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Panel Discussion: Session IV—Descending and Thoracoabdominal Aorta
Panel Discussion: Session IV—Descending and Thoracoabdominal Aorta Moderator: David Spielvogel, MD Panelists: Richard P. Cambria, MD, Joseph S. Coselli, MD, Randall B. Griepp, MD, Ali Khoynezhad, MD, PhD, R. Scott Mitchell, MD, Konstadinos A. Plestis, MD, Marc Schepens, MD, PhD, Geert Willem Schurink, MD, PhD, Lars G. Svensson, MD, PhD, and Grayson H. Wheatley, III, MD
SUPPLEMENT
DR DAVID SPIELVOGEL (Valhalla, NY): I would like to ask all the speakers to please come up for the panel discussion. Do you have any questions for our distinguished panelists? DR EDWARD L. WOODS (Danville, PA): Should every patient with an elephant trunk have clips and pacing wires for a possible endograft? How long do you make the trunk for this purpose? DR LARS G. SVENSSON (Cleveland, OH): A good question. As far as the length of the elephant trunk, as you perhaps recall in a previous paper, we recommend that it be 10 to 15 cm. You want enough length so that if you are going to do a second stage, you can grab it without having to clamp the aortic arch. In other words, you do what we call a slash and grab: open the aorta, grab the graft, and clamp it. So that is what you want to have enough length for. On the other hand, for a second stage elephant trunk stent with an endograft, you don’t want it too long, because, as I pointed out, if it is too long you have got much more risk of it being foreshortened or concertinaed. We actually put clips now and pacing wires on all our patients, even the chronic dissections. Most of our chronic dissections end up having an open second stage procedure, because we still don’t believe that endografting is a good option, but occasionally we will stent a chronic dissection elephant trunk, but generally not. DR RANDALL B. GRIEPP (New York, NY): Let me just add something to that. Remember, when you put that elephant trunk in, it is in its flaccid state when it is hanging in the aorta. Once you connect it to your stent graft and pressurize it, it elongates because it is then pressurized. So you have to allow for that, too. DR R. SCOTT MITCHELL (Stanford, CA): I think it is worthwhile making some effort when you first place your elephant trunk, using your transesophageal echo to image it. When you are first placing it, it is pretty easy to take an aortic occlusion balloon or some other balloon and push it distally so you don’t get that wrapped-up configuration. You will then eliminate a lot of downstream headaches. DR GABRIELE B. BERTONI (Oxford, United Kingdom): We have seen this afternoon quite a few cases of Presented at Aortic Surgery Symposium X, New York, NY, April 27–28, 2006.
© 2007 by The Society of Thoracic Surgeons Published by Elsevier Inc
open operation to correct recent stent implants. Surely all these patients did well and recovered later in an open procedure. And we have also heard something about the cost of endovascular grafting versus open procedures, and that is my question to the whole panel. Do you follow a specific clinical indication for a less invasive treatment versus a safe open repair, and if not, how do you justify your choice in the face of a failure? DR SVENSSON: As a general rule, if I think a patient is going to live more than 5 to 10 years, I will tend to favor doing an open procedure. Certainly in the high-risk patients we will favor stent grafting, including in patients with second stage procedures. And as I mentioned, we usually try to make a decision in the ICU once we see how patients handle the first stage operation if that has preceded the decision, and then decide whether we should just go ahead and stent those patients then or let them recover and do the second stage open but later. DR BERTONI: I was not asking about the second stage operation. I am talking generally speaking about your choice to primarily treat a patient with stent grafting, or with a surgical operation. DR SVENSSON: I tried to answer that in the beginning. If it is a young patient with a likely long-term survival that is going to be very good, then we will often offer them an open procedure, particularly if it is a fairly straightforward operation. But the results are very good for, say, penetrating ulcers. For a straightforward case, like the saccular aneurysms, some of the coarctations, the patients with ischemia and dissection, endovascular stenting is an excellent approach. We have gotten very good results with traumatic ruptures. I will make one comment about the traumatic ruptures. We have learned that you need to cover the subclavian artery in virtually all the patients. So we do that primarily for traumatic ruptures, and the only traumatic ruptures we have had to operate on in probably 3 years have been the ones with failed placement of stent grafts. DR SPIELVOGEL: I would like to ask a question of the panelists and get their opinion. Let’s take a typical patient. Perhaps the patient has had a previous AAA repair and you are planning an endovascular intervention for a descending aneurysm. In this case, you are doing spinal cord monitoring intraoperatively: you have deployed the stent and your MEPs have disappeared or diminished considerably. You boosted the blood presAnn Thorac Surg 2007;83:S890 –2 • 0003-4975/07/$32.00 doi:10.1016/j.athoracsur.2006.11.092
AORTIC SURGERY SYMPOSIUM X DISCUSSION: SESSION IV—DESCENDING AND THORACOABDOMINAL AORTA
sure, you have your CSF drain already in place, you drain some CSF, keep the pressure low. What would you do if that endograft were in place and the MEPs continue to diminish? Or the patient has been awakened from anesthesia, you have asked him to move his legs, and he is not moving his legs. The CSF drain is in, and the stent is in. What would your approach be to that patient? DR GEERT WILLEM SCHURINK (Maastricht, Netherlands): As I tried to show in my talk, that happened in 2 patients, but not so dramatically that we were afraid that they would wake up paraplegic. But the first step would be to elevate the mean arterial pressure, and in most cases you will see the MEPs go up. That is the same as in open surgery. If the motor evoked potential goes down, the first step is to elevate the mean arterial pressure, and in most cases, also in open surgery, the MEPs come back. DR SPIELVOGEL: Would you ever attempt to immediately remove the endograft if the MEPs did not return? DR SCHURINK: Theoretically it is possible, and there is a case report on that for delayed paraplegia after stent grafting where the endoprosthesis was removed and the patient recovered partially. I think it is different to have paraplegia in an endoprosthesis situation than in an open situation, because you still have pressurization of the collateral circulation, and you probably won’t have as low a pressure in the collateral circulation as in an open situation. So perhaps there is more time for conversion. DR GRIEPP: I would just say that I expect that this does happen, and that you cannot reverse it by increasing the blood pressure. It may well be a problem with embolization or thrombosis, and I am not sure there is much you can do at that point. I suppose one theoretical alternative would be to poke a hole in the stent graft if you really thought repressurizing the intercostals would help, but I doubt that doing that would make a difference in most cases. DR SPIELVOGEL: I just remember Dr Jacobs telling me about a case that he had where he had a stent placed and the patient had delayed paraplegia, and he went in the next day when the patient developed neurologic symptoms and removed the endograft and repaired the aneurysm and had partial recovery. And I just wondered—rather than leaving the patient paraplegic— whether some people would consider doing something aggressive. DR RAJ K. BOSE (Tucson, AZ): This question is in reference to the excellent data from the Sinai group, but the question is directed to everyone. Respiratory failure is a major complication after open thoracoabdominal surgery. I would like the opinion of the panel as to how bad a respiratory status one would accept for an open procedure. For example, if you go just by FEV1, how low is too low before you turn the patient down? DR SVENSSON: If I could answer that, we did a study many years ago where we looked at patients having thoracoabdominal aneurysm repairs prospectively, and we found that at 1.2, the FEV1 is more or less where the cut point starts increasing to about a 20% risk of respira-
S891
tory failure. So below that we tend to be more cautious about what we do. DR KONSTADINOS A. PLESTIS (New York, NY): In our series, we had only 50% of the patients with preoperative pulmonary function tests, and when we ran the analysis for this particular group, we did not find that the FEV1 or any other of these volumes were independent predictors of respiratory complications after surgery. We are fairly aggressive in terms of operating on patients with preoperative COPD, and I guess emphasis would be given to preoperative optimization of those patients in an effort to get them through the operation. DR SVENSSON: Just to add that we found the best predictor of function was FEF 25/75, and that really is a test of the patient’s ability to cough after surgery. If that is below about 20% of predicted, then I am pretty cautious about doing an open procedure in those patients. DR MICHAEL T. JANUSZ (Vancouver, British Columbia, Canada): A question for Dr Griepp. When you are doing the cases and monitoring the spinal cord and sequentially dividing the intercostals, how often do you see the motor evoked potentials decrease or disappear, and what do you do about it? DR GRIEPP: It is actually pretty rare. We see it in perhaps as many as 5% of cases. It almost always responds to increasing the blood pressure. Perhaps another 3% or 4% are due to the anesthesiologist increasing the anesthetic agent and it can just be restored to normal by reducing the anesthesia. We divide the intercostals over a period of time. It usually takes an hour or so to dissect out the segment of aorta that you are going to resect, and we usually clip these about two or three at a time and then work somewhere else or do something else while we wait to see if the MEP changes. It is very rare to actually clip the segmental arteries, have the MEPs go away and not have them come back. Dr Spielvogel tells me that I told him for years that he had to watch out for it, and it finally happened in one of his cases. It is pretty uncommon to lose MEPs and not have them come back, but it is not so uncommon to see changes, and you can almost always fix it by increasing the blood pressure. But if what we see is characteristic of what happens in most series, perhaps 5% to 8% of our patients would actually be paraplegic if we hadn’t responded by increasing the blood pressure. There are times, if the MEPs begin to be a little tenuous, we ask ourselves whether we can stop the resection here. There is often a little more aneurysm downstream, but maybe it is not that bad. And so monitoring MEPs does affect our management probably in about 10% of the cases. DR SPIELVOGEL: We had a lot of discussion about malperfusion this morning with thoracic endografts, and I was curious, removing the endografts from the equation, what is the preferred management of these patients? The patient comes in, let’s say, with an arch tear or a tear right at the left subclavian with malperfusion. Perhaps your institution doesn’t have thoracic endografts or the ability to do percutaneous intervention. How
SUPPLEMENT
Ann Thorac Surg 2007;83:S890 –2
S892
AORTIC SURGERY SYMPOSIUM X DISCUSSION: SESSION IV—DESCENDING AND THORACOABDOMINAL AORTA
would you manage those patients? Many people have come up and asked me that question: what if I don’t have these cutting-edge modalities? So I thought about perhaps using some of our traditional techniques and discussing how you would approach it. DR MITCHELL: If it is an arch problem, I would first start with an arch repair and redirect flow surgically with an elephant trunk into the true lumen in the acute situation, but we would then almost immediately do intraoperative imaging to make sure that we had in fact reversed the malperfusion. But we of course have the luxury of interventionalists who are quite talented and can help us there. DR SVENSSON: I would add also that most institutions have bare stents, and for a lot of our acute dissections with ischemia, we just would use bare stents. I don’t think you have to have covered stents to do that. Usually your radiologist or the cardiologist can do that for you. So I would seek advice from them, too. If you do a corrective open procedure and you still have ischemia, then that is what we would do. And we will often, if we suspect that there is, say, gut ischemia, do a minilaparotomy and see if there is evidence of gut ischemia at the same time as their ascending aorta or arch repair. And then if there is ischemia, quickly take the patient to the catheterization lab or the vascular lab and open up the vessels. DR JOSEPH S. COSELLI (Houston, TX): In the past we have actually had some rather good results with replacing the upper portion of the descending thoracic aorta and then redirecting everything back into the true lumen. This has worked even in patients who might otherwise have needed a femorofemoral bypass. And a couple of cases that have been 4 or 5 days after dissection, and then progressed to renal failure and were on hemodialysis, responded to that. It is anecdotal. But over the last number of years, with close association with our interventional radiologists, we have almost never had to take on these malperfusion issues surgically. The combination we have been able to use, as already mentioned, is stenting into the visceral vessels for dynamic occlusion, and fenestration and ballooning the fenestrations for more static malperfusion problems. Similarly in the iliac arteries, it is very rare to have to address malperfusion. I think the more important issue there almost has become the timely diagnosis of malperfusion. If it in-
Ann Thorac Surg 2007;83:S890 –2
volves the leg, it is pretty obvious pretty quickly and it is fairly straightforwardly dealt with. The more complicated questions concern particularly visceral malperfusion, which can present late. I think it is incumbent upon us, as we manage these patients, stents and otherwise, to try to make our best assessment at the completion of the procedure and be as certain as we can that we don’t have a malperfusion problem. And then an equally daunting problem is in the patient who is otherwise in reasonably good shape but has lost one kidney now and has one good kidney. For the time being, the renal function is probably adequate to sustain itself, but as the survival of these patients becomes improved by interventions over time, I think preserving the kidney compromised by malperfusion and not writing that kidney off is going to have an increase in importance. DR SPIELVOGEL: Has anyone had any experience with abdominal fenestration? DR SVENSSON: One of our vascular surgeons had a period when he was trying to do fenestrations for acute dissections with ischemia, and we had a couple of deaths from that. Some of the patients we tried to save, but that didn’t work out well. If you try to do a fenestration and then tear it—and that was the way it was being done— you can tear the entire aorta. There has been some success with just putting a wire across the septum and then ballooning it, but I don’t think that is really the definitive way to handle this. DR COSELLI: Are you referring to the procedure that John Elefteriades describes? DR SPIELVOGEL: Yes. DR COSELLI: I think that is a very valuable technique. We have used that a few times with good success. And I think it needs to be in our repertoire simply because there are some patients that will technically confound our interventional radiologists to rectify the problem, and you may be at an institution or in a situation in the middle of the night or the weekend where you just simply don’t have the interventional capabilities. It is a fairly simple straightforward procedure, and I do think in rare situations it is something that can be successful, and we should at least keep it in our back pocket.
SUPPLEMENT
SUPPLEMENT
DR DAVID SPIELVOGEL (Valhalla, NY): I would like to ask all the speakers to please come up for the panel discussion. Do you have any questions for our distinguished panelists? DR EDWARD L. WOODS (Danville, PA): Should every patient with an elephant trunk have clips and pacing wires for a possible endograft? How long do you make the trunk for this purpose? DR LARS G. SVENSSON (Cleveland, OH): A good question. As far as the length of the elephant trunk, as you perhaps recall in a previous paper, we recommend that it be 10 to 15 cm. You want enough length so that if you are going to do a second stage, you can grab it without having to clamp the aortic arch. In other words, you do what we call a slash and grab: open the aorta, grab the graft, and clamp it. So that is what you want to have enough length for. On the other hand, for a second stage elephant trunk stent with an endograft, you don’t want it too long, because, as I pointed out, if it is too long you have got much more risk of it being foreshortened or concertinaed. We actually put clips now and pacing wires on all our patients, even the chronic dissections. Most of our chronic dissections end up having an open second stage procedure, because we still don’t believe that endografting is a good option, but occasionally we will stent a chronic dissection elephant trunk, but generally not. DR RANDALL B. GRIEPP (New York, NY): Let me just add something to that. Remember, when you put that elephant trunk in, it is in its flaccid state when it is hanging in the aorta. Once you connect it to your stent graft and pressurize it, it elongates because it is then pressurized. So you have to allow for that, too. DR R. SCOTT MITCHELL (Stanford, CA): I think it is worthwhile making some effort when you first place your elephant trunk, using your transesophageal echo to image it. When you are first placing it, it is pretty easy to take an aortic occlusion balloon or some other balloon and push it distally so you don’t get that wrapped-up configuration. You will then eliminate a lot of downstream headaches. DR GABRIELE B. BERTONI (Oxford, United Kingdom): We have seen this afternoon quite a few cases of Presented at Aortic Surgery Symposium X, New York, NY, April 27–28, 2006.
© 2007 by The Society of Thoracic Surgeons Published by Elsevier Inc
open operation to correct recent stent implants. Surely all these patients did well and recovered later in an open procedure. And we have also heard something about the cost of endovascular grafting versus open procedures, and that is my question to the whole panel. Do you follow a specific clinical indication for a less invasive treatment versus a safe open repair, and if not, how do you justify your choice in the face of a failure? DR SVENSSON: As a general rule, if I think a patient is going to live more than 5 to 10 years, I will tend to favor doing an open procedure. Certainly in the high-risk patients we will favor stent grafting, including in patients with second stage procedures. And as I mentioned, we usually try to make a decision in the ICU once we see how patients handle the first stage operation if that has preceded the decision, and then decide whether we should just go ahead and stent those patients then or let them recover and do the second stage open but later. DR BERTONI: I was not asking about the second stage operation. I am talking generally speaking about your choice to primarily treat a patient with stent grafting, or with a surgical operation. DR SVENSSON: I tried to answer that in the beginning. If it is a young patient with a likely long-term survival that is going to be very good, then we will often offer them an open procedure, particularly if it is a fairly straightforward operation. But the results are very good for, say, penetrating ulcers. For a straightforward case, like the saccular aneurysms, some of the coarctations, the patients with ischemia and dissection, endovascular stenting is an excellent approach. We have gotten very good results with traumatic ruptures. I will make one comment about the traumatic ruptures. We have learned that you need to cover the subclavian artery in virtually all the patients. So we do that primarily for traumatic ruptures, and the only traumatic ruptures we have had to operate on in probably 3 years have been the ones with failed placement of stent grafts. DR SPIELVOGEL: I would like to ask a question of the panelists and get their opinion. Let’s take a typical patient. Perhaps the patient has had a previous AAA repair and you are planning an endovascular intervention for a descending aneurysm. In this case, you are doing spinal cord monitoring intraoperatively: you have deployed the stent and your MEPs have disappeared or diminished considerably. You boosted the blood presAnn Thorac Surg 2007;83:S890 –2 • 0003-4975/07/$32.00 doi:10.1016/j.athoracsur.2006.11.092
AORTIC SURGERY SYMPOSIUM X DISCUSSION: SESSION IV—DESCENDING AND THORACOABDOMINAL AORTA
sure, you have your CSF drain already in place, you drain some CSF, keep the pressure low. What would you do if that endograft were in place and the MEPs continue to diminish? Or the patient has been awakened from anesthesia, you have asked him to move his legs, and he is not moving his legs. The CSF drain is in, and the stent is in. What would your approach be to that patient? DR GEERT WILLEM SCHURINK (Maastricht, Netherlands): As I tried to show in my talk, that happened in 2 patients, but not so dramatically that we were afraid that they would wake up paraplegic. But the first step would be to elevate the mean arterial pressure, and in most cases you will see the MEPs go up. That is the same as in open surgery. If the motor evoked potential goes down, the first step is to elevate the mean arterial pressure, and in most cases, also in open surgery, the MEPs come back. DR SPIELVOGEL: Would you ever attempt to immediately remove the endograft if the MEPs did not return? DR SCHURINK: Theoretically it is possible, and there is a case report on that for delayed paraplegia after stent grafting where the endoprosthesis was removed and the patient recovered partially. I think it is different to have paraplegia in an endoprosthesis situation than in an open situation, because you still have pressurization of the collateral circulation, and you probably won’t have as low a pressure in the collateral circulation as in an open situation. So perhaps there is more time for conversion. DR GRIEPP: I would just say that I expect that this does happen, and that you cannot reverse it by increasing the blood pressure. It may well be a problem with embolization or thrombosis, and I am not sure there is much you can do at that point. I suppose one theoretical alternative would be to poke a hole in the stent graft if you really thought repressurizing the intercostals would help, but I doubt that doing that would make a difference in most cases. DR SPIELVOGEL: I just remember Dr Jacobs telling me about a case that he had where he had a stent placed and the patient had delayed paraplegia, and he went in the next day when the patient developed neurologic symptoms and removed the endograft and repaired the aneurysm and had partial recovery. And I just wondered—rather than leaving the patient paraplegic— whether some people would consider doing something aggressive. DR RAJ K. BOSE (Tucson, AZ): This question is in reference to the excellent data from the Sinai group, but the question is directed to everyone. Respiratory failure is a major complication after open thoracoabdominal surgery. I would like the opinion of the panel as to how bad a respiratory status one would accept for an open procedure. For example, if you go just by FEV1, how low is too low before you turn the patient down? DR SVENSSON: If I could answer that, we did a study many years ago where we looked at patients having thoracoabdominal aneurysm repairs prospectively, and we found that at 1.2, the FEV1 is more or less where the cut point starts increasing to about a 20% risk of respira-
S891
tory failure. So below that we tend to be more cautious about what we do. DR KONSTADINOS A. PLESTIS (New York, NY): In our series, we had only 50% of the patients with preoperative pulmonary function tests, and when we ran the analysis for this particular group, we did not find that the FEV1 or any other of these volumes were independent predictors of respiratory complications after surgery. We are fairly aggressive in terms of operating on patients with preoperative COPD, and I guess emphasis would be given to preoperative optimization of those patients in an effort to get them through the operation. DR SVENSSON: Just to add that we found the best predictor of function was FEF 25/75, and that really is a test of the patient’s ability to cough after surgery. If that is below about 20% of predicted, then I am pretty cautious about doing an open procedure in those patients. DR MICHAEL T. JANUSZ (Vancouver, British Columbia, Canada): A question for Dr Griepp. When you are doing the cases and monitoring the spinal cord and sequentially dividing the intercostals, how often do you see the motor evoked potentials decrease or disappear, and what do you do about it? DR GRIEPP: It is actually pretty rare. We see it in perhaps as many as 5% of cases. It almost always responds to increasing the blood pressure. Perhaps another 3% or 4% are due to the anesthesiologist increasing the anesthetic agent and it can just be restored to normal by reducing the anesthesia. We divide the intercostals over a period of time. It usually takes an hour or so to dissect out the segment of aorta that you are going to resect, and we usually clip these about two or three at a time and then work somewhere else or do something else while we wait to see if the MEP changes. It is very rare to actually clip the segmental arteries, have the MEPs go away and not have them come back. Dr Spielvogel tells me that I told him for years that he had to watch out for it, and it finally happened in one of his cases. It is pretty uncommon to lose MEPs and not have them come back, but it is not so uncommon to see changes, and you can almost always fix it by increasing the blood pressure. But if what we see is characteristic of what happens in most series, perhaps 5% to 8% of our patients would actually be paraplegic if we hadn’t responded by increasing the blood pressure. There are times, if the MEPs begin to be a little tenuous, we ask ourselves whether we can stop the resection here. There is often a little more aneurysm downstream, but maybe it is not that bad. And so monitoring MEPs does affect our management probably in about 10% of the cases. DR SPIELVOGEL: We had a lot of discussion about malperfusion this morning with thoracic endografts, and I was curious, removing the endografts from the equation, what is the preferred management of these patients? The patient comes in, let’s say, with an arch tear or a tear right at the left subclavian with malperfusion. Perhaps your institution doesn’t have thoracic endografts or the ability to do percutaneous intervention. How
SUPPLEMENT
Ann Thorac Surg 2007;83:S890 –2
S892
AORTIC SURGERY SYMPOSIUM X DISCUSSION: SESSION IV—DESCENDING AND THORACOABDOMINAL AORTA
would you manage those patients? Many people have come up and asked me that question: what if I don’t have these cutting-edge modalities? So I thought about perhaps using some of our traditional techniques and discussing how you would approach it. DR MITCHELL: If it is an arch problem, I would first start with an arch repair and redirect flow surgically with an elephant trunk into the true lumen in the acute situation, but we would then almost immediately do intraoperative imaging to make sure that we had in fact reversed the malperfusion. But we of course have the luxury of interventionalists who are quite talented and can help us there. DR SVENSSON: I would add also that most institutions have bare stents, and for a lot of our acute dissections with ischemia, we just would use bare stents. I don’t think you have to have covered stents to do that. Usually your radiologist or the cardiologist can do that for you. So I would seek advice from them, too. If you do a corrective open procedure and you still have ischemia, then that is what we would do. And we will often, if we suspect that there is, say, gut ischemia, do a minilaparotomy and see if there is evidence of gut ischemia at the same time as their ascending aorta or arch repair. And then if there is ischemia, quickly take the patient to the catheterization lab or the vascular lab and open up the vessels. DR JOSEPH S. COSELLI (Houston, TX): In the past we have actually had some rather good results with replacing the upper portion of the descending thoracic aorta and then redirecting everything back into the true lumen. This has worked even in patients who might otherwise have needed a femorofemoral bypass. And a couple of cases that have been 4 or 5 days after dissection, and then progressed to renal failure and were on hemodialysis, responded to that. It is anecdotal. But over the last number of years, with close association with our interventional radiologists, we have almost never had to take on these malperfusion issues surgically. The combination we have been able to use, as already mentioned, is stenting into the visceral vessels for dynamic occlusion, and fenestration and ballooning the fenestrations for more static malperfusion problems. Similarly in the iliac arteries, it is very rare to have to address malperfusion. I think the more important issue there almost has become the timely diagnosis of malperfusion. If it in-
Ann Thorac Surg 2007;83:S890 –2
volves the leg, it is pretty obvious pretty quickly and it is fairly straightforwardly dealt with. The more complicated questions concern particularly visceral malperfusion, which can present late. I think it is incumbent upon us, as we manage these patients, stents and otherwise, to try to make our best assessment at the completion of the procedure and be as certain as we can that we don’t have a malperfusion problem. And then an equally daunting problem is in the patient who is otherwise in reasonably good shape but has lost one kidney now and has one good kidney. For the time being, the renal function is probably adequate to sustain itself, but as the survival of these patients becomes improved by interventions over time, I think preserving the kidney compromised by malperfusion and not writing that kidney off is going to have an increase in importance. DR SPIELVOGEL: Has anyone had any experience with abdominal fenestration? DR SVENSSON: One of our vascular surgeons had a period when he was trying to do fenestrations for acute dissections with ischemia, and we had a couple of deaths from that. Some of the patients we tried to save, but that didn’t work out well. If you try to do a fenestration and then tear it—and that was the way it was being done— you can tear the entire aorta. There has been some success with just putting a wire across the septum and then ballooning it, but I don’t think that is really the definitive way to handle this. DR COSELLI: Are you referring to the procedure that John Elefteriades describes? DR SPIELVOGEL: Yes. DR COSELLI: I think that is a very valuable technique. We have used that a few times with good success. And I think it needs to be in our repertoire simply because there are some patients that will technically confound our interventional radiologists to rectify the problem, and you may be at an institution or in a situation in the middle of the night or the weekend where you just simply don’t have the interventional capabilities. It is a fairly simple straightforward procedure, and I do think in rare situations it is something that can be successful, and we should at least keep it in our back pocket.
SUPPLEMENT