Mortality rates associated with acute type B aortic dissection (ABAD) complicated by malperfusion... more 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 ...
Endovascular repair of peripheral arterial trauma using covered stent grafts is a minimally invas... more Endovascular repair of peripheral arterial trauma using covered stent grafts is a minimally invasive alternative to open surgery in selected patients. Although the technical feasibility of endovascular repair has been established, there are a paucity of data regarding outcomes. The purpose of this study was to evaluate the short-term outcomes of endovascular repair in patients with peripheral arterial trauma. A review of a prospectively collected institutional trauma registry captured all patients with peripheral arterial injury who underwent endovascular repair from August 2004 to June 2012. Data collected included demographics, Injury Severity Score (ISS), mechanism, location and type of injury, imaging modality, intervention type, complications and reintervention, length of stay, and follow-up. Descriptive statistics were used for analysis. During the study period, we performed endovascular repair in 28 patients with peripheral arterial injuries. There were 20 male patients (71%)...
Circulation. Cardiovascular genetics, Jan 10, 2015
-ACTA2 mutations are the major cause of familial thoracic aortic aneurysms and dissections. We so... more -ACTA2 mutations are the major cause of familial thoracic aortic aneurysms and dissections. We sought to characterize these aortic diseases in a large case series of individuals with ACTA2 mutations. -Aortic disease, management, and outcome associated with the first aortic event (aortic dissection or aneurysm repair) were abstracted from the medical records of 277 individuals with 41 various ACTA2 mutations. Aortic events occurred in 48% of these individuals, with the vast majority presenting with thoracic aortic dissections (88%) associated with 25% mortality. Type A dissections were more common than type B dissections (54% versus 21%), but the median age of onset of type B dissections was significantly younger than type A dissections (27 years, IQR 18-41 versus 36 years, IQR 26-45). Only 12% of aortic events were repair of ascending aortic aneurysms, which variably involved the aortic root, ascending aorta and aortic arch. Overall cumulative risk of an aortic event at age 85 years was 0.76 (95% CI 0.64, 0.86). After adjustment for intra-familial correlation, gender and race, mutations disrupting p.R179 and p.R258 were associated with significantly increased risk for aortic events, whereas p.R185Q and p.R118Q mutations showed significantly lower risk of aortic events compared to other mutations. -ACTA2 mutations are associated with high risk of presentation with an acute aortic dissection. The lifetime risk for an aortic event is only 76%, suggesting that additional environmental or genetic factors play a role in expression of aortic disease in individuals with ACTA2 mutations.
We present the case of a type IV Ehlers-Danlos syndrome patient with a ruptured right subclavian ... more We present the case of a type IV Ehlers-Danlos syndrome patient with a ruptured right subclavian artery aneurysm and associated arteriovenous fistula who underwent successful endovascular repair requiring simultaneous stent graft repair of the innominate artery using a sandwich technique. A 17-year-old man with known type IV Ehlers-Danlos syndrome developed right neck and shoulder swelling. CTA study demonstrated a 17 × 13-cm ruptured subclavian artery aneurysm with an associated internal jugular vein arteriovenous fistula. In the hybrid suite, a 7 mm × 15-cm stent graft (Viabahn, WL Gore & Associates, Flagstaff, AZ) was advanced from the right brachial approach into the innominate artery. A separate wire was placed into the right carotid artery via the right femoral approach (7 Fr), and a 7 mm × 10-cm stent graft (Viabahn) was advanced into the innominate artery. An additional 8 mm × 10-cm stent graft (Viabahn) was placed from the right brachial approach to obtain a distal-landing ...
The Journal of thoracic and cardiovascular surgery, 2015
Controversy remains regarding management of acute type A dissection with intramural hematoma (IMH... more Controversy remains regarding management of acute type A dissection with intramural hematoma (IMH). Our purpose was to analyze our experience and report outcomes after repair of acute type A aortic dissection with IMH. We analyzed all patients from a single center who underwent open repair for acute type A aortic dissection with IMH. Between 2000 and 2013, we performed 418 repairs for acute type A aortic dissection. These were divided into 2 groups of patients: 64 patients (15%) with type A IMH and 354 patients (85%) with typical dissection. Those with IMH were older (62.4 ± 13.9 years vs 56.7 ± 14.7 years; P < .0046) and presented with reduced renal function (ie, glomerular filtration rate) (P < .0341), less frequently with distal malperfusion, and less frequently with rupture (P < .0116). With IMH, the time from presentation to repair was, by strategy, longer (median, 67 vs 6 hours; P < .0001), but no mortality occurred within 3 days of presentation. Mortality with IMH...
Arteriovenous fistulae (AVF) are the preferred vascular access for hemodialysis patients. However... more Arteriovenous fistulae (AVF) are the preferred vascular access for hemodialysis patients. However, patients who do not have suitable veins require prosthetic arteriovenous graft (AVG) placement. We analyzed the patency and complication rates of upper extremity brachiocephalic AVF compared to brachioaxillary tapered heparin-bonded AVG and conventional AVG. We performed a retrospective analysis of patients who underwent a permanent vascular access procedure at our tertiary referral center from 2006 to 2008. Factors presumed to affect patency and complication rates including age, body-mass index, dyslipidemia, hypertension, and diabetes were analyzed. Complication rates, re-interventions, primary, primary-assisted, and cumulative patency rates were compared using logistic regression analysis. We performed 138 upper extremity access procedures during the study period, including 64 brachiocephalic fistulae, 21 brachioaxillary heparin-bonded, and 21 brachioaxillary conventional AVGs. Nine...
Despite advances in perioperative care, long-term and amputation-free survival rates are poor aft... more Despite advances in perioperative care, long-term and amputation-free survival rates are poor after resection of infected abdominal aortic grafts. We reviewed our cases to determine the rate of reinfection and risk factors for mortality and limb loss. We reviewed cases with infrarenal aortic graft infection from 1999 to 2013. Cases requiring graft excision were included for analysis. Thoracic and thoracoabdominal aortic grafts were excluded. Reconstruction types included both extra-anatomic and in situ grafts. Patient comorbidities, surgical outcomes, and known reinfection rates were assessed. Univariate and Kaplan-Meier analysis were performed. Twenty-eight patients had resection of infected infrarenal abdominal aortic grafts during the study period. Most patients (26/28; 93%) had infected aortoiliac or aortofemoral prosthetic bypass grafts, but two of 28 patients had infected endovascular aortoiliac stent grafts. The median age was 69 years (range, 46-86 years), with 68% men and 3...
Thoracic endovascular aortic repair (TEVAR) is widely used for treatment of traumatic aortic inju... more Thoracic endovascular aortic repair (TEVAR) is widely used for treatment of traumatic aortic injury (TAI). Stent graft coverage of the left subclavian artery (LSA) may be required in up to 40% of patients. We evaluated the long-term effects of intentional LSA coverage (LSAC) on symptoms and return to normal activity in TAI patients compared with a similarly treated group whose LSA was uncovered (LSAU). Patients were identified from a prospective institutional trauma registry between September 2005 and July 2012. TAI was confirmed using computed tomography angiography. The electronic medical records, angiograms, and computed tomography angiograms were reviewed in a retrospective fashion. In-person or telephone interviews were conducted using the SF-12v2 (Quality Metrics, Lincoln, RI) to assess quality of life. An additional questionnaire was used to assess specific LSA symptoms and the ability to return to normal activities. Data were analyzed by Spearman rank correlation and multipl...
Blood conservation using autologous platelet-rich plasma (aPRP), a technique of whole blood harve... more Blood conservation using autologous platelet-rich plasma (aPRP), a technique of whole blood harvest that separates red blood cells from plasma and platelets before cardiopulmonary bypass with retransfusion of the preserved platelets after completion of cardiopulmonary bypass, has not been studied extensively. We sought to prospectively determine whether aPRP reduces blood transfusions during ascending and transverse aortic arch repair. We randomly assigned 80 patients undergoing elective ascending and transverse aortic arch repair using deep hypothermic circulatory arrest to receive either aPRP (n = 38) or no aPRP (n = 42). Volume of aPRP retransfused was 726 ± 124 mL. The primary end point was transfusion amount. Secondary end points were death, stroke, renal failure, pulmonary failure, and transfusion costs. Perioperative transfusion rate was defined as blood transfusions given during surgery and up to 72 hours afterward. The surgeon and intensivist were blinded to the treatment a...
Traumatic aortic injury (TAI) remains a leading cause of death after blunt force. Thoracic endova... more Traumatic aortic injury (TAI) remains a leading cause of death after blunt force. Thoracic endovascular aortic repair (TEVAR) has been widely adopted as an alternative to open repair for the treatment of TAI. Although significant short-term benefits have been demonstrated for patients undergoing TEVAR, longer-term follow-up data are lacking. Trauma registry data were analyzed. Follow-up data were gathered from a combination of medical records, imaging, telephone interviews, and Social Security Death Index. Primary outcomes were in-hospital mortality, stroke, and paraplegia. Secondary outcomes included device-related adverse events (rupture, migration, or endoleak), secondary procedures, open conversion, and all-cause mortality. Between September 2005 and July 2012, 82 consecutive patients (57 males, mean [SD] age, 39.5 [20] years; mean [SD] Injury Severity Score [ISS], 34 [9.5]) underwent TEVAR for TAI. A total of 87 devices were implanted: TAG (n = 36), CTAG (n = 12) (WL Gore, Flag...
The purpose of this study was to investigate the cause of ascending aorta and aortic arch reopera... more The purpose of this study was to investigate the cause of ascending aorta and aortic arch reoperations and to identify determinants of early and late outcome. Between January 1991 and March 2003 we repaired aneurysms of the proximal aorta in 597 patients. Of these patients, 104 had reoperations for replacement of the ascending aorta, aortic root, or transverse aortic arch. Previous surgery was defined as any previous cardiac or proximal aortic repair. Median age was 60 years, and 29 of the patients (28%) were female. Indications for reoperation and replacement of the proximal aorta included acute type A dissection in 6 patients (5.8%), aneurysm with chronic dissection in 60 (57.7%), progression of aneurysm in 23 (22.1%), infection in 12 (1.5%), inflammatory disease in 2 (1.9%), and atheromatous disease in 1 (1.0%). Reoperations included aortic root replacement in 20 patients (19.2%), total arch replacement with elephant trunk in 28 (26.7%), ascending and proximal arch in 39 (37.5%),...
We report on our experience with treatment of adults requiring de novo or redo open aortic coarct... more We report on our experience with treatment of adults requiring de novo or redo open aortic coarctation repair mostly by a resection and interposition graft technique. We retrospectively reviewed all patients older than 16 years requiring open repair of aortic coarctation. Indications for repair, operative details, and outcomes were analyzed. Between 1996 and 2011, we treated 29 adult aortic coarctation patients with open repair. The mean age was 42 years (range, 17-69 years), and there were 15 men. Nine patients had previous repair with recurrence; the remaining 20 had native coarctation. Thoracic aortic aneurysms were present in 22 patients (76%), ranging in size from 3.0 to 9.6 cm (mean, 4.8 cm). Four patients had intercostal artery aneurysms (range, 1.0-2.5 cm), four had left subclavian artery aneurysms, and four had ascending/arch aneurysms. The most common repair was resection of aortic coarctation with interposition graft replacement (93%). Two patients without aneurysm had bypasses from the proximal descending thoracic aorta to the infrarenal aorta without aortic resection. There was no in-hospital mortality, stroke, or paraplegia. Long-term survival was 89% during a median follow-up of 81 months (interquartile range, 47-118 months), with no patient requiring reoperation on the repaired segment. Open repair of native and recurrent adult aortic coarctation has acceptable morbidity and low mortality. Especially in patients with concomitant aneurysm, resection with interposition graft replacement provides a safe and durable repair option.
Introduction.—Aortic dissection can extend into the brachiocephalic arteries. We analyzed carotid... more Introduction.—Aortic dissection can extend into the brachiocephalic arteries. We analyzed carotid duplex ultrasound (CDU) in DeBakey I acute aortic dissection to identify characteristics and establish a protocol to ensure appropriate evaluation.Method.—From 2002 to 2011, patients with CDU and proximal aortic dissection were identified. The protocol included color Doppler in both long and short axis, spectral waveforms of true and false lumens, and imaging of the aortic arch, when appropriate. Imaging was performed on a Philips iE33 or iu22 using a 9-3 MHz linear array probe for the cervical carotid arteries and a curved array 5-1 MHz probe for the aortic arch. Waveforms were analyzed for signs of proximal dissection.Results.—CDU was performed in 87 of 288 patients and comprised the study group. Intimal flaps were noted in 26 common carotid arteries (CCAs) in 20 patients. The false lumen was thrombosed in nine arteries (35%). Eight CCAs had stenosis >50%, with seven having increas...
Aortoesophageal fistula, secondary to thoracic aortic aneurysm, is an uncommon cause of gastroint... more Aortoesophageal fistula, secondary to thoracic aortic aneurysm, is an uncommon cause of gastrointestinal bleeding that is uniformly fatal without surgical intervention. These may be primary fistulas, in cases of thoracic aortic aneurysm without previous repair, or secondary fistulas occurring after surgical repair of thoracic aortic aneurysm. Surgical treatment has been successful in a small number of cases of primary aortoesophageal
The Journal of Thoracic and Cardiovascular Surgery, 2015
Controversy remains regarding management of acute type A dissection with intramural hematoma (IMH... more Controversy remains regarding management of acute type A dissection with intramural hematoma (IMH). Our purpose was to analyze our experience and report outcomes after repair of acute type A aortic dissection with IMH. We analyzed all patients from a single center who underwent open repair for acute type A aortic dissection with IMH. Between 2000 and 2013, we performed 418 repairs for acute type A aortic dissection. These were divided into 2 groups of patients: 64 patients (15%) with type A IMH and 354 patients (85%) with typical dissection. Those with IMH were older (62.4 ± 13.9 years vs 56.7 ± 14.7 years; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .0046) and presented with reduced renal function (ie, glomerular filtration rate) (P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .0341), less frequently with distal malperfusion, and less frequently with rupture (P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .0116). With IMH, the time from presentation to repair was, by strategy, longer (median, 67 vs 6 hours; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .0001), but no mortality occurred within 3 days of presentation. Mortality with IMH did not differ from typical dissection: 7 out of 64 patients (10.9%) versus 52 out of 354 patients (14.7%; P = .4276). A lower incidence of postoperative dialysis in the IMH group approached significance: 6 out of 63 patients (9.5%) versus 64 out of 347 patients (18.4%; P = .0820). When adjusted for age and renal function, late survival was improved with IMH (P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .0343). Repair of acute type A aortic dissection with IMH is associated with significant early morbidity and mortality, differing minimally from typical aortic dissection. Although expectant repair within 3 days may be applied, the purposeful delay imparted little advantage. Improved late outcomes may be seen with IMH, but…
patients. No spinal hematomas were observed. The CSF leaks with spinal headache, CSF leak without... more patients. No spinal hematomas were observed. The CSF leaks with spinal headache, CSF leak without spinal head- ache, spinal headache, intracranial hemorrhage, catheter fracture, and meningitis occurred in 6 (0.54%), 1 (0.1%), 2 (0.2%), 5 (0.45%), 1 (0.1%), and 2 (0.2%) cases, respectively. Mortality from subdural hematoma was 40% (2 of 5), and from meningitis was 50% (1 of 2).
Mortality rates associated with acute type B aortic dissection (ABAD) complicated by malperfusion... more 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 ...
Endovascular repair of peripheral arterial trauma using covered stent grafts is a minimally invas... more Endovascular repair of peripheral arterial trauma using covered stent grafts is a minimally invasive alternative to open surgery in selected patients. Although the technical feasibility of endovascular repair has been established, there are a paucity of data regarding outcomes. The purpose of this study was to evaluate the short-term outcomes of endovascular repair in patients with peripheral arterial trauma. A review of a prospectively collected institutional trauma registry captured all patients with peripheral arterial injury who underwent endovascular repair from August 2004 to June 2012. Data collected included demographics, Injury Severity Score (ISS), mechanism, location and type of injury, imaging modality, intervention type, complications and reintervention, length of stay, and follow-up. Descriptive statistics were used for analysis. During the study period, we performed endovascular repair in 28 patients with peripheral arterial injuries. There were 20 male patients (71%)...
Circulation. Cardiovascular genetics, Jan 10, 2015
-ACTA2 mutations are the major cause of familial thoracic aortic aneurysms and dissections. We so... more -ACTA2 mutations are the major cause of familial thoracic aortic aneurysms and dissections. We sought to characterize these aortic diseases in a large case series of individuals with ACTA2 mutations. -Aortic disease, management, and outcome associated with the first aortic event (aortic dissection or aneurysm repair) were abstracted from the medical records of 277 individuals with 41 various ACTA2 mutations. Aortic events occurred in 48% of these individuals, with the vast majority presenting with thoracic aortic dissections (88%) associated with 25% mortality. Type A dissections were more common than type B dissections (54% versus 21%), but the median age of onset of type B dissections was significantly younger than type A dissections (27 years, IQR 18-41 versus 36 years, IQR 26-45). Only 12% of aortic events were repair of ascending aortic aneurysms, which variably involved the aortic root, ascending aorta and aortic arch. Overall cumulative risk of an aortic event at age 85 years was 0.76 (95% CI 0.64, 0.86). After adjustment for intra-familial correlation, gender and race, mutations disrupting p.R179 and p.R258 were associated with significantly increased risk for aortic events, whereas p.R185Q and p.R118Q mutations showed significantly lower risk of aortic events compared to other mutations. -ACTA2 mutations are associated with high risk of presentation with an acute aortic dissection. The lifetime risk for an aortic event is only 76%, suggesting that additional environmental or genetic factors play a role in expression of aortic disease in individuals with ACTA2 mutations.
We present the case of a type IV Ehlers-Danlos syndrome patient with a ruptured right subclavian ... more We present the case of a type IV Ehlers-Danlos syndrome patient with a ruptured right subclavian artery aneurysm and associated arteriovenous fistula who underwent successful endovascular repair requiring simultaneous stent graft repair of the innominate artery using a sandwich technique. A 17-year-old man with known type IV Ehlers-Danlos syndrome developed right neck and shoulder swelling. CTA study demonstrated a 17 × 13-cm ruptured subclavian artery aneurysm with an associated internal jugular vein arteriovenous fistula. In the hybrid suite, a 7 mm × 15-cm stent graft (Viabahn, WL Gore & Associates, Flagstaff, AZ) was advanced from the right brachial approach into the innominate artery. A separate wire was placed into the right carotid artery via the right femoral approach (7 Fr), and a 7 mm × 10-cm stent graft (Viabahn) was advanced into the innominate artery. An additional 8 mm × 10-cm stent graft (Viabahn) was placed from the right brachial approach to obtain a distal-landing ...
The Journal of thoracic and cardiovascular surgery, 2015
Controversy remains regarding management of acute type A dissection with intramural hematoma (IMH... more Controversy remains regarding management of acute type A dissection with intramural hematoma (IMH). Our purpose was to analyze our experience and report outcomes after repair of acute type A aortic dissection with IMH. We analyzed all patients from a single center who underwent open repair for acute type A aortic dissection with IMH. Between 2000 and 2013, we performed 418 repairs for acute type A aortic dissection. These were divided into 2 groups of patients: 64 patients (15%) with type A IMH and 354 patients (85%) with typical dissection. Those with IMH were older (62.4 ± 13.9 years vs 56.7 ± 14.7 years; P < .0046) and presented with reduced renal function (ie, glomerular filtration rate) (P < .0341), less frequently with distal malperfusion, and less frequently with rupture (P < .0116). With IMH, the time from presentation to repair was, by strategy, longer (median, 67 vs 6 hours; P < .0001), but no mortality occurred within 3 days of presentation. Mortality with IMH...
Arteriovenous fistulae (AVF) are the preferred vascular access for hemodialysis patients. However... more Arteriovenous fistulae (AVF) are the preferred vascular access for hemodialysis patients. However, patients who do not have suitable veins require prosthetic arteriovenous graft (AVG) placement. We analyzed the patency and complication rates of upper extremity brachiocephalic AVF compared to brachioaxillary tapered heparin-bonded AVG and conventional AVG. We performed a retrospective analysis of patients who underwent a permanent vascular access procedure at our tertiary referral center from 2006 to 2008. Factors presumed to affect patency and complication rates including age, body-mass index, dyslipidemia, hypertension, and diabetes were analyzed. Complication rates, re-interventions, primary, primary-assisted, and cumulative patency rates were compared using logistic regression analysis. We performed 138 upper extremity access procedures during the study period, including 64 brachiocephalic fistulae, 21 brachioaxillary heparin-bonded, and 21 brachioaxillary conventional AVGs. Nine...
Despite advances in perioperative care, long-term and amputation-free survival rates are poor aft... more Despite advances in perioperative care, long-term and amputation-free survival rates are poor after resection of infected abdominal aortic grafts. We reviewed our cases to determine the rate of reinfection and risk factors for mortality and limb loss. We reviewed cases with infrarenal aortic graft infection from 1999 to 2013. Cases requiring graft excision were included for analysis. Thoracic and thoracoabdominal aortic grafts were excluded. Reconstruction types included both extra-anatomic and in situ grafts. Patient comorbidities, surgical outcomes, and known reinfection rates were assessed. Univariate and Kaplan-Meier analysis were performed. Twenty-eight patients had resection of infected infrarenal abdominal aortic grafts during the study period. Most patients (26/28; 93%) had infected aortoiliac or aortofemoral prosthetic bypass grafts, but two of 28 patients had infected endovascular aortoiliac stent grafts. The median age was 69 years (range, 46-86 years), with 68% men and 3...
Thoracic endovascular aortic repair (TEVAR) is widely used for treatment of traumatic aortic inju... more Thoracic endovascular aortic repair (TEVAR) is widely used for treatment of traumatic aortic injury (TAI). Stent graft coverage of the left subclavian artery (LSA) may be required in up to 40% of patients. We evaluated the long-term effects of intentional LSA coverage (LSAC) on symptoms and return to normal activity in TAI patients compared with a similarly treated group whose LSA was uncovered (LSAU). Patients were identified from a prospective institutional trauma registry between September 2005 and July 2012. TAI was confirmed using computed tomography angiography. The electronic medical records, angiograms, and computed tomography angiograms were reviewed in a retrospective fashion. In-person or telephone interviews were conducted using the SF-12v2 (Quality Metrics, Lincoln, RI) to assess quality of life. An additional questionnaire was used to assess specific LSA symptoms and the ability to return to normal activities. Data were analyzed by Spearman rank correlation and multipl...
Blood conservation using autologous platelet-rich plasma (aPRP), a technique of whole blood harve... more Blood conservation using autologous platelet-rich plasma (aPRP), a technique of whole blood harvest that separates red blood cells from plasma and platelets before cardiopulmonary bypass with retransfusion of the preserved platelets after completion of cardiopulmonary bypass, has not been studied extensively. We sought to prospectively determine whether aPRP reduces blood transfusions during ascending and transverse aortic arch repair. We randomly assigned 80 patients undergoing elective ascending and transverse aortic arch repair using deep hypothermic circulatory arrest to receive either aPRP (n = 38) or no aPRP (n = 42). Volume of aPRP retransfused was 726 ± 124 mL. The primary end point was transfusion amount. Secondary end points were death, stroke, renal failure, pulmonary failure, and transfusion costs. Perioperative transfusion rate was defined as blood transfusions given during surgery and up to 72 hours afterward. The surgeon and intensivist were blinded to the treatment a...
Traumatic aortic injury (TAI) remains a leading cause of death after blunt force. Thoracic endova... more Traumatic aortic injury (TAI) remains a leading cause of death after blunt force. Thoracic endovascular aortic repair (TEVAR) has been widely adopted as an alternative to open repair for the treatment of TAI. Although significant short-term benefits have been demonstrated for patients undergoing TEVAR, longer-term follow-up data are lacking. Trauma registry data were analyzed. Follow-up data were gathered from a combination of medical records, imaging, telephone interviews, and Social Security Death Index. Primary outcomes were in-hospital mortality, stroke, and paraplegia. Secondary outcomes included device-related adverse events (rupture, migration, or endoleak), secondary procedures, open conversion, and all-cause mortality. Between September 2005 and July 2012, 82 consecutive patients (57 males, mean [SD] age, 39.5 [20] years; mean [SD] Injury Severity Score [ISS], 34 [9.5]) underwent TEVAR for TAI. A total of 87 devices were implanted: TAG (n = 36), CTAG (n = 12) (WL Gore, Flag...
The purpose of this study was to investigate the cause of ascending aorta and aortic arch reopera... more The purpose of this study was to investigate the cause of ascending aorta and aortic arch reoperations and to identify determinants of early and late outcome. Between January 1991 and March 2003 we repaired aneurysms of the proximal aorta in 597 patients. Of these patients, 104 had reoperations for replacement of the ascending aorta, aortic root, or transverse aortic arch. Previous surgery was defined as any previous cardiac or proximal aortic repair. Median age was 60 years, and 29 of the patients (28%) were female. Indications for reoperation and replacement of the proximal aorta included acute type A dissection in 6 patients (5.8%), aneurysm with chronic dissection in 60 (57.7%), progression of aneurysm in 23 (22.1%), infection in 12 (1.5%), inflammatory disease in 2 (1.9%), and atheromatous disease in 1 (1.0%). Reoperations included aortic root replacement in 20 patients (19.2%), total arch replacement with elephant trunk in 28 (26.7%), ascending and proximal arch in 39 (37.5%),...
We report on our experience with treatment of adults requiring de novo or redo open aortic coarct... more We report on our experience with treatment of adults requiring de novo or redo open aortic coarctation repair mostly by a resection and interposition graft technique. We retrospectively reviewed all patients older than 16 years requiring open repair of aortic coarctation. Indications for repair, operative details, and outcomes were analyzed. Between 1996 and 2011, we treated 29 adult aortic coarctation patients with open repair. The mean age was 42 years (range, 17-69 years), and there were 15 men. Nine patients had previous repair with recurrence; the remaining 20 had native coarctation. Thoracic aortic aneurysms were present in 22 patients (76%), ranging in size from 3.0 to 9.6 cm (mean, 4.8 cm). Four patients had intercostal artery aneurysms (range, 1.0-2.5 cm), four had left subclavian artery aneurysms, and four had ascending/arch aneurysms. The most common repair was resection of aortic coarctation with interposition graft replacement (93%). Two patients without aneurysm had bypasses from the proximal descending thoracic aorta to the infrarenal aorta without aortic resection. There was no in-hospital mortality, stroke, or paraplegia. Long-term survival was 89% during a median follow-up of 81 months (interquartile range, 47-118 months), with no patient requiring reoperation on the repaired segment. Open repair of native and recurrent adult aortic coarctation has acceptable morbidity and low mortality. Especially in patients with concomitant aneurysm, resection with interposition graft replacement provides a safe and durable repair option.
Introduction.—Aortic dissection can extend into the brachiocephalic arteries. We analyzed carotid... more Introduction.—Aortic dissection can extend into the brachiocephalic arteries. We analyzed carotid duplex ultrasound (CDU) in DeBakey I acute aortic dissection to identify characteristics and establish a protocol to ensure appropriate evaluation.Method.—From 2002 to 2011, patients with CDU and proximal aortic dissection were identified. The protocol included color Doppler in both long and short axis, spectral waveforms of true and false lumens, and imaging of the aortic arch, when appropriate. Imaging was performed on a Philips iE33 or iu22 using a 9-3 MHz linear array probe for the cervical carotid arteries and a curved array 5-1 MHz probe for the aortic arch. Waveforms were analyzed for signs of proximal dissection.Results.—CDU was performed in 87 of 288 patients and comprised the study group. Intimal flaps were noted in 26 common carotid arteries (CCAs) in 20 patients. The false lumen was thrombosed in nine arteries (35%). Eight CCAs had stenosis >50%, with seven having increas...
Aortoesophageal fistula, secondary to thoracic aortic aneurysm, is an uncommon cause of gastroint... more Aortoesophageal fistula, secondary to thoracic aortic aneurysm, is an uncommon cause of gastrointestinal bleeding that is uniformly fatal without surgical intervention. These may be primary fistulas, in cases of thoracic aortic aneurysm without previous repair, or secondary fistulas occurring after surgical repair of thoracic aortic aneurysm. Surgical treatment has been successful in a small number of cases of primary aortoesophageal
The Journal of Thoracic and Cardiovascular Surgery, 2015
Controversy remains regarding management of acute type A dissection with intramural hematoma (IMH... more Controversy remains regarding management of acute type A dissection with intramural hematoma (IMH). Our purpose was to analyze our experience and report outcomes after repair of acute type A aortic dissection with IMH. We analyzed all patients from a single center who underwent open repair for acute type A aortic dissection with IMH. Between 2000 and 2013, we performed 418 repairs for acute type A aortic dissection. These were divided into 2 groups of patients: 64 patients (15%) with type A IMH and 354 patients (85%) with typical dissection. Those with IMH were older (62.4 ± 13.9 years vs 56.7 ± 14.7 years; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .0046) and presented with reduced renal function (ie, glomerular filtration rate) (P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .0341), less frequently with distal malperfusion, and less frequently with rupture (P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .0116). With IMH, the time from presentation to repair was, by strategy, longer (median, 67 vs 6 hours; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .0001), but no mortality occurred within 3 days of presentation. Mortality with IMH did not differ from typical dissection: 7 out of 64 patients (10.9%) versus 52 out of 354 patients (14.7%; P = .4276). A lower incidence of postoperative dialysis in the IMH group approached significance: 6 out of 63 patients (9.5%) versus 64 out of 347 patients (18.4%; P = .0820). When adjusted for age and renal function, late survival was improved with IMH (P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .0343). Repair of acute type A aortic dissection with IMH is associated with significant early morbidity and mortality, differing minimally from typical aortic dissection. Although expectant repair within 3 days may be applied, the purposeful delay imparted little advantage. Improved late outcomes may be seen with IMH, but…
patients. No spinal hematomas were observed. The CSF leaks with spinal headache, CSF leak without... more patients. No spinal hematomas were observed. The CSF leaks with spinal headache, CSF leak without spinal head- ache, spinal headache, intracranial hemorrhage, catheter fracture, and meningitis occurred in 6 (0.54%), 1 (0.1%), 2 (0.2%), 5 (0.45%), 1 (0.1%), and 2 (0.2%) cases, respectively. Mortality from subdural hematoma was 40% (2 of 5), and from meningitis was 50% (1 of 2).
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