- Email: [email protected]
Comment on Endovascular Stent Placement for Treatment of Spontaneous Isolated Dissection of the Superior Mesenteric Artery
Vol. 28, No. 4, May 2014
nitinol skeleton, and 2 inflatable (with biocompatible fill polymer) sealing rings (Fig. 1). Apart from additional fixation, these rings also provide sufficient apposition to irregularities of calcification and thrombus of the surface of the lumen, conforming also to reverse-tapered necks.2 Interestingly, these specific configuration and consequent adaptation capacity of the inflatable rings to challenging neck anatomies have been recently recruited to achieve complete sealing against a remodeleddwith an Amplatz Vascular PlugdAAA neck surface.3 Schiro et al.1 report for the first time in the literature the successful combination of the Ovation device with a single renal chimney graft, reporting sufficient graft patency and absence of migration and endoleaks during a 12-month follow-up period. Because the presence and size of gutters between the chimney and aortic endografts remain the main concern to compromise the early or late results of this technique,4,5 it seems logical to assume, based on the aforementioned features, that the Ovation’s inflatable rings may better embrace the chimney grafts, thus providing better sealing and elimination of the gutters in the proximal zone. According to our opinion, this suggestion should alarm the interventionalists for further clinical research toward this option, because the latter could markedly improve (if not revolutionize) the chimney technique. Efstratios Georgakarakos1 George Trellopoulos2 Dimitrios Pelekas2 Nikolaos Schoretsanitis1 George S. Georgiadis1 Chris V. Ioannou3 1 Department of Vascular Surgery, ‘‘Democritus’’ University of Thrace, University Hospital of Alexandroupolis, Alexandroupolis, Greece 2 First Surgical Clinic, General Hospital ‘‘G. Papanikolaou’’ Exohi, Thessaloniki, Greece 3 Vascular Surgery Department, University of Crete Medical School, Heraklion, Crete, Greece E-mail: [email protected]
REFERENCES 1. Schiro A, Antoniou GA, Ormesher O, Pichel AC, Farquharson F, Serracino-Inglott F. The chimney technique in endovascular aortic aneurysm repair: late ruptures after successful single renal chimney stent grafts. Ann Vasc Surg 2013;27:835e43. 2. Moulakakis KG, Dalainas I, Kakisis J, Giannakopoulos TG, Liapis CD. Current knowledge on EVAR with the ultra-low profile Ovation Abdominal Stent-graft System. J Cardiovasc Surg (Torino) 2012;53:427e32. 3. Gandini R, Pampana E, Stefanini M, Spano S, Martinelli F, Citraro D, Simonetti G. Neck remodeling using the amplatzer vascular plug to facilitate endovascular repair of a contained abdominal aortic rupture. J Endovasc Ther 2013;20:20e5. 4. Ohrlander T, Sonesson B, Ivancev K, Resch T, Dias N, Malina M. The chimney graft: a technique for preserving or rescuing aortic branch vessels in stent-graft sealing zones. J Endovasc Ther 2008;15:427e32.
Letters to the Editor 1081
5. de Bruin JL, Yeung KK, Niepoth WW, Lely RJ, Cheung Q, de Vries A, Blankensteijn JD. Geometric study of various chimney graft configurations in an in vitro juxtarenal aneurysm model. J Endovasc Ther 2013;20:184e90.
http://dx.doi.org/10.1016/j.avsg.2013.12.004 Comment on Endovascular Stent Placement for Treatment of Spontaneous Isolated Dissection of the Superior Mesenteric Artery
To the Editor: Li et al.1 reported on their experience with endovascular stent placement (ESP) for treatment of spontaneous isolated dissection of the superior mesenteric artery (SIDSMA). Congratulations on their experience. They conclude that ‘‘endovascular stent placement (ESP) was performed as the initial treatment of choice in those symptomatic SIDSMA patients not complicated by intraabdominal hemorrhage or intestinal infarction’’. There are many articles about the treatment of SIDSMA in recent years, and all of them identified that most cases of symptomatic SIDSMA might be successfully treated with medical therapy, and the ESP appears to be an acceptable alternative if medical treatment fails.2e5 We would like to mention our article published in 2013 describing the treatment of 17 patients in symptomatic SIDSMA.3 The medical treatment in 14 patients and 3 patients with severe compression of the true lumen or large dissecting aneurysm underwent ESP as a primary treatment. ESP was performed in 2 patients in whom initial conservative treatment failed. The median follow-up time was 24 months (range, 2e72 months), and the result was good. We believe that the medical treatment is a useful treatment for most of the symptomatic SIDSMA and can be the first choice for those patients, and ESP appears to be an acceptable alternative if medical treatment fails. Zhongzhi Jia Jinwei Zhao Guomin Jiang Department of Interventional Radiography, The Second Hospital of Changzhou, Nanjing Medical University, Chang Zhou, Jiangsu Province, China E-mail: [email protected] REFERENCES 1. Li N, Lu QS, Zhou J, et al. Endovascular stent placement for treatment of spontaneous isolated dissection of the superior mesenteric artery. Ann Vasc Surg 2014;28:445e51. 2. Dong ZH, Fu WG, Chen B, et al. Treatment of symptomatic isolated dissection of superior mesenteric artery. J Vasc Surg 2013;57:69e76. 3. Jia ZZ, Zhao JW, Tian F, et al. Initial and middle-term results of treatment for symptomatic spontaneous isolated dissection of superior mesenteric artery. Eur J Vasc Endovasc Surg 2013;45:502e8. 4. Chao BS, Lee MS, Lee MK, et al. Treatment guidelines for isolated dissection of the superior mesenteric artery based on
1082 Letters to the Editor
follow-up CT findings. Eur J Vasc Endovasc Surg 2011;41: 780e5. 5. Li D, He Y, Alkalei AM, et al. Management strategy for spontaneous isolated dissection of the superior mesenteric artery based on morphologic classification. J Vasc Surg 2014;59: 165e72.
http://dx.doi.org/10.1016/j.avsg.2013.12.003 Regarding ‘Carotid Endarterectomy National Trends over a Decade: Does Gender Matter?’
To the Editor: We read with interest the results by Kuy et al.1 concluding that women show lower perioperative cardiac morbidity and mortality rates than men after carotid endarterectomy (CEA). These results seem to be opposing to other retrospective studies. According to Guzman et al.,2 female gender does not influence 30-day stroke and mortality rates after CEA, regardless of preoperative symptom status. Likewise, Jim et al.3 conclude that women and men demonstrated similar resultsdincluding myocardial infarction (MI) and deathdafter carotid revascularization procedures. However, Bisdas et al.4 have found that asymptomatic women were more prone to acute MI after both open and endovascular treatment procedures. The high diversity of results between retrospective studies, concerning MI and death rates after carotid treatment, justifies the need to generate prospectively planned trials to evaluate a possible correlation between gender and cardiac damage after carotid procedures. Although the high number of patients included in retrospective studies is a major advantage that leads to more powerful statistical results, the superiority of randomized trials and the weakness of retrospective studies to address clinical investigation have been showed with evidence. Furthermore, Hertzer5 underlines in his recent article that the Nationwide Inpatient Sample databasedused by Kuy et al.1 as welldmay contain inaccurate data for carotid endarterectomy and carotid stenting regarding the documentation of periprocedural events and death rates. However, strictly defined protocols of troponin measurement and randomization of patients according to gender can avoid possible patient selection bias or unequal distribution of risk factors at baseline that are observed with the use of clinical databases and retrospective analysis. The Society for Cardiovascular Angiography and Interventions introduced recently a new definition for the diagnosis of MI after coronary revascularization, where it is recommended that a threshold level of biomarker elevation should be used to define a ‘‘clinically relevant MI’’.6 However, in the recently published Third Universal Definition of Myocardial Infarction, the authors underline that perioperative myocardial ischemia is the most common major vascular complication after noncardiac surgery, with most of the patients being asymptomatic.7 According to this consensus, asymptomatic perioperative MI is as strongly associated with 30-day mortality, as is symptomatic MI, and therefore, biomarker measurement is
Annals of Vascular Surgery
recommended postoperatively, especially for high-risk patients. Furthermore, large-scaled studies have concluded that troponin elevation alone is associated with longterm mortality after CEA as well.8 In a recent publication,9 we highlighted the increasing incidence of asymptomatic myocardial ischemia after open carotid surgery and underlined the necessity for strict troponin thresholds to identify and treat postoperative silent cardiac ischemia. In this prospective observational study, we observed an increase of cardiac troponin I (value >0.5 ng/mL) in 14% of all casesdindependently from surgical riskdalthough symptomatic cardiac ischemia was very low. Therefore, it is dictated to investigate the prevalence of postoperative cardiac ischemia in both genders using a strictly defined protocol of troponin measurement. In our knowledge, except from the large-scaled randomized Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) trial,8 where results did not provide evidence that women have a higher carotid artery stenting stroke and death rate compared with men, there has not been another randomized trial investigating the occurrence of cardiac events and morbidity after CEA between the 2 genders. In conclusion, the real effect of silent myocardial ischemia on both genders could be addressed only through prospectively planned and randomly recruiting trials. In this way, strictly planned protocols of detection would help avoid the possible underestimation of cardiac damage prevalence and miscalculation of risk for both genders. George Galyfos1,* Manolis Vavouranakis2 Konstantinos Filis1 1 Vascular Unit, First Department of Propedeutic Surgery, University of Athens Medical School, Ippokration Hospital, Athens, Greece 2 First Department of Cardiology, University of Athens Medical School, Ippokration Hospital, Athens, Greece *Correspondence to: George Galyfos, MD, 6 Melinas Merkouri Street, Neon Iraklion, 14122, Athens, Greece E-mail: [email protected]
REFERENCES 1. Kuy S, Dua A, Desai S et al. Carotid endarterectomy national trends over a decade: does gender matter? Ann Vasc Surg. [Published online on 2013 (10.1016/j.avsg.2013.08.016)]. 2. Guzman RP, Weighell W, Guzman C, et al. Female sex does not influence 30-day stroke and mortality rates after carotid endarterectomy. Ann Vasc Surg 2014;28:245e52. 3. Jim J, Dillavou ED, Upchurch GR Jr. et al; SVS Outcomes Committee. Gender-specific 30-day outcomes after carotid endarterectomy and carotid artery stenting in the Society for Vascular Surgery Vascular Registry. J Vasc Surg. [Published online on 2013 (10.1016/j.jvs.2013.09.036)]. 4. Bisdas T, Egorova N, Moskowitz AJ, et al. The impact of gender on in-hospital outcomes after carotid endarterectomy or stenting. Eur J Vasc Endovasc Surg 2012;44:244e50. 5. Hertzer NR. The Nationwide Inpatient Sample may contain inaccurate data for carotid endarterectomy and carotid stenting. J Vasc Surg 2012;55:263e6.
nitinol skeleton, and 2 inflatable (with biocompatible fill polymer) sealing rings (Fig. 1). Apart from additional fixation, these rings also provide sufficient apposition to irregularities of calcification and thrombus of the surface of the lumen, conforming also to reverse-tapered necks.2 Interestingly, these specific configuration and consequent adaptation capacity of the inflatable rings to challenging neck anatomies have been recently recruited to achieve complete sealing against a remodeleddwith an Amplatz Vascular PlugdAAA neck surface.3 Schiro et al.1 report for the first time in the literature the successful combination of the Ovation device with a single renal chimney graft, reporting sufficient graft patency and absence of migration and endoleaks during a 12-month follow-up period. Because the presence and size of gutters between the chimney and aortic endografts remain the main concern to compromise the early or late results of this technique,4,5 it seems logical to assume, based on the aforementioned features, that the Ovation’s inflatable rings may better embrace the chimney grafts, thus providing better sealing and elimination of the gutters in the proximal zone. According to our opinion, this suggestion should alarm the interventionalists for further clinical research toward this option, because the latter could markedly improve (if not revolutionize) the chimney technique. Efstratios Georgakarakos1 George Trellopoulos2 Dimitrios Pelekas2 Nikolaos Schoretsanitis1 George S. Georgiadis1 Chris V. Ioannou3 1 Department of Vascular Surgery, ‘‘Democritus’’ University of Thrace, University Hospital of Alexandroupolis, Alexandroupolis, Greece 2 First Surgical Clinic, General Hospital ‘‘G. Papanikolaou’’ Exohi, Thessaloniki, Greece 3 Vascular Surgery Department, University of Crete Medical School, Heraklion, Crete, Greece E-mail: [email protected]
REFERENCES 1. Schiro A, Antoniou GA, Ormesher O, Pichel AC, Farquharson F, Serracino-Inglott F. The chimney technique in endovascular aortic aneurysm repair: late ruptures after successful single renal chimney stent grafts. Ann Vasc Surg 2013;27:835e43. 2. Moulakakis KG, Dalainas I, Kakisis J, Giannakopoulos TG, Liapis CD. Current knowledge on EVAR with the ultra-low profile Ovation Abdominal Stent-graft System. J Cardiovasc Surg (Torino) 2012;53:427e32. 3. Gandini R, Pampana E, Stefanini M, Spano S, Martinelli F, Citraro D, Simonetti G. Neck remodeling using the amplatzer vascular plug to facilitate endovascular repair of a contained abdominal aortic rupture. J Endovasc Ther 2013;20:20e5. 4. Ohrlander T, Sonesson B, Ivancev K, Resch T, Dias N, Malina M. The chimney graft: a technique for preserving or rescuing aortic branch vessels in stent-graft sealing zones. J Endovasc Ther 2008;15:427e32.
Letters to the Editor 1081
5. de Bruin JL, Yeung KK, Niepoth WW, Lely RJ, Cheung Q, de Vries A, Blankensteijn JD. Geometric study of various chimney graft configurations in an in vitro juxtarenal aneurysm model. J Endovasc Ther 2013;20:184e90.
http://dx.doi.org/10.1016/j.avsg.2013.12.004 Comment on Endovascular Stent Placement for Treatment of Spontaneous Isolated Dissection of the Superior Mesenteric Artery
To the Editor: Li et al.1 reported on their experience with endovascular stent placement (ESP) for treatment of spontaneous isolated dissection of the superior mesenteric artery (SIDSMA). Congratulations on their experience. They conclude that ‘‘endovascular stent placement (ESP) was performed as the initial treatment of choice in those symptomatic SIDSMA patients not complicated by intraabdominal hemorrhage or intestinal infarction’’. There are many articles about the treatment of SIDSMA in recent years, and all of them identified that most cases of symptomatic SIDSMA might be successfully treated with medical therapy, and the ESP appears to be an acceptable alternative if medical treatment fails.2e5 We would like to mention our article published in 2013 describing the treatment of 17 patients in symptomatic SIDSMA.3 The medical treatment in 14 patients and 3 patients with severe compression of the true lumen or large dissecting aneurysm underwent ESP as a primary treatment. ESP was performed in 2 patients in whom initial conservative treatment failed. The median follow-up time was 24 months (range, 2e72 months), and the result was good. We believe that the medical treatment is a useful treatment for most of the symptomatic SIDSMA and can be the first choice for those patients, and ESP appears to be an acceptable alternative if medical treatment fails. Zhongzhi Jia Jinwei Zhao Guomin Jiang Department of Interventional Radiography, The Second Hospital of Changzhou, Nanjing Medical University, Chang Zhou, Jiangsu Province, China E-mail: [email protected] REFERENCES 1. Li N, Lu QS, Zhou J, et al. Endovascular stent placement for treatment of spontaneous isolated dissection of the superior mesenteric artery. Ann Vasc Surg 2014;28:445e51. 2. Dong ZH, Fu WG, Chen B, et al. Treatment of symptomatic isolated dissection of superior mesenteric artery. J Vasc Surg 2013;57:69e76. 3. Jia ZZ, Zhao JW, Tian F, et al. Initial and middle-term results of treatment for symptomatic spontaneous isolated dissection of superior mesenteric artery. Eur J Vasc Endovasc Surg 2013;45:502e8. 4. Chao BS, Lee MS, Lee MK, et al. Treatment guidelines for isolated dissection of the superior mesenteric artery based on
1082 Letters to the Editor
follow-up CT findings. Eur J Vasc Endovasc Surg 2011;41: 780e5. 5. Li D, He Y, Alkalei AM, et al. Management strategy for spontaneous isolated dissection of the superior mesenteric artery based on morphologic classification. J Vasc Surg 2014;59: 165e72.
http://dx.doi.org/10.1016/j.avsg.2013.12.003 Regarding ‘Carotid Endarterectomy National Trends over a Decade: Does Gender Matter?’
To the Editor: We read with interest the results by Kuy et al.1 concluding that women show lower perioperative cardiac morbidity and mortality rates than men after carotid endarterectomy (CEA). These results seem to be opposing to other retrospective studies. According to Guzman et al.,2 female gender does not influence 30-day stroke and mortality rates after CEA, regardless of preoperative symptom status. Likewise, Jim et al.3 conclude that women and men demonstrated similar resultsdincluding myocardial infarction (MI) and deathdafter carotid revascularization procedures. However, Bisdas et al.4 have found that asymptomatic women were more prone to acute MI after both open and endovascular treatment procedures. The high diversity of results between retrospective studies, concerning MI and death rates after carotid treatment, justifies the need to generate prospectively planned trials to evaluate a possible correlation between gender and cardiac damage after carotid procedures. Although the high number of patients included in retrospective studies is a major advantage that leads to more powerful statistical results, the superiority of randomized trials and the weakness of retrospective studies to address clinical investigation have been showed with evidence. Furthermore, Hertzer5 underlines in his recent article that the Nationwide Inpatient Sample databasedused by Kuy et al.1 as welldmay contain inaccurate data for carotid endarterectomy and carotid stenting regarding the documentation of periprocedural events and death rates. However, strictly defined protocols of troponin measurement and randomization of patients according to gender can avoid possible patient selection bias or unequal distribution of risk factors at baseline that are observed with the use of clinical databases and retrospective analysis. The Society for Cardiovascular Angiography and Interventions introduced recently a new definition for the diagnosis of MI after coronary revascularization, where it is recommended that a threshold level of biomarker elevation should be used to define a ‘‘clinically relevant MI’’.6 However, in the recently published Third Universal Definition of Myocardial Infarction, the authors underline that perioperative myocardial ischemia is the most common major vascular complication after noncardiac surgery, with most of the patients being asymptomatic.7 According to this consensus, asymptomatic perioperative MI is as strongly associated with 30-day mortality, as is symptomatic MI, and therefore, biomarker measurement is
Annals of Vascular Surgery
recommended postoperatively, especially for high-risk patients. Furthermore, large-scaled studies have concluded that troponin elevation alone is associated with longterm mortality after CEA as well.8 In a recent publication,9 we highlighted the increasing incidence of asymptomatic myocardial ischemia after open carotid surgery and underlined the necessity for strict troponin thresholds to identify and treat postoperative silent cardiac ischemia. In this prospective observational study, we observed an increase of cardiac troponin I (value >0.5 ng/mL) in 14% of all casesdindependently from surgical riskdalthough symptomatic cardiac ischemia was very low. Therefore, it is dictated to investigate the prevalence of postoperative cardiac ischemia in both genders using a strictly defined protocol of troponin measurement. In our knowledge, except from the large-scaled randomized Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) trial,8 where results did not provide evidence that women have a higher carotid artery stenting stroke and death rate compared with men, there has not been another randomized trial investigating the occurrence of cardiac events and morbidity after CEA between the 2 genders. In conclusion, the real effect of silent myocardial ischemia on both genders could be addressed only through prospectively planned and randomly recruiting trials. In this way, strictly planned protocols of detection would help avoid the possible underestimation of cardiac damage prevalence and miscalculation of risk for both genders. George Galyfos1,* Manolis Vavouranakis2 Konstantinos Filis1 1 Vascular Unit, First Department of Propedeutic Surgery, University of Athens Medical School, Ippokration Hospital, Athens, Greece 2 First Department of Cardiology, University of Athens Medical School, Ippokration Hospital, Athens, Greece *Correspondence to: George Galyfos, MD, 6 Melinas Merkouri Street, Neon Iraklion, 14122, Athens, Greece E-mail: [email protected]
REFERENCES 1. Kuy S, Dua A, Desai S et al. Carotid endarterectomy national trends over a decade: does gender matter? Ann Vasc Surg. [Published online on 2013 (10.1016/j.avsg.2013.08.016)]. 2. Guzman RP, Weighell W, Guzman C, et al. Female sex does not influence 30-day stroke and mortality rates after carotid endarterectomy. Ann Vasc Surg 2014;28:245e52. 3. Jim J, Dillavou ED, Upchurch GR Jr. et al; SVS Outcomes Committee. Gender-specific 30-day outcomes after carotid endarterectomy and carotid artery stenting in the Society for Vascular Surgery Vascular Registry. J Vasc Surg. [Published online on 2013 (10.1016/j.jvs.2013.09.036)]. 4. Bisdas T, Egorova N, Moskowitz AJ, et al. The impact of gender on in-hospital outcomes after carotid endarterectomy or stenting. Eur J Vasc Endovasc Surg 2012;44:244e50. 5. Hertzer NR. The Nationwide Inpatient Sample may contain inaccurate data for carotid endarterectomy and carotid stenting. J Vasc Surg 2012;55:263e6.