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Outcomes of Thoracic Endovascular Aortic Repair in Adult Aortic Coarctation Patients
e6
Journal of Vascular Surgery
Abstracts
January 2017 data is depicted in the Table. No 30-day mortality events occurred, and two patients (10%) experienced a postoperative complication (nondisabling stroke, n ¼ 2). At a median clinical follow-up time of 8 months (range, 1-106), three endoleaks were detected, all of which were type 2 related to patent left subclavian (n ¼ 2) or aberrant subclavian arteries (n ¼ 1). Four patients (19%) underwent reintervention (median time, 7 months [range, 2-12]), and three out of four of these were subclavian artery embolizations, whereas one was for aortic root replacement because of pre-existing bicuspid aortic valve with concomitant ascending aortic aneurysm. In patients with available computed tomography imaging (n ¼ 6 of 9 primary/recurrent coarctation subjects), nominal stent diameters at the site of coarctation were effectively achieved within these patients (range, -0.4 to -1.2 mm of desired final stent diameter). One- and 3-year survival is estimated to be 95 6 5% (Fig). One late death occurred related to complications from pre-existing congenital heart disease. Conclusions: Adult patients with aortic coarctation can be treated safely with TEVAR. The annular constriction of an aortic coarctation can be successfully dilated by the self-expanding stent graft. Greater patient numbers and longer term follow-up are needed to further define the role of TEVAR in the management adult patients with complications of aortic coarctation. Table. Procedure-related variables of adult aortic coarctation patients undergoing TEVAR (thoracic endovascular aortic repair) Feature, N ¼ 21
No. (%)
Preoperative spinal drain
8 (38%)
Intraoperative adjuncta
10 (47%)
-Left carotid-subclavian bypass/transposition
7
-Left subclavian artery embolization
6
-Left carotid stent
1
-Right carotid subclavian bypass/transposition
2
-Right atrial inflow balloon occlusion
1
-Right subclavian artery embolization
1
Device type Fig.
Medtronic
17 (81%)
-Valiant Author Disclosures: B. Nejim: None; J. Dhaliwal: None; S. Meshkin: None; M. Rizwan: None; A. Gupta: None; S. Locham: None; H. Dakour Aridi: None; C. Hicks: None; M. B. Malas: None.
Outcomes of Thoracic Endovascular Aortic Repair in Adult Aortic Coarctation Patients Satish H. Chandrasekhar,1 Salvatore T. Scali,1 Salim Lala,1 Kristina A. Giles,1 Adam W. Beck,2 Javairiah Fatima,1 Scott A. Berceli,1 Thomas S. Huber,1 Robert J. Feezor1. 1University of Florida- Gainesville, Gainesville, Fla; 2University of Alabama-Birmingham, Birmingham, Ala Objective: Although aortic coarctation is most commonly seen in pediatric patients, adults can present with late sequelae of untreated coarctation or complications of the index repair. To date, there are limited data about the role of thoracic endovascular aortic repair (TEVAR) in this group of patients. The purpose of this analysis is to describe our experience with management of adult coarctation patients treated with TEVAR. Methods: A retrospective review was completed of a prospectively maintained endovascular aortic registry at a university hospital. All patients treated for primary coarctation or for late sequelae of previous open repair (eg, pseudoaneurysm, recurrent coarctation/anastomotic stenosis related to index open coarctation repair) were included. Patient demographics, comorbidities, procedure-related variables, postoperative outcomes, and reintervention were abstracted. Computed tomographic centerline assessments of endograft morphology were also completed to delineate stent anatomy at the site of coarctation. Survival was estimated using Kaplan-Meier life tables. Results: A total of 21 patients were identified (median age ¼ 46 years [range, 33-71]; 67% male [n ¼ 14]). Nine patients (43%) were treated for symptomatic primary (n ¼ 6) or recurrent coarctation (n ¼ 3). Other indications included degenerative thoracic aneurysm (n ¼ 6), pseudoaneurysm (n ¼ 4), and dissection (n ¼ 2). Zone 1 or 2 landings were employed in 15 patients (zone 2, n ¼ 13; zone 1, n ¼ 2). Additional procedure-related
11
-Talent
6
Cook TX2
3 (14%)
Gore TAG
1 (5%)
Operative time, minutesb
139 [70, 200]
Fluoroscopy time, minutesb
15 [12, 20]
Contrast exposure, mLb
95 [40, 130]
Estimated blood loss, mLb a
150 [100, 200] b
Some patients received multiple adjuncts. Median [interquartile range].
Fig.
Journal of Vascular Surgery
Abstracts
e7
Volume 65, Number 1 Author Disclosures: S. H. Chandrasekhar: None; S. T. Scali: None; S. Lala: None; K. A. Giles: None; A. W. Beck: None; J. Fatima: None; S. A. Berceli: None; T. S. Huber: None; R. J. Feezor: None.
Outcomes of Concomitant Renal Reconstruction during Open Para-visceral Aortic Aneurysm Repair Mathew Wooster, Martin Back, Shivangi Patel, University of South Florida, Tampa, Fla
Murray Shames.
Objective: To review the outcomes of direct renal artery revascularizations during open aortic aneurysm repair as a potential comparative technique to renal artery endoprostheses placed during branched, fenestrated, and parallel endograft repairs of paravisceral aortic aneurysms. Methods: Open abdominal aneurysm repairs performed from 2010 to 2015 at a single institution were reviewed, including type IV thoracoabdominal, and supra- and juxtarenal aneurysms. Infrarenal aneurysms, type 1-3 thoracoabdominal, and infectious aneurysms were excluded, as were patients with preoperative end-stage renal disease. Direct renal reconstruction techniques included eversion endarterectomy, bypass, and vessel reimplantation based on patient anatomy. Renal loss was defined by artery occlusion or parenchymal atrophy/length loss >2 cm. Student t-test was used for comparison of continuous variables, and c2 analysis was performed for categorical variables. Results: A total of 125 patients were included, of which 57 patients (46%) had 76 renal reconstructions (38 single, 19 bilateral) performed during aortic operations. Interventions included endarterectomy (n ¼ 21), transaortic stenting (n ¼ 2), reimplantation with (n¼25) or without (n ¼ 17) endarterectomy, bypass (n ¼ 4), and ligation (n ¼ 7). Mean aneurysm size was 6.4 cm with 23% (n ¼ 29) urgent/emergent operations and 20% (n ¼ 25) having had a prior infrarenal open or endovascular repair. Overall major complication rate was 50% with significant increase amongst the group requiring renal intervention, primarily accounted for by a 35% early or late dialysis requirement compared with 16% in no renal revascularization patients (P ¼ .01). Overall 30-day mortality was 9% with no difference between renal (10.5%) and no-renal (7%) intervention groups. Urgent/emergent operation (P < .001) was associated with increased 30-day mortality (24% vs 4% elective procedures), but prior open or endovascular repair (P ¼ .4) was not. Mean follow-up was 26 months with directed imaging out to a mean of 18 months. Early renal loss was observed in 13 (23%) patients undergoing renal intervention vs 1 (1.4%) in those who did not (P < .001), with late renal loss observed in 4 (7%) and 2 (3%), respectively (P ¼ .3). Renal intervention (P ¼ .01) and urgent/emergent status (P ¼ .04) were predictive of dialysis requirement, however, among those undergoing intervention, renal loss was not associated with an increase in dialysis requirement (P ¼ .2). Of the directed intervention techniques, renal reimplantation with or without endarterectomy was associated with increased risk of dialysis requirement (P ¼ .005) and renal loss (P ¼ .04) relative to endarterectomy alone. Mean creatinine on late follow-up was 1.4 mg/dL (from 1.3 mg/dL preoperatively) and was not statistically significantly different between those undergoing renal intervention (1.5 mg/dL) and those who did not (1.4 mg/dL). Conclusions: Renal artery reconstruction at the time of open repair of paravisceral aneurysms is associated with an increased complication rate, primarily driven by occlusion of reimplanted vessels and increased dialysis requirement. However, renal loss does not appear to increase risk of dialysis. Outcomes after elective aortic repair requiring renal reconstruction were respectable, but avoidance of left renal reimplantation might be suggested. Current literature reporting renal patency may be overestimated by reliance on glomerular filtration rate or creatinine as a surrogate for directed imaging.
techniques of revascularization to perform meaningful analysis of outcomes in the treatment of critical limb ischemia (CLI). WifI index is intended to be analogous to the TNM staging system for cancer, with restaging to be done after control of infection and after revascularization. We previously demonstrated that preoperative wound and infection grades are predictive of limb loss, whereas ischemia grade is not. Our goal was to evaluate the effectiveness of WifI restaging after therapy in the prediction of limb loss. Methods: Preoperative WifI scoring was performed prospectively on all patients with CLI who underwent revascularization from January 2014 to June 2015. WifI restaging and assessment of outcomes was performed retrospectively using our vascular database and electronic medical records through August 2016. WifI classification was determined preoperatively, immediately postoperative, and at 1 and 6 months after
Author Disclosures: M. Wooster: None; M. Back: None; S. Patel: None; M. Shames: None.
Importance of Postprocedural Wound, Ischemia, and Foot Infection Restaging in Predicting Limb Salvage Charles Leithead, Emily Spangler, Marc Passman, Zdenek Novak, Adam Witcher, Mark Patterson, Adam Beck, Benjamin Pearce. University of Alabama at Birmingham, Birmingham, Ala Objective: The wound, ischemia, and foot Infection (WifI) classification system was created to encompass demographic changes and expanding
Fig. WIfI restaging and amputation-free survival.
Journal of Vascular Surgery
Abstracts
January 2017 data is depicted in the Table. No 30-day mortality events occurred, and two patients (10%) experienced a postoperative complication (nondisabling stroke, n ¼ 2). At a median clinical follow-up time of 8 months (range, 1-106), three endoleaks were detected, all of which were type 2 related to patent left subclavian (n ¼ 2) or aberrant subclavian arteries (n ¼ 1). Four patients (19%) underwent reintervention (median time, 7 months [range, 2-12]), and three out of four of these were subclavian artery embolizations, whereas one was for aortic root replacement because of pre-existing bicuspid aortic valve with concomitant ascending aortic aneurysm. In patients with available computed tomography imaging (n ¼ 6 of 9 primary/recurrent coarctation subjects), nominal stent diameters at the site of coarctation were effectively achieved within these patients (range, -0.4 to -1.2 mm of desired final stent diameter). One- and 3-year survival is estimated to be 95 6 5% (Fig). One late death occurred related to complications from pre-existing congenital heart disease. Conclusions: Adult patients with aortic coarctation can be treated safely with TEVAR. The annular constriction of an aortic coarctation can be successfully dilated by the self-expanding stent graft. Greater patient numbers and longer term follow-up are needed to further define the role of TEVAR in the management adult patients with complications of aortic coarctation. Table. Procedure-related variables of adult aortic coarctation patients undergoing TEVAR (thoracic endovascular aortic repair) Feature, N ¼ 21
No. (%)
Preoperative spinal drain
8 (38%)
Intraoperative adjuncta
10 (47%)
-Left carotid-subclavian bypass/transposition
7
-Left subclavian artery embolization
6
-Left carotid stent
1
-Right carotid subclavian bypass/transposition
2
-Right atrial inflow balloon occlusion
1
-Right subclavian artery embolization
1
Device type Fig.
Medtronic
17 (81%)
-Valiant Author Disclosures: B. Nejim: None; J. Dhaliwal: None; S. Meshkin: None; M. Rizwan: None; A. Gupta: None; S. Locham: None; H. Dakour Aridi: None; C. Hicks: None; M. B. Malas: None.
Outcomes of Thoracic Endovascular Aortic Repair in Adult Aortic Coarctation Patients Satish H. Chandrasekhar,1 Salvatore T. Scali,1 Salim Lala,1 Kristina A. Giles,1 Adam W. Beck,2 Javairiah Fatima,1 Scott A. Berceli,1 Thomas S. Huber,1 Robert J. Feezor1. 1University of Florida- Gainesville, Gainesville, Fla; 2University of Alabama-Birmingham, Birmingham, Ala Objective: Although aortic coarctation is most commonly seen in pediatric patients, adults can present with late sequelae of untreated coarctation or complications of the index repair. To date, there are limited data about the role of thoracic endovascular aortic repair (TEVAR) in this group of patients. The purpose of this analysis is to describe our experience with management of adult coarctation patients treated with TEVAR. Methods: A retrospective review was completed of a prospectively maintained endovascular aortic registry at a university hospital. All patients treated for primary coarctation or for late sequelae of previous open repair (eg, pseudoaneurysm, recurrent coarctation/anastomotic stenosis related to index open coarctation repair) were included. Patient demographics, comorbidities, procedure-related variables, postoperative outcomes, and reintervention were abstracted. Computed tomographic centerline assessments of endograft morphology were also completed to delineate stent anatomy at the site of coarctation. Survival was estimated using Kaplan-Meier life tables. Results: A total of 21 patients were identified (median age ¼ 46 years [range, 33-71]; 67% male [n ¼ 14]). Nine patients (43%) were treated for symptomatic primary (n ¼ 6) or recurrent coarctation (n ¼ 3). Other indications included degenerative thoracic aneurysm (n ¼ 6), pseudoaneurysm (n ¼ 4), and dissection (n ¼ 2). Zone 1 or 2 landings were employed in 15 patients (zone 2, n ¼ 13; zone 1, n ¼ 2). Additional procedure-related
11
-Talent
6
Cook TX2
3 (14%)
Gore TAG
1 (5%)
Operative time, minutesb
139 [70, 200]
Fluoroscopy time, minutesb
15 [12, 20]
Contrast exposure, mLb
95 [40, 130]
Estimated blood loss, mLb a
150 [100, 200] b
Some patients received multiple adjuncts. Median [interquartile range].
Fig.
Journal of Vascular Surgery
Abstracts
e7
Volume 65, Number 1 Author Disclosures: S. H. Chandrasekhar: None; S. T. Scali: None; S. Lala: None; K. A. Giles: None; A. W. Beck: None; J. Fatima: None; S. A. Berceli: None; T. S. Huber: None; R. J. Feezor: None.
Outcomes of Concomitant Renal Reconstruction during Open Para-visceral Aortic Aneurysm Repair Mathew Wooster, Martin Back, Shivangi Patel, University of South Florida, Tampa, Fla
Murray Shames.
Objective: To review the outcomes of direct renal artery revascularizations during open aortic aneurysm repair as a potential comparative technique to renal artery endoprostheses placed during branched, fenestrated, and parallel endograft repairs of paravisceral aortic aneurysms. Methods: Open abdominal aneurysm repairs performed from 2010 to 2015 at a single institution were reviewed, including type IV thoracoabdominal, and supra- and juxtarenal aneurysms. Infrarenal aneurysms, type 1-3 thoracoabdominal, and infectious aneurysms were excluded, as were patients with preoperative end-stage renal disease. Direct renal reconstruction techniques included eversion endarterectomy, bypass, and vessel reimplantation based on patient anatomy. Renal loss was defined by artery occlusion or parenchymal atrophy/length loss >2 cm. Student t-test was used for comparison of continuous variables, and c2 analysis was performed for categorical variables. Results: A total of 125 patients were included, of which 57 patients (46%) had 76 renal reconstructions (38 single, 19 bilateral) performed during aortic operations. Interventions included endarterectomy (n ¼ 21), transaortic stenting (n ¼ 2), reimplantation with (n¼25) or without (n ¼ 17) endarterectomy, bypass (n ¼ 4), and ligation (n ¼ 7). Mean aneurysm size was 6.4 cm with 23% (n ¼ 29) urgent/emergent operations and 20% (n ¼ 25) having had a prior infrarenal open or endovascular repair. Overall major complication rate was 50% with significant increase amongst the group requiring renal intervention, primarily accounted for by a 35% early or late dialysis requirement compared with 16% in no renal revascularization patients (P ¼ .01). Overall 30-day mortality was 9% with no difference between renal (10.5%) and no-renal (7%) intervention groups. Urgent/emergent operation (P < .001) was associated with increased 30-day mortality (24% vs 4% elective procedures), but prior open or endovascular repair (P ¼ .4) was not. Mean follow-up was 26 months with directed imaging out to a mean of 18 months. Early renal loss was observed in 13 (23%) patients undergoing renal intervention vs 1 (1.4%) in those who did not (P < .001), with late renal loss observed in 4 (7%) and 2 (3%), respectively (P ¼ .3). Renal intervention (P ¼ .01) and urgent/emergent status (P ¼ .04) were predictive of dialysis requirement, however, among those undergoing intervention, renal loss was not associated with an increase in dialysis requirement (P ¼ .2). Of the directed intervention techniques, renal reimplantation with or without endarterectomy was associated with increased risk of dialysis requirement (P ¼ .005) and renal loss (P ¼ .04) relative to endarterectomy alone. Mean creatinine on late follow-up was 1.4 mg/dL (from 1.3 mg/dL preoperatively) and was not statistically significantly different between those undergoing renal intervention (1.5 mg/dL) and those who did not (1.4 mg/dL). Conclusions: Renal artery reconstruction at the time of open repair of paravisceral aneurysms is associated with an increased complication rate, primarily driven by occlusion of reimplanted vessels and increased dialysis requirement. However, renal loss does not appear to increase risk of dialysis. Outcomes after elective aortic repair requiring renal reconstruction were respectable, but avoidance of left renal reimplantation might be suggested. Current literature reporting renal patency may be overestimated by reliance on glomerular filtration rate or creatinine as a surrogate for directed imaging.
techniques of revascularization to perform meaningful analysis of outcomes in the treatment of critical limb ischemia (CLI). WifI index is intended to be analogous to the TNM staging system for cancer, with restaging to be done after control of infection and after revascularization. We previously demonstrated that preoperative wound and infection grades are predictive of limb loss, whereas ischemia grade is not. Our goal was to evaluate the effectiveness of WifI restaging after therapy in the prediction of limb loss. Methods: Preoperative WifI scoring was performed prospectively on all patients with CLI who underwent revascularization from January 2014 to June 2015. WifI restaging and assessment of outcomes was performed retrospectively using our vascular database and electronic medical records through August 2016. WifI classification was determined preoperatively, immediately postoperative, and at 1 and 6 months after
Author Disclosures: M. Wooster: None; M. Back: None; S. Patel: None; M. Shames: None.
Importance of Postprocedural Wound, Ischemia, and Foot Infection Restaging in Predicting Limb Salvage Charles Leithead, Emily Spangler, Marc Passman, Zdenek Novak, Adam Witcher, Mark Patterson, Adam Beck, Benjamin Pearce. University of Alabama at Birmingham, Birmingham, Ala Objective: The wound, ischemia, and foot Infection (WifI) classification system was created to encompass demographic changes and expanding
Fig. WIfI restaging and amputation-free survival.