Permissive Hypertension and Collateral Revascularization May Allow Avoidance of Cerebrospinal Fluid Drainage in Thoracic Endovascular Aortic Repair.

Background: The utility of cerebrospinal fluid drainage (CSFD) for prevention of spinal cord ischemia (SCI) after thoracic endovascular aortic repair (TEVAR) remains unclear. We previously published our institutional algorithm restricting preoperative CSFD to patients deemed high risk for SCI. Since that publication, our algorithm has evolved with preoperative CSFD avoided in all patients undergoing isolated descending TEVAR with or without arch involvement (+/- arch TEVAR).

Back stabber: ladder fall causing traumatic aortic transection.

A 68-year-old man presented with back pain after falling from a ladder and was found to have anterolisthesis of thoracic vertebrae T11-12 with secondary focal aortic injury and disruption of the aortic wall. This was successfully repaired using thoracic endovascular aortic repair (TEVAR) followed by spinal fusion with excellent result.

Outcomes of Planned Two-Stage Hybrid Aortic Repair With Dacron-Replaced Proximal Landing Zone.

Background: Results of hybrid arch repair (HAR) using the native zone 0 proximal landing zone (PLZ) have been unsatisfactory in many series, especially in the setting of ascending aortic dilation (>4.0 cm). This study reports early and late outcomes of planned two-stage HAR with open first-stage proximal aortic replacement, followed by second-stage thoracic endovascular aortic repair (TEVAR) with PLZ within the Dacron-replaced zone 0.

Jejunal arterial access for retrograde mesenteric stenting.

Endovascular approaches have replaced open surgical revascularization in most patients with mesenteric ischemia; however, flush ostial occlusions may not be amenable to traditional antegrade access. Retrograde mesenteric stenting has been previously described, but this technique requires a formal laparotomy and dissection of the proximal superior mesenteric artery. We present here a modification of this technique that requires only a "mini-laparotomy" and no open vascular repair of the superior mesenteric artery as well as a review of our initial institutional experience with this procedure.

Outcomes of Reoperation After Acute Type A Aortic Dissection: Implications for Index Repair Strategy.

Background: The optimal surgical approach for management of acute type A aortic dissection remains controversial. This study aimed to assess outcomes of reoperation after acute type A dissection repair to help guide decision making around index operative strategy.

Methods And Results: All aortic reoperations (n=129) at a single referral institution from August 2005 to April 2016 after prior acute type A dissection repair were reviewed.

Long-term results of endovascular repair for descending thoracic aortic aneurysms.

Objective: Since thoracic endovascular aortic repair (TEVAR) received U.S. Food and Drug Administration approval for the treatment of descending thoracic aneurysms in March 2005, excellent 30-day and midterm outcomes have been described.

Endovascular and Open Repair of Ruptured Infrarenal Aortic Aneurysms at a Tertiary Care Center.

Background: The mortality of ruptured abdominal aortic aneurysms (rAAAs) has been reported as high as 90%. Loss of consciousness and a systolic blood pressure of <80 mm Hg on presentation are the most important predictors of mortality after emergent open repair (OR). Endovascular repair of abdominal aortic aneurysm (EVAR) has reduced short-term operative mortality and morbidity for elective abdominal aortic aneurysm repair, and may be advocated for wider application of EVAR for rAAA.

Complementary roles of open and hybrid approaches to thoracoabdominal aortic aneurysm repair.

Objective: Thoracoabdominal aortic aneurysm (TAAA) repair remains a significant challenge with considerable perioperative morbidity and mortality. A hybrid approach utilizing visceral debranching with endovascular aneurysm exclusion has been used to treat high-risk patients and therefore allow repair in more patients. Limited data exist regarding long-term outcomes with this procedure as well as comparison to conventional open repair.

Concomitant Thoracic Aortobifemoral Bypass With Left Ventricular Assist Device Implantation.

Improved quality of life for patients after left ventricular assist device (LVAD) implantation can be greatly limited by peripheral vascular disease even if heart failure symptoms are resolved by LVAD support. We present a case of concomitant thoracic aortobifemoral bypass and LVAD implantation in a patient with ischemic cardiomyopathy, severe peripheral vascular disease, and multiple previous failed revascularization attempts. In this patient, we used the LVAD outflow to provide the inflow to the femoral artery bypass graft.

Evolving practice pattern changes and outcomes in the era of hybrid aortic arch repair.

Objective: The role of hybrid repair in the management of aortic arch pathology, and long-term outcomes with these techniques, remains uncertain. We report a decade of experience with hybrid arch repair (HAR) and assess institutional practice patterns with regard to the use of hybrid and open techniques.

Methods: Hybrid and open total and distal arch procedures performed between July 2005 and January 2015 were identified from a prospectively maintained, institutional aortic surgery database.

Adult surgical experience with Loeys-Dietz syndrome.

Background: Loeys-Dietz syndrome (LDS) results from mutations in receptors for the cytokine transforming growth factor-β leading to aggressive aortic pathology sometimes accompanied by specific phenotypic features including bifid uvula, hypertelorism, cleft palate, and generalized arterial tortuosity. We reviewed our adult surgical experience with LDS in order to validate current recommendations regarding management of this newly described disease.

Methods: All adult (≥ 18 years old) patients with LDS undergoing surgical treatment at a single referral institution from September 1999 to May 2013 were retrospectively reviewed.

Spliced arm vein grafts are a durable conduit for lower extremity bypass.

Background: Many patients with peripheral vascular disease (PAD) requiring revascularization do not have adequate ipsilateral great saphenous vein (GSV) for constructing a bypass because of intrinsic vein disease or prior harvesting for limb or coronary bypass. Prosthetic conduits have poor long-term patency, especially for distal bypass. With advancing endovascular sophistication, tibial angioplasty may be a good revascularization option, but we hypothesize that using spliced arm vein for distal lower extremity bypass is still a well-tolerated and more durable solution.

Thoracic endovascular aortic repair for chronic DeBakey IIIb aortic dissection.

Background: Thoracic endovascular aortic repair (TEVAR) for chronic DeBakey IIIb dissection with associated descending aneurysm remains controversial. This study examines long-term results of TEVAR for this disorder including examination of anatomic features associated with TEVAR outcomes.

Methods: Between July 2005 and January 2013, 32 patients underwent TEVAR for chronic (>30 days) DeBakey IIIb dissection involving the descending thoracic aorta at a single institution and constituted the study cohort.

Role of cardiac evaluation before thoracic endovascular aortic repair.

Background: Patients with thoracic aortic disease undergoing thoracic endovascular aortic repair (TEVAR) often have concomitant coronary artery disease and are at risk for perioperative adverse cardiac events. Despite this risk, the need for and extent of preoperative cardiac workup before TEVAR remain undefined. This study seeks to assess the adequacy of a limited cardiac evaluation before TEVAR, including assessment of cardiac symptoms, resting electrocardiography (ECG), and transthoracic echocardiography (TTE), as well as to estimate the incidence of perioperative cardiac events in patients undergoing TEVAR.

Current management and outcome of chronic type B aortic dissection: results with open and endovascular repair since the advent of thoracic endografting.

Background: Thoracic endovascular aortic repair (TEVAR) has become the preferred treatment for chronic type B aortic dissection (CTBAD) at our institution. However, it remains incapable of treating all patients with CTBAD. The present study aims to review our contemporary results with open and endovascular CTBAD repairs since the advent of thoracic endografting.

Insurance status predicts acuity of thoracic aortic operations.

Objective: Nonelective case status is the strongest predictor of mortality for thoracic aortic operations. We hypothesized that underinsured patients were more likely to require nonelective thoracic aortic surgery because of reduced access to preventative cardiovascular care and elective surgical services.

Methods: Between June 2005 and August 2011, 826 patients were admitted to a single aortic referral center and underwent 1 or more thoracic aortic operations.

Atypical aortic thrombus: should nonoperative management be first line?

Background: Aortic thrombus in the absence of atherosclerotic plaque or aneurysm is rare, and its optimal management remains unclear. Although atypical aortic thrombus (AAT) has been historically managed operatively, successful nonoperative strategies have been recently reported. Here, we report our experience in treating patients with AAT that has evolved from a primarily operative approach to a first-line, nonoperative strategy.

Comparison of attachment site endoleak rates in Dacron versus native aorta landing zones after thoracic endovascular aortic repair.

Objective: Type I attachment site endoleaks are the most common cause for reintervention after thoracic endovascular aortic repair (TEVAR) and represent treatment failures. Deployment of endografts in segments of the aorta previously replaced with Dacron grafts may be associated with reduced type I endoleak due to mechanical stability and decreased potential for aortic remodeling. However, no study has rigorously examined endoleak rates in Dacron landing zones vs native aorta.

Five-year results for endovascular repair of acute complicated type B aortic dissection.

Introduction: Despite a current lack of U.S. Food and Drug Administration approval for the indication, thoracic endovascular aortic repair (TEVAR) has replaced open surgical management for acute complicated type B aortic dissection due to promising short- and midterm data.

Thoracoabdominal aortic aneurysm: hybrid repair outcomes.

Background: Thoracoabdominal aortic aneurysms (TAAA) remain amongst the most formidable of surgical challenges, particularly degenerative aneurysms in the elderly population with concomitant pulmonary disease. This report presents an update of our robust single-institution experience with "hybrid" TAAA repair including complete visceral debranching and endovascular aneurysm exclusion in high-risk patients.

Methods: Between March 2005 and June 2012, 58 patients underwent extra-anatomic debranching of all visceral vessels followed by aneurysm exclusion via endovascular means at a single institution.

Results with selective preoperative lumbar drain placement for thoracic endovascular aortic repair.

Background: The optimal use of lumbar cerebrospinal fluid drainage for the prevention of spinal cord ischemia (SCI) with thoracic endovascular aortic repair (TEVAR) remains unclear. Here, we report our experience with selective preoperative lumbar drain placement with TEVAR.

Methods: Between May 2002 and January 12, 381 TEVAR procedures were performed at a single referral institution.

Intrathoracic subclavian artery aneurysm repair in the thoracic endovascular aortic repair era.

Objective: Intrathoracic subclavian artery aneurysms (SAAs) are rare aneurysms that often occur in association with congenital aortic arch anomalies and/or concomitant thoracic aortic pathology. The advent of thoracic endovascular aortic repair (TEVAR) methods may complement or replace conventional open SAA repair. Herein, we describe our experience with SAA repair in the TEVAR era.

Management of acute type B aortic dissection.

Acute type B aortic dissection (identified within 2 weeks of symptom onset), as described using the Stanford classification, involves the aorta distal to the left subclavian artery and accounts for 25%-40% of all aortic dissections. The traditional treatment paradigm of medical management for uncomplicated acute type B dissection and open surgical intervention for early or late complications of type B dissection is currently undergoing a period of evolution as a result of the influence of minimally invasive thoracic endovascular aortic repair options. Thoracic endovascular repair has replaced open surgical repair as the preferred treatment for complicated acute type B dissection, and may also prove beneficial for prophylactic repair of uncomplicated acute type B dissection for high-risk patients.