Endovascular treatment of descending thoracic aortic disease. A single center experience.

AIM: Aim of the study was to assess if endovascular treatment is a feasible alternative in patients with descending thoracic aortic disease. METHODS: Seventy-three patients were admitted for stent-grafting of descending thoracic aortic disease during the period 1997-2008. The majority of the patients had aneurysm (35) or type B dissection (21), but also traumas, penetrating ulcers and other conditions were treated. Sixteen (22%) were unfit for open surgery. Thirty-four (47%) of the patients were symptomatic and 18 had rupture. The primary technical success rate was 96%. RESULTS: Early mortality (<30 days) for the whole group was 3%. Early endoleak (<30 days) was identified in 11 patients (15%) of whom 4 (5%) had a secondary procedure. In addition, two trauma patients required insertion of a new stent-graft due to stent-graft collapse. Two patients had stroke, one had paraplegia and two paraparesis. Mean follow-up was 3.1 years (range 0-12 years). Late endoleak (>30 days) was identified in 5 patients (7%) treated by 6 secondary procedures. One patient (1.7%) had an explant. Two patients have had extensions of endografts due to increasing diameter of the aorta at the distal end of the stent-graft. CONCLUSION: Endovascular treatment seems to be a viable alternative in patients with descending thoracic aortic disease.

Surgery for ruptured abdominal aortic aneurysm and early mortality in women. Risk factors and complication profile.

AIM: Repair of ruptured abdominal aortic aneurysm (rAAA) is reported to have a higher mortality in women than in men. The aim was to study whether this difference could be verified in our institution and secondary if difference in risk- and complication profiles could explain the higher 30 day mortality after surgery for rAAA in women. METHODS: During the period 1983-2009 1649 patients, 1348 men and 301 women, were operated consecutively for infrarenal abdominal aortic aneurysm (AAA); 430 patients had rAAA, 98 women and 332 men. Co-morbidities were identified from the patients' medical records. Outcome measures within 30 days were mortality, cardiac disease (heart attack, heart failure), cerebrovascular disease (stroke, TIA), renal insufficiency (serum creatinine >140 µmol/L), major amputation, bowel infarction, pancreatitis and graft related complications. RESULTS: Compared to men, women had higher 30 d mortality after surgery for rAAA (54.1% vs. 36.3%, P=0.002). Women were significantly older than men (76 years vs. 73 years, P=0.001). In the period 1995-2009 women had more autoimmune diseases than men (P=0.045). There was no significant difference between men and women for the other measured outcomes. CONCLUSION: During the period 1995-2009, autoimmune disease were more common among women than men. For all other parameters recorded, there were no differences in risk - or complication profile that could explain the higher 30 d mortality in female patients after surgery for rAAA.

DynaCT in pre-treatment evaluation of aortic aneurysm before EVAR.

OBJECTIVE: DynaCT(®) is a method for obtaining computed tomography (CT)-like images using a C-arm system. Our aim was to compare the accuracy of these images to multidetector CT (MDCT) images prior to endovascular aortic repair (EVAR). METHODS: A non-consecutive group of 20 elective patients were prospectively exposed to MDCT and one additional DynaCT before EVAR. Six arterial measurements and nine anatomical areas were chosen to: (1) visualise the peri-aortic soft tissue and assess the possibility to diagnose a potential haemorrhage from a ruptured aneurysm and (2) make the pre-treatment measurements before insertion of stent graft. Differences between modalities and readers were statistically compared using a linear mixed model. RESULTS: For maximum aortic diameter, a significant difference of 1.3 mm was found between techniques (p = 0.043). Visibility scores were significantly better for all areas in MDCT data. Pre-treatment evaluation with DynaCT before EVAR was possible for all areas; evaluation of the iliac arteries were suboptimal due to a limited imaging volume size. Significant inter-reader differences were found for all anatomical areas. CONCLUSION: The result indicates that DynaCT gives sufficient information to determine the correct treatment and for selecting the proper stent graft before EVAR. A limited volume size reduces the evaluation of the iliac arteries.

Early results after treatment of open abdomen after aortic surgery with mesh traction and vacuum-assisted wound closure.

OBJECTIVES: This study aimed to describe the use of vacuum-assisted wound closure (VAWC) and mesh traction to repair an open abdomen after aortic surgery. DESIGN: Prospective clinical study. MATERIAL AND METHODS: From October 2006 to April 2009, nine consecutive patients were treated; seven of the patients received laparostomy following abdominal compartment syndrome (ACS), while two wounds were left open initially. The indication for laparostomy was intra-abdominal pressure (IAP) > 20 mmHg or abdominal perfusion pressure (APP) < 60 mmHg and development of organ failure. V.A.C. therapy (KCI, San Antonio, TX, USA) was initiated with the laparostomy, and supplemented with a fascial mesh after 2 days. The wound was then closed stepwise with mesh traction and VAWC. RESULTS: All wounds could be closed following a median interval of 10.5 (range: 6-19) days after laparostomy. A median of four (range: 2-7) dressing changes were performed. One patient died on the seventh postoperative day. Two other patients died 38 and 50 days after final closure, respectively. Left colonic necrosis was seen in two patients while incisional hernia was observed in two patients. Mean follow-up duration was 17 (range: 2-36) months. CONCLUSION: VAWC with mesh traction was successful in terms of early delayed primary closure and is a useful tool in the treatment of open abdomen after aortic surgery.

Endovascular treatment of calcified plaque in the thoracic aorta after recurrent massive embolization.

A 65 year old female patient was admitted with acute onset of severe intermittent claudication in the right lower extremity. Angiography revealed embolic material in the right femoral artery and peripheral arterial thrombosis in the right leg. She was treated with thrombolysis first, thereafter calcified embolic material was removed by open embolectomy. A CT scan showed massive calcification in the thoracic aorta at the level of the occluded left subclavian artery, obviously the origin of embolization. On the second postoperative day she developed critical ischemia in the left lower limb. Angiography showed massive embolization in the left common and external iliac arteries. Following open embolectomy, stentgrafting of the descending thoracic aorta was performed. At one year the patient is in good condition.

DynaCT during EVAR--a comparison with multidetector CT.

OBJECTIVES: We have explored the usefulness of an on-table, cross-sectional radiological imaging (DynaCT) in endovascular aortic repair (EVAR). DynaCT images were compared to images from a regular multidetector (16 slice) CT. In the comparison, we tested the accordance of firstly 5 relevant clinical measurements and secondly the visibility of 9 anatomical areas in the two different types of images. This imaging was carried out in addition to the usual angiographic imaging. DESIGN, MATERIAL AND METHOD: 20 patients with infrarenal abdominal aortic aneurysm (AAA) were prospectively enrolled in the study. We compared Images from DynaCT with two different doses of contrast medium to MDCT-images in two different ways. Firstly relevant arterial diameters and lengths and secondly, 9 anatomical areas were evaluated regarding visibility which was scored on a 4-point scale. RESULTS: There were no significant differences in the measured arterial diameters and lengths. MDCT had a significantly higher visibility score than both DynaCT investigations. However, with the highest contrast medium dose we found acceptable diagnostic quality in 78-94% of the cases for 8 of the 9 investigated anatomical areas. CONCLUSION: Our findings indicate that on-table DynaCT are of sufficient quality to give relevant information of arterial measurements, needed in endovascular repair of infrarenal aortic aneurysms.

The durability of EVAR--what are the evidence and implications on follow-up?

BACKGROUND AND AIMS: To investigate the durability of EVAR and to explore the evidence for follow-up investigations. Furthermore, to study the patients' impressions of followup investigations, and how complications and secondary procedures influence cost-effectiveness. MATERIAL AND METHODS: 263 patients were treated by EVAR from February 1995-February 2007. The series is divided into two groups with the year 2000 as a cut-off point since a new generation of stent grafts was then introduced. Early and late complications and secondary procedures were recorded. A questionnaire study was performed to investigate the patients' views on the follow-up program. RESULTS: There was a significant reduction of complications from period I to period II, which was also reflected in the reduction of secondary procedures. Freedom from secondary procedures were 47% and 93% at 5 years follow-up in the two periods, respectively. In phase II, 7.5% of the patients needed a secondary procedure. Limb extension and femoro-femoral bypass were the most common procedures. Since late complications still occur, and can be unpredictable, a follow-up program is necessary. The vast majority of the patients tolerated the follow-up program well. CONCLUSIONS: Although the number of complications following EVAR has decreased significantly over the years, a thorough follow-up program is still necessary. This followup regime is well tolerated by the patients. Reduction of secondary procedures is important to improve the cost-effectiveness of EVAR.

The prevalence of carotid artery stenosis in an unselected hospitalized stroke population.

AIM: The aim of this study was to describe the number and severity of carotid artery stenosis in an unselected stroke population in hospital. METHODS: The carotid arteries were investigated consecutively with color-coded duplex scanning in patients suspected of having stroke and admitted to a stroke unit during a 6-month period. Percent internal carotid artery stenosis by diameter reduction was described. RESULTS: A total of 144 patients were included in the investigation and the mean age was 75 years. The final diagnosis was stroke in 126 patients, while 18 had transient ischemic attacks. On the side, relevant to the neurologic deficit, a stenosis of >70% diameter reduction was observed in 4 patients and occlusion in 3. Severe stenosis and occlusion was found to have almost the same incidence on the contralateral side. Altogether 46 stenoses >30% (16.3%) were observed in 282 arteries investigated. The distribution was equal between the two sides. CONCLUSION: These findings indicate that few patients are eligible for surgery. However, routine duplex ultrasound examination in stroke patients gives information whether there are carotid arterial lesions, which could be a source of emboli. Such information can also be a guide for further medical treatment and lifestyle modification.

Regional distribution of blood flow during proximal aortic cross-clamping: an experimental study using coloured microspheres.

OBJECTIVE: To investigate the effect of thoracic aortic cross-clamping on blood perfusion of the brain, spinal cord, heart, muscular tissue and visceral organs. MATERIAL AND METHODS: Nine pigs underwent 30 min cross-clamping of the descending thoracic aorta. Multiple coloured microspheres (15.0 microm +/- 0.1) were infused into the left ventricle before and during aortic cross-clamping (XC) and after declamping (DC). Tissue samples were analysed by spectrophotometry. RESULTS: Blood perfusion of the middle and lower segments of the spinal cord was significantly reduced during aortic XC. Perfusion of the brain was not significantly altered by aortic XC, while perfusion of myocardium increased 3-fold. During XC, perfusion of the deltoid muscle and diaphragm increased 5-fold and 13-fold, respectively, while a decrease was found in the gluteus muscle. Renal blood flow was significantly reduced during XC. Finally, XC induced a significant decrease of perfusion in the bowel, spleen, liver and pancreas. CONCLUSION: During XC of the thoracic aorta, the perfusion of the muscular tissue was significantly increased proximal to the level of XC. The circulation of the brain was unchanged, probably because of autoregulatory mechanisms. Blood perfusion of the myocardium increased 3-fold during XC.

The inflammatory response to stent grafting of the thoracic aorta.

AIM: The aim of this study was to evaluate the inflammatory reactions in patients with thoracic aortic aneurysms before, during and after stent graft treatment and to relate markers of leukocyte activation to the use of radiographic contrast media. METHODS: Blood samples were drawn from 7 patients undergoing elective stent graft treatment for thoracic aneurysms. The samples were analyzed for leukocyte and platelet counts and the concentrations of iohexol (radiographic contrast medium), myeloperoxidase, lactoferrin, neutrophil activating peptide-2 (NAP-2), soluble intercellular adhesion molecule-1, soluble vascular cell adhesion molecule-1 (sVCAM-1), the complement activation products C3bc and the terminal complement complex (TCC). The preoperative results were compared with 10 healthy blood donors of similar age. RESULTS: Preoperatively, the aneurysm patients had significantly elevated concentrations of myeloperoxidase, neopterin and complement activation products compared to controls. Myeloperoxidase and lactoferrin increased after the first contrast dose and peaked at 8 h postoperatively. Platelet counts decreased, while NAP-2, sVCAM-1 and TCC increased from 8 h postoperatively. CONCLUSION: We conclude that patients with thoracic aneurysms have a low-grade inflammation prior to intervention. Stent graft treatment induces further activation, and markers of endothelial, platelet, and complement activation were increased for several days after the procedure. Radiographic contrast media could be an important contributor to the activation of neutrophil leukocytes.