Surgeon-Modified Fenestrated Stent-grafts for Zone 2 Endovascular Repair of Blunt Traumatic Thoracic Aortic Injury: Early and Midterm Results.

AIM: Blunt traumatic thoracic aortic injury (BTAI) is a highly fatal surgical emergency and is treated with endovascular procedures. We aimed to analyze and report the early and midterm outcomes of surgeon-modified fenestrated stent-grafts (SMFSG) compared with other conventional endovascular methods in patients with BTAI repaired with zone 2 endovascular surgery. MATERIALS AND METHODS: Before and after the study was performed, from January 2015 to January 2020 for a period in which conventional endovascular treatments were used and from January 2020 to January 2023 for the second period in which the SMFSG technique was used. A total of 25 patients who underwent zone 2 endovascular repair for BTAI were included. The patients treated with conventional endovascular methods in the first period, chimney thoracic endovascular aortic repair (TEVAR) (n=3 patients); Left subclavian artery (LSA)-covered (intentionally total) (n=12 patients) LSA-covered (LSAC) TEVAR; carotid-subclavian bypass TEVAR (n=2 patients) was defined as group 1, and the group of patients treated with SMFSG in the second period was defined as group 2. The primary endpoints of the study were technical success, defined as complete closure of BTAI, and in-hospital mortality. Secondary outcomes were aortic pathology-related morbidity, mortality, and re-interventions during the follow-up period. RESULTS: The mean age was 42.6±14.3 years, and 21 (84%) of the patients were male. The patients were compared with respect to the proximal landing zone, fluoroscopy time, duration of the procedure, length of intensive care unit stay, and hospital stay, no statistically significant difference was found between the 2 groups (p>0.05). The mean follow-up time of patients in group I was 46±9 months, while in group II, it was 14±6 months (p<0.001). While no TEVAR-related complications were detected in group II throughout follow-up, they occurred in 4 patients (28.6%) in group I. CONCLUSION: TEVAR is the most appropriate treatment for BTAI in the modern era, especially for polytrauma patients with successful outcomes. Intentional coverage of the LSA can be performed, but SMFSG is an effective, economical, rapid, and available technique for endovascular revascularization of the LSA. CLINICAL IMPACT: Altough intentional left subclavian artery coverage is preferred routinely in patients with blunt traumatic aortic injury (in Zone 2) which is a highly fatal surgical emergency, surgeon-modified fenestrated stent-grafts is also effective, economical, rapid and available technique.

Combined Endovascular Treatment of Complex Aortic Pathologies.

AIM: Multisegmented aortic pathologies present challenging issues independent of the treatment chosen. Whether open or endovascular, staged, or simultaneous, every treatment modality has its own pros and cons. We revealed our patients retrospectively with early and midterm results who had simultaneous endovascular thoracic and abdominal aortic repair for thoracic aortic pathologies and infrarenal abdominal aortic aneurysm (iAAA) as a single-center experience. MATERIALS AND METHODS: Between January 2016 and January 2021, 16 patients were diagnosed with thoracic aortic pathology and iAAA was simultaneously repaired in an endovascular manner. All patients were operated on with the same cardiovascular surgeon team. RESULTS: The average age of the patients were 76.9 ± 6.2 (64-86) years. There was no early mortality. The technical success was 100%. In total, 18 thoracic endografts were deployed in 16 patients for thoracic aortic pathologies. Follow-up period was 21.85 ± 8.96 months, and in the follow-up period, two patients had a secondary intervention. One cardiac and one coronavirus disease 2019 mortality was detected in the follow-up period. There was no aneurysm-related mortality. The postoperative first-year survival was 84.6 ± 10.0. CONCLUSION: Simultaneous endovascular solution for complex multisegmented aortic pathologies provides a rapid, less-invasive approach with successful early and midterm morbidity, mortality with short intensive care unit period, and length of hospital stay. A combination of endovascular aortic aneurysm repair and thoracic endovascular aortic repair where anatomic suitability exists is a strong alternative over staged and hybrid therapies. Contrast-induced nephropathy, postimplantation syndrome, and spinal cord ischemia should be carefully monitored with this strategy.

Funnel technique for wide infrarenal aneurysm neck with Lifetech Ankura™ Stent Graft System.

BACKGROUND: In this study, we present our mid-term results in patients undergoing treatment with the funnel technique and describe technical issues for this bailout technique in extra-wide infrarenal necks. METHODS: Between January 2018 and June 2020, a total of seven male, symptomatic patients (median: 74.5 years; range, 64 to 84 years) who had comorbidities and were in the American Society for Anesthesiologists Class IV and treated by the funnel technique in an endovascular fashion were included. Pre- and post-procedural data of the patients, early mortality and technical success rates were evaluated. RESULTS: There was no early mortality. Technical success rate was 100%. There was no type I or III endoleaks at the completion angiography. All patients were discharged without any problem on the second or third day of the procedure. The median follow-up was 13 (range, 6 to 28) months. The aneurysm sac shrinkage was achieved in all patients over six months of follow up. During the follow-up period, no proximal endoleak or infrarenal aortic neck diameter enlargement was found. CONCLUSION: Based on our limited experience, the funnel technique may be considered more than a bailout procedure under special circumstances.

What factors counteract mid-term survival following endovascular repair of abdominal aortic aneurysms?

INTRODUCTION: Endovascular aortic aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA) is increasingly used, and has become the standard treatment option for AAA. AIM: To evaluate the outcomes and predictors of survival of endovascular treatment of AAA in the short- and medium-term. MATERIAL AND METHODS: A total of 222 patients having endovascular AAA repair between January 2013 and December 2019 by the same surgical team were included in the study. Patient demographics, perioperative and follow-up data including mortality, complications, and need for secondary intervention were collected. The primary endpoint was all-cause mortality. Kaplan-Meier analysis was conducted for survival and Cox regression models were assessed for predictors of survival. RESULTS: The median age was 70 years, with male predominance (202 patients, 91%). Thirty-day mortality was 1.8%. Median follow-up to the primary endpoint was 20 months (range: 1-80 months). Survival rates at 1, 3, and 5 years were 93.5%, 81.4%, and 62.2%, respectively. Freedom from secondary intervention rates were 95.5% at 1 year, 88.7% at 3 years, and 82.1% at 5 years. Cox proportional hazard models showed that preoperative creatinine levels ≥ 1.8 mg/dl (hazard ratio (HR) = 2.68, 95% CI: 1.21-6.42, p = 0.027), haemoglobin levels < 10 gr/dl (HR = 3.38, 95% CI: 1.16-9.90, p = 0.026), ejection fraction < 30% (HR = 5.67, 95% CI: 1.29-24.86, p = 0.021), and AAA diameter ≥ 6.0 cm (HR = 2.20, 95% CI: 1.01-4.81, p = 0.049) were independently associated with mid-term survival. CONCLUSIONS: EVAR is a safe procedure with low postoperative morbidity and mortality. This study confirms that the mid-term survival and results are favourable. However, the analysed factors in this study that predict reduced survival (high preoperative creatinine, low haemoglobin, low ejection fraction and larger aneurysms) should be judged when planning endovascular repair of AAA.

Elective Endovascular Repair of Abdominal Aortic Aneurysms with Modular and Unibody Type Endografts.

BACKGROUND: In this study, we aimed to evaluate the performance of modular and unibody endografts for the endovascular repair of abdominal aortic aneurysm (AAA). METHODS: Between January 2012 and December 2017, 130 elective infrarenal abdominal aortic aneurysms treated in an endovascular manner were retrospectively evaluated. Sixty-six patients with the modular type (Medtronic EndurantTM II and Lifetech AnkuraTM AAA) and 64 patients with the unibody type (Endologix AFX®) were compared with regards to early and postoperative one-year results. RESULTS: There was one in-hospital mortality (0.8%) in the modular group. There was no difference in postoperative first-year mortality rate between the two groups (p = 0.678). Loco-regional anesthesia was used more often in the unibody group [34 patients (53.1%)] and the use of general anesthesia was higher in the modular group [56 patients (84.8%)] (p < 0.001). While the duration of the procedure was shorter in the unibody group (p < 0.001), no statistically significant difference was found in the duration of fluoroscopy (p = 0.813) and the amount of contrast agent used (p = 0.553). The follow-up period in the intensive care unit was shorter in the modular group (p < 0.001). Moreover, the five-year survival rate was similar between the groups (84.8% in the modular group and 78.4% in the unibody group, log-rank p = 0.703). CONCLUSIONS: The results obtained in our study show that modular and unibody grafts are effective and reliable, although there are some negligible differences in the early period.

Long-term results of endovascular intervention with unibody bifurcation endograft for elective abdominal aortic aneurysm management.

Unibody bifurcated endografts have the advantage of reducing the operative time, avoiding migration and iliac limb dislocation in patient with abdominal aortic aneurysm (AAA). We report our long-term experience in patients who underwent endovascular aortic repair (EVAR) due to infrarenal AAA with Endologix AFX® endograft system. Between January 2013-December 2018, 68 patients with infrarenal AAA had EVAR procedure with Endologix AFX® endograft system. Mean follow-up was 40.4 ± 19.5 months, and all patients had computed tomography periodically, with colored Doppler ultrasonography (CDUS) every six months. Mean age was 68.5 ± 7.1 years and, 63 (92.6%) patients were male. Early mortality, renal complications, stent-graft migration and cardiac complications were not seen in early post-operative period. There was no early mortality in the group and no conversion to open repair. In long-term follow-up 12 patients (17.6%) had endoleak (5 with type II, 7 with type III). Overall survival estimated by Kaplan-Meier analysis was 94.1% at 1 year, 85.2% at 2 years, 74.1% at 3 years and 54.0% at 5 years. Freedom from second intervention and conversion was 98.4% at 1 year, 95.3% at 2 years, 93.3% at 3 years and 87.4% at 5 years. Endologix AFX® endograft provides a fast, safe and effective endograft for the early period, therefore it seems more suitable for elderly and comorbid patients. This endograft has low reintervention rates however according to our results, aneurysms larger than 6 cm may have more sideway displacement possibility and by this way type III endoleak. Proper patient selection and sufficient overlap are the key issues. Close monitoring is mandatory at the follow-up period.

Outcomes after EVAR in females are similar to males.

INTRODUCTION: Women are less likely to develop infrarenal abdominal aortic aneurysm; however, when they do, it is almost always associated with challenging anatomy, more rapid aneurysmal growth rate and earlier rupture. Women generally have poorer outcomes following open aneurysm repair; and in this respect, the present study aims to evaluate if it is so after endovascular repair. METHODS: A retrospective analysis of our database was performed for patients underwent endovascular aneurysm repair (EVAR) between January 2013-March 2020. 249 elective EVAR patients were evaluated. Patients were categorized according to gender and 26 patients (10.4%) were female. Demographics and pre-peri-postoperative findings were compared. Propensity score matching (ratio 1:1) was performed to reduce selection bias. RESULTS: In the overall unmatched cohort, female population had more diabetes mellitus (p = 0.016) and hypertension (p = 0.005). However, coronary artery disease (p = 0.005) and coronary artery bypass grafting (p = 0.006) were more in male gender. Non-IFU implantation was higher in female group (38.5% vs. 11.5%, p = 0.025). After propensity matching, even though it was not statistically significant, early mortality for female gender was higher when compared to male gender (7.7% and 0%, respectively, p = 0.490). In the follow-up period, no difference in all-cause mortality, secondary interventions or complications have been observed between the genders. CONCLUSION: Challenging anatomy and subsequently treated patients outside IFU may be the reasons for higher morbidity and mortality in women. However, despite these factors female and male patients revealed equivalent early and late results.

Building a patient blood management program in a large-volume tertiary hospital setting: Problems and solutions.

Successful implementation of a patient blood management program necessitates the collaboration of a strong organization and a multidisciplinary approach. We organized a meeting with broad participation in our center to establish a consensus for implementation of a specific patient blood management program. International and domestic experiences were shared, the importance of coordination and execution of different pillars in patient blood management were discussed, and the problems about the blood transfusion system were also investigated with the proposal for solutions. The data obtained from this meeting are presented to be a guide for similar large-volume tertiary hospitals for integration of a patient blood management protocol.

Perioperative planning for cardiovascular operations in the COVID-19 pandemic.

Coronavirus disease-2019 (COVID-19) is a serious health concern which alert all healthcare professionals worldwide. There are two main issues caused by this pandemic regarding for the healthcare system. First, it is a necessity to postpone many elective procedures/surgeries to reduce the burden of the healthcare system which may be confronted with strain by the increased speed of transmission. Therefore, we aimed to develop an algorithm called as Level of Priority to identify the priority and deferrability of cardiovascular diseases requiring surgery. Second, it is essential to perform surgery and intensive care unit follow-up in a setting where the infection prevention measures are followed for primary patients requiring emergency cardiovascular surgery. In this article, we present necessary precautions to be exercised to provide the patient safety and the highest level of protection for the surgical team.

The comparison of the effects of Bretschneider's histidine-tryptophan-ketoglutarate and conventional crystalloid cardioplegia on pediatric myocardium at tissue level.

Cardioplegic arrest is one of the most common myocardial protection strategies. A wide variety of cardioplegic solutions are routinely being used. There is an ongoing discussion about the relative effectiveness of these solutions considering myocardial protection. This study aims to investigate the hypothesis that the use of histidine-tryptophan-ketoglutarate (HTK) cardioplegia leads to decreased ischemic damage on myocardium compared with the use of conventional crystalloid cardioplegia. The study population was 32 patients operated on at Baskent University, Department of Cardiovascular Surgery for congenital heart diseases. The first group of 16 patients received conventional crystalloid cardioplegia (KK group) which is a modification of St. Thomas' solution, while the second group of 16 patients received HTK solution (HTK group). The echocardiographic measurements and the laboratory values of the patients were taken as the clinical variables. Right ventricular biopsies were taken from every patient before and after cardioplegic arrest. These biopsies were histopathologically examined for apoptosis using caspase-3 antigen and cell proliferation using Ki-67 antigen. The statistical analysis revealed no significant difference between the two groups regarding the clinical variables, apoptotic indices and proliferation indices. The apoptotic indices in the postcardioplegic arrest biopsies positively correlated with aortic clamp time in the KK group but not in the HTK group. Liver function tests on postoperative day 1 positively correlated with aortic clamp time in both groups. On postoperative day 2, this correlation was sustained in the KK group and ceased in HTK group. The difference in the correlation of apoptotic indices and liver function tests between the groups is accepted as a supportive finding for HTK solution. However, it can be postulated that when the aortic clamp times are similar to those in the present study, the clinical manifestation of the difference between the two solutions would not be significant.

Pulsatile flow improves renal function in high-risk cardiac operations.

The effects of pulsatile perfusion on microcirculation and renal function in high-risk patients were evaluated in this study. Pulsatile roller pumps with a pulsatile control module and membrane oxygenator were used in a clinical setting. 40 patients undergoing elective cardiac surgery with a high risk of either having chronically obstructive pulmonary disease or chronic renal failure were randomly included in the study to be perfused using pulsatile or continuous flows. Blood samples were collected at induction of anesthesia, at the time of aortic clamping and declamping and 1 and 24 h following cessation of the bypass. Urea and creatinine concentrations in blood were measured and systemic vascular resistance was calculated. Urine output, crystalloid and colloid infusions were recorded. We observed that pulsatile roller pump perfusion and the extracorporeal circuit used in the clinical study improved microcirculation and renal function in high-risk patients undergoing cardiopulmonary bypass.

Do S100beta protein level increases due to inflammation during cardiopulmonary bypass occur without any neurological deficit?

PURPOSE: S100beta protein level correlates with the duration of cardiopulmonary bypass (CPB) and aortic crossclamp times, but is different during pulsatile and nonpulsatile CPB. In this study, we investigated the time course of the release of S100beta protein during and after pulsatile and nonpulsatile CPB. PATIENTS AND METHODS: This is a prospective study. Twenty patients had open-heart surgery with pulsatile flow and 20 with nonpulsatile flow. We compared complement proteins, interleukins, white blood cells and S100beta protein before the initiation of CPB, immediately prior to aortic crossclamping, following unclamping, and at postoperative 1st and 24th hours. RESULTS: In the pulsatile CPB group following aortic unclamping, S100beta protein (p = 0.028) and C3a (p = 0.011) levels were significantly lower than those of the nonpulsatile group. In the pulsatile CPB group at postoperative first hour, C3a level (p = 0.018) and absolute neutrophil count (p = 0.034) were significantly lower than those of the nonpulsatile group. None of the patients developed a neurological deficit and all of the patients survived after the operation and were discharged from the hospital. CONCLUSION: During CPB, serum S100beta protein level increases and this increase is higher in the nonpulsatile group. High serum level of S100beta protein is associated with increased levels of serum inflammatory mediators and systemic inflammatory response.