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Interact CardioVasc Thorac Surg 2007;6:S1-S172. doi:10.1510/icvts.2007.0000S1 © 2007 European Association of Cardio-Thoracic Surgery
AbstractsSuppl. 1 to Vol. 6 (May 15, 2007)
C1-1 RESULTS OF BEATING HEART SURGERY WITH DOUBLE ITA IN ELDERLY PATIENTS J.Ph.Verhoye, I. Abouliatim, V.G. Ruggieri, I.S. Ibrahim, A. Tauran, A. Ingels, T. Langanay, A. Leguerrier, H. Corbineau Department of Thoracic and Cardiovascular Surgery, Rennes, France Objective: As life expectancy increases, more elderly patients are referred for CABG. Higher patency rate of internal thoracic arteries, lack of adequate venous material and low incidence of stroke can make off-pump bilateral internal thoracic arteries grafting attractive for elderly patients. Methods: Between October 1999 and July 2005, 358 patients aged 70 years or older underwent off-pump CABG using double pedicled internal thoracic arteries. 7.3% of patients (n=26) were 80 years or older, 10.1% (n=36) had emergent surgery. Twenty four percent of patients (n=85) were obese and 8.9% (n=32) were diabetics. Mean number of distal anastomoses was 2.4±0.6 per patient. Mean follow-up was 3.4±1.6 years and completed for all patients but six. Results: Hospital mortality rate was 2.8% (n=10). Survival rate was 94.3, 88.4 and 67.6% at respectively 1, 3 and 6 years. Mediastinitis rate was 1.95% (n=7). Postoperative infarction was 3.6% (n=13). Peri-operative intra-aortic balloon contra-pulsation was required in 2% (n=7). During the postoperative time, 19 patients (5%) required inotropic support. Postoperative stroke was 0.3% (n=1). Mean bleeding rate was 496.95 ml. Atrial fibrillation occurred in 84 patients (23.4%) after surgery persisting in 13 patients at discharge. Two patients required hemodialysis. Freedom from cardiac death was 99.7, 99 and 95% at respectively 1, 3 and 6 years. Eight patients (2.2%) required control coronarography for remaining angina. We found two thrombosed graft and one significant stenosis. Conclusions: Off-pump CABG using double internal thoracic arteries for elderly patients carries relatively low mortality and morbidity rate that can be compared with on-pump surgery with the advantage of very low incidence of neurological events in this series.
Department of Cardiac Surgery, Montreal Heart Institute, Montreal, Canada Objective: Off-pump coronary artery bypass surgery (OPCAB) is currently used as an alternative to conventional ‘on-pump’ surgery, especially on higher-risk patients such as diabetic patients. The aim of this study was to compare long-term results of OPCAB surgery in diabetic and non-diabetic patients. Methods: This is a retrospective analysis of prospectively gathered data over an 8-year period of 1000 consecutive and systematic OPCAB patients operated on between September 1996 to April 2004. Average follow-up period was 57±26 months and was 97% complete. Results: Two hundred and seventy eight procedures were performed in diabetic patients (DM) and 722 in non diabetic patients (NDM). Prevalence of hypertension (P<0.0001), obesity (P<0.0001), chronic renal failure (P<0.0001), pulmonary hypertension (P<0.0001), peripheral vascular disease (P=0.009), congestive heart failure (CHF) (P<0.0001), emergent surgery (P=0.03), and triple vessel disease (P=0.01) were more frequent in diabetics. Redo surgery (P=0.005) and bilateral internal thoracic artery bypass (<0.0001) were more frequent done in the non diabetic group. The ‘no touch’ technique was more frequent in diabetics (P=0.01). There was no difference in 30 day mortality between the two groups. Univariate study determined that age (P=0.005), carotid vascular disease (P=0.057), and chronic renal failure (P=0.005) were determinant for operative mortality for the entire cohort, while preoperative chronic atrial fibrillation (P=0.004), chronic renal failure (P=0.044) and emergent surgical revascularization (P<0.0001) were more specifically determinant of operative mortality in the diabetic population. Eight year survival (P=0.01) and survival free of major cardiac adverse event (MACE) (P=0.02) was decreased in the diabetic group. Cox regression analysis model revealed that age (RR=1.07), peripheral vascular disease (RR=1.9), carotid disease (RR=1.6), CHF (RR=1.97), incomplete revascularization (RR=2.02), and LVEF (RR=0.17), but not diabetes (P=0.13) were significant determinants of long-term survival. Similarly, CHF (RR=1.74), PVD (RR=1.98), chronic renal insufficiency (RR=2.45), emergent operation (RR=2.04), and previous percutaneous coronary intervention (RR=1.6) were determinant of MACE-free survival but not diabetes (P=0.3). Breaking down the MACE, diabetes was found a borderline independent predictive factor of CHF (P=0.06) and cardiac death (0.07). Conclusions: In our series OPCAB was as safe and effective in diabetic than non-diabetic patients. Long-term survival was comparable in both populations. However diabetes was a potential risk factor for long-term CHF and cardiac death.
University Hospital of Strasbourg, Strasbourg, France; University Hospital, Strasbourg, France Objective: The aim of the study is to evaluate angiographic results in a prospective randomised study comparing off pump coronary bypass surgery (Group I) and conventional technique (Group II). Methods: Three hundred and forty five patients were prospectively included (183 in group I, 163 in group II). Exclusion criterias were: severe ventricular arrythmia, associate mitral or aortic insufficiency and extensive coronary calcifications. There was no significant difference in age, gender, risk factors, ventricular function between the two groups. 86.1% of the patients suffered triple or double vessel disease and they received 2.2–2.4 conduits per patient with no difference in the two groups. Death (0.6%) and complications rates were comparable and we observed as published in other papers less blood transfusion, less bleeding, less myocardial damage (Troponine and CPKmB) in group I. Results: Two hundred and thirteen patients finally accepted post operative angiography (62.3% in group I, 61.1% in group II) with 470 bypass grafts controlled. Early patency rates were 92% (group I) vs. 95.7% (group II) for the LAD revascularisation (n=206), 76.2% vs. 100% in the Diagonal branches (n=43 P=0.021), 76.6% vs. 93.3% on the marginal branches (n=124, P=0.010), 67.4% vs. 86.1% on the right coronary artery (n=79, P=0.053) and 85.7% vs. 90.9% on the retroventricular branches (n=18, P=0.73). Conclusions: Beating heart surgery offers a valuable alternative to conventional CABG in terms of clinical results and complications rates. Quality of surgical revascularisation is equal on the LAD and right coronary artery but is significantly lower on the marginal and diagonal branches. These results suggest more selective indications for OPCAB and further controlled studies with evaluation of the quality of the technical results using angiograms or coro CT scan.
Silesian Centre for Heart Disease, Zabrze, Poland Objective: The incidence of coronary bypass surgery in elderly patients has been increasing. Clinical outcomes and problems following coronary artery bypass surgery in elderly patients have not been clarified. This retrospective study was aimed at assessing the results and rate of complications following bypass surgery using two surgical techniques in elderly patients. Methods: We analyzed 1128 consecutive patients over 65 years of age who underwent myocardial revascularization with (n-669, group CABG) and without (n-459, group OPCAB) extracorporeal circulation from January 2003 to December 2005. After matching age, gender, extent of coronary artery disease, EF, NYHA, and diabetes the two groups were compared in two revascularization modalities. The number of patients with carotid disease in the CABG group was lower: 7.5% (50/669) vs. 12.2% (56/459) P<0.01 in the OPCAB group. Preoperative and postoperative variables were analyzed such as reoperation, MI inotropic support, IABP, wound infection, neurological complications. Time-related events were described using the Kaplan-Meier estimate. Results: The mortality rate was 2.8% (19/669) vs. 2.6% (12/459) in the OPCAB group. The incidence of complications (CABG vs. OPCAB) such as low cardiac output were 36.2% (242/669) vs. 22.2% (102/459) P<0.001, IABP6, 7% (45/669) vs. 3.3% (15/459) (P<0.05), MI 3.9% (26/669) vs. 3.5% (16/459), reoperations 4.2% (28/669) vs. 1.5% (7/459) P<0.05, neurological complications 12.3% (82/669) vs. 6.3% (29/459) P<0.001. Postoperative intensive care unit and hospital stays were lower in OPCAB group, 7.29 vs. 6.84 days <0.001. The frequency of blood transfusion was significantly higher in the CABG group, 334 (49.9%) vs. 121 (26.4%) P<0.001. The Kaplan-Meier estimate revealed a similar 36-month survival rate: 92.5% vs. 91% and cardiac eventfree rate 78% vs. 77% in the CABG vs. the OPCAB technique. Conclusions: Off-pump technique used in coronary bypass surgery in elderly patients provides better results in terms of inotropic and IABP support, reoperations, time of ICU and hospital stay compared to the results of the CABG technique. Furthermore, the rate of neurological complications were lower in the OPCAB group despite the higher number of patients with carotid disease.
Division of Cardiac Surgery, Ospedale Papardo, Messina, Italy; Division of Cardiac Surgery, Università Cattolica del Sacro Cuore-Pol. A. Gemelli Roma, Roma, Italy Objective: To evaluate the clinical results and the biocompatibility of the mini-extracorporeal circulation system (MECC) in comparison to off-pump coronary revascularization (OPCABG). Methods: In a prospective, randomized study 161 patients underwent coronary surgery with the use of the mini-extracorporeal circulation system and 159 patients underwent OPCABG. Endpoints were: a) circulating markers of inflammation and organ injury; b) hemostatic activation indices; c) operative results; d) outcome at one-year follow-up. Results: Operative mortality and complications rates were comparable among groups. Release of inflammatory markers was similar between groups at all timepoints (peak IL-6 169.0±113.5 vs. 181±5.9, in the OPCABG vs. miniextracorporeal circulation system group, respectively, P=0.15). Peak creatine kinase was 422.4±100.1 vs. 325±74.3 (P=0.30), and peak S100 protein 0.13±0.09 vs. 0.29±0.2 (P=0.059). Length of hospital stay was similar for both groups. Three cases of angina recurrence at one year in mini-extracorporeal circulation system group vs. five cases in OPCABG group could be observed (P=0.50). Residual perfusion defect at myocardial nuclear scan was less frequent among individuals operated on with the mini-extracorporeal circulation system (4 vs. 10 cases; P=0.16). There were seven (OPCABG group) vs. four (mini-extracorporeal circulation system group) occluded or severely stenotic coronary grafts at one year (P=0.52, OR 0.55, 95% CI 0.13-2.16). Conclusions: The clinical results of coronary revascularization with the mini-extracorporeal circulation system are optimal when performed by experienced teams. The one-year outcome is comparable to OPCABG. The mini-extracorporeal circulation system is associated to little pump-related systemic and organ injury. It may achieve the benefits of OPCABG (less morbidity in high-risk patients) while facilitating complete revascularization in case of complex lesions unsuitable for OPCABG.
Cardiovascular Surgery, Lausanne, Switzerland Objective: Cardiopulmonary bypass (CPB) with aortic cross-clamping and cardioplegic arrest remains the method of choice for patients requiring myocardial revascularization. Very high risk patients suffering of instable angina and acute cardiac decompensation, can have a poor outcome after CPB and cardioplegic arrest. On-pump beating heart surgery seems to be the valid solution for these patients. We describe our clinical experience. Methods: From December 2004 to January 2006, 25 patients (mean age 69±7 years) requiring emergency myocardial revascularization were operated in our hospital. The mean left ventricle ejection fraction (LVEF) was 27±8%. Nine patients (35%) suffering of acute cardiac decompensation needed a preoperative intra-aortic balloon pump. The majority of them (88%) suffered of tri-vessel coronary disease and only six (25%) had a left main stump disease. Thirteen patients (53%) had a EuroSCORE above 9. Results: Mean number of graft/patient was 2.9±0.6 and LIMA was used in 21 patients (88%). Mean CPB time was 84±19 min. The in-hospital mortality was 11% and there were no postoperative myocardial infarctions. Eight patients had transitorily kidney insufficiency and one patient developed a sternal wound infection. The mean hospital stay was 12±6.7 days. Twenty two patients survived at surgery were followed-up (mean time: 20±5.5 months). One patient died for cardiac arrest. The LVEF grew to 38±6% at the echocardiogram. All patients have a good quality of life. Conclusions: In our clinical experience, patients undergoing urgent on-pump beating heart coronary revascularization have a better outcome compared to the standard procedure. For this reason we strictly recommend this technique in this group of patients.
Department of Cardiac Surgery, Heart Center, Euromedica Kyanous Stavros, Thessaloniki, Greece Objective: Coronary artery by-pass surgery on the beating heart without extracorporeal circulation is a milder aggravation for the patient compared to on pump surgery, allowing immediate extubation of the patient in the operating room. The benefits of this technique are reduced intensity of postoperative care, shorter stay in the ICU and fewer complications from shorter mechanical ventilation and ICU length of stay. Methods: We present our experience in 192 unselected patients that underwent coronary artery by-pass on the beating heart under general anesthesia using an ultra short acting opiate (remiphentanyl) without epidural analgesia. Results: One hundred and eighty patients of the total 192 were extubated in the operating room (177 in <20 min), while 12 cases were converted to standard fast track anesthesia during the operation. Two patients died, four stayed in the ICU for more than 20 h, five had longer overall hospital stay and 13 experienced major complications (myocardial damage 6, transient cerebral ischemia 1, worsening of the renal function 3, psychosis 3). Conclusions: Immediate termination of the mechanical ventilation after coronary artery by-pass grafting on the beating heart is applicable and safe even in high risk patients and adds to the advantages of avoiding the cardiopulmonary by-pass.
Department of Cardiac Surgery, University of Munich, Munich, Germany Objective: The overall benefit of intracoronary shunts in OPCAB procedures is not yet fully realised. Due to constant coronary bloodflow shunts reduce myocardial ischemia and allow longer time spans for performing distal anastomoses. On the other hand it is believed that shunts cause significant damage to the endothelial cell layer of the respective coronary arteries. Our experiences from previous postoperative angiographies indicated that the use of a shunt may lead to vasoconstriction of the respective coronary arteries. Methods: Ten vein graft anastomoses were performed by use of an intracoronary shunt (group 1). The first two patients received 10000 IE Heparin, the latter seven patients additionally diltiazem i.v. throughout the whole procedure. Ten anastomoses were performed without use of a shunt in different patients (group 2). Intraoperative bypass-angiography was performed prior to the central anastomoses and at the end of the operation. Additionally, bypass blood flow measurements were done at the end of the operation. Results: Group 1: All anastomosed coronary arteries showed stenotic areas immediately adjacent to the anastomoses. In two cases we performed a revision of all anastomoses although intraoperativ bypass blood flow was sufficient. When diltiazem was administered the stenotic lesions were either less impressive or not detectable. Group 2: There were no stenotic areas detectable. Conclusions: We conclude that the use of an intracoronary shunt may cause a vasoconstriction of the respective coronary artery. When diltiazem is administered vasoconstriction is reduced. Therefore diltiazem should be administered whenever possible in order to exclude vasospasms.
Struttura Complessa Cardiochirurgia Ospedale Santa Croce, Cuneo, Italy; Struttura Complessa Di Cardiologia Ospedale Santa Croce, Cuneo, Italy; Struttura Complessa Di Terapia Intensiva Cardiovascolare, Cuneo, Italy Objective: Quality of revascularization and incidence of early and late adverse events have been examined for two different indication strategies of off-pump coronary artery bypass (OPCABG) in a single centre. Methods: From June 2000 to January 2005 three-hundred patients underwent OPCABG in S. Croce Hospital, Cuneo, Italy. One hundred-twenty patients (group A) were selected for co-morbidities considered high-risk for cardio-pulmonary bypass by four surgeons (14% of their CABG, low volume procedure surgeons). One-hundred eighty unselected patients (group B) were operated by a single surgeon (90.9% of his CABG, high volume procedure surgeon). Mean follow-up of 42 months was 98.4% complete. Results: All-causes hospital mortality was 1.3%. Six-years actuarial freedom from recurrence of ischemia, all-causes death, cardiac death, target vessel revascularization and revascularization for failure of OPCABG was respectively 88.4%±2.9%, 84.6%±3.3%, 93.0%±2.7%, 94.2%±1.9%, 93.8%±2.0%. Patients of group A had older age (mean 71 vs. 67.7), higher mean risk predicted by EuroSCORE (6.18 vs. 4.56), less diffuse coronary disease (threevessel disease 38.3% vs. 77.7%), less complete numeric revascularization (44.1% vs. 80.5%) and less complete lateral wall revascularization (45.9% vs. 96.5%) than patients of group B. At follow-up 11/16 repeat revascularizations were in group A. Conclusions: Repeat revascularization was principally caused by graft failure and was more frequent in the group of selected patients. This finding suggests a benefit of high OPCABG procedure volume on mid-term outcome.
Department of Cardiac Surgery, Erasme Hospital-Brussels University, Brussels, Belgium Objective: We report our experience of on-pump (Group ON) and off-pump (Group OFF) full arterial coronary artery bypass grafting (CABG) using both internal mammary arteries anastomosed as a Y-shaped mounting. Methods: A prospective single center non randomized clinical study was conducted between January 2003 and November 2006. It compared the short-term clinical outcomes of ON- and OFF-pump arterial revascularization where the LIMA was anastomosed to the LAD while the free RIMA graft taking off from the LIMA was used to bypass different coronary targets. Results: One hundred and twenty three patients were divided into 51 on-pump and 72 off-pump procedures based on the intention to treat. The mean age in both groups was 59.5±11 and 69±11 year old respectively (P<0.05). Mean predictive logistic EuroSCORE was 2.4% for the ON-pump group and 7% for the OFF-pump group (P<0.0001). Operating times were 223±39 min (group ON) and 175±48 min (group OFF) (P<0.001). Mean number of distal anastomoses were 2.7±0.6 (group ON) and 2.5±0.6 (group OFF) (P=0.11). Postoperative mortality was four patients (5.5%) in the off-pump group and three patients (6%) in the on-pump group (P=0.86). No major adverse coronary event and no late death were reported during the follow-up that averaged 20.5±13.8 months. Conclusions: The use of a free RIMA as Y-graft from the LIMA is a valuable option to enable total arterial revascularization. In off-pump CABG it eradicates aortic manipulations and provides a mortality similar to the one achieved in a lower risk population operated ON-pump.
C2-1 FLANGED BENTALL TECHNIQUE: TEN YEARS EXPERIENCE B. Kiran, K. Kirali, I. Mataraci, M. Rabus Bülent, M. Toker Erdem, A. Erkin, M. Balkanay, C. Yakut Kosuyolu Heart and Research Hospital, Istanbul, Turkey Objective: Surgical technique for aortic root replacement is replacement of aortic root with a composite graft integrated with prosthetic mechanical valve. The aim of our study was to evaluate the 10-year results of aortic root replacement with our new modified Bentall technique. Methods: Between January 1996 and December 2006, 200 patients underwent aortic root replacement. Aortic root was replaced with a new modified flanged composite graft. Operation indications were the ascending aortic aneurysm, acute aortic dissection, the ascending aortic dilatation with severe calcified aortic stenosis or severe aortic insufficiency and combinations of all. One hundred and sixty four patients were male (82%), 36 were female (18%) and mean age was 49.5. Forty two patients (21%) underwent more than one cardiac procedure. Results: Mean aortic cross clamp time was 91.2 min and cardiopulmonary bypass time was 147.3 min. Retrograde cerebral perfusion was used in 37 patients. Mean operation time was 4.8 h. Operative mortality was 8% with 16 patients. There were no patient mortality by the complications of flanged technique and no patient was re-operated. Late mortality was observed only in eight patients (4%). Conclusions: Flanged composite graft has favorable late results with the fewer complication percentages due to prosthetic materials. Newly reconstructed sinuses by the help of flanged technique are useful especially to remain the physiologic of aortic root.
Department of Cardiothoracic Surgery, University Hospital Policlinico ‘G.Martino’, Messina, Italy; Department of Cardiothoracic Surgery, University Hospital ‘San Giovanni Battista’, Turin, Italy; Department of Cardiothoracic Surgery, University Hospital ‘Policlinico San Matteo’, Pavia, Italy Objective: The use of minimally invasive approach for the treatment of the cardiac diseases is increasing and is obtaining a wide consensus but is it still challenging for many surgeons. We report our experience of the treatment of the ascending aortic diseases using the Bentall-de Bono procedure through a minimally invasive approach. Methods: Between September 1997 and June 2005 at Policlinico San Matteo, Pavia, we treated 40 patients affected by ascending aortic diseases using a Bentall-DeBono procedure through a minimally invasive approach, by the mean of a reversed T or J ministernotomy. Data were analysed retrospectively. Thirty patients were male (75%). All of the patients had ascending aortic diseases with aortic valvular regurgitation. Moreover three patients had Stanford Type A aortic dissection, one had chronic dissection, Stanford type B, one a concomitant prosthetic endocarditis on aortic valve prosthesis, one an associated aortic coarctation and one an aortic valve stenosis-insufficiency. Short and mid-term mortality, perioperative complications were analyzed. Results: None died during the 30-day after surgery. The mean ICU and LOS time were 3.3±8.2 and 9.3±7.2 days. Six patients (15%) had one or more postoperative complications. One patients (2.5%) underwent early reoperation for bleeding. None underwent a reoperation related to the Bentall-De Bono procedure. Mechanical ventilation was longer than 48 h in five patients (12.5%). The mean follow-up was 38.4±31, the total follow-up was 93 months. Survival at 1, 3 and 5 year was respectively 94.1%, 90.6%, and 90.6%. At the end of the follow-up there were 37 survivors. Twenty seven patients (73%) were in NYHA I, six (16%) in NYHA II, and four (11%) were in NYHA III. Conclusions: Reversed T or J ministernotomy is a feasible and secure alternative to full sternotomy. The short incision may enhances the outcome and does not affect the survival, offering proper access to the anatomic structures.
Bakoulev Center for Cardiovascular Surgery, Moscow, Russian Federation Objective: The purpose of this presentation was to analyse the 16-year experience with clinical use of biological conduit in the surgery of ascending aortic aneurysms according to Bentall-DeBono technique. Methods: From 1990 to December 2006 xenopericardial conduit was implanted in 415 patients, in 28 (6.7%) of them the conduit contained biological valve made of the same tissue, in 387–different mechanical prostheses. Main causes of aneurysm formation were cystic media necrosis in 41.9% (174 patients) and atherosclerosis in 34.5% (143 patients). Two hundred and eight (50.2%) patients were re-operated for dissecting aortic aneurysms. Dissection of DeBakey type I was diagnosed in 67 (15.7%) patients. In all cases bioconduit was implanted according to Bentall-DeBono technique, ten patients underwent simultaneous intervention on the aortic arch. In 46 cases (11.2%) the surgery on the ascending aorta was combined with the correction of associated pathology (CABG, interventions on AV valves, resection of aortic coarctation). Results: Total hospital mortality was 9.2%. The causes of death were not conduit-related. Three patients underwent successful re-operation within 1.5 months in connection with prosthetic endocarditis. All of them received a new xenopericardial conduit. Mean follow-up period was 7.6±1.4 years (6 months – 16 years). Seven patients were re-operated: three for mechanical valve thrombosis; two for conduit rupture. Microscopic study of the conduit's wall revealed the thinning of xenopericardial tissue with calcification foci in both cases. Two patients were re-operated after 12 and 13 years due to biodegeneration of the valvular prosthesis and the conduit's wall. There were 21 late deaths: three patients died from AHF after re-operations; one death was caused by biological valve dysfunction; two–by late prosthetic endocarditis of the mechanical prosthesis and two–by thromboembolism; in 13 cases the death was not conduit-related. Biodegeneration of the xenopericardial conduit's wall with calcification, without clinical manifestations, was revealed in 15 patients more than 12 years after the implantation. Late freedom from conduit biodegeneration was 71.6%, and the survival by the 16th year after surgery–64%. Conclusions: Sixteen-year experience with the use of xenopericardial conduit in the surgery of the ascending aortic aneurysms showed good late survival and low morbidity. However, after 12 years we noticed a significant incidence of xenopericadium biodegeneration, especially after conduit implantation in young patients.
Yamaguchi University, Graduate School of Medicine, Ube, Japan Objective: The aim of the study is to assess whether cannulation of bilateral axillary artery may be optimal perfusion technique for acute type A aortic dissection. Methods: Fifty-one consecutive patients were operated on because of acute type A aortic dissection from September 2003 to December 2006. During this interval, cannulation of bilateral axillary artery was attempted for all patients. All patients had aortic surgery with open distal anastomosis during deep hypothermic arrest with selective cerebral perfusion (three arch vessels). Replacement of ascending aorta was done in 25 (49%) patients, and extended total arch replacement with individual arch-vessel reconstruction with a modified elephant trunk procedure at the distal anastomosis was in 26 (51%). Concomitant aortic root surgery was carried out in six (11.7%) patients, and coronary artery bypass grafting in three (5.8%). Results: Attempted cannulation of bilateral axillary artery was successful in all patients but two (3.9%) patients, in whom inflow from the pump had to be shifted to femoral artery from right axillary artery in which the dissection had involved. Three patients died (early mortality rate: 5.8%), one from low cardiac output syndrome due to coronary malperfusion and two from intestinal necrosis. Two (3.9%) patients suffered from postoperative permanent stroke. No complication regarding cannulation occurred. Conclusions: Our results suggest that cannulation of bilateral axillary artery followed by selective cerebral perfusion, successful in 96% of patients, may be the optimal technique for providing stable outcome in emergency surgery for acute type A aortic dissection.
CHU Clermont Ferrand, Service de chirurgie cardiovasculaire, Hôpital Gabriel Montpied, Clermont-Ferrand, France Objective: Retrospective assessment of perioperative and mid-term effectiveness of the conservatory management of aortic root in the type-A acute aortic dissection. Methods: Between January 1990 and December 2005, 22 patients (20 males and two female aged 62±9 years) underwent surgical procedure for type-A aortic dissection with complete resection of the non-coronary sinus, associated with a replacement of the ascending aorta with or without aortic arch replacement. Two patients came to the operating theatre in bad hemodynamic conditions. Fourteen patients had aortic valve regurgitation, which in 13 cases was due to the dissection of the non-coronary sinus and the two adjacent aortic commissures, and in one case to calcification of the aortic valve. Twelve patients were operated for ascending aorta replacement; extended to the aortic arch in nine patients; in one patient, the ascendant aorta, the aortic arch and the aortic valve were replaced. In all patients, the complete resection of the non coronary sinus removed the totally-dissected layer of the aortic root. Results: Five patients died perioperatively (22.7%), three of them from multi-organ failure, one patient from digestive ischaemia, and one patient for pneumonia. Four patients (18.1%) had a prolonged postoperative neurological dysfunction with complete recover in two of them. One patient (4.5%) needed surgical procedure for sternal infection. Two patients (9%) need reoperation for bleeding. The mean stay in ICU was 16±8 days. Postoperative echocardiography did not show any significant aortic regurgitation at discharge. The mean follow-up time was 90±45 months. During the follow-up, one patient died for pulmonary cancer, one patient for pulmonary embolism and no patient needed further surgery. Conclusions: Surgical remodelling the aortic root by resecting the noncoronary sinus is a safe procedure with an acceptable rate of morbidity and mortality. This technique can achieve a durable restoration of the diameter of the aortic root and a favourable valve competence.
University Hospital Zurich, Cardiovascular Surgery, Zurich, Switzerland Objective: Arterial perfusion through the right subclavian artery is considered to avoid intra-operative malperfusion during surgical repairing of acute type A dissection. This retrospective study examined mortality and neurological outcomes following subclavian arterial cannulation of patients who underwent surgery for acute aortic type A dissection in a greater patient group to approve a recent study. Methods: A total of 259 patients have been retrospectively analysed. One hundred and sixty nine patients were recruited consecutively with surgery for acute type A aortic dissection from 2/2000–7/05 and in all the technique of subclavian cannulation was performed. Mean age was 61 years (S.D.±14 years, 77% male). Patient outcomes were measured by prevalence of clinical complications, especially neurological deficits, mortality after 30 days, perioperative morbidity and time of body temperature cooling. A comparison has been performed to 90 patients with the femoral cannulation technique, consecutively observed in the period of 1996 to 2000. Results: The consecutive group undergoing subclavian cannulation demonstrated significantly improved neurological outcomes (P=0.002) compared to patients following femoral cannulation (90 patients). Re-exploration rate for postoperative bleeding was significantly reduced in the subclavian group (P<0.0001), as well as occurrence of renal insufficiency (P<0.023), and duration for body temperature cooling (P=0.0083). 30-day mortality was 8.7%. Conclusions: Arterial perfusion through the right subclavian artery still remains to provide an excellent approach for repairing acute type A dissection with optimized arterial body perfusion. These results are confirming data to a former study in our institute. This technique allows for antegrade selective cerebral perfusion during circulatory arrest. It is safe and results in a significantly reduced early mortality rate and improved neurological outcomes.
Hospital Universitari De Bellvitge. Idibell, Hospitalet De Llobregat, Spain Objective: The postsurgical false aneurysms of ascending aorta (PSFA) are very rare and only case reports have been published. The natural risk of rupture is important and also at surgery. The surgical technique can be complex. We study our experience and their causes, prevention, diagnosis, extracorporeal circulation and surgery technique and results. Methods: We review 12 cases of PSFA after seven aortic replacement (one combinated with Robiseck's technique), one mitral and tricuspid valve replacement, three heart transplantations and one coronary bypass. In six cases the diagnosis was done before three months and in the rest until 12 years after surgery. Seven cases was presented as mediastinal mass, four as infection, two as bleeding and one was a surgical finding. In four cases with a big anterior aneurysm we did a femoro-femoral bypass, deep hypothermia and circulatory arrest before sternotomy. Results: The site of the PSFA was in the aortic anastomoses in six cases, in the aortic canulation in four, in the ostium of the coronary bypass in one and in the upper limit of the Robiseck's graft. We did five sutures of the orifice, three grafts, two patches and one Bentall-Bono procedure. One patient died before surgery. The rest were operated. Only one patient (9%) died due to oclussion of the right coronary artery. Conclusions: For the diagnosis is necessary a high degree of suspicion in aortic patients with mediastinal masses, bleeding or infection. Is convenient avoid to leave dilated ascending aorta not treated or a disproportion between the aorta of the donor and the recepient in heart tranasplantation. In cases of a big PSFA is necessary a femoro-femoral bypass, deep hypothermia and circulatory arrest to avoid the non controlled rupture. Although the high risk, the mortality can be low.
Division of Cardiac Surgery, Università Cattolica del Sacro Cuore-Sede di Campobasso, Campobasso, Italy Objective: To analyse the 24-months clinical and instrumental results of the modified button technique for reimplantation of the coronary ostia in aortic root replacement. Methods: We analyzed the first twenty patients operated on consecutively for aortic root replacement (16 for annulo-aortic ectasia and four for type A aortic dissection) who received reimplantation of the coronary ostia in the aortic prostheses by the ‘button-inside’ technique. The coronary buttons are applied on the internal aspect of the composite valve graft and the anastomosis is performed from the inside of the graft. The patients were followed-up both clinically and instrumentally (echocardiography and con-trast-enhanced angio-magnetic resonance nuclear scan, angio-MRI). Results: The button-inside technique allowed little tension at the site of anastomosis between the coronary arteries and the graft, and the aortic graft wall directly reinforced the coronary buttons. No bleeding from the suture line of the coronary buttons occurred intraoperatively. There were no deaths in the study population at the 24-months follow-up. All patients were in NYHA class I-II. There were no cases of myocardial infarction. One case occurred of pericardial effusion at six months; it was drained and the presence of pericardial blood was excluded. Angio-MRI detected no coronary ostial leakages at 24 months. There were no cases of pseudoaneurysm at the site of coronary anastomosis and no cases of aneurysm of the coronary buttons. Proximal and distal graft leakages were excluded in all patients with the same technique. Conclusions: The ‘button-inside’ technique is easy to perform, and is safe and reliable at the early surgical/clinical evaluation. The Angio-MRI follow-up at 24 months indicates that the technique achieves complete surgical control of the entire circumference of the coronary button and avoids distorsion/tearing at the site of coronary anastomosis. The clinical results are optimal and larger patients series operated on with this technique are being evaluated.
Hospital Universitario de La Princesa, Madrid, Spain Objective: Severe aortic regurgitation is sometimes related to aortic root dilatation with or without ascending aortic dilatation. The need of aortic root replacement requires a more complex surgery increasing thus the surgical mortality. But in the last years new advances in surgical techniques and heart protections have raised. Our policy in our centre has changed in the last years and more and more patients are being referred to aortic surgery. Thus all patients with aortic regurgitation and ascending aortic dilatation over 45 mm received Bentall-Bono surgery because we thought that we could offer similar results to simple aortic valve replacement even in high risk patients. Our objective is to analyze our results comparing those patients undergoing simple aortic valve replacement and those patients undergoing Bentall-Bono surgery due to severe aortic regurgitation. Methods: All patients with severe aortic regurgitation were included. Bentall-Bono was group A (n=59) whereas simple aortic valve replacement was group B (n=116). Emergency patients, aortic dissection and patients needing mitral or tricuspid valve surgery were excluded. Baseline clinical characteristics, operative outcomes and surgical mortality were compared. Results: Mean age was 61.8±16.5 years in group A and 59.7±14.8 in group B. We found no differences between both groups regarding sex, cardiovascular risk factors, BCNO or peripheral disease. More patients with ejection fraction <30% were found in group B (60.2% vs. 0%; P=0.05). We found no differences regarding pulmonary hypertension or NYHA class. Cardiopulmonary bypass time and crossclamp time was significantly longer in group A (152 vs. 82 and 113 vs. 52 min; P<0.001). Hours of intubation, 24 h bleeding, ICU length of stay and incidence of complications were similar in both groups. Surgical mortality in group A was 7.1% and 5.7% in group B (P=0.74). Conclusions: In our population similar results were obtained comparing patients undergoing simple aortic valve replacement or Bentall-Bono surgery due to severe aortic regurgitation. A higher proportion of patients with poor ejection fraction were found in group B. Surgical mortality and morbidity was similar in both groups. These results suggest that aortic surgery may be offered in patients with severe aortic regurgitation without increasing surgical mortality. This must be in account especially in patients with moderate aortic dilatation.
CV-1 OUTCOMES AFTER REPAIR OF ACUTE AND CHRONIC TRAUMATIC THORACIC AORTIC INJURIES M. Peltz, T. Hamilton, M.A. Wait, J.M. DiMaio, D.M. Meyer, A. Estrera, W.S. Ring, M.E. Jessen University of Texas Southwestern Medical Center at Dallas, Dallas, USA Objective: Thoracic aortic injuries are a major cause of trauma related morbidity and mortality. Injuries may be repaired early or in a delayed fashion depending on associated injuries. If repair is delayed or the injury is not diagnosed, a chronic pseudoaneurysm develops that may complicate repair. Outcomes after acute and chronic repair of traumatic aortic injuries have not previously been directly compared. Methods: Trauma and surgical data bases at the University of Texas Southwestern Medical Center were searched to identify traumatic injuries from 1991-2006. All injuries that were surgically repaired either by open or endovascular techniques were included in this analysis. Acute repairs were defined as injuries that were corrected <14 days after the injury. Injuries were considered chronic when 14 or more days had elapsed prior to repair. The chronic group included known injuries that underwent delayed repair due to the patient's clinical condition and injuries that went undiagnosed during the initial trauma. Patient demographics, surgical technique, perfusion strategy and outcomes were recorded. Results: A total of 107 injuries were identified. Eighty eight patients (56 Acute, 32 Chronic) were included in the analysis. Sixteen patients were not repaired either due to minor injuries or prohibitive associated comorbidities. Four of these died-all unrelated to the aortic disruption. Three undiagnosed patients exsanguinated from aortic rupture. Eighty two patients underwent open and six patients endovascular repair. Five patients in the surgical cohort died (3/56 Acute, 2/32 Chronic-NS). Cardiopulmonary bypass times were significantly longer (102±56 min vs. 66.4±28 min) and hypothermic circulatory arrest was utilized more frequently (9/32 vs. 2/56) in the Chronic group (P<0.05). Aortic repair related complications per patient were lower in the Chronic group (0.84±0.9 vs. 1.94±1.6) (P<0.01). Postoperative cardiac complications (Acute 6/56, Chronic 3/32), stroke (Acute 4/56, Chronic 1/32), and paraplegia (Acute 2/56, Chronic 1/32) were not different between the two groups. Patients undergoing repair of Chronic injuries recovered more quickly after surgery compared to the early repair strategy (13.3±8.8 days vs. 26.7±21.7 days) (P<0.01). Conclusions: Repair of acute and chronic traumatic aortic injuries can be performed with low mortality. Chronic repairs require longer CPB times and more frequent hypothermic circulatory arrest, consistent with the greater technical challenge presented by these injuries. Despite the greater complexity of chronic injury repairs, postoperative complications are lower and recovery is more rapid after surgery.
Cardiac Surgery Department, University of Parma, Parma, Italy; Department of Radiology, University of Parma, Parma, Italy Objective: Post-traumatic aortic rupture is a potentially lethal injury. Stentgraft repair has recently proved to be a valid option for these patients. Timing of the treatment, anyway, is still a debated issue. We here report mid-term results of our experience with immediate stent graft repair. Methods: From 1998 to 2006 17 patients (12 males, five females) with blunt aortic injury were submitted to immediate endovascular repair. In ten patients with clinical and radiological signs of impending rupture stent grafting was performed on an emergency setting. In the remaining seven patients aortic lesion was treated urgently after clinical management. When present, immediate life-threatening non-aortic lesions were treated before endovascular treatment (seven cases). In one case emergent laparotomy and stent positioning were performed simultaneously. Endovascular procedure was carried out in a cardiac surgery operating theatre and monitored by trans-oesophageal echocardiography in all cases. Results: Stent grafting was successful in 100% of the patients. Two patients died perioperatively as a consequence of a multi-organ failure. Both patients were in ASA class V and presented severe intractable hemorrhagic shock before procedure. CT scan performed before discharge showed correct positioning of the stent-graft and absence of endoleaks in all cases. At a mean follow-up of 36 months (range 1–72) all patients are alive and no intervention related complication occurred. Conclusions: Immediate endovascular repair of blunt aortic injury is a feasible and safe procedure. Mid-term results are promising. Longer follow-up and larger series are mandatory to definitively validate this approach.
Pitie Salpetriere University Hospital, Paris, France Objective: Symptomatic right aortic arch in adults is rare and usually reported as case reports. We present our experience with ten patients (pts). Methods: From 1979 to 2005 we have operated 10 adult patients with a right aortic arch that was symptomatic or associated with an aortic aneurysm. There were six women and four men with a mean age of 47.1 years. In nine patients with an abnormal left subclavian artery (SA) revascularization of the upper extremity was routinely performed (seven subclavian-carotid transposition, two aorto-subclavian bypasses). Three patients had vertebrobasilar insufficiency and upper extremity ischemia due to occlusive lesions of the SA (stenosis or hypoplasia of an aberrant left SA in two, isolation of the left SA in one). They had isolated revascularization of the upper extremity. Three patients had dysphagia. One patient with an aneurysm of an aberrant left SA was treated by transaortic patch angioplasty via right thoracotomy. The other two patients were treated by section of a left ligamentum arteriosus via mid sternotomy. Three patients had an aberrant left SA and a thoracic aortic aneurysm. They had aortic resection and grafting via right thoracotomy. One patient with an aberrant left SA and an aortoesophageal fistula (AEF) due to prolonged nasogastric intubation was treated by allograft aortic replacement and subtotal esophagectomy via mid-sternotomy. Results: One patient with dysphagia died at D7 of a ruptured esophagus due to transesophageal echography. The patient with AEF died at 4 months from herpetic encephilitis. All other patients are alive and well with a mean fol-low-up of 154.9 months (16–285). Conclusions: Routine left upper extremity revascularization in patients with abnormal SAs, right thoracotomy approach in patients with associated aortic aneurysms and precise postoperative care allow optimal and durable results in these complex patients.
University of Rome ‘La Sapienza’-Department of Radiological Sciences-Interventional Radiology UN, Rome, Italy Objective: To report our 6-year experience in the endovascular treatment of type-B aortic dissections and thoracic aortic aneurysms. Methods: From November 2000 to January 2007, 47 patients with type B dissections (24 acute and 23 chronic) and 26 patients with thoracic aneurysms (diameter ranging from 41 to 83 mm–Mean 58.8 mm) were treated using different commercially available stent-grafts: Thoracic Excluder-TAG (WL Gore) n=53, Talent-Valiant (Medtronic) n=19, Zenith TX (Cook) n=1. Four cases of acute dissections were complicated by renal ischemia requiring a renal stenting. In 37 cases (26 dissections and 11 aneurysms), due to a short proximal neck (<2 cm) the origin of the left subclavian artery (LSA) was covered in 36, while in the other case a transposition of the left carotid artery was performed. Results: After a mean follow-up of 25.1±16.8 months (range 1–72 months) no patients experienced paraplegia and no complications correlate to the LSA exclusion were recorded. Aneurysms: Immediate aneurysmal exclusion was achieved in all cases with average sac reducion from 67 mm to 43 mm. Two patients (7.6%) died after 4–10 days for cardiovascular disease, while the other 24 patients (92.3%) are in good clinical conditions. A 30-day mortality rate of 7.6% was recorded. Endoleak occurred in two patients (7.6%) originating from the excluded left subclavian artery. Dissections: Technical success was achieved in 45/47 cases. Intraoperative complications occurred in 2/47 cases (4.2%): retrograde extension of the dissection into the ascending aorta which required surgery. Forty two patients (89.3%) are alive and in good health conditions. Intraoperative mortality was 2.1%, 30-day mortality rate 2.1% and 6.3% of late mortality. Progressive reduction of the false lumen from 2.41 to 0.9 cm and an increase of the true lumen from 1.68 to 4 cm was observed. Endoleak occurred in nine patients (19.1%): one type I treated with a proximal cuff and the other eight from the excluded left subclavian artery treated with coil embolization (n=1), Onyx injection (n=2), injection of both coils and Onyx (n=4). Only in one case the leak sealed spontaneously after 9 months. Conclusions: Endovascular treatment of type B aortic dissection and aneurysms seems to be a feasible and safe technique however technical improvement is required to improve the long-term results. However on the basis of our experience some important technical doubt are still unsolved: management of the left subclavian artery in patients with short proximal neck and stent-graft length selection.
Kosuyolu Heart and Research Hospital, Istanbul, Turkey Objective: The main purpose of surgical therapy is to detect the cardiovascular involvement as early as possible and to avoid fatal complications in Marfan syndrome. We made an analysis on the Marfan patients operated in our clinic to find the risk factors for early and late outcome. Methods: We operated 55 Marfan patients between February 1987 and August 2005. Forty-one were male (74.5%) and 14 were female (25.5%). The average age of the patients was 31.64±10 (11–56) years. Sixty-eight surgical interventions were performed on these 55 patients. One or more reoperations were made for nine patients (16.4%). The most frequently performed procedure was aortic root replacement on 39 patients (70.9%). Results: Early mortality was 3.6% with two patients. Survival rates for 1, 5 and 11 years were 91.9%±3.9%, 88%±5.3% and 66%±19.5%. Risk factors were analyzed for their effect on survival by means of univariate and multivariate analyses. Emergency operation (P=0.0001) and reoperation (P=0.0001) were found to be significant risk factors with univariate analysis whereas multivariate analysis showed emergency operation (P=0.0001) as the only risk factor significantly effecting long-term survival. The most frequently encountered complication was arrhythmia in ten patients (18.2%). Two patients were undertaken revision operations for bleeding. Two patients, who had normal renal functions preoperatively, developed renal dysfunction. Conclusions: Marfan syndrome patients must be followed carefully for cardiovascular involvement. Although surgery is associated with improved survival, emergency operations may decrease life expectancy in long-term follow-up.
Silesian Centre for Hart Disease, Zabrze, Poland; Silesian Medical University, Katowice, Poland Objective: Endovascular procedures are becoming an established part of cardiovascular methodology. The aim of the study was to compare two homogenous groups of patients treated with stentgraft implantation due to: (1) degenerative and (2) posttraumatic aneurysm. Methods: In our centre we treated endovascularly 69 patients (1999–2006) with various diseases of the thoracic aorta. All of these procedures were performed by the same team, and all the patients were under general anesthesia in the cath lab, apart from six hybrid cases treated in the operating theatre. From this material we chose patients with proven posttraumatic (n=14) and degenerative (n=15) etiology of aneurysm and compared retrospectively their preoperative, intraprocedural and postoperative data.
Results: All patients in both groups survived the procedure and hospital mortality rate was 0%. The mean age of patients was 39±10.7 (posttrau-matic–P) and 68±7.6 (degenerative-D) (P<0.01 Wald-Wolfowitz test). There were three women in group D (20%) and two in group P (14%) (P=ns Conclusions: In our material patients with degenerative true aneurysm had significantly more comorbidities, higher preoperative risk and their procedure was longer and more complicated than in the posttraumatic aneurysm group. Patients with degenerative true aneurysm were prone to have more complications, although these differences were not significant.
Istanbul University Istanbul Medical Faculty, Department of Cardiovascular Surgery, Istanbul, Turkey Objective: Surgical treatment of Type B aortic dissection can be performed with hypothermic circulatory arrest, partial cardiopulmonary bypass or left atriofemoral bypass methods. The distal aortic arch clamp can lead to cerebral complications more frequently in atherosclerotic descending aortic aneuryms than Type B dissections. Thus some authors prefer hypothermic circulatory arrest during proximal anastomosis to minimize cerebral complications. Methods: Thirty-one patients with acute or chronic Type B aortic dissections underwent descending aortic replacement with partial cardiopulmonary bypass and clamping the aortic arch between the left common carotid artery and left subclavian artery. In 18 patients proximal 1/3 of the descending aorta was replaced, in ten patients proximal 2/3 of descending aorta was replaced and in three patients near total descending aorta replacement was performed. Proximal graft anastomosis was performed between the left common carotid artery and left subclavian artery in five patients. Results: In the early postoperative period cerebral comlication ensued in three patients due to proximal clamp. Minor left hemispheric infarct resolving spontaneously occured in two patients. In one patient massive left hemispheric infarct occured and this patient died due to decerbration. Conclusions: Although the incidence of cerebral complications in Type B aortic dissections is lower than atherosclerotic descending aortic aneurysms, in patients with enlarged and/or calcified aortic arch, in order to minimize the cerebral complications, clamping of the aortic arch should be avoided. However, aortic arch clamp can safely be used in normal and uncalcified aortic arch during the replacement of the descending aorta.
National Cardiovascular Center, Osaka, Japan Objective: The aim of this study is to analyze the long-term outcomes of aortic surgery in patients with Marfan syndrome. Methods: From 1979 to 1996, 87 patients with Marfan syndrome have undergone aortic surgery (mean age 37±10, 55 male). Eighty-three cases were the first operation and the rest four patients had undergone the first operation before. The operations were aortic root replacements in 49 cases, arch replacements with aortic root replacements in 14, ascending replacements in five, descending replacements in 14, and thoracoabdominal replacements in four. Emergent operations were performed in 14 cases and the major reason of the emergency was acute aortic dissections. Results: The mortality rate of the first operation was 14.9% (13/87). Among the seventy-four survivors, 38 patients had other operations. Eighteen patients had second operations, 13 had third operations, four had fourth operations, and three had fifth operations. The reasons of the other operations after the first operations were mainly the aortic dilatations due to chronic aortic dissection. Post operative survival rate (Kaplan-Meier) after the first operations were 89.1% in 5 years, 83.2% in 10 years, and 76.1% in 15 years. Eighteen patients died in the follow-up period, and the reasons were operative death in seven patients, rupture of aortic aneurysm in three, other reasons in four, and unknown in four. Conclusions: The surgical result of aortic surgery in patients with Marfan syndrome who survived the first operations was acceptable. To improve the results in the follow-up periods, refinement of the strategy of the multiple operations and careful observations are supposed to be essential.
Clinic of Vascular and Endovascular Surgery, Department of Cardiac, Thoracic and Vascualr Sciences, Padova, Italy Objective: Stroke is a major complication of coronary operation. The risk of stroke after isolated CABG has been estimated at <2% in patients with no significant carotid artery stenosis, 3% in case of significant unilateral stenosis in asymptomatic patients, 5% if a high grade bilateral stenosis exists and in 7–11% in case of occlusion of a carotid artery. The presence of carotid and coronary disease at the same time is assessed around 10–12% of patients requiring myocardial revascularization. Thirty-five years after the first publication of combined surgical revascularization the timing of carotid endarterectomy (CEA) and coronary revascularization (CABG) for concomitant disease is controversial. The aim of this study is the assessment of clinical outcome and the evaluation of costs reduction in the combined treatment of coronary and carotid revascularization. Methods: From February 2003 to March 2006 all patients with coronary disease or carotid stenosis presented at the department of Cardiac Thoracic and Vascular Sciences of the University of Padova underwent first level diagnostic screening to demonstrate the simultaneous presence of both disease. All patients with simultaneous presence of carotid and coronary disease were treated with combined surgical operation with CEA, performed in general anaesthetic and constant EEG monitoring, using delayed shunt inserction technique preceding CABG.
Results: We observed three group of patients. Six hundred and fifty-one patients underwent isolated CEA (group A), 676 patients underwent isolated CABG (group B), and 67 patients underwent combined procedure (group C). There was no difference among the three groups with respect to permanent stroke (0.6%, 1.2%, and 2.7%, respectively). Hospital cost was 2839.75 Conclusions: Combined surgical operation does not increase surgical risk compared with single myocardial revascularization. Moreover, this surgical approach reduces hospital costs of 13.7% and National Health Service costs of 27.6%.
Kosuyolu Heart and Research Hospital, Istanbul, Turkey Objective: Distal vital organ damage is an important problem during the surgical management of thoraco-abdominal aortic aneurysm. Surgical repair of thoraco-abdominal aortic aneurysm with/without dissection with femorofemoral perfusion technique was retrospectively evaluated. Methods: Between 2000 and February 2007, 15 patients (aged between 29 and 80) years whit thoraco-abdominal aortic aneurysm±dissection underwent seventeen surgical interventions with femoro-femoral perfusion technique. Three patients were female (20%). Fourteen operations (82.35%) were elective and three (17.64%) were emergencies. Distal perfusion was carried out at 60–70 mmHg and 1000–1500 ml/min. Rectal temperature was kept over 32 °C. Mean follow-up period was 3.35 years (0.1–6 year). Results: Four patients (23.5%) died at early postoperative period. Respiratory problems were seen in three patients (17.6%), acute renal failure was seen in three patients (17.6%), paraplegia was seen in one patient (5.8%) and temporary paraparesis was seen in one patient (5.8%). Conclusions: Surgical treatment of thoracoabdominal aortic aneurysms is still a dilemma in the world. We believe that surgical repair with femorofemoral perfusion technique would decrease the mortality and morbidity with preventative measures from visceral organs and spinal cord ischemia.
Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy Objective: To prevent kidney injury in tipe IV thoraco-abdominal aortic aneurysm surgery. Using standard hypotermic solutions for kindey perfusion, postoperative renal failure represents an important mortality and morbidity risk factor after thoraco-abdominal aneurysm surgery. It is more frequent in type IV (11.9%) than in type II, III and I whereas paraplegic and paraparetic complications are significantly less (1.5%). Two independent predictive factors for renal failure are more significant: renal total ischemic time, related to the surgical procedure, and preoperative renal disfunction (serum creatinine 1.3–1.5 mg/dl) or renal failure (mild 1.5–2.5 mg/dl, severe >2.5 mg/dl). Renal protection from prolonged ischemia (average 52', range 45'–100') is obtained by splitting the renal total ischemic time in two or three partial ischemic times (<30'), performing a temporary reperfusion (3') of the renal arteries using a Pruitt-Inahara shunt. This short-term arterial blood reperfusion of normothermic kidney permits repeated periods of safe ischemic time. Methods: Twenty-one patients were treated for type IV thoraco-abdominal aneurysms and underwent kidney short-term (3') arterial blood reperfusion obtained by Pruitt-Inahara shunt. The reperfusion was repeated every 30 min of ischemia, whenever necessary. Patients were assessed by serum creatinine, CT scan, digital angiography, and radioisotope renography using technetium 99M. Results: The post-op mortality was 2/21 patients (emorragic shock and ARDS). Post-op renal function was preserved in all patients. A moderate and temporary decline in renal funcion was observed in the first post-op days, returning to normal values after one week. Conclusions: The results of this study indicate that kidney short-term reperfusion may protect renal tissue from prolonged cross-clamping ischaemia (up to 180–200 min), also in patient considered at high risk for acute renal failure. It is a low cost and easy tecnique, showing very good and reproducible results. It seems possible to propose this method also in patients with preoperative renal insufficiency.
V1-1 INFLAMMATORY ROLE OF SERUM CREATININE AND INTRAMURAL THROMBUS AFTER ENDOVASCULAR TREATMENT OF AORTIC ANEURYSMS E.A. Gabriel, R.F. Locali, C.C. Romano, A.S. Duarte, H. Palma, E. Buffolo Federal University of Sao Paulo/Heart Hospital of Sao Paulo/University of Sao Paulo, Sao Paulo, Brazil Objective: To evaluate the relation between intramural thrombus, serum levels of creatinine and expression of inflammatory markers in patients underwent endovascular treatment of aortic aneurysms.
Methods: From March to December 2005, 25 patients were followed from preoperative time up to 3rd month postoperatively (1, 6, 24 and 48 h; 7 days; 1–3 months). The variables were intramural thrombus and serum levels of creatinine. The inflammatory markers were: C reactive protein, sedimentation velocity, interleukins (IL-6, IL-8), tumor necrosis factor alpha (TNF-
Results: There was relation of parallelism between presence of intramural thrombus and marked expression of IL-6, IL-8 and TNF-
Conclusions: Endovascular treatment of aortic aneurysms may reveal correlation between intramural thrombus and IL-8, IL-6 and TNF-
Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy Objective: Endovascular Aneurysm Repair (EVAR) is a relatively new technology to treat patients with Abdominal Aortic Aneurysm (AAA). Uncertainty exists about how endovascular compares with conventional open repair (OR). The objective of this prospective study was to compare postoperative and follow-up results of EVAR vs. OR concerning mortality, major and minor complications, need for reintervention and quality of life in patients undergoing elective AAA repair by open or endovascular repair with 3rd generation endografts. Methods: From 1999 to 2006, 784 consecutive patients underwent 499 (63.6%) OR and 285 (36.4%) EVAR of AAAs. Bias was evident in patient allocation due to different comorbidities and anatomical complexity. Patients were regularly followed-up at 1, 6, 12 and every 6 months thereafter. Results: EVAR patients were older (70 vs. 73 years) with a statistically significant increase of coronary/pulmonary diseases and ASA III-IV score rates. Postoperative EVAR vs. OR results showed a mortality of 0.35% vs. 2.2% (P=0.04), a major morbidity of 5.9% vs. 8.6% (P=0.17) and secondary procedures of 5% vs. 1% (P<0.0001) respectively. Mean postoperative hospital stay was 4 vs. 7 days in EVAR vs. OR respectively. Mean follow-up was 32 months (range 3–84) with a mortality of 7% vs. 4.3% (P=0.68.) and secondary procedures 6% vs. 3.5% (P=0.10) in the EVAR vs. OR group respectively. 96.5% of EVAR patients showed a full recovery at six months compared with 87% of OR patients (P<0.0001). After six months functional outcome was similar to the preoperative level in both groups. Conclusions: EVAR patients show a lower perioperative mortality and complication rate compared to the younger and healthier OR group. Need for secondary open or endovascular procedures was increased in the EVAR group mainly due to endoleaks. EVAR was more appealing to patients due to the shorter hospital stay and acceptance of the procedure.
Department of General, Vascular and Transplant Surgery, Medical University of Warsaw, Warsaw, Poland; 2nd Department of Radiology, Medical University of Warsaw, Warszawa, Poland Objective: Introduction of endovascular treatment of abdominal aortic aneurysm was a breakthrough in treatment of abdominal aortic aneurysm. It is responsible for extension of inclusion criteria for treatment of this disease in patients with different comorbidities. The aim of our study was to present our experience and results of endovascular treatment of abdominal aortic aneurysms based on over 500 consecutive cases. Methods: From April 1998 to December 2006 endovascular abdominal aneurysm exclusion was performed in 505 patients. In this group 409 (81%) were assessed to be in high risk in the ASA scale (grade III and IV). Diagnosis was made by: Doppler ultrasonography, spiral computed tomography and digital subtraction angiography in uncertain cases. Using these investigations the following aneurysm morphologies were determined: maximum AAA diameter (42–110 mm, mean 62 mm), AAA neck diameter (18–30 mm, mean 24 mm), AAA neck length (10–45 mm, mean 22 mm). Early and late results were evaluated based on the Eurostar registry protocol. Results: In 492 (97.4%) patients successful exclusion of the AAA was achieved. In 13 patients (2.6%) conversion to open surgery was necessary because of migration of the stentgraft into the aneurysm sac (eight patients) and in five patients because of the inability to remove the introducer device from the iliac artery. In the early postoperative period 13: patients died from myocardial infarction, three from a pulmonary embolism and one from mesenteric artery embolism. Endoleaks were observed in 83 (16.8%) patients postoperatively which were treated by either extension, balloon angioplasty or left for observation. In three patients late rupture occurred in 23-rd, 29-th and 32-nd postoperative month, which was successfully treated by open aneurysmectomy. Other complications included: stentgraft limb thrombosis–28 (5.7%) cases, stentgraft limb stenosis–35 (7.1%) cases. The mean observation period was 35 months (range 1–109 months). Conclusions: Based on our experience with preciously followed-up 500 consecutive patients treated endovasculary we conclude that this method is particularly valuable for high-risk patients. However, due to the necessity of postoperative scrutiny and possibility of complications, open aneurysmectomy remains the method of choice for patients not burdened with comorbidities.
Department of Vascular Surgery-University of Florence, Florence, Italy Objective: The aim of this study was to retrospectively compare early and late results of open (OR) and endovascular repair (EVAR) of abdominal aortic aneurysm (AAA) in older (>80 years) patients.
Methods: From January 2002 to June 2006, 631 patients with AAA were electively operated on with OR or EVAR; whose 96 were octogenarians. All these patients underwent preoperative assessment to evaluate the feasibility of EVAR. In 42 cases patients were unfit for EVAR and underwent OR (group 1); in 54 cases EVAR was performed (group 2) Early ( Results: The two groups were homogeneous with respect to risk factors and comorbidities, except fro a slight prevalence of coronary artery disease in group 2. Thirty-day mortality was similar in the two groups (two deaths in group 1 and no death in group 2, P=n.s.); major complication and reintervention rates were |
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May 18, 2007 2nd...
May 18, 2007 2nd...
2 Pearson test); since there is no risk stratification scale for endovascular procedures, preoperative risk assessment was made with the EuroSCORE risk stratification scale as the patients would have been operated on using open surgical technique and was significantly higher in group D both in additive (P<0.01) and logistic (P<0.01) EuroSCORE. There were five emergent cases in group P and two in group D (P=ns). Comorbidities (CAD, hypertension, peripheral vascular disease, abdominal aneurysm) were more frequent in group D (P<0.01). Mean aneurysm diameter was significantly higher in group D (P<0.05). The number of implanted elements, diameters of prostheses, covered length of the prosthesis and time required to complete the procedure were significantly higher in group D (P<0.05). Postoperatively we compared between the groups the rates of endoleaks (P=D), strokes (D>P, P=ns), postimplantation syndrome (P>D, P=ns), new discomfort in lumbar or thoracic area (P=D), vascular access site complication (D>P, P=ns), and serum creatinine level increase (D>P, P=ns). 
for group A, 8659.10
), L-selectin and intercellular adhesion molecule (ICAM-1).