading the surrounding vital structures. CASE REPORT: We present the case of a 46-year-old patient who had been initially diagnosed with a large retroperitoneal mass 18 months ago. At that moment the mass was resected en bloc with the inferior cava vein, which was reconstructed using a cadaveric graft, the histopathological studies demonstrating the presence of a leiomyosarcoma. One year later she was diagnosed with recurrent disease invading the abdominal aorta and a liver metastasis. This time the recurrence was resected en bloc with the abdominal aorta, which was reconstructed by placing a cadaveric graft; atypical liver resection was also performed. The postoperative course was uneventful. CONCLUSION: Extended vascular resections and cadaveric graft reconstructions might be needed in order to achieve a good local control of the disease in patients with retroperitoneal sarcomas.

Noncoronary sinus of Valsalva aneurysm resembling a cystic cardiac mass.

A sinus of Valsalva aneurysm is a rare cardiac anomaly, and it is usually clinically silent. However, it may lead to symptoms when it compresses adjacent cardiac structures. Herein, we would like to report a 45-year-old lady with exertional dyspnea who was first diagnosed with having a cystic cardiac mass on transthoracic echocardiogram. Then, transesophageal echocardiogram and cardiac computed tomography revealed an unruptured aneurysm of noncoronary sinus of Valsalva.

En bloc resection of visceral aorta and right kidney due to aortic sarcoma using temporary extracorporeal bypass grafting.

Aortic sarcomas have not been linked to Lynch syndrome in humans, although other soft tissue malignancies have been. We report the case of a 31-year-old man with Lynch syndrome, who presented with abdominal pain and severe claudication. The clinical and diagnostic workup revealed near occlusion of the infrarenal aorta due to aortic angiosarcoma. En bloc resection of the visceral and infrarenal aorta with right nephrectomy was performed, facilitated by temporary extracorporeal bypass to the visceral arteries. The aorta was reconstructed with a bifurcated Dacron graft. At the 24-month follow-up examination, the patient was free of disease but was experiencing chronic diarrhea.

Aortic Reconstruction Using a Main Pulmonary Artery Flap in an Isolated Aortopulmonary Window.

Aortopulmonary window (APW) is a rare cardiac anomaly that was reported to occur in only 43 cases over 33 years at a large-volume cardiac center. It can present as an isolated anomaly or in combination with another cardiac anomaly. The surgical technique for APW has evolved from simple ligation to separation of the 2 great arteries. However, because of the rarity of APW, there is no standard surgical treatment for this disease entity. Herein, we present successful aortic reconstruction using a main pulmonary artery flap after separation of the 2 great arteries in a neonate with isolated APW.

Aortic graft infection with enteric organism after embolization of late type II endoleak.

An 82-year-old man with a history of endovascular repair for ruptured abdominal aortic aneurysm 6 years ago presented with a type II endoleak and enlarging sac. He had successful transabdominal direct sac puncture embolization but developed fever 2 days postoperatively. Contrast-enhanced computed tomography showed a rim-enhancing collection, and sac aspiration was positive for enteric organisms, confirming endograft infection. The patient underwent graft explantation and neoaortic reconstruction using superficial femoral veins. Three months postoperatively, computed tomography showed complete resolution of fluid collection and no signs of graft infection. This report illustrates direct puncture embolization complicated by endograft infection from enteric bacteria.

Factors that impact kidney function during open and endovascular reconstruction of aortic aneurysms.

BACKGROUND: To analyze the factors that influence the deterioration of postoperative renal function in patients undergoing open or endovascular aortic reconstruction, and the impact on survival. METHOD: Retrospective review of patients who underwent invasive treatment was conducted. Demographics, laboratory data, clinical, intraoperative and postoperative variables were recorded; renal function was determined, Fisher's exact test was used to find associations and Kaplan Meier analysis to estimate survival. RESULTS: From 2007 to 2017, 80 patients (mean age: 70 years) were studied. Fifty-eight (73%) were male, none of these patients had known diagnosis of chronic kidney insufficiency. Twelve (15%) patients had elevated creatinine in the postoperative period; variables such as intraoperative bleeding greater than 1500 ml were associated with acute renal failure (p = 0.005). During the follow-up period of 60 months, 8 (10%) patients progressed to chronic renal failure, 2 (2.5%) requiring hemodialysis, 18 (22%). Age, gender, comorbidities and anatomic characteristics of the aneurysm, type of intervention or level of aortic cross-clamping did not impact the postoperative renal function. CONCLUSIONS: The repair of complex aortic aneurysms continues to be a challenge. Intraoperative bleeding greater than 1500 ml and the need of blood transfusion was associated with deterioration of postoperative renal function, affecting the 5-year survival of patients.

OBJETIVO: Analizar qué factores influyen en el deterioro de la función renal en pacientes sometidos a reconstrucción aórtica abierta o endovascular, y su impacto en la supervivencia. MÉTODO: Estudio retrospectivo. Se analizaron variables demográficas, de laboratorio, transoperatorias y posoperatorias. Se determinó la función renal y se utilizó la prueba exacta de Fisher en la búsqueda de asociaciones, y el análisis de Kaplan-Meier para estimar la supervivencia. RESULTADOS: De 2007 a 2017, 80 pacientes (media de edad: 70 años) fueron sometidos a procedimientos de reconstrucción aórtica. Cincuenta y ocho (73%) eran de sexo masculino. Doce (15%) tuvieron elevación de creatinina en el posoperatorio y sangrado mayor de 1500 ml con necesidad de transfusión que se asoció a insuficiencia renal aguda (p = 0.005). Durante el periodo de seguimiento de 60 meses, 8 (10%) pacientes desarrollaron insuficiencia renal crónica, 2 (2.5%) requirieron hemodiálisis y 18 (22%) fallecieron. La edad, el sexo, la comorbilidad y las características anatómicas del aneurisma, así como el tipo de intervención o el nivel de pinzamiento aórtico, no impactaron la función renal posoperatoria. CONCLUSIONES: La reparación de los aneurismas aórticos complejos continúa siendo un reto. Un sangrado superior a 1500 ml, con necesidad de transfusión, se asoció a deterioro de la función renal posoperatoria e impactó en la supervivencia a 5 años.

Urgent Surgical Treatment of Aortic Endocarditis in Infants and Children.

Infective endocarditis (IE) in the pediatric population can present as a life-threatening condition. Optimal timing for surgical intervention should consider surgical risks versus the risk of neurologic complications. We herein report our experience with this group of critically ill children. Retrospective analysis of patient charts of all patients who underwent urgent surgical treatment of aortic IE from 1994 to 2014 was performed. Nine patients with acute storming IE of the aortic valve or the ascending aorta were urgently operated (eight normal heart, one congenital aortic stenosis), age ranged from 8 weeks to 4.2 years. Causative organisms were Staphylococcus aureus (2), Staphylococcus coagulase negative (1), Kingella kingae (2), Streptococcus pneumoniae (2), or culture negative (2). Presenting symptoms other than hemodynamic instability were neurologic decompensation (5) coronary embolization (1) and cardiogenic shock due to scalded skin syndrome (1). CT and MRI demonstrated significant brain infarcts in four patients. Operations performed were the Ross operation (7) and ascending aortic reconstruction (2). There were no operative deaths. At a median follow-up of 6 years (range 2-196 months), all patients are alive and well. Re-intervention included homograft replacement (2) and transcatheter Melody valve implantation (1). At their last follow-up, the neo-aortic valve was functional in all patients with minimal regurgitation and all had full resolution of the neurological deficits. Urgent surgical treatment for aortic valve IE in infants is challenging. Although surgery is complex and pre-disposing conditions such as sepsis, neurologic and cardiac decompensations are prevalent, operative results are excellent and gradual and significant neurologic improvement was noted over time.