IFABP levels predict visceral malperfusion in the first hours after open thoracoabdominal aortic repair.

Introduction: Intestinal ischemia after open thoracoabdominal aortic repairs, is a rare but devastating complication, associated with high mortality. Notoriously challenging to diagnose, visceral malperfusion necessitates immediate surgical attention. Intestinal fatty acid-binding protein (IFABP) has been proposed as a biomarker for the diagnosis of intestinal wall damage. In this prospectively conducted, observational study we evaluated the diagnostic capacity of IFABP levels in patients' serum and their correlation with visceral malperfusion. Methods: 23 patients undergoing open thoracoabdominal aortic repairs were included in this study and 8 of them were diagnosed postoperatively with visceral malperfusion-defined as a partial or complete thrombotic occlusion of the superior mesenteric artery and/or the coeliac trunk. IFABP levels and laboratory parameters often associated with intestinal ischemia (leucocytes, CRP, PCT and lactate) were measured at baseline, directly postoperatively, and at 12, 24 and 48 h after surgery. Postoperative visceral malperfusion-as revealed in CT angiography-was assessed and the predictive ability of IFABP levels to detect visceral malperfusion was evaluated with receiver-operator curve analysis. Results: Patients with visceral malperfusion had a relevant risk for a fatal outcome (p = .001). IFABP levels were significantly elevated directly postoperatively and at 12 h after surgery in cases of visceral malperfusion. High IFABP concentrations in serum detected visceral malperfusion accurately during the first 12 h after surgery, with the maximum diagnostic ability achieved immediately after surgery (AUC 1, Sensitivity 100%, Specificity 100%, p < .001). Conclusion: We conclude, that IFABP measurements during the first postoperative hours after open thoracoabdominal aortic surgery can be a valuable tool for reliable and timely detection of visceral malperfusion.

Emergency Endovascular Management of Inadvertent False Lumen Stent Graft Implantation After Frozen Elephant Trunk Procedure: A Case Report.

CLINICAL IMPACT: This technology is a good supplement to the clinical practice, providing a new solution to the problem of stent placement in the prosthetic cavity, avoiding the patient to have another surgical operation, which is good for both medicine and patients.

Surgical and endovascular repair for type B aortic dissections with mesenteric malperfusion syndrome: A systematic review of in-hospital mortality.

Objectives: Mesenteric malperfusion is a feared complication of aortic dissection, with high mortality. The purpose of this study was to systematically review in-hospital mortality (IHM) of endovascular and surgical management of acute and chronic Stanford type B aortic dissections (TBAD) complicated by mesenteric malperfusion (MesMP). Methods: A systematic search of English language articles was conducted in relevant databases. Data on patient demographics, procedure details, and survival outcomes were collected. Reports were classified by type of intervention performed. Studies that failed to report patient-level outcomes based on specific intervention performed or IHM were excluded. Retrospective chart review of previously published data from a single institution was also performed to further identify cases of TBAD that were managed endovascularly. The Fisher exact test was performed to determine statistical significance. Results: In total, 37 articles were suitable for inclusion in this systematic review, which yielded 149 patients with a median age 55.0 years (interquartile range, 46.5-65 years) and 79% being male. Overall, in-hospital mortality was 12.8% (19/149) and was similar between endovascular and open surgical interventions (13% vs 11%, P = .99). Among endovascular strategies, IHM was greater, although not statistically significant in the thoracic endovascular aortic repair group compared with the fenestration/stenting without thoracic endovascular aortic repair group (24% vs 11%, P = .15). Conclusions: Multiple strategies exist for the management of TBAD with MesMP; however, a majority of cases were managed endovascularly. Despite advances in therapies, mortality remains high at 13%.

Long-term Results of Thoracic Endovascular Aortic Repair for Type B Aortic Dissection and Risk Factors for Survival.

Purpose: To compare characteristics of acute, subacute, and chronic type B aortic dissection and their influence on long-term results of thoracic endovascular aortic repair (TEVAR). Materials and Methods: In a single-center, retrospective cohort study, 314 patients (median age 52 years; 244 men) with acute (n=165), subacute (n=115), or chronic (n=34) type B aortic dissection underwent TEVAR between January 2009 and December 2013. Patient demographics, risk factors, and imaging characteristics were compared among the groups. Univariable and multivariable Cox regression analyses were performed to identify any factors influencing survival. Results: The acute and subacute patients exhibited more complications at presentation than chronic patients. However, the chronic patients exhibited more aneurysmal dilatation (p<0.001) and true lumen collapse (p<0.001). Over a mean follow-up of 68.1±22.9 months (range 2-108), subacute patients showed a lower reintervention rate (3.6% vs 12.1% vs 12.1%, p=0.045), a lower major complication rate (14.4% vs 33.1% vs 27.3%, p=0.002), and better cumulative overall survival (p=0.03) than the acute and chronic groups, respectively. Furthermore, acute patients developed more stent-graft-induced distal erosion (p=0.017) and retrograde type A dissection (RTAD) (p=0.036), whereas chronic patients had less aortic remodeling in the stented segment (p<0.001), distal thoracic aorta (p<0.001), and abdominal aorta (p=0.047). Finally, multivariable analysis demonstrated age >52 years, visceral malperfusion, and RTAD as independent factors influencing overall survival; aneurysmal dilatation, rupture/impending rupture, and RTAD were independent factors influencing aorta-specific survival. Conclusion: Acute and subacute patients had increased risks of rupture and complications at presentation, whereas chronic patients had increased risks for aneurysmal dilatation. From a long-term perspective, the subacute phase might be an optimal time for TEVAR in cases of type B aortic dissection that do not need emergent interventions. The risk factors influencing survival should be identified, carefully managed, and possibly prevented.

Arc of Buhler: A lifesaving anatomic variation. A case report.

The presence of malperfusion syndrome in cases of complicated acute type B aortic dissection is a negative predictive factor and urgent intervention is indicated. Anatomic variations, such as the Arc of Buhler, contribute anastomotic channels and can preserve the visceral blood supply. In this case report, we describe the overall management of a 54-year-old man who presented with a type B aortic dissection. Initially, conservative management was chosen, as indicated for an uncomplicated type B dissection, but the dissection deteriorated. Despite the fact that severe occlusion of the celiac artery was detected on Computed Tomography (CT) angiography, the Arc of Buhler anatomical variation was present, contributing adequate visceral blood supply. After considering this finding, the patient was treated effectively with thoracic endovascular aortic repair (TEVAR).

A presença da síndrome de má perfusão em casos de dissecção aórtica aguda do tipo B complicada é um fator preditor negativo, e uma intervenção urgente é indicada. As variações anatômicas, tais como o arco de Buhler, contribuem como canais anastomóticos e podem preservar o suprimento sanguíneo visceral. Neste relato de caso, descrevemos o manejo geral de um paciente do sexo masculino, de 54 anos, que apresentou uma dissecção aórtica do tipo B. Inicialmente, o manejo conservador foi escolhido, conforme indicado para dissecção do tipo B não complicada, mas a dissecção sofreu deterioração. Apesar de uma oclusão grave da artéria celíaca ter sido detectada na angiotomografia computadorizada, a variação anatômica do arco de Buhler estava presente, contribuindo para o suprimento sanguíneo visceral adequado. Após levar em consideração esse achado, o paciente foi tratado de forma efetiva com reparação endovascular da aorta torácica.

Arc of Buhler: A lifesaving anatomic variation. A case report / Arco de Buhler: uma variação anatômica que salva vidas - relato de caso

Abstract The presence of malperfusion syndrome in cases of complicated acute type B aortic dissection is a negative predictive factor and urgent intervention is indicated. Anatomic variations, such as the Arc of Buhler, contribute anastomotic channels and can preserve the visceral blood supply. In this case report, we describe the overall management of a 54-year-old man who presented with a type B aortic dissection. Initially, conservative management was chosen, as indicated for an uncomplicated type B dissection, but the dissection deteriorated. Despite the fact that severe occlusion of the celiac artery was detected on Computed Tomography (CT) angiography, the Arc of Buhler anatomical variation was present, contributing adequate visceral blood supply. After considering this finding, the patient was treated effectively with thoracic endovascular aortic repair (TEVAR).

Resumo A presença da síndrome de má perfusão em casos de dissecção aórtica aguda do tipo B complicada é um fator preditor negativo, e uma intervenção urgente é indicada. As variações anatômicas, tais como o arco de Buhler, contribuem como canais anastomóticos e podem preservar o suprimento sanguíneo visceral. Neste relato de caso, descrevemos o manejo geral de um paciente do sexo masculino, de 54 anos, que apresentou uma dissecção aórtica do tipo B. Inicialmente, o manejo conservador foi escolhido, conforme indicado para dissecção do tipo B não complicada, mas a dissecção sofreu deterioração. Apesar de uma oclusão grave da artéria celíaca ter sido detectada na angiotomografia computadorizada, a variação anatômica do arco de Buhler estava presente, contribuindo para o suprimento sanguíneo visceral adequado. Após levar em consideração esse achado, o paciente foi tratado de forma efetiva com reparação endovascular da aorta torácica.

Visceral malperfusion after thoracic endovascular aortic repair for type B aortic dissection in a post-abdominal aortic grafting patient.

A 69-year-old woman with a history of graft replacement for abdominal aortic aneurysm developed a complicated type B aortic dissection that resulted in renal malperfusion after thoracic endovascular aortic repair (TEVAR). The primary entry tear was formed at the aortic arch and the false lumen (FL) continued to the abdominal aorta. The distal end of the FL formed a pouch-like blind alley above the suture line of the bifurcated abdominal graft. The true lumen (TL) was compressed and caused severe limb ischemia. The right renal artery (rRA) originated from the FL. The patient had initially undergone emergent axillofemoral bypass for limb malperfusion. Three weeks later, restenosis of the TL caused visceral malperfusion, and a huge thrombus formed in the FL pouch. TEVAR expanded the TL and restored visceral vascularization. However, the expanded TL compressed the thrombus in the blind alley to the rRA orifice and caused right renal malperfusion. The history of abdominal graft replacement may have increased the risk of a thrombotic event after TEVAR. Primary TEVAR may have helped prevent thrombus formation in the FL pouch. .

Management of visceral malperfusion complicated with acute type A aortic dissection.

OBJECTIVES: The extent of visceral malperfusion due to acute type A aortic dissection remains difficult to assess in view of the clinical signs that typically present at a late stage. We suspected that visceral malperfusion can persist after proximal aortic graft replacement despite redirecting blood flow into the true lumen. We therefore evaluated the operative outcomes of visceral malperfusion complicated with acute type A aortic dissection. METHODS: Among 121 patients with acute type A aortic dissection treated at our hospital between January 2000 and December 2014, 10 (8.2%) were preoperatively complicated with visceral malperfusion. Eight of them had been treated by visceral arterial branch bypass followed by central repair, and 2 with circulatory instability had undergone central repair followed by laparotomy. RESULTS: The 2 patients who underwent initial central repair required extensive intestinal resection due to necrosis and died of multiple organ failure related to visceral necrosis in hospital (hospital mortality rate, 20.0%). The ischaemic time (interval between the onset of dissection and visceral arterial revascularization) was significantly longer for patients who initially underwent central repair compared with those who were initially treated by visceral arterial revascularization. However, base excess and lactate levels did not significantly differ between the two groups. CONCLUSIONS: We believe that if visceral ischaemia is severe and extensive in patients with type A aortic dissection, abdominal surgery should proceed before the aorta is surgically approached to avoid further irreversible ischaemic damage caused by circulatory arrest in organs with compromised perfusion.

Complicated type B aortic dissection causing ischemia in the celiac and inferior mesenteric artery distribution despite patent superior mesenteric artery bypass.

Mortality rates associated with acute type B aortic dissection (ABAD) complicated by malperfusion remains significant. Optimal management of patients with ABAD is still debatable. We present a case report of a 50-year-old man who was admitted due to ABAD. He was treated medically with his pain resolved and he was discharged on oral antihypertensive medications. One month after initial diagnosis, he was readmitted with abdominal pain, nausea, vomiting, and diarrhea. On imaging, an extension of the aortic dissection into the visceral arteries with occlusion of the celiac and superior mesenteric arteries (SMA) was noted. He underwent thoracic endovascular aortic repair (TEVAR) and bypass grafting to the SMA. Despite the intervention, the patient developed large bowel, liver, and gastric ischemia and underwent bowel resection. He died from multi-organ failure. In selected cases of uncomplicated ABAD, TEVAR should be considered and when TEVAR fails and visceral malperfusion develops, an aggressive revascularization of multiple visceral arteries should be attempted.

Delayed visceral and spinal cord malperfusion after axillo-bifemoral bypass for complicated acute type B aortic dissection.

We describe a successfully treated case of acute type B aortic dissection complicated with lower extremity, visceral, and spinal cord malperfusion. To restore perfusion to both lower extremities, we performed an emergency right axillo-bifemoral bypass. Furthermore, we performed total arch replacement, including primary entry closure, because of delayed visceral organ ischemia. Unexpectedly, delayed paraplegia occurred after hospital discharge; however, the patient recovered without any neurologic sequelae after early introduction of hyperbaric oxygen therapy. Because another episode of organ malperfusion in the long term cannot be anticipated, and even though the previous organ malperfusion episode was treated successfully, close observation is mandatory for detecting clinical manifestations in combination with the availability of imaging modalities.

Simultaneous Surgical Treatment of Type B Dissection Complicated With Visceral Malperfusion and Abdominal Aortic Aneurysm: Role of Aortic Fenestration.

Aortic dissection occurs in about 5% of patients with coexistent abdominal aortic aneurysm (AAA); combined type B dissection complicated with visceral malperfusion and AAA is an uncommon aortic emergency and patients presenting with complications of thoracic aortic dissection have a dismal prognosis related to difficulties in treatment strategies. Despite tremendous improvement of endovascular techniques, surgical aortic fenestration represents a quick, safe, and effective procedure able to restore flow in an otherwise malperfused aorta. This procedure has to be kept in mind because subsets of patients cannot be treated conventionally due to either prohibitive risk of aortic replacement, anatomic contraindication, or limitations of percutaneous procedures. Herein we report a case of a patient presenting with type B aortic dissection complicated by visceral malperfusion and AAA which was successfully treated simultaneously by open AAA repair and surgical fenestration. We focus on the mechanism of malperfusion and on the role of surgical fenestration.

Emergency Thoracic Endovascular Aneurysm Repair in Acute Type B Dissection with Visceral Malperfusion.

A 46-year-old female patient was admitted to the emergency room with the sudden onset of abdominal pain, back pain, and paresthesia in the right leg. An emergent chest computed tomography (CT) showed an acute Type B aortic dissection. An emergency thoracic endovascular aneurysm repair (TEVAR) procedure was subsequently performed, for an evolving visceral malperfusion syndrome. We performed the procedure using an axillary approach because the small diameter of the true lumen precluded transfemoral endovascular access. This case illustrates that TEVAR permits the treatment of complicated acute Type B aortic dissection; specifically, technical variations can expand the applicability of endovascular procedures.

Acute gallbladder necrosis in a patient with acute type B aortic dissection.

Although vascular complications induced by acute aortic dissection are varied and common, gallbladder necrosis induced by acute aortic dissection is rare. We experienced the case of a 42-year-old woman who suffered from acute gallbladder necrosis that occurred the following day after the onset of acute type B aortic dissection. Contrasted computed tomography, which showed the thickened wall of the gallbladder and the pericholecystic fluid, as well as the occluded celiac artery, was an effective diagnostic procedure. We performed cholecystectomy and revascularization of the celiac artery using autologous saphenous vein. Her postoperative course was uneventful, and she was discharged after 20 postoperative days.