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Interact CardioVasc Thorac Surg 2008;7:S1-S138. doi:10.1510/icvts.2008.0000S1 © 2008 European Association of Cardio-Thoracic Surgery
AbstractsSuppl. 1 to Vol. 7 (April 2008)
C1-1 IS MECC THE BEST APPROACH FOR CABG? A. de la Fuente, J. Barado, J.L. Frenandez, R. Sanchez, L. Esparza, I. Oses, I. Moriones Hospital de Navarra, Spain Objectives: CABG under cardio-pulmonary bypass (CPB) is a common and successful procedure, but not free of risks. New techniques, such as the minimal extracorporeal circulation method (MECC), have been developed to minimize these risks. We present our experience with MECC for CABG and compare MECC with standard CPB. Methods: The study includes 300 consecutive CABG patients operated on in our institution. We used standard CPB for the first 150 patients (the SCPB group) and MECC for the following 150. Both groups were similar in terms of patient age, gender, number and type of coronary lesions, indications for surgery, types of angina, number of previous myocardial infarcts, and risk factors. Results: Hospital mortality was 3% in the SCPB group and 0% in the MECC group (P<0.03). Peri-operative infarcts were 8% with standard CPB and 2.6% with MECC (P<0.02). Incidence of atrial fibrillation was 14 in the standard CPB group and 12 in the MECC group (p ns). Postoperative cardiac troponin-I was lower in the MECC group (P<0.005). Postoperatively, SCPB patients bled more and required more transfused blood (P<0.003). On entry into the intensive care unit, MECC patients had fewer leukocytes (P<0.001) and more platelets (P<0.001) than SCPB patients. Duration of mechanical ventilation, time in the intensive care unit, and duration of hospitalization were shorter in the MECC group (P<0.002, P<0.001 and P<0.01, respectively). Conclusions: Both standard CPB and MECC give good results. However, in our experience. The majority of the pernicious effects (e.g. inflammatory response) resulting from standard CPB are minimized with MECC. The rates of mortality and preoperative infarcts are significant lovers with MECC technique than SCPB. Therefore, to prove the superiority of MECC would require a larger and randomized study.
Mediclin Herzzentrum Coswig, Germany Objectives: Cardiac surgery offers three options to perform coronary artery bypass grafting (CABG), conventional cardiopulmonary bypass (CCPB), minimal extracorporeal circulation (MECC) and off-pump coronary artery bypass (OPCAB). At present advantages of each technique are under discussion. In recent publications patency rates of OPCAB are inferior to those of CABG performed with cardiac arrest. Methods: We investigated 1472 coronary operations, 1143 using CCPB, 220 were performed using MECC and 109 using the OPCAB technique. All patients were recorded prospectively. Perioperative follow-up was focused in the occurance of arrythmia, neurocognitive outcome and the need of blood and blood products. Results: Operative mortality was comparable in all groups. The mean number of bypass grafts reached an average of 3.2±0.6 in the MECC group, 3.4±0.7 in the CCPB group and 1.9±0.8 in the OPCAB group (P<0.01). Arrythmia occurred in 24.8% in the MECC group, 35.6% in the CCPB group (P<0.05) and 21.7% in the OPCAB group. Neurocognitive disorders occurred in eight patients (3.6%) of the MECC group, 74 patients (6.5%) of the CCPB group (P<0.05) and in three patients (2.8%) of the OPCAB group. The median number of blood transfusions per patient was 0.8 in the MECC group, 1.8 in the CCPB group and 0.8 in the OPCAB group (P<0.0001). Conclusions: Perioperative morbidity of the MECC and OPCAB technique is comparable and less compared to CCPB. The MECC technique allows coronary surgery with cardiac arrest. The benefits of longer patency rates and completeness of revascularizations favours MECC over OPCAB.
1Kangwon National University Hospital, Chuncheon, Kangwondo, Republic of Korea; 2Dong A University Hospital, Pusan, Republic of Korea Objectives: Internal thoracic artery (LITA) has been selected as a best graft conduit for left anterior descending (LAD) area. However, distal part of LITA is usually discarded because of its small size and another reasons. There was little information about distal part of LITA as a graft conduit, so we tried to investigate the efficacy of the distal LITA in coronary artery bypass graft. Methods: From July 2003 to August 2004, 20 consecutive patients (17 male, 3 female) who required total LAD area revascularization underwent coronary artery bypass graft using LITA Y-graft itself. They were included 8 cases of 3 vessel disease, 6 cases of left main disease, 4 cases and 2 cases of 2 vessel disease and single vessel disease, respectively. Mean age was 62.8±8.3-year-old and number of diseased vessels were 2.6±0.9. OPCAB was performed in 18 cases and the other two cases underwent on-pump beating CABG. LITA harvesting was performed all semi-skeletonized manner. Initially we measured the distant to the target point on LAD, then cut off the LITA graft and made of Y-shape graft. After the LAD anastomosis, we performed diagonal branch anastomosis using another hand of Y-graft while kept LAD perfusion. Mean operation time was 295±45 min. Intraoperative mean LAD and diagonal flow was 27.2±16.0 and 15±8.9 ml/s, respectively. Results: Postoperative angiography was performed mean 37 months after surgery. There were no in-hospital mortality and no serious complication. Superficial wound infection occurred in three cases and acute renal failure developed in one case which recovered soon after. Three-year follow-up results were excellent. All patients have been alive and had patent graft in LAD area. Two cases of RCA stenting was performed during follow-up periods. Conclusions: In the selective cases, LAD and diagonal revascularization with LITA auto Y-graft is technically feasible and may reduce the requirement of another grafts. Moreover, graft flow limitation resulting from diamond shape anastomosis in sequential anastomosis using radial artery can be avoided.
Cardiovascular Division of L Sacco Hospital, University of Milan, Italy Objectives: Off-pump myocardial revascularization through a small thoracic incision can be adopted for isolated left anterior descending (LAD) disease. An evolution of this technique can be accomplished for multiple coronary disease using dedicated instruments for coronary stabilization and exposure (Multi-Vessel Small Thoracotomy MVST). Methods: A 6–8 cm antero-lateral chest incision is created in the 4th intercostal space. The left internal thoracic artery (LITA) and the radial artery (RA) are simultaneously harvested, LITA either under direct or video assisted vision, RA using a minimally invasive video assisted technique. A composite Y-graft between LITA and RA is performed through the thoracic incision. Medtronic Octopus® and Starfish® NS are respectively, used to stabilize and expose the coronary arteries, bringing coronary targets into the operative thoracic window. Both instruments are provided with shafts allowing remote insertion. Coronary anastomoses are completed using conventional instruments and techniques. Results: From September 2005 to January 2008, 35 patients underwent MVST. Mean grafts number was 2.2±0.5. LITA was always used on the LAD, RA either as single or sequential graft on marginal branches and posterior descending coronary artery. There were no perioperative death or myocardial infarction. Mean follow-up time is 325±179 days. All patients are free from angina with negative ergometric stress test. Conclusions: Complete arterial myocardial revascularization through a mini-thoracotomy is feasible using dedicated instruments for myocardial stabilization and exposure. This approach uphold all the benefits coming from off pump myocardial revascularization avoiding complications from median sternotomy, aortic manipulation and allowing a faster postoperative patient recovery.
1Gaziantep University School of Medicine, Department of Cardiovascular Surgery, Gaziantep, Turkey; 2Gaziantep University School of Medicine, Department of Pathology, Gaziantep, Turkey; 3Gaziantep University School of Medicine, Department of Cardiology, Gaziantep, Turkey Objectives: The increasing prevalence of the routine use of radial artery in CABG has rendered the pharmacological prevention of spasm of this artery in the early period a critical point. With this purpose, the effects of iloprost and diltiazem on vasospasm were compared in our study. Methods: Seventy patients who underwent CABG using the radial artery were randomized into two groups and the vasodilator effects of iloprost and diltiazem were studied prospectively. RA flow was measured using Doppler USG. Following harvesting, a 5-mm piece was removed from the RA distally for pathological examination. In Group B, diltiazem infusion was made prior to removal of the RA, while iloprost infusion was initiated five days prior to surgery in Group A. At the end of a two-year follow-up, each case underwent coronary angiography. Results: Doppler flow measurements made during harvesting revealed statistically significant flow reduction and pathological examination of the RA revealed significant luminal narrowing in Group B. Two-year angiographic follow-up revealed patent all of RA grafts in Group A. Conclusions: The results evaluations revealed superior efficiency of iloprost over diltiazem in prevention of RA spasm in the early period and these results have been supported by two-year angiographic findings.
1Insubria University Circolo Hospital and Macchi Foundation, Varese, Italy; 2Monzino Cardiological Centre IRCCS, Milan, Italy Objectives: The incidence of left ventricular (LV) dysfunction and atrial fibrillation (AF) after coronary artery bypass grafting have paradoxically increased together with population aging and profile of comorbidities. The aim of this study was to determine the incidence of postoperative AF and its independent predictors in patients with LV dysfunction undergoing coronary artery bypass grafting (CABG). Methods: We retrospectively analysed data collected from 2790 CABG cases in two university hospitals between January 2000 and December 2006. A total of 223 patients with an echocardiographic ejection fraction <35% were selected and constituted the study population (mean age: 65.6±9.1 years; 85.2% men). Hospital mortality and postoperative survival data were also investigated. Results: Postoperative AF occurred in 73 (32.7%) patients. Patients suffering from AF revealed age (OR 1.08, 95% CI 1.04–1.12) and postoperative intra-aortic balloon pump (OR 4.73, 95% CI 1.98–11.29) and, with a borderline correlation, chronic obstructive pulmonary disease (COPD, OR 3.56, 95% CI 0.96–6.79) as independent predictors for AF development. The overall hospital mortality in AF patients was 5.5% vs. 2.7% of patients without it, although not significant. Early and mid-term survival was significantly decreased in AF patients compared with patients without this arrhythmia. Conclusions: In patients with reduced LV function, AF after cardiac surgery is an important sign of reduced postoperative survival. A close surveillance in patients with LV dysfunction and postoperative AF should be applied. In these patients age, IABP requirement and COPD may be considered relevant independent AF predictors in order to establish an effective preventive prophylactic approach.
Department of Cardiac Surgery and Transplantology Silesian Center for Heart Diseases, Zabrze, Poland Objectives: Coronary artery disease (CAD) surgery during or shortly after antiplatelet therapy with acetylsalicylic acid (ASA) is identified as a predictor of bleeding complications after the procedure. Until now there are not known a good laboratory tests for estimation of platelets function: adhesion and aggregation and prediction of bleeding after surgery. The purpose of this study is to evaluate the influence of prolonged occlusion time (OT) (Coll/Epi) measured by PFA 100 platelet analyzer on early postoperative results after CABG or OPCAB procedures.
Methods: Three hundred and twenty-three consecutive CAD patients, operated from January 2004 till December 2007, treated with ASA, in whom platelet reactivity exam was performed during last 24 preoperative hours with PFA-100. The patients transfused with platelet concentrate intra or postoperatively were excluded from the study. Patients were divided into two groups: GROUP I: 177 patients with normal OT (85–165 s) and GROUP II: 146 patients. with prolonged OT >165 s. Preoperatively the demographic data, CCS and NYHA status, LV EF value, EuroSCORE risk value, co-morbidities and full blood count were analyzed. Postoperatively the mortality rate, morbidity, total chest tube drainage, need for re exploration because of bleeding and blood transfusion were compared. Statistical analysis was made using t-student, Results: Preoperatively the demographic data, CCS and NYHA status, LV EF value and EuroSCORE risk value were comparable. In group I the blood hemoglobin level was higher then in group II (8.6±0.8 mmol/l vs. 8.4±0.9 mmol/l, P<0.05). The rate of COPD was lower in group I (3% vs. 10%, P<0.05) as well as the rate of cerebrovascular disease (13% vs. 23% P<0.05). Overall mortality rate was 1.5% (five patients). There were no differences in postoperative total chest tube drainage (885.1±400.7 ml vs. 918.2±327.8 ml, P=NS), rate of re exploration because of bleeding (1.6% vs. 1.3%), rate of RBC transfusion (50% vs. 53%). There were no differences on postoperative major neurological events, gastrointestinal complications and renal insufficiency. The time of ICU stay, hospital stay, mechanical ventilation was comparable between the groups. Conclusions: Prolonged occlusion time (Coll/Epi) measured by PFA-100 before surgery is not a predictor of postoperative bleeding complications in coronary artery surgery patients.
Veterans Affairs Medical Center, Washington DC, USA Objectives: Diabetics after CABG have poor long-term survival. Our practice emphasized strict gylcemic control and risk factor modification. Whether this strategy provides a survival advantage remains undefined. Methods: Between 1991–2000, 973 patients underwent isolated CABG. There were 313 patients (32%) with diabetes (DM). Perioperative glucose was maintained <200 mg/dl, and angiotensin converting enzymes, statins, B-blocker, and ASA were used routinely postoperatively. Data was prospectively collected and medication use was captured via electronic patient record system. Results: DM vs. non-diabetics (NDM) were older (64 vs. 62 years, P=0.017), had larger BSA (2.02 vs. 1.9, P<0.001), and higher LVEDP (17.6 vs. 16.2 mmHg, P=0.021), hypertension (AOSP) (140 vs. 134 mmHg, P=0.004), pulmonary hypertension (PASP) (35.8 vs. 31.7 mmHg, P=0.012), and NYHC III–IV (P=0.001). Although DM had more diffuse CAD (P=0.005), they had similar number of grafts (2.57 vs. 2.49, P=0.065). Survival for DM vs. NDM at one, five, and ten years was 90% vs. 95%, 78% vs. 85%, and 58% vs. 72%, respectively (P<0.001). Among the DM cohort, regression analysis demonstrated only PASP affecting survival (P=0.04). AOSP, age, BSA, LVEDP, and OPCAB did not influence survival. A prior history of an MI in patients with DM did not adversely affect survival (P=0.132). Conclusions: Diabetics, regardless of aggressive postoperative risk management, have sustained lower survival benefit long-term. Technique of revascularization does not appear to influence survival in diabetics. Surgical revascularization in DM may attenuate the reported adverse prognostic impact of a prior MI. It remains to be determined whether more strict perioperative glucose control (<180 mg/dl) and incorporation in to a risk-factor modification clinic reduces long-term mortality.
Division of Cardiac Surgery, University of Brescia, Italy Objectives: Albeit a steadily growing number of octogenarians are referred for CABG nowadays, controversial data are available in such specific subset of patients. We, therefore, sought to evaluate the potential advantages of a no-touch aorta technique for myocardial revascularization when compared to conventional CABG. Methods: We retrospectively evaluated 51 consecutive patients older than 80 years of age undergoing isolated CABG between January 1, 2000 and December 31, 2006. Twenty-four patients undergoing no-touch aorta technique (Group A, off-pump total arterial CABG with composite grafts) were compared with 27 patients undergoing conventional CABG (Group B, on-pump LITA on LAD, with/without composite arterial grafts plus additional saphenous grafts). Pre-operative variables were similar between the groups, in terms of number of diseased coronary vessels, age, gender, obesity, diabetes, pulmonary or systemic hypertension, chronic renal failure, atrial fibrillation, previous myocardial infarction and ascending aorta calcification. Mean Additive EuroSCORE was 9.7 in Group A vs. 8 in Group B (P=NS). Functional health and quality of life (by means of SF-36 questionnaire) was performed at follow-up. Results: All patients in Group A successfully underwent full arterial CABG surgery by means of an off-pump no-touch aorta technique. The degree of myocardial revascularization was similar between the groups (grafts/patients: Group A=2.16 vs. Group B=2.3, P=NS). Hospital mortality was different among the groups (Group=0% vs. Group B=11%, three patients) although it did not reach statistical significance (P=NS). The overall incidence of post-operative complications was significantly inferior in Group A than in Group B (P=0.046). All patients were followed-up for a mean of 3.6 and 4.1 years in Group A and B, respectively; four patients died in Group A (cardiac-related, n=3) and six patients in Group B (cardiac-related, n=3). Survival-free from cardiac related events was better in Group A either at one year (Group A=96% vs. Group B=70%) and at four years (Group A=83.4% vs. Group B=70%). All survivors at follow-up in both groups enhanced their functional status (NYHA class I–II), and none required additional PTCA procedure or redo surgery. Finally, the SF-36 Questionnaire demonstrated similar results in patients undergoing full arterial OPCAB and conventional CABG (MCS score: Group A=46 vs. Group B=37, P=NS; PCS score: Group A=32.5 vs. Group B=30, P=NS). Conclusions: Our results suggest that totally arterial CABG, with no-touch aorta technique is feasible in octogenarians and able to improve early and mid-term outcomes.
1Bakoulev Cardiovascular Scientific Center, Moscow, Russian Federation; 2Albert Ludwigs University of Freiburg, Germany Objectives: The present article is a report of our first clinical results of a new treatment for coronary artery disease (CAD) using human recombinant Growth Factor (GF) alfa-ECGF (Endothelial Cellular Growth Factor) in combination with transmyocardial laser revascularization to increase perfusion and to improve quality of life of patients with chronically ischemic myocardium. Methods: This is the first randomized single-blind placebo-controlled clinical trial of an intramyocardial infusion of alfa-ECGF in combination with TMR. To be enrolled in the trial, patients were required to meet the following criteria: Canadian Cardiovascular Society (CCS) class III or IY angina that was refractory to medical treatment, reversible ischemia of the left ventricular free wall, and coronary disease that was not amenable to coronary artery bypass grafting or percutaneous transluminal coronary angioplasty. Twenty patients were treated to TMR (sole, combined with CABG performed with extracorporeal circulation or OPCAB – 1-st group) in combination with alfa-ECGF and 20 other patients had TMR (sole, combined with CABG performed with extracorporeal circulation or OPCAB – 2-nd group) with PLACEBO. The results were analyzed in both groups: 1st group – patients with angiogenic factor; 2nd group – patients with PLACEBO. Efficacy of the procedure was evaluated at 1, 3, 6 and 12 month. We studied changes of angina symptoms, exercise tolerance, left ventricular ejection fraction, myocardial perfusion and short form 36 questionnarie score. Results: The demand of daily nitroglycerine and mean angina class was significantly decreased and exercise tolerance increased in both groups. But we did not establish significant differences between groups. Myocardial perfusion imaging demonstrated significant changes in the rest or stress. Physical and emothional components of SF-36 form demonstrate the increased scores in both groups. But no significant differences was seen between groups. Conclusions: A single intracoronary infusion of alfa-ECGF in combination with TMR improve exercise tolerance, decline angina class and daily demand in nitroglycerine. This combination improves myocardial perfusion and quality of life. But there was no differences when compared with placebo group. These data gives evidence that all those changes has not been caused by growth factor alfa-ECGF.
C2-1 26-YEAR EXPERIENCE OF TYPE A AORTIC DISSECTION SURGICAL TREATMENT: LONG-TERM RESULTS AND ANALYSIS OF THE INVOLVED VARIABLES P. Borsani, G. Mariscalco, S. Ferrarese, A. Scannapieco, M. Napoleone, C. Cantore, V.D. Bruno, A. Sala Insubria University, Varese, Italy Objectives: Acute type A aortic dissections are considered surgical emergencies because affected patients are at risk for life-threatening complications. We report a single-centre 26-year-experience in the surgical treatment of type A aortic dissection. Methods: From 1981 to 2006, 177 consecutive patients (127 males) underwent emergent surgery for type A aortic dissection. Mean age was 60.6±12.1 years. The diagnosis was achieved by angio-CT scan and transesophageal echocardiography. All operations were performed using cardiopulmonary bypass (CPB) by cannulation of a common femoral artery (n=144) or right axillary artery (n=33) and the right atrium. Mean CPB time was 207.2±79.8 min, mean aortic cross-clamping was 128.7±56.4 min. Profound hypothermia (18–25 °C) was used in all cases. The aortic arch was repaired during circulatory arrest (mean arrest time 50.0±37.4 min), with retrograde or, more recently, antegrade cerebral perfusion. Perioperative and long-term mortality have been investigated by Kaplan–Meyer curves, comparing patients gender, different cannulation sites and the period of operation (1981–1996 vs. 1997–2006). Results: Mean follow-up time was 70.7±65.6 months. We report an overall perioperative mortality of 37.3%. Freedom from death was 47% at 1 year, 39% at 5 years, 29% at 10 years, 23% at 20 years. In-hospital mortality was 45% for patients operated between 1981 and 1996, 28% for patients operated after 1996 (P=0.021). A tendency to better long-term survival has been observed in males, while not reaching statistical significance (P=0.12). A statistically significant better long-term survival has been observed in patients who underwent right axillary artery cannulation (P=0.006) and in patients operated after 1996 (P=0.027). Conclusions: Type A aortic dissection is a life-threatening condition, requiring emergent surgery. Despite the still elevated mortality in operated patients, a considerably better outcome has been achieved in the recent years by a global improvement in surgical and clinical management. The main determinant seems to be the site of arterial cannulation, with a significant better survival in patients undergoing right axillary artery cannulation.
1Department of Thoracic and Cardiovascular Surgery, West German Heart Center, University Hospital Essen, Germany; 2Department of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Germany; 3Department of Cardiology, West German Heart Center, University Hospital Essen, Germany Objectives: In acute type A aortic dissection emergent surgical repair with resection of the proximal entry tear/-s is essential. However, in case of additional entries in the distal aorta, the false lumen in the descending aorta remains perfused, so that secondary surgical and/or endovascular interventions for malperfusion as well as aneurysm formation may be mandatory. In order to intend primary a complete thoracic aortic repair in those cases, a new hybrid stentgraft was used. Methods: From January 2005 to January 2008 in 27 of 47 patients, who underwent emergent surgery for acute type A aortic dissection, the false lumen extended into the descending aorta. In 18 cases (mean age 59±12 years) a hybrid stentgraft prosthesis (E-vita open®) was inserted in antegrade fashion into the descending aorta after total aortic arch resection. At the proximal stentgraft-end an integrated woven vascular prosthesis allows continuous arch replacement. Nine patients underwent isolated ascending and arch replacement and were excluded from the study. Selective antegrade cerebral perfusion (SACP) and hypothermic circulatory arrest (HCA) was performed in all cases. Postoperative imaging procedures were performed in all patients to investigate the fate of the false lumen throughout the follow-up period. Results: Cardiopulmonary bypass time was 249±58 min, SACP was 63±17 min and HCA was 11±8 min. Complete thoracic aortic repair was achieved immediately in 17/18 (94%) cases. In one case a retrograde endovascular stentgraft stenting for a type II endoleak was required. The in-hospital mortality was 6% (1/18). The false lumen in the stentgrafted aorta remained thrombosed in 16/18 (89%) cases during a follow-up period of a mean of 16 months. In one case a new distal endoleak was observed after 16 months and has been overstented. Four patients (4/17, 24%) succumbed in this period, not related to thoracic aorta associated complications. Conclusions: The new hybrid stentgraft allows complete thoracic aortic repair in acute type A aortic dissection without increased mortality due to the extension of the emergent surgery into the descending aorta. The thrombosed false lumen remained occluded in all but one patient and demonstrated a tendency to shrink.
Istituto Clinico Humanitas, Rozzano, Italy Objectives: Reimplantation valve-sparing aortic root replacement has been increasingly performed with improving peri-operative and mid-term results. The success of this operation primarily depends on preserving the extremely sophisticated dynamic function of the aortic valve by recreating an anatomical three-dimentional configuration similar to that of the aortic root, thus minimizing the mechanical stress and strain on the cusps. Over the years, several techniques have been proposed to reproduce the sinuses of Valsalva. We reviewed our experience with aortic valve reimplantation by means of a modified Dacron graft that incorporates sinuses of Valsalva, in a series of 100 consecutive patients. Methods: During a 60-month period, 100 patients with aortic root aneurysm underwent aortic valve reimplantation using the Gelweave Valsalva prosthesis. There were 74 males and the mean age was 60±12 years (range 28–83 years). Five patients had the Marfan's syndrome, 15 had a bicuspid aortic valve. Cusp repair was performed in five patients. The mean follow-up time was 28.6 months (range 1–60). Transesophageal echocardiogram was performed at the end of each procedure to assess the aortic valve dynamic motion within the graft. None of the patients left the operating room with an aortic incompetence (AI) >2+. Results: There was one hospital death and two late deaths. Overall survival at 60 months was 91.7±5.1%. Five patients developed severe aortic AI during follow-up requiring aortic valve replacement (AVR). The 60-month freedom from reoperation due to AI was 90.9±4.4%. One patient had moderate AI at latest echocardiographic study. The 60-month freedom from AI>2+ was 91.6±7.9%. Cox regression identified cusp's repair as independent risk factor (P=0.001) for late reimplantation failure (AVR or AI>2+). There were no episodes of endocarditis and the majority of the patients (88%) were in New York Heart Association functional class I. Conclusions: The aortic valve reimplantation with the Gelweave Valsalva prosthesis provided satisfactory mid-term results. An accurate assessment of the valve's dynamic motion by means of intraoperative transesophageal echocardiogram at the end of each procedure is mandatory in order to detect any cusp's prolapse and avoid early reimplantation failure. Cusp's repair may play an important role in the development of late AI. However, long-term results are needed in order to define the durability of this technique.
Department of Surgery and Clinical Science, Yamaguchi University Graduate School of Medicine, Japan Objectives: The aim of this study is to assess the natural course of residual distal dissection after repair of acute type A aortic dissection. Methods: From September 2003 to March 2007, 52 consecutive patients underwent repair of acute type A aortic dissection at our aortic center. Excluding three hospital deaths, two late deaths within six months after the operation, and 11 patients without preoperative dissection in the descending aorta, 36 patients with preoperative patent false lumen in the descending aorta were divided into two groups: 1) 16 patients with ascending aortic graft replacement (Group 1) and 20 patients with extended total arch graft replacement (Group 2). Contrast-enhanced computed tomography (CT) was repeated after 26±13 months in all 36 patients. The entry resection was performed in all patients but only one patient who had the entry at the supra-celiac aorta. Results: CT revealed that the residual distal aorta was dilated in 11 (69%) in Group 1 and 7 (35%) in Group 2 (P=0.19), and false lumen in the descending aorta was patent in these dilated 18 patients. In patients with patent false lumen in the descending aorta, 8 (73%) of 11 in Group 1 had new entry at the site of distal anastomosis, and remaining three in Group 1 and all of seven in Group 2 had new entry in the descending aorta, which had been preoperative re-entry. Incidence of new entry at the site of distal anastomosis was 50% in Group 1, while 0% in Group 2 (P<0.01). Aneurysmal change (diameter more than 50 mm) occurred in 4 patients in Group 1 and in no case in Group 2 (P<0.05). Conclusions: Our results suggest that extended total arch replacement may be optimal surgery to prevent progression of distal aortic disease in emergency repair for acute type A aortic dissection with preoperative patent false lumen in the descending aorta.
Division of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan; Division of Cardiovascular Surgery, Osaka General Medical Center, Osaka, Japan; Division of Vascular Surgery, Morinomiya Hospital, Osaka, Japan Objectives: Total arch replacement (TAR) is generally recommended for acute type A aortic dissection (AD(A)) when the intimal tear is located in the transverse arch, but the treatment is associated with high operative risk. We have performed TAR with open stent grafting technique (OSG) since 1994 and modified the procedure with branched stent grafting from 2004 to perform TAR in the same process as hemiarch replacement. The objective of this study is to elucidate the result of TAR with branched OSG for acute AD (A) in comparison with conventional procedures. Methods: From January 2000 to August 2007, 75 patients with acute AD (A) underwent emergent surgery at our institution. Among them, eight patients who were treated with TAR with branched OSG (group A), 40 with ascending aorta/hemiarch replacement (group B), 10 with conventional TAR (group C) are involved in this study. Seventeen patients with concomitant procedures such as valve replacement or CABG are excluded. All the patients underwent MDCT or angiography preoperatively to detect the location of the intimal tear. TAR with branched OSG is discribed briefly as follows; During core cooling, the proximal anastomosis in the ascending aorta is completed in usual fashion. After deep hypothermic circulatory arrest, the aortic arch is transected between the brachiocephalic artery and the left common carotid artery. The main body of the stentgraft is inserted into the descending thoracic aorta. Simultaneously, the branches of the stentgraft are inserted into the left common carotid artery and the left subclavian artery. Results: The average operative time was 396, 443, 619 min in group A, B, C, respectively (A vs. C; P<0.05, B vs. C; P<0.01, A vs. B; NS). The average circulatory arrest time was the same between group A and B. Operative mortality was 0, 15, 0% in group A, B, C, respectively (NS). Conclusions: TAR with branched OSG for acute AD (A) could be performed in the same operative time and invasiveness compared with ascending aorta/hemiarch replacement.
Thoracic Surgery Centre, Krasnodar, Russian Federation Objectives: For reconstruction in children for right ventricular outflow tract (RVOT) biological conduits are commonly used, with increased risk for accelerated calcification with subsequent valvular stenosis. New synthetic conduit was created for RVOT re-implantation. Methods: Aortic root (AR) was chosen as prototype. AR consists of some elements: ventriculo-arterial ring, fibrous annulus, sinus of Valsalva (SV), leaflets, commissures, undercommissure's triangulares and sinotubular junction. In a morgue on 40 hearts, according to a specially worked out original protocol we counted morphometry all of AR's elements. Results: Based on the observed data new synthetic tree leaflets, semilunaris AR was created. This conduit has not only all AR's elements, but has a similar form (licensed under RU#2293543, April 25, 2005). The conduit was used in Ross procedure in 13-years girl for RVOT reconstruction. In 24 months there was no any degeneration process in conduit. The most recent peak and mean transvalvular gradients were counted after operation, in 12 and 24 months – 22 mmHg, 25 mmHg, 22 mmHg and 14.8 mmHg, 15.3 mmHg, 13.0 mmHg, respectively. The conduit was used in Ross procedure in 13-years girl for RVOT reconstruction. In 24 months there was no any degeneration process in conduit. The most recent peak and mean transvalvular gradients were counted after operation, in 12 and 24 months – 22 mmHg, 25 mmHg, 22 mmHg and 14.8 mmHg, 15.3 mmHg, 13.0 mmHg, respectively. Conclusions: New synthetic conduit has no any degeneration, comparing to a biological one, and we see good hemodynamics, as a biological conduit as well. This synthetic AR may be one of the variant for RVOT reconstruction.
National Amosov Institute of Cardiovascular Surgery, Kiev, Ukraine Objectives: Aneurysms at the site of coarctation of the aorta refair is relatively rare, but life threatening complication, which causes aorta rupture and death. Methods: The remote results of 4196 patients after aorta coarctation correction operated upon from 01.01.960 to 01.01.2007 were studied. The management of aorta coarctation includes the resection of the narrowing followed with the end-to-end anastomosis (2547 patients; 60.7%), aortoplasty with a patch (1161; 27.7%), aorta prosthesis (207; 4.9%), shunting (61; 1.4%), Waldhausen operation (63; 1.5%), Blalock (11; 3%), and balloon dilatation of the narrowing (146; 3.5). The aneurysm was diagnosed during X-raying, when the rounded shadow was visualized as left-contouring the arc of aorta. The diagnosis was verified aortographically. Results: The aneurysm formation in the aorta coarctation correction zone was established in 114 (2.7%) operated patients. Eighty-nine patients (78.1%) underwent operation; 25 patients (21.9%) turned down the treatment on various grounds and all of them died within seven years. The operations were carried out under conditions of distal circulatory support with the help of by-pass ascending-and-descending aortal shunt in 82 patients (92.1%); in five cases (5.6%) extracorporeal circulation was used, and two patients (2.3%) were operated on without support. Conclusions: These results allow concluding that in some cases the aneurysms after the correction of aorta tend to develop in the remote period threatening the patients life, which needs lifelong regular medical check-up in order to timely diagnose and treat this complication.
Department of Cardiovascular Surgery, Villa Maria Cecilia Hospital, Cotignola, Lugo, Italy Objectives: Aortic type A dissection is a dramatic event that requires emergency replacement of ascending aorta. In those cases in which the aortic arch and the thoracic descending aorta are not dealt with the patients are exposed to late complications such as expansion of the residul false lumen and delayed rupture. Methods: Between January 2005 to March 2007, 18 patients were referred to our department with the diagnosis of aortic Type A dissection. The mean age was 66.25 years. After the replacement of ascending aorta, during antegrade selective cerebral perfusion and moderate hypothermic circulatory arrest, a balloon-expandable uncovered stent (Djumbodis-Dissection System, Saint Come-Chirurgie, Marseille, France) was inserted in the aortic arch and descending thoracic aorta. Results: The in-hospital mortality was 7.6%. The major complication were bowel ischemia and renal failure in two patients. In the postoperative CT-scan the false lumen was completely closed with trombi in 11 patients. Neither delayed rupture or dilatation were reported. Conclusions: In our experience the insertion of the Djumbodis System, together with replacement of ascendig aorta and/or aortic arch, allowed the restoration of the true lumen and the complete exclusion of the false lumen in the majority of the patients with easy and reproducible technique.
C3-1 WHEN THE AMPLATZER® ATRIAL SEPTAL OCCLUDER CAN MIGRATE R. Martinezsanz1, F. Bosa2, R. de la LLana2, C. Perera3, I. Nassar3, F. Marrero3, P. Garrido3, C. Vaquero4 1Instituto Canario Cardiovascular, Tenerife, Spain; 2La Laguna University, Tenerife, Spain; 3Consorcio Sanitario de Tenerife, Spain; 4Valladolid University, Spain Objectives: To close atrial septal defects (ASD) the Amplatzer® atrial septal occluder (AASO) is widely used. However, it can migrate into the pulmonary artery. Our aim is to determine why it does that and how to avoid it. Methods: The AASO was used in 75 consecutive patients in our institution. These were 5–63 year old (23.4±18.6); 39 were females. In 33 cases the AASO was needed to close a POF (permeable oval foramen). In the remaining 42 cases AASO was used to close an ASD: 40 of them were <30 mm and the other two were longer. All ASD had a clear rim. Results: The AASO migrated into the pulmonary artery in two cases (man and woman, 17 and 21 year old), both ASD bigger than 30 mm, so it had to be removed performing a CPB procedure. In both cases the operation went well, they could be weaned shortly after closure of the ASD and the AASD rescue, being hospital-discharged in good condition. All AASO remaining implants were fine. Conclusions: AASO device implantation can be safe in all POF and ASD cases with diameter <30 mm but unsuccessful when that was bigger. Therefore, the Amplatzer atrial septal occluder must be avoided when the diameter is bigger than 30 mm.
Bakoulev Scientific Center of Cardiovascular Surgery, Moscow, Russian Federation Objectives: Resection of the coarctation area and extended end-to-end anastomosis with preserved growth potential and no graft material used may be a good option in young children. But in adolescents, adults or previously operated patients, graft replacement of the distal arch and isthmus are often needed. Despite evidence in the literature, no deep hypothermic circulatory arrest was used for brain or spinal cord protection. Methods: Fifty-five patients (42 male and 13 female) were operated on for hypoplastic aortic arch between 1990 and 2007. Their mean age was 14.5±6 years (range 4–58 years). The mean systolic gradients, as shown by echocardiography and cardiac catheterization, were 60±18 mmHg and 53±24 mmHg, respectively. There were 20 patients with complex coarctation after one or two previous repairs. Seventeen cases of extraanatomic bypass grafting were accomplished through a right thoracotomy without cardiopulmonary bypass. Other operations were performed through a left thoracotomy using an extended end-to-end anastomosis in 16 patients, graft interpositioning in 18 patients and polytetrafluoroethylene patch in two patients. Two cases repaired using arch enlargement by left brachiocephalic trunk formation. In addition, to arch enlargement, 14 patients had left common carotid and left subclavian artery reconstructions. Distal aortic perfusion with antegrade selective perfusion of brachiocephalic branches and moderate hypothermia without circulatory arrest were used for brain and spinal cord protection in 22 cases. The mean perfusion time was 57±26 min. Results: There was no in-hospital mortality. All patients had an eventful postoperative course and were discharged home 8–12 days following operation. Antihypertensive medication was stopped in all patients. The midterm 5-year survival was 98%. The time-related freedom from recurrent coarctation, defined as the presence of arm to leg gradient exceeding 20 mmHg on follow-up echocardiogram, was 99% and 96% for 3 and 5 year, respectively. Conclusions: Effective repair of distal aortic arch hypoplasia in adolescents and adults can be performed through a left thoracotomy without hypothermic circulatory arrest. In patients with high operative risk or with unfavorable anatomy extraanatomic bypass grafting can be used more safely. This approach allows decreasing the rate of early complications and provides satisfactory late result.
Topchibashev Research Institute of Surgery, Baku, Azerbaijan Objectives: To present mortality and morbidity after repair of GUCH. Methods: Seven hundred and ninety-two patients. with GUCH divided in to five age groups: 16–20 years – 392 patients, 21–30 years – 315 patients, 31–40 years – 56 patients, 41–50 years – 19 patients, >50 years – 10 patients. Sex ratio 1.4 with predominance of male patients. Two hundred and forty-seven patients underwent surgery including: 126 - with ASD, 34 - with VSD, 38 - with PDA, 13 - with PA valve stenosis, 12 - with TOF, 7 - with AVC (partial form), 8 - with Coarctation of the Aorta, 6 - with Lutembacher syndrome, 2 - with Ebstein Anomaly and 1 - with Ao Valve stenosis. Results: Ninety-one patients (36.8%) underwent complicated ICU-period and 18 (7.3%) of them were lost. Morbidity/mortality rate 5.04. Spectrum of post/op. complications included: right cardiac failure - 20 patients, wound complications - 14 patients, bleeding - 13 patients, respiratory insufficiency - 11 patients, leakage (minimal) - 11 patients, neurological complications - 4 patients, renal block - 6 patients. Most of patients spent ICU-period with rhytm disturbances such as AF-7 patients, supravenricular arrythmias - 18 patients, high graded VEB - 27 patients, sinus bradycardia - 20 patients, acute heart block in post-pump and ICU-period - 7 patients. In six of them sinus rhytm restored before discharge from the unit and one patient underwent pacemaker insertion. Two months later he also restored sinus rhytm, but refused from pacemaker extraction. More complicated ICU-period and poor results observed after repair of PA valve stenosis, TOF and VSD with rate of mortality: 30.7%, 25% and 11.7%, consequently. Insertion of bloodless CPB, cool farmacology cardioplegia (St. Thomas), prolonged administration of nitrates resulted in reducing morbidity and mortality from 45.5% >36.8% and 9% >7.3%, consequently. In last 45 procedures no one of patients was lost. Our experience with sildenafil in high PA hypertension restricted by four patients with ASD, underwent per os medication during one month until surgery. Use of sildenafil in GUCH complicated with high PA hypertension need in more experience and research. Conclusions: 1. Most of GUCH underwent surgery in more gravity status than young patients with such common complications of natural history as: high PA hypertension (40.3% patients, including 6.3% with Eizenmenger syndrome), cardiac rhytm disturbances (70% patients) and bacterial endocardites (3% patients). 2. In spite of essential premorbidity the vast majority of GUCH could be repaired with suitable in-hospital and follow-up results. 3. GUCH complicated with high PA hypertension need in nitrates infusion in post-pump and ICU-period with prolonged per os nitrates medication at least for one year follow-up period. Sildenafil medication vs. nitrates in such patients demand a cup of experience.
Bakoulev Center for Cardiovascular Surgery, Moscow, Russian Federation Objectives: One and one half ventricular repair is a strategy used in patients with right ventricular hypoplasia as an alternative to Fontan operation or as an attempt to minimize right ventricular failure after biventricular repair. However, indications for this procedure are not well established. The study is aimed to analyze the experience with one and one half ventricular repair and to clarify indications for this type of intervention in different categories of patients. Methods: During the years 1999–2007, one and one half ventricular repair was used in 50 patients aged from 1.5 to 28 years (mean, 7.9±4.5 years). Retrospectively, they were divided into four groups: I. Patients with hypoplastic right ventricle (n=16); II. Patients with Ebsteins anomaly and compromised right ventricle (C and D type by Carpantiers classification) (n=18); III. Patients with hypoplastic right ventricle combined with double outlet right ventricle, tetalogy of Fallot or transposition of the great arteries with VSD (n=9); IV. Patients after a complete repair of transposition of the great arteries with VSD, isolated pulmonary stenosis or Ebsteins anomaly resulted in acute right ventricular failure (n=7). In all cases, intracardiac repair was combined with bidirectional cavopulmonary shunt. The duration of follow-up period in 25 patients ranged from six months to seven years (mean, 3.2±1.4 years). Results: Group I patients had a tricuspid valve Z-score ranged from –2 to –10 (median, –6.75), and right ventricular inlet/outlet ratio ranged from 0.53 to 0.77 (mean, 0.71±0.10). Group II patients had hypoxemia (mean arterial blood oxygen saturation of 81.1±7.6%) and cardiomegaly (mean cardio-thoracic index equal to 69.6±7.4%). Group III patients had a moderate right ventricular hypoplasia (median tricuspid Z-score and mean right ventricular inlet/outlet ratio equal to –5.03 and 0.67±0.11, respectively). Hospital mortality was as high as 100% in group IV. In groups I, II, and III, mortality was equal to 14%, 17%, and 33%, respectively. Late mortality was absent. At follow-up examination, 92% of patients were in I–II New York Heart Association class. Conclusions: Elective one and one half ventricular repair is indicated for patients with a moderate right ventricular hypoplasia or dysfunction when a complete repair is associated with a high risk. Bidirectional cavopulmonary shunt performed as an urgent intervention aimed to treat right ventricular failure after a complete repair is accompanied by a poor result.
Baskent University, Department of Cardiovascular Surgery, Ankara, Turkey Objectives: Arterial switch operation (ASO) is the preferred surgical procedure for transposition of great arteries with favorable late results. Yet, it is associated with a number of complications. Pulmonary artery stenosis (PAS) is the most common complication necessitating surgical intervention after ASO. Many surgical measures have been defined to overcome PAS after ASO. Aim of this study is to discuss possible causes of PAS and to revise management strategy by reviewing past experience. Methods: Two hundred and seven patients who had undergone ASO between 2000 and 2006 were revised. Pulmonary stenosis occurred in 27 of the 185 survivors (14.6%). Branch pulmonary artery stenosis was present in 10 patients. Nine patients had initially a balloon angioplasty. Relief of the stenosis could be achieved in four patients. Twenty-three patients were operated for pulmonary stenosis. Half of these patients had a limited transannular patch with bovine pericardium. The other half received an anterior triangular patch for main pulmonary trunk and branches. The mean duration between ASO and reoperation for PAS was 13 months (3 months to 5 years). Results: Peak right ventricular pressure decreased from 86 to 45 mmHg. There has been no mortality. One patient experienced a temporary neurological dysfunction. None of the patients required a second intervention after pulmonary reconstruction. Conclusions: Surgical reintervention after ASO for stenotic branch pulmonary arteries, main pulmonary trunk or pulmonary annulus is sometimes necessary. Such a reoperation is generally well tolerated by an anatomically corrected heart. Early intervention is encouraged before development of infundibular hypertrophy which may require a transannular patch enlargement or a conduit placement in order to avoid the need for further interventions.
1The Department of Cardiovascular Surgery, Kobe Childrens Hospital, Japan; 2The Department of Cardiovascular Surgery, Kobe University Hospital, Japan Objectives: Single ventricle physiology with apicocaval juxtaposition is relatively rare complex, and there is difficulty to decide a route of conduit to complete total cavopulmonary connection (TCPC). The purpose of this study is to examine our cases and consider the appropriate route. Methods: Twenty-three consecutive patients with single ventricle physiology with apicocaval juxtaposition (mean age 4.4±3.6 years) who underwent TCPC from 1996 to 2007 were enrolled in this study. Viscero-atrial situs solitus was seen in 8, situs inversus in 10 and heterotaxy in 5. The bidirectional Glenn anastomosis had preceded TCPC in seventeen (74%). An artificial graft was placed in the same side of apex in ten (group A), the opposite side in thirteen (group B). The intra-atrial conduit TCPC was performed in eight and the extra-cardiac conduit TCPC in two of group A. All of group B underwent extra-cardiac conduit TCPC. The location of the inferior caval vein was evaluated retrospectively using the following index (IVC index=width of the part of IVC that overlapped the vertebra/width of the vertebra*100%) from the frontal view of preoperative angiography. The similar data was measured in ten patients with tricuspid atresia as the control group (group C). Results: There were four early mortalities caused by arrhythmia in two patients with heterotaxy, pulmonary venous obstruction in one of group A and systemic venous thrombosis in one of group B. The IVC index of group B was larger than group A and group C (45±26, 21±22 and 28±19%, P=0.03). In one of group A, whose IVC index was 80%, the sternum had to be removed partially to release oppression to the extra-cardiac conduit occurred between the heart and the sternum. In one of group B, whose IVC index was 13%, the conversion to intra-atrial conduit TCPC improved stagnant blood flow caused by a long and curved extra-cardiac conduit. One month after operation, cardiac catheter examinations showed that the length of conduit in group B was significant longer because of curved graft than group A and C (65±12, 36±14 and 44±10 mm, P<0.001), but no statistical difference neither in central venous pressure nor cardiac output. Conclusions: The route of the same side with apex could give smooth blood flow due to a shorter and straight conduit, however, the optimal route is different in each patient. To evaluate the detailed location of the IVC is helpful to decide the appropriate route of conduit for apicocaval juxtaposition.
National Amosov Institute of Cardiovascular Surgery, Kiev, Ukraine Objectives: To analyse surgical treatment of left sided heart tumors (LSHT) and recommend optimum technique of LSHTl based on these results. Methods: Four hundred and twenty-six consequtive patients (pts) with primary tumor of the LSHT were operated from January 1, 1984 till January 1, 2007 years. Tumors based at the left atrium (LA) (n=415 patients), left ventricle (LV) (n=11 patients). Malignant forms were in 10 (2.4%) patients: LA (n=9), LV (n=1). In other cases myxomas were marked in 97.6% (416): LA (406), LV (10). Mean age of patients was 54.4±6.4 year (range 8–78 years). Females 331 (77.7%), males 95 (22.3%). In the most of patients (98.2%) the bottom of the myxoma was based on any part of interatrial septum (frequently at fossae ovale). In 287 (69.5%) patients myxoma was in capsule and in 130 (30.5%) patients without one. Episodes of emboli before operation were occurred in 21 (4.4%) patients. Maternal basement was removed by wide resection of the interatrial septum (n=259 patients) (group A) and without broad resection of the septum (n=148 patients) (group B). Malignant tumor of the LA was removed with LA's wall and replaced this part of the LA with the autopericardial patch. All operations were performed with CPB and moderate hypothermia. At the last five years modified biatrial approach to LA's myxoma was used. Results: During last six years hospital mortality (HM) in the group with LA’ tumors was 2.4% (205/5). HM for malignant tumors was 20.0% (10/2): LA (n=9/2), LV (n=1/0) and for other forms – 7.9% (n=416/33): LA (n=406/31–7.6%), LV (n=10/2) The main reasons of HM were heart failure and brain damage because patients had entered to clinic with heart failure (as a rule, giant myxoma) and with previous episodes of emboli (absence of myxoma's capsule). At the late period 314 (93.8%) patients with myxomas were observed during one till 19 years after correction. There were 7 (1.9%) recurrences of myxoma (all left atrium). Four were successful reoperated. All patients belonged to group B. Conclusions: Myxomas were occurred frequently in female age more than 45-year-old. The late result of myxoma's correction should be successful in cases with broad resection of maternal bottom (interatrial septum) and replacement one with autopericardial patch.
1Department of Cardiovascular Surgery, University Hospital, Zurich, Switzerland; 2Institute of Surgical Pathology, University Hospital, Zurich, Switzerland; 3Department of Cardiac Surgery, City Hospital, Triemli, Zurich, Switzerland Objectives: Most common intracardiac tumors are the benign myxomas. Early surgical intervention mitigates morbidity and usually offers cure. Some data suggest an infectious factor in these tumors and certain histopathological features indicate herpes-simplex-virus type-1 infection. The aim of the study was to analyse the clinical data for the long-term follow-up and to perform immunohistochemical examination for the antigens of this virus. Methods: Between 1965 and 2005, 79 patients (46 female, mean age: 52.6 years (range: 17 to 83 years) underwent a resection of an atrial myxoma, from a total amount of 124 intracardiac tumors. Mean follow-up was 7.4 years. Immunohistological studies with monoclonal antibodies against HSV type 1 and 2 were performed on tumor biopsies of 40 patients. Perioperative data and written questionaires have been analysed for the clinical course and follow-up. Results: There was no early postoperative mortality. Three patients suffered from a transient neurological disorder. The follow-up was 76% complete. Two patients had been reoperated for recurrent myxomas, after two and nine years. 14 (17%) patients had to undergo additional cardiac surgery. Immunohistology revealed no positive signals for anti-HSV-1 or -2 antigens among the 40 analysed cases. Conclusions: Complete surgical resection, septum included is the treatment of choice and mandatory to prevent relapse. Perioperative morbidity and mortality is low even these tumor is observed in a more elderly and higher risk population and is mostly considered as an urgent surgery. In contrast to prior reports, no association between HSV infection and occurrence of cardiac myxoma was studied.
Bakoulev Scientific Center for Cardiovascular Surgery, Moscow, Russian Federation Objectives: to present the experience of surgical treatment of CHD with single (right/left) pulmonary artery (SRPA/SLPA). Methods: During the years 1983–2007, 38 patients with CHD and SPA (34 with SRPA, 4 with SLPA) were operated on: Thirty with TOF, 4 with VSD and absent PV (APV), 1 with VSD, 1 with ASD, 1 with CAVC, DORV and PS, 1 with aortic valve stenosis (AVS). In all patients the ipsilateral lung was present. Twenty three patients underwent palliative surgery: Blalock-Taussig shunting (8 patients), right ventricular outflow tract (RVOT) obstruction relief without VSD closure (11 patients), balloon pulmonary valvuloplasty (4 patients). The median age during the palliative operation was 3.0 (2.2; 7.0) years. Second/third palliative operations were necessary in five cases because of an inadequate growth of SRPA. Complete repair was done in 29 patients (with SRPA, n=25; SLPA, n=4): Twenty-two with TOF, 4 with VSD and APV, 1 with VSD and pulmonary hypertension, 1 with ASD, 1 with AVS. The median age during the complete repair was 7.0 (3.0; 9.0) years. Single PA index (SPAI) before complete repair in patients with TOF was 241±47 mm2/m2, median Z-score of normal Nakata index (NI): –3.0 (–3.7; –2.4). In two more patients with SLPA endovascular procedures were carried out: occlusion of PDA and pulmonary angioplasty in patient with SPA stenosis. Results: Overall hospital mortality was 5.3% (2/38): after palliative surgery – 4.3% (1/23), after complete repair – 3.4% (1/29). Diameter of RVOT after palliative repair without VSD closure was 11.0±2.4 mm, median Z-score of normal PV diameter was – 1.8 (–3.2; –1.2), PA systolic pressure was 33.6±6.9 mmHg. The ratio of systolic pressure in right and left ventricles after complete repair of TOF and VSD with APV was 0.57±0.12. All patients with Z-score NI equal to -5 or higher survived complete repair of TOF. One of two patients with Z-score NI less than –5 died after complete repair of TOF. Conclusions: The hospital mortality after surgical treatment of patients with CHD and SPA was low. The majority of patients (14/23) required palliative interventions as a first step of correction. At present the successful complete repair in patients with TOF corresponds to minimal Z-score NI equal to –5.
C4-1 POTASSIUM CHANNEL-RELATED RELAXATION BY LEVOSIMENDAN IN THE HUMAN INTERNAL MAMMARY ARTERY V. Yildirim, O. Yildiz, S. Doganci, C. Bolcal, U. Demirkilic Gulhane Military Academy of Medicine, Ankara, Turkey Objectives: Levosimendan is a potent inotropic and vasodilator drug used in the treatment of decompensated heart failure. There is no study on in vitro effects of levosimendan in human isolated arteries. Methods: We investigated the effect of levosimendan on contractile tone of human isolated internal mammary artery (IMA). The responses in IMA were recorded isometrically by a force-displacement transducer in isolated organ baths. Levosimendan was added to organ baths either at rest or after precontraction with phenylephrine (1 µmol/l). Levosimendan-induced relaxations were tested in the presence of cyclooxygenase inhibitor indomethacin (10 µmol/l), nitric oxide synthase inhibitor N122-nitro-L-arginine methyl ester (100 µmol/l), large-conductance calcium-activated potassium-channel inhibitor tetraethylammonium (1 mmol/l), adenosine triphosphate-sensitive potassium-channel inhibitor glibenclamide (10 µmol/l), and voltage-sensitive potassium-channel inhibitor 4-aminopyridine (1 mmol/l). Results: Levosimendan (10 nmol/l to 3 µmol/l) produced potent relaxation in human IMA (maximal effect, 75.3%±4.9% of phenylephrine maximum contraction, 6.8±0.1, n=15; –log10 of 50% effective concentration). Vehicle had no significant relaxant effect. The relaxation to levosimendan is not affected by either potassium-channel inhibitors (tetraethylammonium and 4-aminopyridine) or cyclooxygenase and nitric oxide synthase inhibitors. Glibenclamide (10 µmol/l) inhibited levosimendan-induced relaxation significantly (P<0.01). Conclusions: Levosimendan effectively and directly decreases the tone of IMA. The mechanism of levosimendan-induced relaxation in IMA appears in part to be adenosine triphosphate-sensitive potassium-channel opening action. Levosimendan may be a cardiovascular protective agent by its relaxing action on the major arterial graft, IMA.
Third Department of Cardiac Surgery, Onassis Cardiac Surgery Center, Athens, Greece Objectives: Controversy exists whether carotid endarterectomy combined with coronary artery bypass (CABG) results in increased postoperative morbidity compared with isolated CABG. To investigate this issue, we reviewed our experience with patients who had CABG with and without synchronous carotid endarterectomy. Methods: From 1995 to 2006, 60 patients (10 female) with coronary artery disease and severe (>80%) carotid artery stenosis underwent CABG with cardiopulmonary bypass combined with carotid endarterectomy in our Department. Their age was 67.4±0.9 years (±S.E.M.). Ejection fraction was 46.8±2.2%. Six of the patients (10%) had previous CABG. These 60 patients were compared with a matched control group (n=60) from our patients without severe carotid disease who had isolated CABG. The patients were matched for age, gender, NYHA class, and major pre-existing morbidity including myocardial infarction, diabetes, stroke and other neurological conditions. Standard CABG and carotid endarterectomy techniques were used. Comparisons were done using the Mann–Whitney (Wilcoxon RankSum) Test for continuous variables, and the Fisher's Exact Test for categorical variables. Results: There was no difference in ejection fraction, previous CABG, perfusion or aortic crossclamp times, number of coronary bypass grafts, and postoperative hospital stay between groups (P>0.05). There was no operative (30-day) mortality in either group. Postoperative complications in the combined surgery group of patients vs. control (isolated CABG) group occurred as follows: Atrial fibrillation in 13.3% vs. 18.3%; low cardiac output, 1.7% vs. 0; prolonged (>48 h) ventilation, 5% vs. 5%; perioperative myocardial infarction, 1.7% vs. 0; stroke, 1.7% vs. 5%; coma, 0 vs. 1.7%; other neurological complications, 5% vs. 1.7%; any major complication, 23.3% vs. 31.7%, respectively. There was no difference in complications between groups (P>0.2). Conclusions: Carotid endarterectomy can be performed in combination with CABG without increasing the operative morbidity and mortality.
Bakoulev Scientific Center of Cardiovascular Surgery, Moscow, Russian Federation Objectives: To evaluate the results of surgical treatment of abdominal aortic aneurysm (AAA) and concomitant arterial lesions. Methods: There were 173 consecutive patients who underwent AAA surgical repair. There were 153 (89%) men and 20 (11%) women with a mean age of 63.4±8.4 years (range 23–87). Ninety-six percent of the cases were elective and 4% - urgent admissions. An extensive preoperative examination was included ultrasound duplex scanning, angiography, CT and MRI. The location of AAA was infrarenal (87.8%), juxtarenal (9.8%) and suprarenal (2.3%). Aneurysms ranged in size from 37 to 164 mm with a mean diameter of 70.8±26.2 mm. The operative approach in cases of infrarenal AAA was laparotomy, in more proximal aneurysms - extended left flank extraperitoneal exposure. In addition, patients with significant lesions of coronary, carotid and renal arteries underwent myocardial revascularization, carotid endarterectomy and renal artery reconstruction, respectively. The operations on abdominal aorta, coronary and carotid arteries were conducted either separately in two stages (19.0%) or simultaneously as one-stage procedure (10.4%) depending on haemodynamical significance of concurrent arterial lesions and type of the aneurysm. The incidence of concurrent coronary artery disease and carotid artery lesion was 90.1% and 73.9%, respectively. Associated essential hypertension was found in 26.5% of cases and chronic obstructive pulmonary disease in 8.7% of patients. Renal artery stenosis were detected in 42.7% and 21.9% of cases, respectively. Coexisting lesions of three arterial regions (coronary, carotid and renal arteries) were observed in 12.1% and lesions of four arterial regions (coronary, carotid, renal and lower limb arteries) in 6.9% of cases. Occlusive and aneurysmal lesions of iliac arteries were found in 29.4% of patients. Results: In cases of correctable coronary artery disease AAA repair was added by CABG (26.4%) or PTCA (6.8%). 19.4% of patients with significant carotid stenosis underwent carotid endarterectomy. Simultaneous iliac and renal artery reconstructions were performed in 29.4% and 6.8% of cases, respectively. Staged operations in cases of coexistent coronary and carotid lesions were performed correspondingly five and 2.5 times more frequently than simultaneous repairs. The overall in-hospital morbidity and mortality comprised 16.7% and 3.4%, respectively. Mortality following staged repair was 2%. There was no postoperative death following simultaneous reconstructions. Conclusions: The management of AAA and coexistent arterial lesions includes either staged or simultaneous repair. The choice of surgical strategy depends on the haemodynamical significance of concomitant arterial lesions. The results of staged and simultaneous repair of AAA and coexistent arterial lesions are satisfactory.
Chirurgia Vascolare Azienda Ospedaliera Santandrea Universita La Sapienza di Roma, Italy Objectives: perioperative stroke rate in patients with carotid artery disease undergoing cardiac surgery is 10% when stenoses are 50–80% and 11–19% in stenoses >80%. Patients with untreated bilateral carotid disease have a 20% rate of stroke. The staged procedure of carotid revascularization followed by CABG has lower stroke risk but higher incidence of myocardial events. The staged procedure of CABG followed by carotid artery revascularization has higher incidence of cerebrovascular complications and fewer cardiac events. Synchronous procedures have medium incidence of both complications. In those patients optimal treatment remain controversial. Carotid artery stenting (CAS) in the past few years have demonstrated, expecially in high-risk patients, to be a valid alternative to carotid endarterectomy (CEA). Transcervical carotid stenting reduces periprocedural thromboembolic complications, avoiding the aortic arch instrumentation. We report the results of a prospective study designed to evaluate the feasibility, safety and benefits in a reduction of neurological perioperative events in patients undergoing carotid artery stenting synchronous coronary artery bypass or combined by-pass and valve replacement. Methods: From March 2003 to December 2007 a total of 22 patients were included (14 male; 8 female). The mean patients age was 70.6±7 years. The procedural success rate of CAS was 100%. Transfemoral approach was performed in 10 cases, a transcervical approach in 12 cases, with a mini-incision at the base of the neck to access at the common carotid artery. In 16 (72.7%) cases a CABG was performed after CAS, in 4 (18%) cases the CABG were associated with aortic valve replacement and in 2 (9%) with mitral valve replacement. All patients underwent general anestesia, and a transcranial Doppler monitoring was performed during all the procedure. Results: Two (9%) patient had a minor stroke, in one case it was ipsilateral, in the other it was controlateral. Both of them had bilateral carotid stenosys and the one with controlateral minor stroke underwent to valve replacement too. One (4.5%) patient had a major controlateral stroke after CAS, CABG and valve replacement. None of the patients that underwent CAS and CABG had miocardial or cerebral events. There were no deaths. Conclusions: Patients that need valve replacement associated with carotid and cardiac revascularization have an higher risk to develop cerebral ischemia compared to those that underwent CAS with CABG. Patients with hemodynamically carotid artery stenosis can undergo synchronous CAS/CABG with a low morbidity and mortality rates.
Gulhane Military Academy of Medicine, Ankara, Turkey Objectives: To evaluate the impact of interpleural analgesia (IP) on postthoracotomy pain and respiratory function as an alternative to thoracic epidural analgesia (TEA). Methods: Design: prospective, randomized study. Setting: tertiary-care military hospital. Patients: sixty young patients scheduled for elective thoracic surgery (correction of aorta coarctation and patent ductus arteriosus). Interventions: patients were randomized into two groups to receive either IP or TEA for postthoracotomy pain management. Measurements: patients in the IP group (n=30) had a catheter inserted between the parietal and visceral pleura by a surgeon, and 0.2% ropivacaine was given through this catheter. In the TEA group, ropivacaine was administered through a thoracic epidural catheter. The impact of both methods on pain control, respiratory function, and pulmonary complications was analyzed and compared. Results: The frequency of atelectasis and pleural effusion was also significantly high in the IP group (P<0.01). Respiratory function and postoperative pain scores were better in the TEA group (P<0.01). Arterial blood gas analysis on the fifth postoperative day was significantly better in the TEA group. Conclusions: Thoracic epidural analgesia has more beneficial effects on respiratory function and postoperative pain after thoracotomy than does IP.
Rajaee Heart Center, Tehran, Iran Objectives: Constrictive pericarditis (CP) demonstrates a heterogenous pattern and has different aetiologies depending on the geographic areas reporting it. Today in the western hemisphere radiation and previous cardiac surgery have become important causes of CP, but it seems that Tuberculosis is still a common cause of CP in the developing countries. Methods: We reviewed the records of 45 patients with the diagnosis of CP who underwent pericardiectomy between 1994 to 2006. The mean age was 46.6 year (21–84 year) Preoperatively 4.5% were in New York Heart Association (NYHA) Class I, 45.5% in class II, 47.7% in class III and 2.3% in class IV. Pericardial calcification was seen in 21% of plain chest X-rays. The mean follow-up period was 40±18 months (3–144 months). Results: Postoperatively only 15.6% of patients were in NYHA class III and the others were in class I (18.2%) or II (66.2%), (P<0.001). The etiologic factors were Tuberculosis in 22.2%, chronic renal failure in 8.8%, post-sternotomy in 4.5% and malignancies in 4.5%. The cause of CP was idiopathic in 60%. Low output state was the most common postoperative problem (22.3%). The overall mortality was 4.4%. There was one in-hospital death due to respiratory insufficiency in a tuberculosis patient and one patient died due to metastatic adenocarcinoma during follow-up period. Conclusions: We conclude that the tuberculosis despite vaccination programs and anti-tubercular medications is still an important cause of chronic CP at least in our area. Pericardiectomy is an effective treatment of chronic CP because it provides an important and durable improvement in symptoms and functional status with low mortality.
Gulhane Military Academy of Medicine, Ankara, Turkey Objectives: Levosimendan is a potent inotropic and vasodilator drug used in the treatment of decompensated heart failure. There is no study on in vitro effects of levosimendan in human isolated arteries. Methods: We investigated the effect of levosimendan on contractile tone of human isolated internal mammary artery (IMA). The responses in IMA were recorded isometrically by a force-displacement transducer in isolated organ baths. Levosimendan was added to organ baths either at rest or after precontraction with phenylephrine (1 µmol/l). Levosimendan-induced relaxations were tested in the presence of cyclooxygenase inhibitor indomethacin (10 µmol/l), nitric oxide synthase inhibitor N122-nitro-L-arginine methyl ester (100 µmol/l), large-conductance calcium-activated potassium-channel inhibitor tetraethylammonium (1 mmol/l), adenosine triphosphate-sensitive potassium-channel inhibitor glibenclamide (10 µmol/l), and voltage-sensitive potassium-channel inhibitor 4-aminopyridine (1 mmol/l). Results: Levosimendan (10 nmol/l to 3 µmol/l) produced potent relaxation in human IMA (maximal effect, 75.3%±4.9% of phenylephrine maximum contraction, 6.8±0.1, n=15; –log10 of 50% effective concentration). Vehicle had no significant relaxant effect. The relaxation to levosimendan is not affected by either potassium-channel inhibitors (tetraethylammonium and 4-aminopyridine) or cyclooxygenase and nitric oxide synthase inhibitors. Glibenclamide (10 µmol/l) inhibited levosimendan-induced relaxation significantly (P<0.01). Conclusions: Levosimendan effectively and directly decreases the tone of IMA. The mechanism of levosimendan-induced relaxation in IMA appears in part to be adenosine triphosphate-sensitive potassium-channel opening action. Levosimendan may be a cardiovascular protective agent by its relaxing action on the major arterial graft, IMA.
Kings College Hospital, London, UK Objectives: BNP which stands for brain natriuretic peptide is a cardiac neurohormone and is secreted in response to myocardial stress and causes natriuresis and vasodilatation. Some studies have reported close correlation between the high concentration of BNP in blood and worse short-term and long-term prognosis post myocardial Infarction and heart failure. In this study we have tested its usefulness and predictive value in the outcome, post cardiac surgery. Methods: Between March 2006 to June 2007, 141 patients, undergoing cardiac surgery, were enrolled in this study. Their BNP concentration was measured prior to the operation and their co-morbidities were examined against their BNP level. Postoperatively their outcome was closely monitored. Main clinical end points were; atrial fibrillation; inotropic use, renal impairment, early deaths, ICU and hospital stay. Comparative descriptive tests and Spearman rank were used for analysis. A P<0.05 was considered to be statistically significant. Results: Some preoperative co-morbidities, such as; renal impairment, peripheral vascular disease and low ejection fraction were associated with higher BNP concentration. Statistically EuroSCORE and parsonnet score, showed significant correlation with preoperative BNP concentration (P<0.001). High BNP concentration, also predicted inotropic requirement, higher than the baseline creatinine concentration post operatively, longer ventilation time, and longer ICU and hospital stay (P<0.05) but our study did not reveal any predictive value for BNP and developing AF or wound infection. Conclusions: BNP is a valuable biochemical marker, which is easy to measure and can be beneficial in predicting the operative outcome.
Clinic for Cardiothoracic Surgery, Klinikum Augsburg, Germany Objectives: The number of patients receiving coronary stent angioplasty is still increasing. And some cardiologists are of the opinion that coronary artery surgery will be unnecessary in some years. However, with the increasing number of stent angioplasties the number of patients with a need for coronary artery surgery after these procedures is also increasing. Especially in patients a short time after angioplasty or patients who received drug eluting stents the hemostasis is one of the major problems in surgery. There are also a number of patients entering the operation room under unstable conditions due to acute stent thrombosis or complications in the catheter laboratory. Methods: All our patients from 2004 and 2005, who underwent coronary artery bypass grafting following coronary angioplasty within a period of six months were investigated (n=124). Several items as the number of vessels diseased, localisation of stents, preoperative medication (especially clopidogrel and aspirin), amount of blood loss, need for transfusion, length of stay in ICU and in hospital and 30-day-mortality were compared to all other patients that underwent coronary artery bypass grafting during this period (n=1730). Results: The majority (n=83; 67%) of the angioplasty collective suffered from three-vessel-disease. 75.8% (n=94) needed emergency revascularisation. Consumption of clopidogrel and aspirin, blood loss, need for transfusion (1.7 vs. 0.77 units transfused per patient), cardiogenic shock and length of stay in ICU (3.6 vs. 2.6 days) and hospital (15 vs. 9.0 days) were significantly higher than in the control group. There was even an increasing number of patients after angioplasty (n=55 in 2004 vs. n=69 in 2005). In one case a fatal myocardial infarction following acute stent thrombosis required implantation of a ventricular assist device. Nevertheless no increase in mortality could be observed. Conclusions: The big number of patients with three-vessel-diseases shows that these patients should have received coronary artery bypass surgery in the first place. This is also according to the guidelines. At least a discussion between cardiologist and surgeon should have been held before stent angioplasty. It is also most important to keep the connection with the cardiologist running in order to discuss the greater risks for the patients. Especially the increasing number of patients with clopidogrel medication implicates a better management and analysis of hemostasis during the surgery. Despite the risk there is also the problem of increasing consumption of resources and costs in this collective.
V1-1 EFFECT OF EVAR WITH TRF AND IRF ON RENAL FUNCTION COMPARED TO OPEN REPAIR: RESULTS OF A PROSPECTIVE COMPARATIVE STUDY M. Antonello, P. Frigatti, M. Menegolo, A. Dall'Antonia, F. Grego, G.P. Deriu Department of Cardiac Thoracic and Vascular Sciences, Section of Vascular and Endovascular Surgery, University of Padua, Italy Objectives: Recent studies have shown that progressive renal dysfunction may develop in patients after EVAR, data are conflicting about the effect of EVAR on renal function compared with open repair (OR). The purpose of this prospective study was to asses the effects of EVAR both with TRF and infrarenal fixation (IRF) vs. OR on renal function detected with serum creatinine (SCr), creatinine clearance (CrCl) and renal perfusion scintigraphy (RPS) and to compare them with OR. Methods: A prospective comparative study was carried out at the Department of Vascular and Endovascular Surgery - University of Padua, from January 2003 to June 2006. To assess renal function a RPS, SCr, CrCl (estimated with the Cockcroft-Gault) were performed preoperatively and in the 4th postoperative day. A postoperative change >20% of SCr, CrCl or of the glomerular filtration rate (GFR) at the RPS was considered significant for renal dysfunction. The follow-up included: dosage of SCr, CrCl, Duplex scan of renal artery and angio-CT at 6, 12 months and than yearly. Patients wit a preoperative SCr >2.5 mg/dl were excluded. Results: The patients enrolled in the study were 320; 111 underwent EVAR; 57 (51.3%) received a TRF and 54 (48.7%) a IRF; 209 underwent open repair. No significant change were observed for SCr, CrCl from the preoperative to the postoperative period (4th day) in both EVAR groups. A significant reduction of the GFR at the RPS was observed in 9 patients (8.1%), 5 (8.8%) from the TRF group and 4 (7.4%) from the IRF group in absence of relevant variation of SCr and CrCl. In five patients (4.5%; 3 TRF, 2 IRF) the decrease was limited to a single kidney. No difference emerged by comparing preoperative and postoperative SCr and CrCl, between EVAR group and OR. During the follow-up (mean 26 months, range 12–54), a slight and progressive decline of renal function was observed in EVAR group differently in OR group renal function improved (Fig. 1). No sign of renal artery occlusion or renal infarction was observed at the angio-Ct and renal artery Duplex scan. Conclusions: An early decrease of renal function is seen after EVAR at the RPS in 8.8% of patients, regardless of fixation level. Long-term results showed a slight worsening of renal function in EVAR group and by contrast an improvement in OR; this result must be considering in selecting patients for this procedure.
Department of Vascular and Endovascular Surgery, Hospital Nuremberg, Germany Objectives: Endovascular aortic aneurysm repair (EVAR) is now being evaluated as an alternative to surgical repair for treatment of anatomy suitable infrarenal abdominal aortic aneurysms (AAAs) and is becoming accepted as gold standard. Methods: The successful treatment is to place an endoluminal exclusion channel to prevent rupture of the aneurysm without mid and long-term adverse events. The essence of this technique is to build an endoluminal exclusion system with strong fixation (stability) of the endograft and complete exclusion (seal) of the aneurysm sac. The Endologix Powerlink endograft (Irvine, CA, USA) is a unibody fully supported bifurcated device which can be implanted sitting on the aortic bifurcation – anatomical fixation on the abdominal aortic bifurcation, this has been proven by our single center seven year experience to be the best way of eradicating distal migration of the endografts. Building upon the foundation of the bifurcated endograft, a suprarenal or infrarenal proximal cuff with a long overlapping segment inside the bifurcated mainbody endograft (for prevention of type III endoleak) is built up to the renal artery level, thus providing a stable endoluminal exclusion system. Normally, a good seal can be achieved by balloon angioplasty in the neck. If not, a Palmaz stent can be used to achieve proximal seal. Accordingly, with a quite different philosophy from the other devices, the Endologix Powerlink endograft with fixation on the aortic bifurcation is best for most AAAs. Results: Our EVAR experience has proved that the Powerlink device is good for morphology challenging AAAs with flared necks. Theoretically and practically, the Endologix Powerlink device is good for most of the challenging AAAs, and we are using it for cases with short and angulated necks, thrombus affiliated necks, calcified necks and flared necks. When can it not be used. Our experience of more than 450 cases has shown only two situations: the first is the limitation of the delivery access which is very narrow or severely tortuous, the second is the limitation of the neck diameter which is more than 25 mm, as the larger angioplasty balloon for Palmaz stent is not yet commercially available. However, these limitations apply for all endovascular devices. Conclusions: The Endologix Powerlink endograft with fixation on the aortic bifurcation has been proven best for most AAAs, and it is also good for many challenging cases like flared necks. The larger diameter of the neck may be a limitation of the application of this device.
1Vascular Surgery Division of Hospital Clinic, University of Barcelona, Spain; 2Cardiology Division of Hospital Clinic, University of Barcelona, Spain Objectives: To systematically review the findings of the use of contrast-enhanced ultrasound scan (CUS) and to determine its value as an alternative to computed tomographic angiography scan (CTA) in the follow-up after endovascular repair of abdominal aortic aneurysm. Methods: A search of PubMed and Medline databases for English-language literature was performed to find studies published between 1997 and 2007. Studies comparing the diagnostic accuracy of contrast enhanced ultrasound with that of computed tomographic angiography were included, and analysis was performed to value of the detection of endoleaks and follow-up in endovascular aneurysm repair. Results: Eight studies met the criteria and were included for analysis. A total of 293 (ranging between 20–102 for each study) patients underwent paired scans (ranging between 20–96) in two studies they were not specified (NS). All studies used a spiral CTA, six biphasic (an arterial and a delayed scan), one uniphasic (only arterial scan) and was one not specified. The CUS scan was performed using first (in 6 studies) and second (in 1 study) generation contrast agent, in six studies contrast agent was applied in bolus form (0.5–2.4 ml) and one by continuous saline dissolved solution. The inhomogeneous group of studies makes it impossible to calculate a pooled estimate of sensitivity, specificity, positive and negative predicted value for endoleak detection. Most articles stated a high false positive number of endoleaks compared to the CTA, yet many question these as rather ‘true positive’ caused by failure of CTA to detect them. Some studies mentioned CUS to be more sensitive to the detection of slow-flowing endoleaks due to its superior contrast resolution on delayed imaging. The added value of CUS is a higher sensitivity in specifying the type of endoleak as well as the information of hemodynamic characteristics. Conclusions: This systematic review shows a consistent bias in the studies by defining the CTA as the gold standard for detection of an endoleak. Another bias is the mathematical coupling caused by retrospectively redefining the gold standard as the outcome of the studied CTA and CUS scan. These biases call upon a large randomised prospective trial with clear definition and imaging protocol to determine the specific sensitivity, specificity, positive and negative predicted value for endoleak detection. Together with the substantial lower cost and the radiation, nephrotoxic and anaphylactic reduction CUS and plain X-ray should be considered as a possible candidate in becoming the ‘gold standard’ protocol for follow-up in EVAR.
Barts and The London NHS Trust, UK Objectives: The purpose of this study was to evaluate the efficacy of duplex ultrasound (DUS) compared to computed tomography (CT), which is considered to be the gold standard for surveillance of patients post endovascular abdominal aortic aneurysm repair (EVAR), at a single centre. Methods: Eighty patients [57 males, mean age 74.7 years (range 51–91)] underwent infra-renal EVAR from August 2003 to August 2007. Follow-up was performed with paired CT and DUS scans (within eight weeks of each other) pre-discharge; at 3, 6, 12 months post-discharge and yearly thereafter. Sensitivity, specificity, positive and negative predictive value of DUS was compared to CT for detecting endoleaks. Accuracy in assessing change in aneurysm sac size was also evaluated. Results: Paired CT and DUS scans were obtained in 112 instances. CT identified 16 endoleaks in 15 patients (5 type 1, 8 type 2 and 3 of uncertain origin). Of these, DUS identified 10 endoleaks (4 type 1, 4 type 2 and 2 of uncertain origin). DUS identified an additional 13 endoleaks in 12 patients (3 type 1, 8 type 2 and 2 of uncertain origin). Compared to CT, DUS had a sensitivity of 62.5%, specificity of 86.3%, positive predictive value of 43.5% and negative predictive value of 93.6%. Of the five type 1 endoleaks detected on CT, one resolved spontaneously. The remaining four requiring intervention were also detected by DUS. The additional three type 1 endoleaks detected only by DUS, resolved spontaneously. Statistical analysis performed using the Mann–Whitney U-test, found no significant difference in assessing change in aneurysm sac size by either modality (P=0.87). Conclusions: Although less specific and sensitive than CT in detecting endoleaks, DUS detected all endoleaks requiring intervention. DUS could form an integral part of a surveillance programme for patients post EVAR.
1Department of General Vascular and Transplant Surgery, Medical University of Warsaw, Poland; 2Second Department of Radiology, Medical University of Warsaw, Poland Objectives: Improved long-term survival of kidney transplant recipients contributed to increase number of incidence of abdominal aortic aneurysm (AAA) in this group of patients. Open aneurysmectomy is technically difficult and burdened with high risk of ischemic injury to transplanted kidney upon cessation of aortic blood flow. The aim of the study was to present results of endovascular AAA exclusion by stentgraft implantation in patients after kidney transplantation. Methods: In our Department since 1998, 593 patients with AAA were treated endovasculary. In this group eight (1.34%) were kidney transplant recipients. Time between kidney transplantation and AAA management was from 3 to 19 years. In five patients grafts renal artery was anastomosed in end-to-end fashion to hypogastric artery, in remaining patients end-to-side to external iliac artery. Aneurysm diameter were 50–76 mm. Commercial bifurcated stentgrafts were used (Zenith, Excluder and PowerLink). All procedures were performed under epidural anaesthesia. All patients were followed-up with CT-scan performed postoperatively, in 3-rd, 6-th, 12-th month and annually thereafter according to Eurostar protocol. Kidney function was assessed two times a year. Results: Successful AAA exclusion (without any endoleak) and preserved flow to transplanted kidney was confirmed on completion angiogram in all patients. Temporary deterioration of transplanted kidney function was observed in two patients, one of them required transient haemodialysis. In follow-up there was one stentgraft limb thrombosis contralateraly to transplanted kidney in 9th month after stentgraft implantation that required femoro-femoral bypass. In one patient there was endoleak type I treated successfully with proximal extension. The mean observation period was 33 months (range 9–68 months). Conclusions: Endovascular treatment of AAA in kidney transplant recipients is safe and effective method and can be performed without serious impairment of graft function.
1Division of Vascular Surgery, Novara Hospital, Italy; 2Institute of Interventional Radiology, Novara Hospital, Italy Objectives: To report our early experience with endovascular treatment of patients with ruptured abdominal aortic aneurysms. Methods: Between January 2005 and September 2007, 90 patients with a ruptured abdominal aortic aneurysms presented to our Unit. All hemodynamically unstable patients (systolic blood pressure <80 mmHg) were transferred directly to the operating room for open repair. The hemodynamically stable patients underwent computed tomography angiography to evaluate anatomic suitability for emergency endovascular treatment (EVAR). Twenty-two patients (21 males; 1 female; mean age: 78.8 years) underwent EVAR procedure. A total of 20 bifurcated and two aortouni-iliac stent grafts were implanted. The mean dose of contrast medium was 140 ml. Results: Overall successful graft deployment was 100%. The 30-day mortality was 14% (3/22 patients); two patients died from cardiac causes and one patient developed a multiple organ failure. There were no postoperative reinterventions. Patients underwent computed tomography angiography scan at 1, 6, 12 months and yearly (Eurostar protocol). The mean follow-up is 192.6 days (range: 90–540 days); the overall mortality rate was 23% (5/22). We observed no type I and III endoleaks and two cases of type II endoleak (9%). Conclusions: Endovascular treatment of ruptured abdominal aortic aneurysms is feasible and the early experience is promising.
Service de chirurgie cardiovasculaire et thoracique Cliniques universitaires UCL de Mont Godinne Yvoir, Belgium Objectives: The purpose of this study was to assess the effectiveness of EVAR at our institution. Methods: Between January 2002 and December 2007, 244 consecutive patients underwent elective treatment of an infrarenal aorto iliac aneurysm; 145 with open repair and 101 with EVAR. An adequate morphology of the proximal aortic neck determined by CT-scan and routine preoperative angiography was the main criterion used to select the patients for EVAR. All EVAR were performed in the operating room under general anesthesia through surgically exposed femoral arteries. Postoperatively all the patients underwent contrast enhanced ct scans before discharge, then at 1, 3, 6, 12, 18, 24 months and yearly thereafter. Results: The demographic data of the 101 patients are as follows: mens: 96, womens: 5, mean age: 68 years, CAD: 50 patients, hypertension: 52 patients, diabetes: 10 patients, stroke/TIA: 14 patients, severe obesity: eight patients, COPD: 17 patients, renal insufficiency: two patients previous laparotomy: 23 patients EVAR was successfully performed in 99 patients. There were two conversions to open surgery because of failure access. Ninety-eight bifurcated and one aortouniliac endo grafts were implanted. Sixteen patients required additional procedures including coil embolization of one hypogastric artery (10 patients), femoro femoral bypass (1 patients), thromboendarterectomy of the common femoral artery (4 patients), and balloon angioplasty of a renal artery (1 patient). Mean operative time was 116 min. There was no perioperative death and none of the patients required blood replacement. Mean postoperative length of stay was five days. A rupture occurred on postoperative day eight in a patient who had no endoleak on the angiogram obtained after completion of the EVAR. This patient was successfully treated with placement of an iliac extension. Three patients required also an early reoperation for groin complications (lymphocele 2, skin necrosis 1). Mean follow-up is 23 months. There were six late deaths (traffic accident 1, Alzheimer's disease 1, mesenteric infarction 1, and cardiac failure 2). There were one graft occlusion treated with femoro femoral bypass and three stenoses treated with balloon angioplasty and placement of a new stent. Three endoleaks type I b were detected in two patients 6.22 and 26 months postoperatively and were treated with placement of iliac extensions Expansion of the diameter of the aneurysmal sac with no demonstrated endoleak occured in one patient who was treated with placement of a new bifurcated aortoiliac endograft 48 months after the previous EVAR. A significant reduction of the aneurysmal sac was noted in 52 patients and no change was noted in the 45 others. Conclusions: Our results suggest that EVAR can be performed in almost half the patients with an infrarenal aorto iliac aneurysm with an acceptable rate of early and mid-term complications.
1Department of General Vascular and Transplant Surgery, Medical University of Warsaw, Poland; 2Second Department of Radiology, Medical University of Warsaw, Poland Objectives: Since the endovascular treatment of abdominal aortic aneurysm was described, this type of operation became the method of choice in patients with high perioperative risk. The aim of this study was to estimate the outcome of endovascular treatment of infrarenal abdominal aorta aneurysm in patients with high perioperative risk. Methods: From April 1998 to January 2008, 593 patients with abdominal aortic aneurysm were treated by means of stentgraft in our Department. The aneurysm diameter was from 42 to 110 mm. Operative risk was estimated in ASA scale and SVS-ISVS scale. We evaluated 453 patients more then grade II in ASA scale, considered high perioperative risk. Three hunderd and eighteen (70.2%) were classified as ASA III and 135 (29.8%) - ASA IV. The age ranged from 47 to 91 years, 42 patients were older than 80. Severe ischemic heart disease was stated in 420 (82.7%) patients, 323 (71.3%) of them had myocardial infarction in the past, in 55 (12.1%) the ejection fraction was <40%. Arterial hypertension occurred in 432 (95.3%). Chronic obstructive pulmonary disease was confirmed in 178 (39.3%) patients. Spiral CT-scan was used for preoperative evaluation and postoperative follow-up, performed according to Eurostar registry protocol. Four hundred and twenty-one (94.6%) of operations were performed under regional anesthesia. In 27 cases general and in five local anesthesia were used. Results: The technical success was achieved in 447 patients (98.7%). In six patients (1.3%) early conversion to open aneurysmectomy was necessary. Eight-one (17.9%) patients required reintervention because of endoleaks. Three patients required aneurysm sac opening and ligation of endoleak. There was no aneurysm rupture in early postoperative period. The rupture of four aneurysms occurred over one year after EVAR. Perioperative mortality occured in 19 patients (4.2%). Pulmonary insufficiency occurred in six patients (1.3%) operated in general anesthesia. They required controlled ventilation up to 16 h after the operation. Impaired renal function with the rise of creatinine level over 1.5 mg percent occurred in 25 (5.5%) patients. Three (0.7%) of them required transient, 6 (1.3%) permanent dialysis. Conclusions: We have shown EVAR to be feasible, durable, and safe option for patients with several comorbidities. The procedure is currently performed with low in-hospital mortality, even in patients with the highest risk.
Barts and The London NHS Trust, UK Objectives: This study aims to quantify the incidence of renal impairment in patients post EVAR and compare it with open surgery. Methods: One hundred and thirty-two patients underwent elective repair of infra-renal abdominal aortic aneurysms at our institution from January 2003 to October 2007. Seventy-three patients underwent EVAR and 59 underwent open repair. Serum creatinine levels were recorded preoperatively, immediately postoperatively and one year post surgery. Renal impairment was classified as mild, moderate and severe using glomerular filtration rates, calculated by the 4-variable MDRD (modification of diet in renal disease) method. All patients with pre-existing renal impairment were given N-acetylcysteine and re-hydration preoperatively. Both groups were comparable for gender (EVAR – 55 men, open – 50 men), age [EVAR – mean age 73.9 (range 59–90), open – mean age 71.2 (range 44–85)] and ASA grade [EVAR - mean 3.3 (range 2–4), open - mean 2.8 (range 2–4)]. Pre existing renal impairment was detected in 41 patients in the EVAR group (40 mild, 1 moderate) and 23 patients in the open group (21 mild, 1 moderate, 1 severe). Statistical analysis was performed using the paired t-test. Results: There were 8/73 (11%) new cases of renal impairment in the EVAR group and 12/59 (20.3%) new cases in the open group. In addition, one patient in each group had progressed from moderate to severe renal impairment at one year follow-up. In all, 9/73 (12.3%) patients in the EVAR group and 13/59 (22%) in the open group experienced deterioration in renal function. Statistical analysis performed revealed no significant difference in the creatinine levels in both groups either preoperatively and immediately postoperatively (EVAR P=0.3, open P=0.7) or preoperatively and one year post surgery (EVAR P=0.5, open P=0.9). Conclusions: Our results do not suggest an increased incidence of renal impairment post EVAR as compared to open surgery.
V2-1 EVALUATION OF CARDIAC TROPONIN I LEVELS AND CORRELATION WITH EARLY AND LATE CARDIAC AND NEUROLOGIC COMPLICATION AFTER CAROTID REVASCULARIZATION WITH TRADITIONAL OR ENDOVASCULAR SURGERY P. Frigatti1, L. Ferretto1, C. Sarais2, G. Deriu1 1Clinic of Vascular and Endovascular Surgery, Department of Cardiac Thoracic and Vascular Sciences, University of Padua, Italy; 2Clinic of Cardiology, Department of Cardiac Thoracic and Vascular Sciences, University of Padua, Italy Objectives: When compared with carotid endarterectomy (CEA), percutaneous carotid angioplasty with stent replacement (CAS) is a less invasive technique in the treatment of carotid stenosis. However, periprocedural hemodynamic instability still remains a challenge. This instability might lead to myocardial damage, which is now measured accurately by using cardiac troponin I (CTnI). The purpose of this report is also to compare cardiac and neurological early and late outcomes in symptomatic and asymptomatic patients treated with CAS and carotid endarterectomy (CEA). Methods: From September 2004 to September 2006, 513 consecutive patients underwent to elective carotid revascularization through CAS or CEA and have been included perspectively in the study: 415 patients underwent to CEA (80.9%) while 98 underwent to CAS (19.1%). All patients have been evaluated CTnI preoperative, postoperative, and in days 1, 2, 3. The follow-up in the long-term has been carried out through one systematic clinical review of the patients from 1 month to 12 months. End point the clinicians were major and minor neurological and cardiac events. Results: An increased level of CTnI (>0.5 ng/ml) has been found with the same frequency and without statistically difference in the patients who underwent to CEA (19 ps: 4.58%) and also in the patients who underwent to CAS (4 pz: 4.08%). Also separately analyzing to cardiological major events (1.93% CEA vs. 1.02% CAS) and minors (2.65% CEA vs. 3.06% CAS) the values are the same about. None have been cases of cardiac death. No correlation has been found between periprocedural homodynamic instability and increase of the levels of the troponina. Analyzing only the patients with preoperative heart disease we have had the same percentage as far as the major and minor cardiological events. Instead the percentage of neurological events was higher in subgroup of patients with preoperative heart disease and who underwent to CAS: all the neurological events of group CAS occurred in the subgroup of patients with previous cardiological heart disease. Conclusions: The increase in the levels of CTnI is an objective measure of ischemic lesion of the heart and a sure preannouncer of the cardiac morbidity in the postoperative periods and in the mid-term. The advantage in the employment of the CAS is, above all, in the total reduction of the cardiological complications between the patients with high clinical comorbidity also considering an increased risk of neurological complications in the patients with previous cardiomyopathy. This increased risk comes, however, reorganized if the CAS is conceived not like an alternative intervention but like a complementary intervention to the CEA.
1Chirurgia Vascolare Universita di Roma Sapienza direttore Prof Francesco Speziale, Italy; 2Emergency Department Stroke Unit Universita di Roma Sapienza, Italy Objectives: Reviews on prospective randomized trial on carotid endarterectomy (CEA) on symptomatic patients definitely showed that operation performed within two weeks from symptoms gives benefit in terms of prevention of early recurrent stroke. A published Italian Registry on early CEA after stroke demonstrated its safety and feasibility. This registry continued after publication and the number of cases recruited doubled within one year. The aim of this paper is the presentation of the results of the complete registry. Methods: The neurologists, neuroradiologists and vascular surgeons on duty in emergency departments enrolled 179 patients who underwent very early CEA according to a predefined protocol within three years. The protocol included evaluation of neurological status by National Institute of Health Stroke Scale (NIHSS), neuroimaging assessment, ultrasound of the carotid arteries and Transcranial Doppler. Patients with NIHSS>22 and with neuroimaging showing brain infarct >2/3 of the middle cerebral artery territory were excluded. All eligible patients underwent CEA as soon as possible. Primary end points of the study were mortality, neurological morbidity and postoperative hemorrhagic conversion on neuroimaging. Results: The mean time elapsing between the onset of stroke and endarterectomy was 1.5 days (±2 days). The overall 30-day morbidity mortality rate was 4% (7/179). No neurological mortality occurred. On hospital discharge, three patients (1.6%) experienced worsening of the neurological deficit (NIHSS score 1–2, 1–3 and 9–10, respectively). At hospital discharge 12/179 patients (6.7%) had no improvement in NHISS scores, 89 (50%) were asymptomatic and 75 (42%) showed a median decrease of 3 NIHSS points (range 1–20). Conclusions: The further enrolment of patients confirmed that this protocol properly select the patients who can safely undergo surgery soon after (1, 5 days) acute brain ischemia. In this subset of patients such a short elapse of time from surgery warrant the best secondary prevention of the risk of early recurrent stroke. This risk is much higher than it was previously accepted as a recent prospective observational study reported (recurrent stroke rate 8–12% within seven days). However, large randomized multicenter prospective trial are warranted to compare very early CEA vs. best medical therapy.
1Doctorate School in Surgical Sciences, Coordinator Prof A Stella, University of Bologna, Italy; 2Unit of Vascular and Endovascular Surgery, Ferrara, Italy Objectives: Aim of this study is to report our experience after simultaneous and staged bilateral carotid endarterectomy. Methods: Between 1996 and 2007, a total of 2121 patients were treated for symptomatic and for high grade asymptomatic carotid stenosis. In 105 cases stenosis involved both carotid bifurcations and therefore, simultaneous or staged bilateral endarterectomy was performed. In order to compare the results between the above mentioned procedures, 42 bilateral consequent carotid stenosis were considered and were subdivided into two groups: the first included 21 patients treated simultaneously (SBCS) whereas the second one included 21 cases of staged endarterectomy (BCS). Patients in both groups were comparable in age, heart disease, smoking status and gender whereas indications for surgery and the surgical management were similar. Preoperative examinations included duplex ultrasonography of the supraaortic trunk and cerebral CT-scan. When needed cardiological evaluation was also performed before surgery. All surgical procedures were performed under general anesthesia and in all cases a Pruitt-Inhara carotid shunt was utilized. After surgery all patients underwent follow-up by means of duplex scan and clinical evaluation one, three and six months and yearly thereafter. Results: Postoperative complications such as transient or permanent neurological deficits, myocardial infarction, pulmonary insufficiency, postoperative hypertension and death were compared in both groups and no statistical differences were found. However, it was observed that most severe complications occurred in patients treated with staged endarterectomy and were caused by the repeated surgical and anesthesiological stress. Conclusions: Our study demonstrates that in high risk, accurately studied patients, simultaneous bilateral carotid endarterectomy performed by experienced vascular surgeons, reduces operative risk and anesthesiological complications. Moreover, reduces the risk of symptoms related to contralateral lesion, patient stress and obviates intersurgical delay.
Department of Vascular Surgery, University of Florence, Italy Objectives: Aim of this study was to compare perioperative results of carotid endarterectomy (CEA) performed with conscious sedation under remifentanil (RA) with results obtained with general (GA) and local anaesthesia (LA) in our experience. Methods: Between January 2005 and December 2007, 1040 consecutive CEAs were performed at our Institution. Data concerning these interventions were prospectively collected in a dedicated database and were divided in three groups on the basis of the kind of anaesthesia: RA group (226 interventions), GA group (218 interventions) and LA group (596 interventions). Patients operated on under GA underwent cerebral monitoring with somatosensory evoked potential (SEPs); selective use of shunt on the basis of SEPs or clinical modifications was used in all the patients. Early (<30 days) results in terms of stroke, death and myocardial infarction were analysed; differences between the groups were calculated with two text and Fisher's exact text. No ethical approval was required for this study. Results: The three groups were homogenous in terms of demographic data and comorbidities, except for a significant prevalence of coronary artery disease (CAD) in GA group. Clinical and anatomical features were similar in the three groups; in patients undergoing reinterventions GA was significantly preferred. Shunt insertion rate was higher in RA and LA patients (14% and 12%, respectively) than in GA patients (8%), but the difference was not statistically significant. In RA and LA group there was a significantly lower rate of neurological deficits at the end of the interventions (no cases and one case, respectively) than in GA group (4 cases, 1.8%, P=0.05). No significant differences were recorded in terms of perioperative deaths and acute myocardial infarction; surprisingly, no perioperative neurological transient and permanent events occurred in RA group, while in LA and GA groups the corresponding values were 1% and 2%, respectively (P=0.03). Cumulative 30-day stroke and death rates were 2.2% in GA group, 0.5% in LA group and 0 in RA group (P=0.01). Conclusions: In our experience, local anaesthesia offers significantly better results than general anaesthesia. In selected patients conscious sedation under remifentanil may be a valuable alternative.
Kings College Hospital, London, UK Objectives: Cerebral monitoring is essential in patients undergoing carotid endarterectomy (CEA) for selective shunting. Several techniques are available for monitoring, however, none is superior to the awake test performing the procedure under local anaesthesia (LA). Cerebral oximetry (CO) has previously shown to assess cerebral perfusion in patients undergoing CEA. The aim of this study is to assess the reliability of CO in predicting the need for shunting in patients undergoing CEA compared with the awake test and trans-cranial Doppler (TCD). Methods: All patients undergoing CEA under LA were included. Patients undergoing CEA under GA and patients with no TCD window were excluded from the analysis. The Somanetics INVOS® CO was used for ipsilateral cerebral monitoring in all patients, in addition to TCD and monitoring of the clinical neurological status of the patients (awake test). The percentage fall in CO regional oxygen saturation (rSO2), and decline in the flow volume (FVm) in TCD following carotid artery clamping were recorded. A drop in rSO2 of >20% or FVm of >50% was considered an indicator of cerebral ischemia that may predict the need for carotid shunting. Patients were only shunted if clinically indicated based on neurological manifestations (awake test). Results: The series consisted of 63 men and 12 women (median age of 71 years, range; 46–87 years). Eleven patients were converted to GA and 22 patients did not have a TCD window, were excluded from the analysis. Forty-two patients had triple assessment for cerebral monitoring were analysed. The median clamp time was 29 min. No patient suffered any permanent peri-operative neurological deficit. Eight out of forty-two patients (19%) patients were shunted based on the clinical manifestation. In this group, six patients had >20% drop in rSO2, and six patients had >50% drop in FVm. In the non-shunted group (34/42) only one patient had significant drop in the rSO2 (false positive) while 8/34 patients had >50% drop in FVm. This represents a sensitivity of 80%, and a specificity of 97.1% for the CO in comparison to a sensitivity of 80% and a specificity of 82.9% for the TCD in detection of the need for shunting. The correlation coefficient between TCD and CO was 0.727. Conclusions: Triple assessment for cerebral monitoring in patients undergoing CEA is reliable in predicting the need for shunting. However, CO is more specific compared to TCD. Using CO, a 20% drop in rSO2 is a reliable cut-off in predicting the need for shunting.
Vishnevsky Institute of Surgery, Moscow, Russian Federation Objectives: The aim of our investigation was to analyse the results of patients treatment for non-specific aortoarteritis with brachiocephalic arteries lesion. Methods: From November 1993 till January 2008, 229 patients for non-specific aortoarteritis were examined and treated in the A.V. Vishnevsky Institute of Surgery, Moscow, Russia. Out of the total number of patients there were 39 males and 190 females. The average age of the patients was 32.5. The laboratory signs of the inflammation were discover in 55.5% of cases. The acute stage of the disease was found in 32.5% of cases and subacute stage - in 23.2% of cases. The most common type of the arterial lesion was type 3 (Lupi-Herrera et al., 1977 classification), it was discovered in 57% of cases, type 1 was found in 29% of cases and type 2 - in 14% of cases. For patients with acute and subacute stages of the disease we used the intravenous injections of corticosteroids and cyclophosphan (1 g) per three days. The effectiveness of that therapy was 83.9%. We use methotrexate therapy as maintenance chemotherapy. Primarily we operated 120 patients and carried out 140 operations. Fifty-four patients underwent reconstructions of brachiocephalic arteries, 47 patients underwent reconstructions of thoracoabdominal aorta and its branches, 29 patients underwent solitary reconstructions of renal artery. In the cases of combined lesions 11 patients underwent multi-stage operations. In cases of brachiocephalic arteries reconstructions the surgery of choice are considered to be extrathoracic operations - the total number 29. The transthoracic operations were carried out in 26 cases if there were no suitable donor artery. Results: We had no post surgical lethality after extrathoracic operations. After one-sided transthoracic reconstructions of carotid arteries we had neither postoperative complications nor lethality. After aorta-bicarotid graft replacement done for 12 patients we had four hemorrhagic strokes, three of them with lethal outcome. After aorta-bicarotid graft replacement done for 12 patients we had four hemorrhagic strokes, three of them with lethal outcome. After the other types of transthoracic operations we had neither postoperative complications nor lethality. Conclusions: 1) Surgery is indicated for patients suffering from non-specific aortoarteritis with occlusion and critical stenosis of common carotid arteries. 2) The surgery should be performed in the remission stage. 3) Extrathoracic reconstructions are the surgery of choice in cases of brachiocephalic arteries lesion. 4) Staged reconstruction of carotid arteries is indicated for patients with bilateral lesion.
Division of Vascular Surgery of IRCCS S Matteo General Hospital Foundation, Pavia, Italy Objectives: Reconstruction of the supraortic trunks can in most cases be performed with either a transthoracic or a cervical approach, or endovascular repair. Patients with severe co-morbidity or candidate to redo-surgery for previous mediastinal approach, are also poor candidates for a transthoracic operation. This patients should undergo reconstruction with cervical or endovascular technique. We present our experience in the treatment of these complex lesions Methods: Over a 15-years period (1991–2006), we treated 64 patients (76 total interventions: 10 transthoracic, 34 cervical and 32 endovascular) with supraortic trunk complex lesion (8 for aneurysmal and 56 for occlusive disease). There were 5 endarterectomies, 27 bypasses, 4 arterial transposition, 8 resection of aneurysm and 32 endovascular procedures. The hybrid approach was required in five patients. Forty-two patients were asymptomatic and 22 symptomatic (cerebrovascular ischemia in eight patients and upper extremity ischemia in 14). The innominate artery, common carotid artery and subclavian artery were involved in 5, 28 and 40 patients, respectively. Multiple trunks were reconstructed in eight patients. Results: No intraoperative mortality or stent-graft related complication were observed. Two perioperative deaths and one non-fatal stroke occurred, for a combined stroke/death rate of 4.6%. Perioperative complications included 1 asymptomatic graft occlusions, 1 non-fatal myocardial infarction, 2 significant pulmonary complications, 1 wound infection, and 2 cranial nerve injury. Conclusions: Direct reconstruction of complex symptomatic supraortic trunk lesions can be performed with acceptable death/stroke rates and with long-term patients benefit. Asymptomatic lesions in patients who have significant concomitant conditions should be managed with a less-invasive either cervical or endovascular approach, though long-term outcome of the latter is inferior.
San Paolo Hospital, Civitavecchia, Roma, Italy Objectives: Nerve injuries, wound complications and especially poor cosmetic results still show an important impact on the carotid endarterectomy (CEA) morbidity. Introduction of the mini skin incision in clinical practice seems to be safe with reduction in postoperative pain and superficial nerve lesions, and better aesthetical results. Few reports evaluate the transverse and longitudinal incision to define the best surgical approach. This study compare the results between the short longitudinal with the transverse cervical skin incision.
Methods: From January 2004 and December 2007, 266 patients underwent 300 primary CEA procedures. Two hunderd and nineteen patients were submitted to short longitudinal cervical incision (group A), 81 performed a transverse cervical skin incision (group B). In all cases a preoperative CEA Duplex assisted skin marking was carried out. The length of the skin incision was ranging from 5 to 8 cm. (A) and 4–6 cm. (B). Preoperative and postoperative cranial nerves evaluation was always performed. Stroke/TIA, death, wound complications, cranial and cervical nerves injuries and re-stenosis rate were reported and evaluated through statistical analysis ( Results: The 30-day mortality rate was 0.3% (1/300). The TIA rate was 0.91% in group A and 1.2% in group B (P>0.9). Wound complications were 1.8% and 1.2%, respectively (P>0.1). No statistical differences were reported in the incidence of cranial and cervical nerves injuries between the two groups (P>0.9). No difference in re-stenosis rate was detected (P>0.9). Conclusions: No difference was achieved between longitudinal and transverse cervical skin incision in term of stroke, wound complications or nerve impairment. As optimal cosmetic results were gained in both groups, on the basis of our experience the longitudinal cervical approach is to prefer because can lead to a more easy proximal and distal extension, shunt deployment and control of the distal internal carotid artery in cases of atheromatous extension of the plaque.
1Deparment of Vascular Surgery, Kings College Hospital, London, UK; 2Vascular Surgery Unit, Royal Infirmary of Edinburgh, UK Objectives: The aim of this study is to assess the accuracy of cerebral oximetry CO in predicting the need for shunting of patients undergoing carotid endarterectomy (CEA) under local anaesthesia (LA). Methods: This is a prospective study of 118 consecutive patients undergoing CEA under LA in three tertiary referral centres between November 2004 – October 2006. The Somanetics INVOS® cerebral oximeter was used for cerebral monitoring in all patients. A 20% decrease in regional oxygen saturation (rSO2) reading from the pre clamp baseline was used as an indicator of cerebral ischaemia that may predict the need for carotid shunting. Patients were only shunted if clinically indicated based on neurological manifestations. The series consisted of 93 men and 25 women (median age; 73 years, range; 62–85 years). Results: Fifteen patients required shunting (shunt rate 12.7%). The median clamp time was 34 min. The peri-operative stroke rate was 1.7% (2/118 patients). In the group of patients that required shunting (15/118) the median percentage drop in rSO2 was 22% (range; 14–40%) whereas in the non-shunted group (103/118) it was 7.5% (range; 0–30%). One patient in the shunted group (n=15) i.e. 6.7% had a non-significant drop in the rSO2, whereas 13 patients in the non-shunted group (n=103) i.e. 12.6% had a significant drop in rSO2. This represents a sensitivity of 93.3% and a specificity of 87.4% and provides a positive predictive value of 51.9% and a negative predictive value of 98.9%. Conclusions: Cerebral oximetry has shown a high negative predictive value, but its positive predictive value is low in selecting patients for carotid shunting during CEA under LA. A 20% drop in rSO2 as a predictor of the need for carotid shunting should be used with another cerebral perfusion monitoring method during CEA under GA.
C5-1 CRYOLIFE O'BRIEN STENTLESS VALVE REOPERATION: A LOW RISK PROCEDURE WITH SATISFACTORY LONG-TERM RESULTS D. Pavoni1, F. Ius1, L.P. Badano1, I. Vendramin1, E. Mazzaro1, V. Tursi1, G. Thiene2, U. Livi1 1Department of Cardiopulmonary Sciences, University Hospital, Udine, Italy; 2Department of Pathology, University of Padua, Padua, Italy Objectives: Stentless valve reoperations are becoming more common as they reach the durability limits. Relatively few studies have reported results of stentless valve reoperation. Accordingly we reviewed our experience on redos surgery for the Cryolife O'Brien (CLOB) stentless valve. Methods: All patients with CLOB stentless valve undergoing redo aortic valve replacement (AVR) at our institution were reviewed (n=30; 60% males; mean age 70±12 years). Results: Redo AVR was performed 69±40 months (range 1–133 months) after stentless valve implantation. Fifteen patients (50%) underwent urgent or emergency procedures. The indication for redo AVR was structural valve disfunction in 18 patients (60%). Pathological examination of the explanted valves showed cusp tears in five patients, calcification alone located primarily in the basal and commissural regions of the cusps in three patients and evidence of calcification associated with cusp tears in ten patients. Other causes of redo AVR were peri-prosthetic leak in three cases (10%), sinotubular dilatation in three cases (10%), and acute endocarditis in six cases (20%). Severe aortic insufficiency was present in 26 patients (87%). Only three aortic root replacement operations (10% of patients) were required due to native aortic root dilatation. Nobody died within 30 days after operation. Long-term survival at one and five years postoperatively was 90±6 and 58±12, respectively. Of the late deaths (n=10), none was valve related, and three were cardiac related. Conclusions: Reoperation for CLOB stentless failure is a simple procedure that only in few cases requires aortic root replacement. In our experience CLOB valve reoperation is associated with no risk of early death and with satisfactory long-term survival.
Cliniques universitaires St Luc UCL, Brussels, Belgium Objectives: In patients with aortic valve insufficiency (AI), valve repair requires a tailored surgery determined by the leaflets and proximal aorta anatomy which prompt us to develop a functional classification of AI. This classification has implication on the surgical strategy and outcome. In this study, we analyze one decade experience with aortic valve (AV) repair. Methods: Between January 1996 and December 2006, 298 patients underwent elective aortic valve repair. Aortic annulus, root or ascending aorta dilatations were managed by following techniques: subcommissural annuloplasty, sinotubular junction plication, ascending aorta replacement, root remodelling or valve reimplantation. Cusp prolapses were corrected by plication, triangular resection or free margin shortening with PTFE (Goretex 7/0). Cusps perforation were closed with autologous pericardial patches. Results: Hospital mortality was 1.5% (4 patients). Five (2%) patients needed early aortic valve reoperation, two of them were re-repaired. Follow-up is 94% complete and reach a mean of 45±32 months. During this period, 14 late deaths occurred, 10 cardiac related. Eleven patients needed late aortic valve reoperation, two of them were re-repaired. At three and six year, overall survival, freedom from aortic valve reoperation and freedom from aortic valve regurgitation >2 were 96±2% and 91±6%, 95±3% and 94±4%, 93±4% and 86±7% respectively. Thromboembolic events occurred in 6 (2.3%) patients during the follow-up and no aortic valve endocarditis were recorded. Conclusions: The functional classification allows a systematic approach of AI and may enhance the reparability rate. Moreover, it facilitates anticipation of the surgical technique and the prediction of the durability. Cusp restrictive motion (type III), due to fibrosis or calcification, is an important imitation for conservative surgery.
Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum, Berlin, Germany Objectives: To investigate early and mid-term results following valve replacement with Shelhigh stentless bioprosthesis made entirely of biological material in patients with active infective endocarditis (AIE). Methods: Over the last 20 years, 1143 AIE operations were performed. Of these, 255 patients (mean age 59 years) received Shelhigh bioprostheses between 02/2000 and 03/2007. A total of 73.7% had native AIE and 26.3% prosthetic AIE. Surgery was regarded as urgent in 57.3 and as an emergency procedure in 38.4%. The mean follow-up time is 1.6±0.12 years (1 months to 6.6 years). Results: There was a highly significant difference in the survival rate between patients who were operated on urgently vs. in an emergency (30-day, 1-year, 3-year and 5-year survival was 83.7%, 67.7%, 63.6%, 56.0% vs. 57.3%, 45.3%, 34.9%, 31.0%; P<0.0001), single vs. double valve replacement (P=0.033), and patients with and without abscess formation (P=0.0245). Main cause of early death was septic multiorgan failure. Only five patients required reoperation due to early reinfection (1.9%). TEE doppler gradients (3, 6, 12 months) showed good hemodynamics. Conclusions: Our experience in the use of Shelhigh bioprostheses in patients with native and prosthetic endocarditis shows the early and mid-term results, in particular the low reinfection rate and the good hemodynamics, to be comparable with the results achieved using homografts. Better survival should be achieved if patients could be operated on earlier. Since these prostheses are readily available and their implantation straightforward, they are increasingly being used in patients with endocarditis. These promising results need to be verified in the long-term.
1Department of Cardiopulmonary Sciences, University Hospital, Udine, Italy; 2Department of Anesthesia and Critical Care, University Hospital, Udine, Italy Objectives: Aortic valve replacement (AVR) in patients over 80 years of age has been demonstrated to have satisfactory functional results also in the long-term. However, the impact of concomitant procedures on early and late outcomes following AVR remains to be investigated. Methods: Between 1990 and December 2007, cardiac surgery was performed in 560 octogenarians. A retrospective review was performed in 297 patients (180 women, 61%) with a mean age of 83±2 years, who underwent isolated AVR (n=153), AVR with CABG (n=117), and AVR with mitral valve surgery (MVS) and with or without CABG (n=27). Data were analyzed with Kaplan–Meier estimates of survival. Results: Preoperative NYHA classes were I in 7%, II in 28%, III in 57%, and IV in 7%. Operative (30-day) mortality was 5% for isolated AVR, 3% for AVR+CABG, and 15% for AVR+MVS±CABG. One-year, 5-years and 10-years survival were 91±2%, 73±5%, 45±8%, respectively, for AVR; 89±3%, 60±7%, 23±1%, respectively, for AVR+CABG; and 79±8%, 45±12%, 22±17%, respectively, for AVR+MVS±CABG (P=0.025). Preoperative NYHA class did not affect operative or long-term survival. Conclusions: Octogenarians patients who undergo AVR have acceptable short- and long-term survival regardless of NYHA class. Performing concomitant CABG was protective in terms of operative mortality. Conversely, MVS with or without CABG conveys a significant worse short- and long-term prognosis.
Silesian Center for Heart Diseases, Department of Cardiosurgery and Transplantology, Zabrze, Poland Objectives: Most patients with good LVEF and moderate patient prosthesis mismatch (ppm) after small size (19–21 mm) aortic valve replacement (AVR) become asymptomatic, but different outcomes in exercise capacity and LV mass regression occur in individual subjects in long-term observation. We endeavour to estimate whether dobutamine stress echocardiography (DSE) could predict a worse long-term recovery of such group of patients. Methods: Forty-eight asymptomatic patients (17 males and 31 females) with identified moderate ppm (EOA Index: 0.85 0.65 cm2/m2) and mean LVEF 52±5% were studied 12 months after AVR with reference to NYHA class and LV mass value. DSE to maximal 40 µg/kg/min dose of dobutamine and/or HR>120/min was performed in each patient with analysis of peak (PG) and mean (MG) stress transprosthetic gradients. DSE findings divided patients into two groups. Group I (23 patients) with significantly higher stress PG and MG: 72 and 40 mmHg and group II (25 patients) with lower: 53 and 25 mmHg PG and MG (P=0.024). Results: NYHA and LV mass were comparable in both groups at one year observation: 321 and 313 g, (P=NS). At three years group I present significantly lower LV mass reduction than group II: 281 vs. 215 (P=0.003). Thirteen patients (56%) of group I and two patients (8%) of group II changed NYHA class from I to II and became symptomatic (P=0.0062). Follow-up values of BSA: 1.84 vs. 1.86 m2, rest MG 19 vs. 21 mmHg and LVEF 51.4 vs. 52.9% were comparable (P=NS). Conclusions: Asymptomatic patients, with good LVEF and moderate ppm after AVR despite of good early results are at risk of worse long-term clinical and hemodynamic recovery. In our observation dobutamine stress echocardiography could specify such a group of patients and predict their late outcome.
1Department of Cardiovascular Surgery, Charite Hospital, Berlin, Germany; 2Department of Radiology, Charite Hospital, Berlin, Germany; 3Department of Anesthesiology, Charite Hospital, Berlin, Germany Objectives: Although the Ross procedure allows optimal left ventricular regeneration and excellent hemodynamic behavior, it is controversial to perform this operation in patients at the age of 60 years and older. Methods: Since 1994, 428 consecutive patients received a Ross operation in which we identified 167 patients over the age of 60 years. The mean age was 64.8±3.4 years (range 60–76 years). Concomitant procedures were performed in 71 patients (49%), coronary bypass surgery in 25 patients, ascending aorta treatment in 19 patients mitral valve treatment in 18 patients and atrial ablation in 11 patients. Transthoracic echocardiography was obtained preoperatively, at discharge and at yearly intervals. Records were evaluated for survival, clinical status, adverse events and valve function. Results: Follow-up was 100% complete. Hospitality mortality was 2.6% (3 patients). Up to four years of follow-up three more patients dead, one cardiac and two non-cardiac death. During follow-up, two patients were reoperated on the neo-aortic valve. The average mean pressure gradient at discharge over the neo-aortic valve was 5±2 mmHg and at the at the latest follow-up 4±1 mmHg, with absence of neoaortic regurgitation regurgitation. Conclusions: The Ross operation seems to be an appropriate option in elderly patients with low operative mortality and low rate of reoperation.
Department of Cardiovascular Surgery, Charite Hospital, Berlin, Germany Objectives: Two-year experience with a decellularized porcine heart valve for reconstruction of the right ventricular outflow tract during the Ross operation. Methods: From September 1, 2005 to August 31, 2007, a total of 161 patients underwent the Ross procedure with the use of the Matrix-P Plus for pulmonary valve replacement. Mean age was 58.6±8.2 years (range 17–75 years). Mean logistic EuroSCORE was 6.3±5.0% (range 1.3–85.6%). Eight patients suffered from active infective endocarditis. Fifty-two patients (32.5%) required one to three additional cardiac surgery. Twenty-four received one to three coronary artery bypass grafts, thirteen reconstruction or replacement of the ascending aorta, eight mitral valve repair or replacement, eight left atrial ablation and three other procedures. Follow-up was performed by clinical evaluation, echocardiography and reporting of adverse events. Results: Follow-up is 100% complete. Hospital mortality was 5% (8/161). During follow-up three patients died and five patients required reoperations. Three on the pulmonary valve due to stenosis at the distal anastomosis (n=1) or external compression (n=2). All received again a Matrix-P Plus valve. One patient required replacement of the ascending aorta and one patient was reoperated due to persisting endocarditis. Histological evaluation of the explanted Matrix-P Plus showed repopulation with host cells. Echocardiography of the pulmonary valve showed a mean pressure gradient of 2.5±1.2 mmHg without any rise up to two years, 85% of the patients are currently in NYHA class I with no valve related complications during follow-up. Conclusions: The Matrix-P Plus decellularized heart valve shows excellent two years performance.
University of California, San Francisco, USA Objectives: Progressive dilatation of the pulmonary autograft can lead to aortic insufficiency requiring reoperation. We have defined regionally specific, anisotropic and non-linear material properties for the aorta and pulmonary artery to develop the first of its kind finite element model (FEM) of the Ross procedure. Methods: Tissue samples (1 cm2, n=8) cut from five regions of the aorta and pulmonary artery - anterior, posterior, and each sinus – were subjected to displacement controlled equibiaxial stretch testing. Calculated stress-strain data was used to derive individual strain energy functions for each region. Two asymmetric aortic root meshes were created (TrueGrid) representing the undialated native aorta and autograft using measured tissue thickness with annular and sinus dimensions from literature. Meshes contained five individual materials merged, each defined by derived material properties. Systolic pressure curves were input to LS-DYNA as loading conditions on the FEM, and the degree and direction of tissue dilation was examined to evaluate postoperative root dynamics. Results: During biaxial testing, the aorta and pulmonary artery exhibited similar material properties qualitatively. Evaluation of tissue stiffness, defined as the slope of the stress-strain plot at normal aortic dilation, revealed both tissues were significantly stiffer in the circumferential than longitudinal axis (161 kPa vs. 128 kPa, P=0.0007 pulmonary; 297 KPa vs. 246 KPa, P=0.0005 aortic). Both had greater non-linearity in the sinus than the ascending region, reaching a transition point of rapidly increasing stiffness between 32–45%. However, the pulmonary artery was significantly more compliant than the aorta overall for both axes in the sinus (235 KPa vs. 409 KPa, P=0.0002) as well as distal to the sinotubular junction (144.93 KPa vs. 271.57 KPa, P=1.22*10–11). As such, the autograft remained well within the high stiffness region at all times during the simulation, and underwent a small change in diameter during systole as compared to the total lumen dilation caused by aortic pressure. Conclusions: Autograft compliance causes large, non-linear tissue deformation when subjected to aortic pressures, but a relatively small systolic dilation. Cyclic loading of the tissue in the stiff, highly deformed region may contribute to arterial remodeling and progressive dilatation following the Ross procedure.
Department of Cardiovascular Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland Objectives: The Contegra® bioprosthesis (valved heterologous bovine jugular vein) is used for reconstruction of the right ventricular outflow tract (RVOT) in congenital heart malformations and pulmonary valve replacement in different settings. Compared to pulmonary homografts, the Contegra® conduit is readily available on the shelf. So far, its use was mainly described in children. The aim of this study is to evaluate the feasibility and the outcome of Contegra® graft implantation in the adult. Methods: Between November 1999 and August 2007, a total of 30 Contegra® grafts were implanted in 29 patients (23 men and 6 women), with a mean age of 35.6 years (range 18–54 years). All operations have been completed through median sternotomy with cardiopulmonary bypass. Conduit sizes included 22 mm (n=29), 20 mm (n=1). Results: There was no hospital mortality and no conduit related early morbidity. Important postoperative complications included haemorrhage and pericardial tamponade requiring operative revision (n=2), postoperative rythmologie disorders (n=7) and pneumonia (n=3). One patient presented a mediastinitis requiring operative revision of the sternum, treatment by vacuum assistance and systematic antibiotic application for six weeks before secondary closure of the sternotomie. In the median follow-up there was one late death, due to a heart failure (total mortality 3.5%), not conduit related. Main indication for pulmonary valve replacement in adults was the Ross procedure (n=20) follwed by reoperations of corrected Fallot tetralogies (n=5) and isolated pulmonary valve replacement (n=2) (others: n=2). A replacement of the Contegra® tube had to be done in one patient 16 months after a Ross procedure for a symptomatic graft stenosis. Postoperative echocardiography follow-up showed low transvalvular pressure gradients: in the Ross group (mean pressure 13.1 mmHg, 11.7 mmHg at mid-term follow-up), the Fallot group (mean pressure 12.2 mmHg – postoperative, 14.4 mmHg at mid-term follow-up) and isolated pulmonary valve replacement (mean pressure 6 mmHg, 11.5 mmHg at mid-term follow-up) with all patients being in NYHA functional class II or I. Conclusions: The main indication for using a Contegra® graft for pulmonary valve replacement in adults is the Ross procedure. In this review of 30 operations mortality was low, mid-term results showed good functional results and low transprothetic gradients with sizes of 22 or 20 mm. Graft degeneration was not an issue with only one reoperation. The use of Contegra® graft for pulmonary valve replacement in adults is a good option. Follow-ups are still needed to evaluate long-term results, especially concerning degeneration and calcifications.
C6-1 ACTIVE AORTIC VALVE ENDOCARDITIS: IMMEDIATE AND LONG-TERM RESULTS A. Tuncer, E.Y. Tuncer, S.G. Tas, M. Aksut, E. Eren, K. Kirali, M. Balkanay, C. Yakut Kosuyolu Heart and Research Hospital, Istanbul, Turkey Objectives: This study aimed to determine risk factors for in-hospital mortality, morbidity and long-term survival following surgery due to active aortic valve endocarditis. Methods: This retrospective study included 154 patients operated on active aortic valve endocarditis between February 1993 and December 2006. Of the patients 32 (20.8%) were women and 122 (79.2%) were men. Median age was 45.65±13.83 (ranging between 14 and 80 years). Of 21 (13.6%) were prostetic valve endocarditis while the remaining was native valve endocarditis. Results: The overall in-hospital mortality was 24 (15.6%). Univariate analysis demonstrated that female gender, preoperative NYHA class, prosthetic valve endocarditis, postoperative renal failure and postopertive AV block were the risk factors for early mortality. Multivariate analysis revealed that female gender (OR: 5.270) and postoperative renal failure (OR: 48.879) have significantly associated with increased early mortality. Late mortality was 10.5% (13/124). The only predictor of late mortality was mitral valve involvement (P=0.037). Recurrent endocarditis was 7.1% (11/154) and reoperation rate was 3.2% (5/154). Cumulative survival was 81.9±6.5%. Mean follow-up time was 6.49±4.63 years. Conclusions: Although active aortic valve endocarditis is still a challenging pathology, surgical treatment can be done with acceptable early and late results in selected patients.
1Vilnius University Heart Surgery Center, Lithuania; 2Vilnius University, Department of Chemistry, Lithuania; 3Vilnius University, Lithuania Objectives: If untreated, the natural response to these xenografts is acute rejection with cytotoxic elimination of donor cells and degradation of the extra cellular matrix. The most effective treatment to overcome this prohibitive predicament seemed to be cross linking, which was shown to mask xenogenicity and to mitigate degradation. So, current research is investigating the development of additional anticalcificant treatments. Methods: Valved conduits were harvested in local slaughterhouse, prepared and pretreated with glutaraldehide (glu) alone or in association with different compounds (ethylenediaminetetraacetic acid (EDTA), sodium ethylenediaminetetraacetic acid (na EDTA), D-Alanine, D-Norvaline). As opposite treatments were tested acil azide or carboimide alone, or together with other compounds. All samples were implanted subcutaneously in 30 days old Wistar rats. Explantation performed after 60 days. Residual calcium level was assessed, also histological examination was performed. Results: Data were divided into groups: first analysing how all different agents effect on each biomatherial sample, second group how each agent separatelly influences all materials. Aortic valve leaflet explants showed the lowest calcium level in samples treated with carboimide alone 0.64±0.15 mg/g and it was statistically significant different from all agents in this group. In samples from aortic wall the lowest calcium concentration was revealed also in carboimide alone treatment 8.3±1 mg/g, the mean was statistically significant different comparing to all agents. Low residual calcium amount was found in mitral valve samples treated with glu/Na EDTA 0.69±0.18 mg/g, but comparing their means in case of treating with carboimide, we do not find it statistically not different. The best impact on lowering calcium level comparing each agent effect on the different biomaterials was found in mitral valve samples. Conclusions: The most effective anticalcification treatment comparing all agents is in case of usage carboimide alone and with glu/Na EDTA in mitral valve. The best effect comparing single agents was found when used glu/Na EDTA in most cases.
1Paul Stradins Clinical University Hospital, Riga, Latvia; 2Riga Stradins University, Latvia Objectives: The major problem with heart valve bioprostheses made from chemically treated porcine aortic valves (AoV) is their limited longevity caused by structural deterioration. There are no published studies on the mechanical properties of modern, commercially available bioprostheses comparing them to native human valves. Objective of this study is to determine the mechanical properties of EPIC bioprostheses and to compare them with native human and porcine AoV. Methods: Leaflets from eight porcine AoV and three EPIC bioprostheses (St. Jude Medical, Minnesota, USA) were analysed using uniaxial tensile tests in radial and circumferential directions. Mechanical properties of human AoV have been previously published by our group (Stradins et al., 2004). Results are represented as mean values±S.D. Results: In both directions there is a shift to the stress axis of the stress-strain curve for the EPIC bioprostheses when compared to native valves. Modulus of elasticity (E) of EPIC bioprostheses in circumferential direction at the level of stress 1.0 MPa is 134.92±37.4 MPa, E of native porcine AoV – 42.3±4.96 MPa, E of human AoV – 15.34±3.84 MPa. Ultimate stress is highest for EPIC bioprostheses – 6.84±0.66 MPa, human AoV have ultimate stress of 1.74±0.29 MPa and porcine AoV – 1.58±0.26 MPa. Ultimate strain in circumferential direction is highest for human valves 18.35±7.61% followed by 7.26±0.69% for porcine valves and 5.15±0.61% for EPIC bioprostheses. In radial direction the relations of E among samples are the same as in circumferential direction – 7.8±1.25 MPa for EPIC bioprostheses, 5.47±0.67 MPa for native porcine, and 1.98±0.15 MPa for human AoV. In the radial direction ultimate stress is highest for EPIC bioprostheses 0.8±0.26 MPa followed by native porcine valves – 0.51±0.1 MPa and 0.32±0.04 MPa for human valves. For human AoV ultimate strain is 23.92±3.94%, for native porcine valves – 8.71±0.92% and 6.45±0.93% for EPIC bioprostheses. Conclusions: EPIC bioprostheses have a non-linear stress-strain behaviour similar to native valvular tissue, but they are significantly stiffer and hence less elastic compared to native porcine and human AoV. Reported biomechanical properties of native human and porcine AoV, and EPIC bioprostheses provide important information on current bioprostheses and an important insight for heart valve tissue engineering.
Bakoulev Center for Cardiovascular Surgery, Moscow, Russian Federation Objectives: There is a constant search for an optimum material for heart valve bioprosthesis. Ten years ago, we introduced a new biological valve Bioglis made of hepatic Glissons capsule which is more elastic than bovine pericardium. Our further investigations, when Bioglis was used for tricuspid valve replacement, have shown good early and mid-term results. The aim of the present study is to assess long-term results of Bioglis valve implanted into tricuspid position. Methods: Hepatic Glissons capsule taken from bull calves was used for Bioglis valve, which was formed on a flexible frame. The biological valve was implanted in 21 patients with Ebsteins anomaly or congenital tricuspid insufficiency. The age of patients ranged from 3 to 48 years (mean, 24.6±4.2 years). All patients were followed-up for 36–120 months (mean, 80 months). Bioglis function was assessed by means of two-dimensional echocardiography and Doppler examination. Follow-up evaluation also included ECG and X-ray examination. Results: There were no early or late deaths. All followed-up patients were in I–II New York Heart Association functional class. The peak pressure gradient across the bioprosthesis was as low as 4.5±1.0 mmHg (range, 4–8 mmHg). The mean pressure gradient ranged from 1.3 to 2.5 mmHg (mean, 1.7±0.5 mmHg). The mean effective orifice area of the valve calculated from Doppler flow velocity reached 2.25±0.05 cm2. The signs of calcinosis were absent. Left ventricular ejection fraction ranged from 54% to 67% (mean, 59.2±9.1%). Conclusions: Excellent results achieved with Bioglis valve made of hepatic Glissons capsule gives the rationale to recommend it for tricuspid replacement in patients with congenital valvular lesions. Comparative assessment of biological valves made from hepatic Glissons capsule and bovine pericardium should be considered.
S Ambrogio Clinic, Milan, Italy Objectives: Evaluation of postoperative data, hemodynamic performance and medium-term result. Methods: Between March 2000 and October 2007, 230 aortic elan stentless bioprostheses were implanted at the S. Ambrogio Clinic in Milan; in the period mentioned we implanted 14 n°19 prostheses, 83 n°21 prostheses, 97 n°23 prostheses and 36 n°25 prostheses. There were 90 patients over the age of 75; the prevalent pathology was aortic valvular stenosis; 76 associated operation were performed: 65 CABG, seven mitral repairs, four CABG plus mitral repair. Postoperative data and complications have been considerated; the transvalvular gradient and valvular surface area were monitored by means of echocardiogram upon discharge, after three months, six months and after one year. Results: Average cardiopulmonary bypass time was 112.25±19.50 and aortic clamp 92±13.45; the mean intubation time was 18.2±1.5 and the average time to discharge was 13 days. Operative mortality was 0.8% (2 our of 230), the cause of death was cardiogenic shock in both patients; 12 patients died 60 days after the operation (2 for pulmonary disease, 3 stroke, 2 cancer, 2 myocardial infarction); reoperation for valvular regurgitation: 1 patient; reoperation for endocarditis: two patients. Among the immediate complications, postoperative reopening because bleeding occurred in six patients, in two patients a pace-maker had to be implanted because of complete atrio-ventricular heart block. Reduction of transvalvular gradients, reduction of left ventricle wall thickness and increase in the valvular surface area was observed after six months and one year. Conclusions: The results of our study have demonstrated that these valves have a satisfactory hemodynamic performance, the absence of annulus reinforcement tissue allows the prosthesis to be implanted in very small aortas, especially if using sizes from 19 to 25, it can be seen that the aortic valve perfectly adapts to the aortic wall. A porcine root in a size larger than 25 is more rigid and has a thicker wall, this reduces the advantages of the stentless prostheses non-permitting it to perfectly adapt to the aortic wall which, especially in this type of valve with no reinforcement, is very noticeable. Also this type of prosthesis is preferable in cases of bacterial endocarditis, especially because of the absence of artificial tissue.recently Aortech Elan stentless bioprostheses is used in Biovalsalva Valved conduit, the only aortic valved conduit with biological porcine prosthesis. We believe that the long-term data will confirm the good results we have had in the medium term.
Department of Cardiac Surgery, Medical University, Graz, Austria Objectives: Valve replacement in small aortic root without annulus enlargement remains a surgical challenge and raises concern about its long-term results. Methods: Between January 1993 and December 2004, 263 (16%) of 1639 underwent aortic valve replacement using a 19-mm prothesis. In 49 (18.6%) of the 263 patients a mosaic bioprosthesis was implanted. There were 45 females and 4 male, with mean age of 77.2 years (49.7–84.4 years). Twenty-two (44.5%) patients underwent concomitant procedures; Twenty (40.8%) patients required coronary artery bypass grafts and 2 (4%) double and triple valve procedures. The mean body surface area (BSA) was 1.64 m2 (range, 1.26 2.04 m2). Thirteen (26.5%) patients had BSA of >1.7 m2. Results: Follow-up was 100% complete in regards to mortality. The 30-day mortality was 12.2% (6 patients). There were two late deaths. The survival rate at five years was 79%. One valve related re-operation was performed because of a paravalvular leakage. NYHA class was improved from 3.45 preoperatively to 1.67 postoperatively. There was no incidence of thromboembolism. There were no deaths in the patients with severe prosthesis – patient mismatch (PPM <0.65 cm2/m2). Urgent and emergency operations were an independent risk factor (P=0.0053) with a 2.5xhigher relative risk for mortality (with a 95% confidence limit between 1.33–5.17). Conclusions: Aortic valve replacement with the 19 mm Medtronic mosaic bioprosthesis offers excellent mid- and long-term results in terms of functional capacity and valve related complications.
1Department of Cardiovascular Surgery, Villa Maria Cecilia Hospital, Cotignola, Italy; 2Department of Cardiac Surgery, Salus Hospital, Reggio Emilia, Italy Objectives: Aortic valve disease associated with coronary atherosclerosis is increasingly common in older population. Surgery is still the treatment of choice in young patients, but indications and results of aortic valve replacement combined with coronary grafting are still under debite in older patients. Methods: Between January 2001 to December 2007, 165 combined aortic valve replacement (AVR) with coronary artery bypass grafting (CABG) were performed in patients older 80 years. The patients were studied retrospectively by collecting data from hospital records and followed for 0–7 years. Results: The mean age was 84±2.5 years, 97 were male. We analyzed the preoperative, intraoperative and postopertive risk factors for outcome. Preoperative factors as low ejection fraction, chronic atrial fibrillation, high NYHA class, aortic regurgitation and polivasculapathy were predictors of poor outcome. Intraoperative factors as clamp time, calcified aorta, incomplete revascularization were predictors of poor outcome. Postoperative factors as acute renal failure, long time ventilation and tracheostomy, mediastinitis, postoperative acute myocardial infarction, and major neurologic complications were risk factors for a poor and long-term outcome. The in hospital mortality was 7.5%, and the three years survival rate was 75.4%. Conclusions: AVR with concomitant CABG in older population is a complex operation. A carefully evaluation of preoperative status is very important to achieve a good surgical indication and outcome. Afterwards in literature and in our experience the in hospital mortalità is still high compared with the younger population. We feel that aortic valve surgery in healthy octuagenarians with concomitant coronary artery disease may be performed with an acceptable risk. In the other patients we need further studies to evacuate the better and safer strategy.
1First Chair of Cardiology and Cardiac Surgery, Medical University of Lodz, Poland; 2Department of Internal Diseases and Cardiological Rehabilitation, Medical University, Lodz, Poland Objectives: According to available data there are few well-known predictors of increased morbidity and mortality in patients subjected to aortic valve replacement (AVR). The aim of the study was the evaluation of significance of essential hypertension on the prognosis in patients with aortic stenosis and regurgitation subjected to AVR. Methods: It was a prospective analysis of 300 patients subjected to aortic valve replacement due to aortic stenosis (AS, n=150) and aortic regurgitation (AR, n=150). Each patient included for the study underwent preoperative coronary angiography, and no significant changes were found. Echocardiography was performed in the preoperative period (upto 48 h), early postoperatively (on average after 9 days) and as a follow-up examination (18–24 months following cardiac surgery). Results: Early postoperative mortality in patients with aortic stenosis was 6.49% (n=5) and long-term mortality (following 21 months) 3.9% (n=3). Respectively, in patients subjected to aortic valve replacement due to aortic regurgitation early mortality was 6.25% (n=6) and long-term – 8.0% (n=6). On the basis of statistical analysis authors selected predictors of increased mortality in these groups of patients (e.g. high BMI, postoperative AF, and low output syndrome for AS, and e.g. high BMI, pre- and postoperative LVEF, LVESd and LVEDd and postoperative LCOS). Among these predictors it was observed that, in patients with aortic regurgitation, essential hypertension (grade 2 or 3 according to ESH/ESC 2007 guidelines) was an independent risk factor of death, both in the early postoperative period (OR 3.2; 95% Cl 2.4–5.7; P<0.001), and in long-term observation (P<0.05). Similarly results were noticed analyzing all deaths during the observation period essential hypertension was an independent risk factor of death in patients with aortic regurgitation subjected to aortic valve replacement (OR 2.9; 95% CI 1.9–4.7; P<0.001). In patients with aortic stenosis subjected to AVR we did not notice such correlation. Conclusions: In conclusion, essential hypertension was an independent predictor of death in patients with aortic regurgitation subjected to AVR. All patients with essential hypertension undergoing cardiac surgery should be treated as high risk patients of postoperative complications, and the optimal hypotensive treatment should be implemented in order to effectively reduce the preoperative blood pressure. Further studies are necessary to confirm these results.
1University of California, San Francisco, USA; 2University of California, Davis, USA Objectives: Transcatheter aortic valves (TAV) present a minimally invasive treatment for high risk surgical patients with severe aortic stenosis. However, their long-term safety and durability are unknown. The objective of this study is to evaluate hemodynamic changes within TAV created by bioprosthetic leaflet degeneration. Methods: Computational fluid dynamics simulations were performed to evaluate the hemodynamics through normal, mildly and severely stenosed TAV. A three-dimensional surface mesh of the TAV within the aortic root was generated for each simulation. Leaflets were contained within an open, cylindrical body without attachment to the sinus commisures representing the stent. A continuous surface between the annulus and TAV excluded the geometry of the native calcified leaflets and prevented paravalvular leak. Unsteady control volume analysis (320 computational steps per second) throughout systole was used to calculate fluid velocity, and shear and total force on the solid elements. Results: Mild stenosis increased total force on the TAV by over 60% (0.602– 0.98 N), severe stenosis another 80% (1.79 N). For all three simulations, 99% of the calculated force was in the direction of axial flow, along the ventricular surface of the prosthetic leaflets. Shear stresses on both the TAV and aortic root were greatest during peak systolic flow. Shear stress was greatest immediately below the sinotubular junction of the aorta and on the tips of the leaflets of the TAV. Average shear stress throughout systole increased during mild stenosis, but the peak and profile of stress distribution were unaltered. This result indicates that the aortic root geometry and physiologic flow dominate location and magnitude of shear. This result is no longer observed once the TAV has been severely stenosed. A dramatic increase in peak leaflet shear stress was observed (120 KPa severe vs. 45 KPa normal/mild) and the stress profile was dictated by the shape of the stenosis not the sinus. Conclusions: Shear stress has long been recognized as a mechanism of leaflet degeneration and can lead to stent migration over time. Stenosis leads to significant forces of TAV during systole. Significant changes in shear stress do not occur until severe stenosis, but even mild stenosis causes a significant increase in total force. As the first implanted TAV begin to stenose, the authors recommend watchful examination for device failure.
C7-1 LONG-TERM FOLLOW-UP OF POST INFARCT LEFT VENTRICULAR ANEURYSMS D. Dronamraju, B. Govini, R. Jayakumar, A. Kiran, L. Bangalore, V. Bhan, N. Manni, R. Pamlati SVIMS, Tirupati, India Objectives: Long-term follow-up of 27 patients with post infarct left ventricular aneurysms operated over a period of 12 years from 1995–2007. Twenty (74%) were males and 7 (2.6%) were females. Age ranged from 50 to 70 years. Six (2.2%) had single vessel disease, 13 (48.1%) had double vessel disease and 4 (1.5%) had triple vessel disease. Six patients (2.2%) were diabetics, 10 patients (37%) were smokers and 18 patients (66.7%) were hypertensive. Twenty-five patients (92.6%) were operated electively and two patients (0.7%) within 15 days of acute myocardial infarction. Two patients (0.74%) died immediate postoperative period due to low cardiac output and arrhythmias. Follow-up was done over a period of 2–6 years by clinical examination and 2D echocardiography. Methods: Twenty-seven patients underwent surgery for left ventricular aneurysm. All were approached by median sternotomy incision. Aortic canulation was done after heparinisation (3 mg/kg). Aortic canula (Sarns metal, USA) and Bicaval canulation (Cal Med, Edwards-USA) was employed. Membrane oxygenators (Polystan, Dideco) were used in all patients. After cross-clamping aorta, blood cardioplegia was used in all patients. Aortic cross-clamp time varied from 40 to 90 min and bypass time varied from 90 to 120 min. Aneurysm was resected and sutured with 2/0 prolene and teflon felt reinforcement. Total number of grafts were 36. Inotropic support with adrenaline, dopamine or dobutamine was given for all patients. IABP was employed in 24 patients. All patients were electively ventilated for 24–48 h. Three patients (1.1%) required re exploration due to bleeding. Five (1.85%) patients had mild MR which was left alone. Results: Twenty-seven patients were operated for left ventricular aneurysm over a period of 12 years. Two patients (0.7%) died postoperatively due to low cardiac output and arrhythmias. Follow up was done clinically and with 2D Echocardiography. At the end of two years, 11 patients (40.7%) showed no improvement in LVEF, 16 patients (59.2%), LVEF improved by 10–15%. All patients required decongestive management. Three patients died at the end of two years. Conclusions: Timely surgery for left ventricular aneurysms can be done with acceptable mortality and morbidity.
1Department of Cardiac Surgery and Transplantology, Silesian Center for Heart Diseases, Zabrze, Poland; 2School of Pharmacy, Trinity College, Dublin, Ireland Objectives: Extracorporeal circulation (ECC) in CABG is associated with the systemic inflammatory response syndrome (SIRS). Matrix metalloproteinases (MMPs) including gelatinases (MMP-2 and MMP-9) are important mediators of inflammation and their up-regulation has been reported in CABG. Complications of OPCAB may be lower than those of CABG. The objective of this study was to measure plasma and myocardial MMP-2 and MMP-9 levels in patients undergoing OPCAB and CABG. Methods: Thirty-two patients were enrolled into the study: 16 patients operated on CAD with ECC (CABG), and 16 patients without ECC (OPCAB). In CABG blood was collected at the beginning of the operation (A), before ECC initiation (B), at the aortic declamping (C), after ECC (D), 30 min (E), 6 (F) and 12 h (G) after ECC. In OPCAB group blood was collected in equivalent time points: at the beginning of the operation (A), after harvesting of RITA/SVG/RA (B), after completion of distal anastomoses (C), after proximal anastomoses (D), 30 min (E), 6 (F) and 12 h (G) after grafting. The right atrial auricle biopsies were collected before and after ECC in CABG and after harvesting and completion of proximal anastomoses in OPCAB. MMPs (total pro and activated MMP-2 and MMP-9) in plasma and myocardium were measured in samples (20 µg protein) by zymography and quantified using gel documentation system. Myeloperoxidase (MPO, a specific granulocyte marker) was measured using commercially available ELISA kit. Results: There were no significant differences (P>0.05) in age, gender, LVEF and EuroSCORE between CABG and OPCAB patients. CABG, but not OPCAB, led to a significant increase in plasma MMP-9 levels that peaked at time point D. A small, but significant, increase in MMP-2 levels was detected both in CABG and OPCAB (Fig. 1b). The levels of MMP-9 in biopsies significantly increased at point D of CABG and OPCAB. In contrast, the levels of MMP-2 were not significantly changed in atria during CABG and OPCAB. The MMP-9 content in plasma at point D correlated with MPO plasma concentration (r2=0.8212, P<0.05). Conclusions: 1. Systemic MMP-9 levels greatly (700–900 fold) increased during and directly after CABG, but not OPCAB. 2. Myocardial MMP-9 levels increased both in CABG and OPCAB indicating that local MMP-9 up-regulation is common for both types of surgery. 3. The correlation of plasma MMP-9 with MPO suggests that MMP-9 was released by activated granulocytes during ECC. 4. Thus, the ECC-mediated increase in systemic MMP-9 levels may contribute to the pathogenesis of SIRS.
University of Rome, La Sapienza II Faculty of Medicine, Cardiac Surgery Division, Ospedale S Andrea, Italy Objectives: Coronary artery bypass graft (CABG) surgery may result in perioperative myocardium injury during cardioplegic arrest. Angiotensin-converting enzyme (ACE) inhibitors protect myocardium from ischemia in several clinical conditions but no previous study has attempted to evaluate the impact of preoperative ACE inhibitor therapy on myocardium protection in patients undergoing CABG surgery. Methods: A propensity score-based analysis of 481 patients undergoing isolated on pump CABG surgery. Two hundred and forty-five patients received preoperative ACE inhibitors and 236 were not treated with ACE inhibitors. Peri-operative myocardial injury was assessed by ischemia marker cardiac troponin I (cTnI). Results: Preoperative cTnI concentration was similar for patients receiving ACE inhibitors and patients who did not (0.1 ng/ml [0.06–0.19] vs. 0.1 ng/ml [0.06–0.19]; P=0.3). At ICU admission, cTnI concentration was lower in patients receiving preoperative ACE inhibitors (0.8 ng/ml [0.44–0.1.35] vs. 0.96 ng/ml [0.50–1.89]; P=0.03) and this difference was more evident at the 1st (1.6 ng/ml [1.05–3.4] vs. 2.4 ng/ml [1.13–6.10]; P=0.0006) and 2nd postoperative day (0.8 ng/ml [0.5–1.8] vs. 1.4 ng/ml [0.64–3.98]; P=0.0015). After adjusting for propensity score and covariates, preoperative ACE inhibitors were found to decrease postoperative cTnI peak concentration (B=–0.12; P=0.004). Other independent predictors of postoperative cTnI peak concentration were female gender (B=0.15; P=0.009), emergency surgery (B=0.20; P=0.003), number of distal anastomoses (B=0.08; P=0.03) and aortic cross clamp time (B=0.002; P=0.03). Conclusions: ACE inhibitors prior to surgery may add myocardial protection during surgical revascularization. Prospective, randomized clinical trials will be necessary to better define the role of ACE inhibitors in improving outcomes when they are prescribed prior to CABG surgery.
1Acibadem Kadikoy Hospital, Istanbul, Turkey; 2Kirikkale University School of Medicine, Ankara, Turkey Objectives: This study is designed to determine and compare the effects of transfusion and use of coated circuits on the systemic inflammatory response and protein adsorbtion of the circuit surface during cardiopulmonary bypass. Methods: Alterations in the inflammatory parameters and protein adsorbtion were observed in 40 patients undergoing elective coronary bypass surgery with CPB. Patients were prospectively enrolled equally in to four groups (group 1: patients who received no red blood cell (RBC) during CPB with using standard oxygenator, group 2: patients who received at least 1 RBC during CPB with standard oxygenator, group 3: patients who received no RBC during CPB with coated oxygenator, group 4: patients who received at least 1 RBC during CPB with coated oxygenator). Serum lactate, interleukin-6 (IL-6), human tumor necrosis factor alpha (TNF-alpha), D-dimer and CRP levels were measured at three different time points (T1: before cardiopulmonary bypass, T2: after aortic cross clamping, T3: after the administration of protamine). Results: Basal (T1) measurements of TNF-alpha, IL-6, D-dimer, CRP and lactate were similar between groups. These parameters were increased at T2 and T3 in all groups (P<0.05 within groups); measurements of all were the highest at T3 in group 2 (with transfusion and no coating) and lowest at group 3 (with no transfusion and coating) when compared to the other groups (P<0.05). Anova test for repeated measurements revealed that the increase in IL-6 was significantly higher at T2 in group 2 when compared to group 1 (P=0.03). The increase in TNF-alpha was significantly higher at T2 in group 1 when compared to group 3 (P<0.05). The increase in D-dimer was significantly higher at T3 in group 2 when compared to group 3 (P=0.04). Lactate levels were increased at T2 and T3 significantly at group 1 when compared to group 4 (P=0.02 at T2 and T3). The measured protein adsorbtion was higher in group 1 and group 2 (group 1 vs. group 3; P=0.01, group 2 vs. group 3; P=0.02, group 2 vs. group 4; P=0.04). It was also higher at group 4 when compared to group 3 (P=0.03). ICU stay time and entubation time was shorter in groups with coated circuits (P<0.05 between group 4 vs. group 2 and group 3 vs. group 2) and the ones with no transfusion (P<0.05 between group 1 vs. group 2 and group 3 vs. group4). Conclusions: There is an increased inflammatory response after cardiopulmonary bypass. Allogenic red blood cell transfusion attenuates this inflammatory response and increases the surface protein adsorbtion. The use of polymethoxyethylacrylate-coated circuit systems has a limiting effect on these processes. The combination of transfusion and not using a coated system has the highest risk for increased inflammatory response and protein adsorbtion.
V3bis-1 SURGICAL MANAGEMENT OF CAROTID BODY TUMOR (CBT): NEW DIAGNOSTIC TOOL AND MULTIDISCIPLINARY APPROACH M. Piazza1, M. Antonello1, M. Menegolo1, P. Frigatti1, G. Opocher2, F. Grego1, G.P. Deriu1 1Clinic of Vascular and Endovascular Surgery, Padova, Italy; 2Endocrinology Padova, Italy Objectives: Management of CBT is difficult in both diagnosis and treatment especially when patient is asymptomatic or the tumor is associated with multiple paragangliomas. In this study we analyzed patients treated for neck paraganglioma to evaluate the necessity of preoperative genetic studies and a multidisciplinary approach for correct surgical management. Methods: Sixteen patients admitted to our institution between January 1986 and December 2007 surgical treated for cervical paraganglioma resection was analyzed. Only in one patient, with more than 6 cm mass, preoperative embolization was performed. Genetic study for SDH mutations was collected for all patients but only from 2003 (6 TGC) like part of preoperative diagnostic tool. Clinical data and follow-up were collected prospectively and analyzed retrospectively. Statistical data are shown as mean values and standard deviation. Results: Of the 16 patients with a mean age of 54.1+15.8 years there were 12 (75%) female and 4 (25%) male. At time of diagnosis two patients (12.5%) presented with bilateral CBT and one with clinical history of multiple paraganglioma (0.6%). Four patients (25%) tested positive for SDHB and D gene mutation; one sporadic monolateral CBT, one multiple paraganglioma and in two patients with bilateral CBT. Major stroke or important cranial nerve lesions did not occur in any case. Reversible cranial nerve lesions occurred in four patients; intraoperative limited blood loss in one subject. In one case internal carotid artery reconstruction was performed. Histological analysis showed benign paraganglioma in all 16 patients and no malignant form were reported. After a follow-up of 3 to 195 months (mean 86.0+57.2) 15 patients were free of disease with no evidence for local recurrence whereas one patient was lost to follow-up. Conclusions: In a cohort of 16 patients consecutively referred with cervical paraganglioma, in all cases with multiple presentation we identified an SDH gene mutation; in two of those patients genetic test was an important tool for diagnosis and choice of treatment. Tumor surgical excition gave excellent postoperative results when classified Shamblin class I or II. Long-term survival in patients after surgical removal of CBT appears not limited. In conclusion SDHB, SDHC and SDHD molecular screening is mandatory in patients with bilateral CBT presentation and should be recommended in patient's families and in cases of sporadic CBT too also for guiding surgical way of treatment. CBT is a rare condition which needs accurate preoperative multidisciplinary evaluation and surgical exicition by experienced vascular surgeon.
1Department of Vascular and Endovascular Surgery, University Hospital, Genoa, Italy; 2Department of Cardiovascular Surgery, University Hospital, Geneva, Switzerland; 3Department of Biomedical Engineering, Virginia Commonwealth University, Richmond, USA Objectives: Vascular tissue engineering necessitates a degradable scaffold. The purpose of this study was to evaluate biocompatibility, patency and mechanical properties of the following electrospun degradable polymer grafts: poly-dioxanone (PDO) alone, mixed with poly-lactic-acid (PDO-PLA), and mixed with polycoprolactone (PDO-PCL). Methods: In 30 anaesthetised Sprague Dawley rats, 2 mm ePTFE grafts (controls n=9), 1.5 mm PDO (n=3), 1.5 mm PDO-PLA (n=9) and 1.5 mm PDO-PCL (n=9), were interposed in the infrarenal abdominal aorta and followed for a period of 3, 6 and 12 weeks. Digital substraction angiography was performed for patency, stenosis and aneurysmal dilatation assessment before euthanasia and grafts were harvested for morphologic as well as scanning electron microscopic examination. Results: Patency rates were excellent for all types of grafts (100%) and no relevant stenoses were found. Angiography follow-up showed 100% aneurysmal dilation for PDO alone at 3 weeks (therefore, no further implantations were carried out) and no aneurysmal dilatation for PDO-PCL grafts. Morphometric and planimetric studies showed that the neo-endothelization of the graft at 12 weeks is significantly better for PDO-PLA and PDO-PCL grafts vs. ePTFE (P<0.05 Mann–Whitney U-Test). Conclusions: Patency of electrospun PDO, PDO-PLA, PDO-PCL grafts is excellent. Aneurysm formation represents a major problem for degradable synthetic vascular grafts (PDO). Therefore, combinations of PDO with slower degrading polymers, such as PCL seems to eliminate aneurysm formation in small calibre vascular prosthesis. Electrospun random nano-fibre PDO-based polymers may be promising materials for vascular tissue engineering.
Clinic of Vascular and Endovascular Surgery, Department of Cardiac Thoracic and Vascular Sciences, Padova, Italy Objectives: This randomized prospective study was designed to compare the effectiveness of treating superficial femoral artery occlusive disease (SFAOD) with expanded polytetrafluoroethylene (ePTFE)/nitinol self-expanding stent-grafts vs. surgical femoral-to-above knee popliteal (AKP) artery bypass. The main end-point of the study was primary and secondary patency rate. Methods: From March 2006 to November 2007, 45 patients with SFAOD were enrolled in the study. Fourteen patients were excluded for poor distal run-off, contraindication to anti-platelet, anti-coagulant or thrombolytic therapy. Patients had symptoms ranging from claudication to rest pain, with or without tissue loss. Once admitted in the study they were prospectively randomized into the two arms of treatment: 24 patients to open repair (OR) that underwent a femoro-AKP artery bypass using homologous great saphenous vein or ePTFE grafts and 21 patients to endovascular treatment (ET) in which a Viabahn® endograft was deployed. Associated procedures were: endarterectomy of the common and profunda femoral artery in six patients of OR (25%) and in four of ET group (19.1%) and PTA of a tibial artery performed in three cases (14.3%) after the endograft deployment. Follow-up was based on clinical evaluation and color flow duplex sonography performed at 3, 6, 9, and 12 months and then every six month after treatment. A restenosis >60% was considered a failure of the procedure. Results: No statistical differences were observed for primary and secondary patency rate between the two treatment groups both in the early and middle term results. At 30 days the primary and secondary patency rate were 100% for OR and 95.2% for ET. One endograft occluded 72 h after the procedure in a patient with a concomitant profunda endarterectomy, the thrombolytic therapy failed and no adjunctive procedure was performed. At 20 months the primary patency rate was of 83.2% for OR (two bypass occlusion) and of 73.7% for ET (two endograft occlusion and one restenosis >60%), with a secondary patency rate, respectively, of 90.7% and 80.2%. Conclusions: Results of this preliminary study seem to show that the management of SFAOD with covered stent-graft is a safe procedure with comparable results to OR with conventional femoral-to-AKP artery bypass. Larger studies with longer follow-up are required to establish the role of ET in the management of SFAOD.
Vascular Surgery Division, Thorax Institute Hospital Clinic, Barcelona, Spain Objectives: To report a 10 year experience in the endovascular treatment of acute traumatic thoracic aorta rupture in our hospital. Methods: We reviewed 20 patients with an acute traumatic thoracic aorta lesion treated with a thoracic endograft between August 1997 and July 2007. All were multitrauma patients, victims of high velocity accidents or accidents with great impact. The diagnosis of aortic injury was made on clinical basis and conventional imaging, confirmed by computed tomographic angiography (CTA). The following parameters were studied: age, sex, type and site of the lesion, type of endovascular graft, endovascular operation time, length of stay in the intensive care unit (ICU), length of stay in the hospital, immediate and peri-operative complications and mortality. In addition, we recorded follow-up data consisting of clinical visit, computed tomographic angiography (CTA) and plain chest radiographs at regular intervals (3rd, 6th and 12th month and later, every subsequent year). Median follow-up was of 58 months. Results: All endovascular procedures were technically successful, and the median operating time for the endovascular procedure was 74 min (range 55–130 min). We recorded an external iliac lesion during the procedure as unique immediate complication and was corrected by an ilio-femoral bypass. The only peri-operative death (peri-operative mortality rate of 4%) was unrelated to the aortic rupture or stent placement. There was no intervention-related mortality during the follow-up. Postoperative data showed no severe endovascular graft- or procedure-related morbidity. We recorded two cases of stent fracture, diagnosed by chest radiograph and CTA, without clinical impact or signs of endoleak. Conclusions: Short- and mid-term results of immediate endovascular repair of traumatic aortic injuries are very promising, especially when compared with open surgical treatment. This induces us to consider endovascular therapy preferable in these multitrauma patients with traumatic ruptures of the thoracic aorta. Nevertheless, long-term follow-up data are necessary for assessing the overall durability of this procedure, considering the young age of these patients. The long-term follow-up results will determine whether the endovascular treatment should replace open surgery as first-line therapy in thoracic aortic injuries.
Hospital Universitari de Bellvitge, Barcelona, Spain Objectives: To analyze wich factors are associated with rAAA mortality and if there was any impact after the introduction of endovascular emergency repair on the prognosis of the disease. Methods: Eighty-two patients diagnosed of rAAA between january 2003 and september 2007 were enrolled prospectively. Fifty-one of those were submitted to emergent surgery (14 endografts and 37 on an open fashion). Clinical data and blood samples were taken to calculate the Glasgow Aneurysm Score (GAS). Arterial and aneurysm diameters, type and area of rupture were assesed on presurgery CT scan. Surgical parameters, perioperative evolution and 3-month follow-up were also collected. Two groups were established to asses the impact of endovascular emergent repair: 2003–2004 and 2005–2007 (after introduction of emergency EVAR). Results: A significant association was found between death and: location and type of rupture, aortic diameter, GAS, time to reach emergency department and technique used for repair (endovascular/open). There were no significant differences in survival between the two time periods analyzed both in the group submitted to surgery and on the whole series. The clinical-anatomic most lethal combination was (accounting 2 out of 3): GAS>92 (percentil 75), retroperitoneal posterior rupture with active bleeding (RAP) on CT scan and a time to reach emergency higher than 20 h after the onset of symptoms, wich summoned a 100% (7/7) mortality on the operated group (P=0.0072). Suprarenal aneurysm perisurgical mortality (12 cases, 3 operated) was also 100%. Conclusions: Emergency endovascular repair of a rAAA decreases operative mortality. The combination of a high GAS score, a retroperitoneal active bleeding and a delay on the arrival to hospital or the presence of a suprarenal aneurysm may predict a nule survival.
Department of Cardiac Thoracic and Vascular Sciences, Vascular and Endovascular Section, University of Padua, Italy Objectives: After EVAR an impairment of renal function (RF) has been observed in 3–5% of patients when it is study with biochemical marker such as serum creatinine (SCr), this percentage of patients increase to 8–10% when a more sensible test as renal perfusion scintigraphy (RPS) is used. Recently a new biochemical marker has been introduced to detect renal function: cystatin-C. The aim of the study was to evaluate the role of cystatin-C in monitoring renal function after EVAR by comparing it with SCr and RPS. Methods: From June 2007 to January 2007 a prospective comparative study was performed at the Department of Vascular and Endovascular Surgery of Padua University, during this period 20 consecutive patients underwent EVAR for AAA and were enrolled in the study. The preoperative and postoperative (3rd postoperative day) protocol included the dosage of SCr, cystatin-C; at the same time point a RPS was performed as parameter of control of the glomerular filtration rate (GFR). Furthermore the RPS is able to evaluate separately the GFR of each kidney. A variation of SCr, cystatin-C, CrCl, CcCl or of the GFR at the RPS >20% from base line was considered relevant. Results: No significant variation of the mean value of biochemical marker of renal function were observed from base-line to postoperative period. SCr ranged from 1.05±0.2 to 1.15±0.3 (9.06% of variation from base-line), cystatin-C from 1.087±0.2 to 1.086±0.2 (0.09% of variation from base-line); the GFR at the RPS ranged from 65.3±16.7 to 63.8±12.8 (2.29% of variation from base-line). Analyzing the results of biochemical marker and of RPS in every single patient in 3 (15%) a significant variation (>20%) of the GFR was observed in absence of a significant variation of SCr and cystatin-C. In 2 (10%) of these patients the RF impairment was limited to a single kidney. Moreover, the RPS showed in other 2 (10%) patients a significant impairment of the GFR (>20%) limited to a single kidney without a significant variation of the total GFR. Conclusions: Results of the study showed that cystain-C as SCr are not useful markers in identifying RF impairment after EVAR. In fact in the 3 (15%) cases with a significant impairment of total GFR and consequently in the 2 (20%) with a GFR decrease limited to a single kidney, non-significant variation of cystatin-C or SCr were observed.
Department of Cardiac Thoracic and Vascular Sciences, Section of Vascular and Endovascular Surgery, University of Padua, Italy Objectives: The aim of the study was to determine variables that could be used to predict survival in patients with ruptured abdominal aortic aneurysm (RAA) and to asses the accuracy of Glasgow Aneurysm Score (GAS) and APACHE II. Methods: Data of all patients admitted at the Department of Vascular and Endovascular Surgery of the University of Padua for a RAAA between January 1998 and July 2006 were retrospectively collected in a data-base and thereafter analyzed. A RAA was defined as a defect in the aneurysmal wall, that had allowed the extravasation of a quantity of blood. For each patient, 44 variables were recorded, analyzed and divided in to three subgroups: preoperative, intraoperative and postoperative. In the preoperative subgroup the analysis was completed with the GAS and in the postoperative with the APACHE-II score. Data were analyzed by both univariate and multivariate methods and performed using SPSS software, version 13.0 (SPSS Inc., Chicago, Illinois). To compare dead vs. alive patients we used Student t-test for continuous variables and Fisher Exact test for categorical ones. Stepwise logistic regression was used to estimate the independent Odds Ratio, and their confidence interval, of a optimized subset of predictor variables significantly associated to death in univariate analysis. Results: During the study period, 1141 patients underwent an AAA repair. The elective procedures were 1008, and 251 (24.9%) of these were endovascular; 169 (16.7%) patients underwent emergency operations for symptomatic AAA, of which 116 had an evidence of rupture. Thirteen patients were excluded from the study, due to missing data for most of the prognostic variables. There were 82 men and 21 women. The mean age was 72.9 years, ranging from 47 to 91-years-old. At the univariate analysis significant predictors of death were: hypotension (P=0.001), pre-existing peripheral vascular disease (P<0.001), renal insufficiency (P=0.037) and chronic obstructive pulmonary disease (P=0.028), the level of HCO3 – (P<0.001), intra-peritoneal rupture (P=0.001), blood transfused (P<0.001), cardiac complications (P<0.001), and Apache II score (P=0.001). Multivariate analysis confirmed a statistical significance for coexisting peripheral vascular disease (P<0.001), diastolic blood pressure at admission <60 mmHg (P=0.039), APACHE II score >18.5 (P=0.025), HCO3 - <21 mg/dl (P<0.001) and intra-peritoneal rupture of the aneurysm (P=0.011) as predictors of death. Conclusions: Results of the study suggested that different factors can be helpful in identifying those patients whose operative risk is prohibitive. The APACHE II, contrary to GAS, is an accurate system to predict postoperative death after repair for RAA.
Hospital Universitario Getafe, Madrid, Spain Objectives: Endothelin-1(ET-1) is a powerful vasoconstrictor agent produced by the endothelial cells as response to different stress stimuli. We aimed to define the role of Endothelin-1(ET-1) in Peripheral Arterial Disease (PAD) and to determine the relationship between ET-1 circulating levels and the endothelial function assessed by the flow mediated arterial dilation (FMAD), as well as to find out the association of the ET-1 with the clinical presentation of the disease and the inflammatory processes acting in atherosclerosis. Methods: We carried out a study with a group of 103 patients with clinical PAD and a control group with 38 healthy people. We estimated the endothelial function measuring the FMAD in the brachial artery in all the enrolled individuals. We analyzed the C-Reactive Protein plasma level, as an inflammatory marker in cardiovascular diseases, and measured the ET-1 serum level using the ELISA method. The sample size was calculated for this study with a statistical power of 0.8 and an Alfa error of 0.5. Results: We found significant differences in ET-1 plasma levels between the patients and the control group (8.76 pmol/l ±7.1 vs. 6.45 pmol/l ±0.89; P=0.002). The analysis of the pooled sample by clinical stage showed significantly differences in ET-1 levels regarding the severity of the PAD (10.97 pmol ±7.9 in patients with intermittent claudication vs. 4.82 pmol/l ±2.57 in critical limb ischemia; P<0.001). There were no differences in regard to age, genre, cardiovascular risk factors, FMAD and Nitric Oxide plasma levels between the patient groups according to their clinical presentation. Otherwise, we did find significantly differences in hsPCR levels depending on the clinical severity (4.73 [3.32; 7.37] mg/l in the claudication group vs. 16.94 [5.6; 66.37] mg/l in critical ischemia group; P=0.001). In the other hand, the correlation coefficient between the ET-1 plasma levels and FMAD measurements was almost valueless (r=0.040; P=0.68) Conclusions: Endothelin-1(ET-1) might play a triggering role in Peripheral Arterial Disease, as its elevated plasma levels in the early stages don't increase with the clinical severity progression of the disease.
Clinical Center of Serbia, Clinic for Vascular Surgery, Belgrade, Serbia Objectives: The aim of the study was to identify the factors influencing surgical treatment outcome following upper extremity arterial injuries. Methods: This 15-year study included 167 patients with 189 civilian, iatrogenic and war upper extremity arterial injuries requiring surgical intervention. Patient data were prospectively entered into Vascular trauma database and retrospectively analyzed. There were 31 (18.6%) war, 120 (71.8%) civilian and 16 (9.6%) iatrogenic injuries. The most frequently injured vessel was the brachial artery (55% of the injuries), followed by the axillary (21.7%), antebrachial (21.2%) and subclavian (2.1%) arteries. Associated skeletal, neural and venous injuries of the ipsilateral upper extremity were present in 64.7% of the cases. The presence of hard signs of arterial injury was diagnostic in majority of the cases. Additional, arteriography and Duplex ultrasonography were performed in 36.5% and 19.2% of the cases, respectively. The majority of arterial reconstructions were performed with the use of saphenous vein graft (55.7%). Fasciotomy was required in 9.6% of the patients. Results: The operative mortality was 2.4%. Three primary amputations (1.8%) were performed due to extensive soft tissue destruction and sings of irreversible ischemia on admission. Seven secondary amputations (4.2%) were due to graft failure, infection, anastomotic disruption or the extent of soft tissue and nerve damage. Early graft failure, compartment syndrome, polytrauma, skeletal, brachial plexus injuries and war injuries were found to be significant risk factors for amputation after upper extremity arterial injury (P<0.01). Conclusions: Although the careful physical examination should diagnose the majority of upper extremity arterial injuries, the use of angiography is helpful in establishing the localization and extent of the injuries. Prompt and adequate reconstruction of arterial injuries is essential for optimal results. Traumatic nerve injuries are the primary cause of long-term functional disability.
1Academic Vascular surgical Unit, Hull Royal Infirmary, Hull, UK; 2Department of Computer Science, University of Hull, UK Objectives: Existing risk models for risk prediction fail to predict individual patients risk. The aim of this study was to use data mining and neural network (NN) techniques to improve risk prediction for Carotid endarterectomy (CEA). Methods: The data set of 840 CEAs derived from two vascular units, five vascular surgeons prospectively collected over six years was available. The outcome end points were the occurrence of stroke or death within 30 days. Data was split for training and cross validation (500) and test set (340). Three supervised NN techniques (Multi layer perceptions, Radial basis function and Support vector machines) were used. Ten fold cross validation technique was used as internal validation on WEKA data mining software. Later on K Mix algorithm was used to cluster input data. Sensitivities and specificities were compared to the NNs using confusion matrixes Results: Low sensitivities (0.13–0.27) but high specificities (0.85) were obtained with supervised NNs with out K Mix. High sensitivities (1.0) and specificities (0.99) were obtained with K mix generated supervised NNs. Conclusions: The use of data mining methods (KMix) to cluster input data first improved predictive accuracy of NNs for CEA. Further validation on independent data set is necessary before clinical use.
Department of General Vascular and Transplant Surgery, Medical University of Warsaw, Poland Objectives: Dialysis dependent patients have often central venous drainage problems, usually due to percutaneous vein catheterization. In case of functioning arm arterio-venous fistula outflow thrombosis can be the reason of venous hypertension, arm edema and vascular access failure. Percutaneous angioplasty and stenting of narrowed vessels is sometimes not sufficient. In such circumstances there is the possibility to create new fistula with venous anastomosis to subclavian or iliac vein, superior or inferior vena cava. In case of existing fistula failure, it is possible to create veno-venous graft to bypass the thrombosed vein. The aim of the study was to assess the possibility of creation and function of arterio-venous fistula with the outflow to central veins. Methods: Between 1990 and 2007 in our Department 49 patients with central veins occlusion were treated. Mean age was 43 years (range 19–64 years), mean duration of hemodialysis was 4.2 years (range 16 months to 6 years), mean number of previous vascular access surgery was 7.6 (3–17). We performed 19 axillo-iliac, 14 axillo-axillary bypasses and 16 conduits from arm fistula to jugular (9) or subclavian (7) vein for hemodialysis purposes. We used 5 or 6 mm diameter external supported PTFE grafts. Results: All except one fistulas were used for hemodialysis. One patient died with good function of fistula before it is initial usage. Follow-up period ranged from 1 to 84 months. In four cases of stenosis of venous anastomosis occured (8, 12, 14 and 16 months postoperatively), two of which were successfully treated by angioplasty and one required a new anastomosis to the inferior vena cava. In 12 cases (24%) graft trombectomy was necessary 1 to 38 months after the operation. One axillo-iliac and one axillo-axillary bypass was removed 14 and 22 months after the operation due to infection. Conclusions: In conclusion we found extraanatomic conduits an efficient option as a permanent vascular access for hemodialysis purposes in patients with central venous occlusion.
Hospital Universitario Getafe, Madrid, Spain Objectives: To analyse the role of the nitric oxide (NO) plays in the peripheral arterial occlusive disease (PAOD) pathogeny and its relation with inflammation processes at the origin and development of the disease as well as the nitric oxide concerns on the endothelial dysfunction characterized by the flow-mediated dilation (FMD) of the brachial artery. Methods: We carried out a cross-sectional study in our population randomizing a sample sized in 123 subjects. The nitrites serum levels were determined using a flow-injection analysis based on the Griess reaction. The variables flow-mediated dilation (FMD) of the brachial artery, the high sensitive C-reactive protein (hsCRP) and the plasma levels of nitrites were assessed in a group of 82 patients diagnosed with PAOD and compared with the data resulted in a control group of 41 healthy subjects. In addition, we analyzed the data in the subgroups of patients regarding their clinical severity (50 Fontaine stage II and 32 Fontaine stage III–IV patients). Results: Patients with PAOD had significantly increased plasma levels of nitrites compared with healthy control subjects (23.92±23.27 M vs. 12.77±11.12 M, P=0.001). The groups resulted by pooling the patients according the clinical severity of the disease were comparables with regard to cardiovascular risk factors and current medication. However, we did not significantly find differences in the levels of NO between both groups of patients with PAOD (25.24±24.47 M vs. 21.86±19.86 M, P=0.38). Neither we found differences between both groups in FMD (4.7±4.2% vs. 4.3±2.8%, P=0.1). Values of hsCRP were significantly higher in Fontaine stages III–IV (8.2±13.5 vs. 29.2±33.2, P=0.0001). Conclusions: Increased levels of plasma nitrites in PAOD, as well as increased levels of hsPCR, state the inflammatory nature of the disease. No correlation of the levels of NO with the severity of the PAOD, as well as it occurs in FMD, supports the hypothesis that endothelial dysfunction is a fact that happen in the earliest stages of the disease, and not this way the inflammation events that do act in the progression of the PAOD.
University Hospital in Pilsen Vascular Surgery Department, Czech Republic Objectives: Research in the field of the etiopathogenesis of abdominal aortic aneurysm (AAA) continues in many spheres. One of the most important areas is experimental aneurysm modeling in animals and their further evaluation. It seems that one of the most important factors for AAA formation are the inflammatory reactions proceeding in the aortic wall. Adhesion molecules are probably markers which play very important role in this process. The aim of our experimental work was to determine the dynamics of the soluble forms of two adhesion molecules (VCAM-vascular cell adhesion molecule and ICAM-intercellular adhesion molecule) in animal experimental AAA model during the formation of the aneurysm itself. Methods: Twelve experimental domestic piglets were used for the experiment. Animals were divided into two groups. In the group A (7 animals) we used our own method for creation of AAA by combination of the classic Anidjar/Dobrin method (intraluminal elastase infusion) with mechanical compression of abdominal aorta just below renal arteries by a plastic cuff to create a turbulent flow. Group B (5 animals) was a control group with normal abdominal aorta. The blood samples for evaluation VCAM and ICAM were taken at the beginning and 21 days after experiment. Serum from all the samples were immediately frozen at –70 °C. An assay of soluble forms of VCAM and ICAM was performed in the Radioimmunoanalytical Laboratory by Enzyme-Linked Immunosorbent Assay (ELISA) using porcine antibodies. The values obtained were expressed as their mean and standard deviations. The results were statistically evaluated using Student's test and the ANOVA method. Results: In group A we observed after 21 days typical sacciform aneurysms in all seven cases, the front-back diameter was on average 15.60±1.21 mm. (measured with ultrasound). In Group A the VCAM values at the end of the experiment were significantly higher than the values at the beginning of the experiment (P<0.0156). The ICAM values showed no significant increase throughout the experiment (P<0.9). In Group B the values for both adhesion molecules, VCAM and ICAM, were comparable at the beginning as well as at the end of the experiment. Conclusions: We demonstrated the importance of inflammatory reaction in the aortic wall for the development of AAA. The next experimental work in the field of blocking of inflammatory process in the AAA wall by specific antiinflammatory drugs should be important for clinical practice especially in patients with small AAA or patients contraindicated for elective surgical or endovascular treatment.
V4-1 DOES DIABETES INFLUENCE OUTCOME OF FEMORO-DISTAL BYPASS USING THE DISTAFLO PTFE GRAFT M. Desai, K. Brennan, M.K. Mariappen, A.H. Quddus, M. Welch South Manchester University Hospital, UK Objectives: Autologous vein remains the gold standard with respect to infrainguinal bypass for critical limb ischaemia. In the absence of vein, a vein cuff or patch may be created at the distal anastomosis so that prosthetic graft is not anastomosed directly to a small distal artery. The Distaflo PTFE graft has a pre-formed hood at the distal end designed to mimic the shape of a vein cuff, enhancing haemodynamic forces and thereby reducing the risk of neointimal hyperplasia. Diabetes mellitus remains a significant risk factor for both development of arterial disease and patency rates of endovascular and surgical revascularisation. This study evaluates the value of the Distaflo graft, and whether diabetes is associated with inferior short-term outcome. Methods: A retrospective analysis of all patients undergoing femoro-distal bypass under the care of one senior surgeon using the Distaflo graft over a six year period was performed. All patient notes were retrieved, with particular attention given to diabetic status, operation notes, angiographic findings and outcome. Cumulative patency, limb salvage and survival were estimated using Kaplan-Meier analysis. Diabetes as a specific adverse risk factor was analysed using a log-rank test. Results: Forty-four Distaflo graft were implanted into 24 men (62%) and 15 women (38%) with mean ages of 63 and 76 years, respectively; of these 14 (36%) were diabetics. All were medicated with either antiplatelet agents or warfarin. Primary patency at one year was 28% in diabetics and 34% in non-diabetics (P=0.24). Secondary patency was 35% in diabetics and 34% in non-diabetics (P=0.51). Limb salvage rates were 51% in diabetics and 54% in non-diabetics (P=0.23). 30-day mortality was 7% in diabetics and 6% in non-diabetics (P=0.99). Conclusions: Whilst primary patency rates appear poor, it is important to consider that the majority of these patients had undergone multiple previous procedures, and the aim was limb salvage. In this respect, the Distaflo graft would seem to have a role in patients whose only other option is major limb amputation. Results in diabetics are not significantly different to non-diabetics, and so it is appropriate to offer diabetics the same aggressive approach to limb salvage.
Vakif Gureba Hospital, Cardiovascular Surgery Clinic, Istanbul, Turkey Objectives: Chronic limb-threatening ischemia is a distressing pathology for the patient and surgeon. Timing of the surgery determines the mortality and morbidity rates. Methods: We rewieved our six year experience of surgical treatment in 101 consecutive patients with limb-threatening ischemia. A total of 68 men and 33 women underwent femorodistal bypass graft replacements. Seventy patients had diabetes mellitus, 50 had coronary artery disease, 50 had Chronic obstructive pulmonary disease. All of the patients had rest pain. Fifty-two of them had distal gangrene and 42 had colour changes. Digital subtraction angiography and Doppler USG was performed in all patients. Saphenus vein was used in 83 patients, basilic vein in three patients and vascular bioprosthesis in 15 patients. Femoro-tibialis posterior bypass was performed in 41 patients. Thirty-two had femoro-tibialis anterior bypass, five had femoro-dorsalis pedis bypass. Fifteen had both tibialis anterior and tibialis posterior bypass, three had peroneal artery bypass. Five patients had only exploration. Twenty-five of the patients had additional aortobifemoral bypass and 40 patients had femoropopliteal above knee bypass. Twenty-five of the patient had general anesthesia, 68 had regional anesthesia. Sixty saphenous procedure was performed in which 15 was insitu procedure. Results: Seventy-five of all patients were followed for 38 months (3–60). Thirty patients had distal amputations additionally to the bypass procedure. During the early postoperative period, three patient which was performed a. tibialis posterior bypass, three patients which was performed a dorsalis pedis bypass and two patient that was performed a perenoalis bypass had graft occlusion. Five of these patients suffered from embolectomy. Prostoglandin was also applied in these patients. Remaining three patient had no chance of revascularisation. All the patients had Hyperbaric oxygen treatment before and after the surgery. Graft patency was 68%. Twenty patients had additional amputations. One patient died due to myocardial infarction. Conclusions: Chronic limb-threatening ischemia is a distressing pathology for the patient and surgeon. Femorodistal bypass surgery is a useful and effective strategy in patients with critical limb ischemia.
Seconda Universita degli Studi di Napoli Scuola di Specializzazione in Chirurgia Vascolare Dir A Matarazzo, Italy Objectives: The authors report their experience on the role of the profunda femoral artery in the revascularization of the ischemic lower limb with particular reference to the indication and results obtained with Profundaplasty surgery. It is well known that the first vessel of supply in the event of superficial femoral artery obstruction is the profunda femoral artery that is capable, with its collateral branches, to create anastomosis with geniculate branches or more downstream, with the arterial branches of leg constituting a natural bypass with the popliteal and/or tibial vascular bed. In patients with obstruction of the superficial femoral and alterations of proximal segment of the profunda femoral, it is often sufficient a surgical intervention of profundaplasty to enhance the collateral circulation; it constitutes also a valid alternative to the failure or the impossibility to construct a femoro-popliteal or femoro-distal bypass. However, the success of an isolated profundaplasty is strictly connected with the run-off of the collateral network around the knee and through the tibial vessels. In patients with obstruction of the femoro-popliteal axis and/or tibial axes and it is not possible to perform a femoro-popliteal bypass or a distal bypass or they presents steno-obstructive alterations of the deep femoral artery can certainly benefit of profundaplasty intervention which with the restore of a valid inflow in the profunda femoral artery can significantly reduce the ischemia of the limb. Methods: Eighty-four interventions of profundaplasty were performed at the UO of Vascular Surgery of the SECONDA UNIVERSITA’ DEGLI STUDI DI NAPOLI. The patients were: 57 males, 27 females, with mean age of 66.5 years; 31 were diabetics; five patients were at stage II B, 41 at stage III and 38 at stage IV A. Results: In six months of follow-up the results were favourable in 67 patients; amputations were 14. Three patients died for cardiovascular arrest. In one year follow-up 51 cases were favorable with 12 amputations, and four patients died. In three years follow-up the results were favourable in 43 cases with six amputations and two patients died. Conclusions: The femoro-popliteal bypass and/or distal bypass remains the leading therapeutic procedure in significant lower limb ischemia, but when conditions does not permit to perform such intervention, profundaplasty can represent, even on the basis of Our experience, an acceptable therapeutic support.
Barts and The London Hospitals, NHS Trust, London, UK Objectives: There are very few reported clinical outcomes following percutaneous transluminal angioplasty (PTA) for isolated external iliac occlusive (EIA) occlusive disease. This study aims to examine the role of PTA ± stenting for EIA occlusive disease. Methods: Data prospectively collected on patients who had PTA±stenting for EIA occlusive disease were obtained from our dedicated vascular registry. From January 2003 to February 2007, 51 patients (40 male) with a mean age of 65.6 years (range 41–83 years) underwent EIA PTA±stenting. Indications for intervention were graded according to Fontaines classification; moderate claudication (2A) - n=5, severe claudication (2B) - n=34, rest pain (III) n=2 and critical limb ischaemia with tissue loss (IV) - n=10. Mean followed-up was 12.4 months (range 6–52 months). Results: Thirty-four patients underwent PTA and 14 had PTA and stenting of the EIA. There were three failed attempts at stenting that underwent open revascularization. Forty-eight patients had successful PTA±stenting. During the study period primary patency was maintained in 20 patients (41.7%) and in another eight patients (16.7%) secondary patency was achieved. Of the 20 patients that re-occluded, 10 were graded as Fontaine IV (with non-healing ulcers) and associated superficial femoral artery disease. Of these, five had redo PTA+stenting and the other five had open revascularization. Of the remaining 10 patients, five were managed conservatively and five went on to have surgery. The following complications were encountered; one EIA rupture requiring emergency surgery and two large groin haematomas that were managed conservatively. There was one death following infra-inguinal revascularisation surgery and another two patients underwent a major amputation. Conclusions: PTA for EIA occlusive disease should be used selectively as short-term patency rates are poor, particularly for Fontaine IV patients.
Departement of Cardiovascular, Operative Unit of Vascular Surgery, Treviso General Hospital, Italy Objectives: Improuving the operability rate in patients with CLI and offer a different chance in graft infections. Methods: From May 1995 and August 2007, in our operative unit of vascular surgery we have performed 194 revascularizations using criopreserved omologous veins in 175 patients (135 male, 40 female) 40% were diabetics. Twenty-six were reconstructions in graft infections. Eighty-three CLI, and 85 redo surgery in CLI. Results: We reach the goal of limb salvage in graft infections in 79% of reconstructions. Eighty-six percent in CLI and 80% in redo surgery. After three years 72%, 61% and 53%, respectively. Conclusions: Criopreserved veins can be a good alternative in limb salvage, best results are obtained with composite bypass in CLI, in the group of graft infections a 30% of reconstructions should be considered a bridge solution.
Department of Vascular Surgery, University of Florence, Italy Objectives: To retrospectively analyse our experience with endovascular treatment of peripheral arterial disease, comparing early and mid-term results in patients with TASC-2 C and D lesions with those obtained in class A and B patients. Methods: From May 2005 to December 2007, 198 endovascular procedures in patients with peripheral arterial disease were performed. Patients were divided on the basis of the characteristics of the lesions in TASC-2 A and B patients (Group 1, 101 cases) and TASC-2 C and D patients (group 2, 97 cases). Early (<30 days) results were assessed and were compared in the two groups with two and Fishers exact tests. Mid-term results were assessed with Kaplan–Meyer curves and the comparison between the two groups was performed with log-rank test. Multivariate analysis for the risk of late graft thrombosis was performed with Cox regression analysis. Results: Technical success was obtained in 194 cases (98%); all technical failures occurred in group 2 (4.5%; P=0.04 with respect to group 1). There were no perioperative deaths and cumulative 30-day thrombosis and amputations rates were 1.5% and 0.5%, respectively, with no significant differences between the two groups. Mean duration of follow-up was 10 months (range 1–30, S.D. 7.2). Estimated primary and secondary patency rates at 12 months were significantly better in group 1 than in group 2 (89.5% and 63.3%, respectively; P=0.001, log rank 10.2; 95.5% and 79.5%, respectively, P=0.009, log rank 6.7). Univariate analysis demonstrated that also the presence of critical limb ischemia and the localization of the lesions at a femoro-popliteal level significantly increased the risk of thrombosis during follow-up (P=0.05, log rank 3.7 and P<0.001, log rank 14.8, respectively). Multivariate analysis confirmed a statistical influence on the risk of thrombosis during follow-up only for femoro-popliteal localization (P=0.009, 95% CI 0.05–0.6). Conclusions: Endovascular treatment of patients with peripheral arterial disease and TASC-2 C and D lesions is feasible, providing acceptable early and mid-term results, even if significantly poorer than those obtained in A and B lesions, particularly in femoro-popliteal district.
Institute of Cardiovascular Diseases, Clinical Centre of Serbia, Belgrade, Serbia Objectives: We present the experience of our Institute with rare forms of peripheral arterial embolism within the past 20 years in order to define the clinical presentation, method of diagnosis and results of treatment. Methods: A review of all the patients with the discharge diagnosis of arterial embolism caused by some unusual causes, was conducted. Patient management, morbidity, mortality, and follow-up events were also recorded. Results: Eleven patients - eight males and three females with average age of 49.5 years (range 25–73 years) underwent the urgent surgical treatment due to rare forms of peripheral arterial embolism. Three patients were operated due to a foreign body embolism; three due to emboli originated from malignant tissues; two due to a septic embolism; two due to an embolism from cardiac myxoma and one due to an embolism from myxomatous atrial septal defect. In all patients clinical presentation was acute ischemia of lower extremities. The preoperative evaluation included physical examination, laboratory findings and electrocardiography; in the majority of cases Doppler ultrasonography and angiography were performed. In all the patients (except those with a foreign body embolism), the intraoperative embolic material was pathohistologically and bacteriologically examined. Surgical treatment included foreign body extraction in three cases; thromboembolectomy in seven, and artery resection followed by saphenous graft interposition in one patient with septic embolism. In addition, three cardiosurgical procedures were performed: aortic valve replacement in the patient with a septic embolism and tumor excision in patients with atrial myxoma. Two patients with a malignant embolism were reoperated due to a recurrent arterial embolism within the same hospitalization. In addition, to the usual clinical signs of acute limb ischemia, in the rare forms of arterial embolism the presence of certain uncommon clinical symptoms were also observed. The early results of vascular surgical treatment were very good in all the patients. Further follow-up indicated poor prognosis in patients with malignant arterial embolism. Conclusions: Our experience suggests the importance of being persistent in efforts to find the source of the embolism, because this is the only way for the proper treatment to be recognized and therefore, for the patient to recover completely as well as for the further further embolic complications to be prevented. A thorough pathohistological examination of embolic material in all patients with peripheral arterial embolism is strongly recommended. Recommendations for treatment depend on the certainty of diagnosis and should be individualized.
Siyami Ersek Thoracic and Cardiovascular Surgery Center, Istanbul, Turkey Objectives: Tromboembolic events may be highly morbid and mortal especially in elder age group of patients. The aim of this study is to discuss the most beneficial way of limb salvage treatment in octogenarians. Methods: Twenty-six patients over eighty years old presented to our hospital with acute upper extremity thromboembolism during 2000 2007 were identified retrospectively. The time between symptoms and admittance to emergency room was noted. Demographic findings, the management either surgery or medical, and the prognosis was searched. Results: The origin of embolus material was found to be cardiac in most of the cases (67%) and primary reason was identified as atrial fibrillation. More than half of the patients were female (57%). Other demographic findings are as follows: diabetic (60%), with a history of cardiac disease (83%), and had at least one tromboembolic event previously (34%). Fourteen of the patients underwent early surgical treatment and the symptoms revealed after surgery. Twelve of the patients were treated with medical approach, only. Four of these patients had admitted at very early hours after the beginning of symptoms and the treatment was successful. In the rest of the patients, medical treatment was unsatisfactory and the patients needed surgical embolectomy. In these patients the hospital stay and re admittance was found to be significantly higher than the early surgery group. Conclusions: The overall mortality is similar for medical and surgical treatment of upper extremity thromboembolic events. Nevertheless, early surgery may lower the morbidity such as longer hospital stay and recurrence. We suggest early surgical embolectomy is superior than medical approach for octogenarians with upper extremity thromboembolic events.
Unit of Vascular Surgery, University of Messina, Italy Objectives: The aim of this study was to compare the results of primary OS for CLI in general population with the results in dialysed patients and in patients with previous failure of PTA, in order to determine the correct approach to every patient with CLI and the actual role of OS. Methods: Between January 2004 and July 2007, 402 patients (266 male, 136 female) aged between 46 and 95 (average age 72) underwent OS or EV in response to CLI (39% foot finger or ante foot gangrene, 12% hind foot gangrene, 28% ulcers, 11% rest pain, 10% severe claudicatio). General comorbidities were: diabetes 66%, clinically apparent coronary artery disease 47%, previous CABG 8%, COPD 70%, chronic renal insufficiency 20%, ESRD 13%. We performed in these patients 239 EV (47%) and 267 OS (53%). Open revascularisations were femoro-tibial or plantar and popliteo-plantar bypasses with autologous material in 93% and PTFE in 7%. OS involved 29 (11%) dialysed patients (group 1), 98 patients with failure of previous EV treatment (37%), frequently performed in different and non-surgical centres (group 2), and 140 patients (52%) with CLI non-dialysed and not previously submitted to EV treatment (group 3, control group). We retrospectively compared the early results in these three groups of patients treated by OS in term of level of revascularisation, primary patency, amputation and mortality. Results: Revascularizations have been directed to the tibial or to the plantar arteries at the ankle or foot. Those directed to the plantars were respectively, 83% in dialysed patients (P 0.005); 76% in patients with previous failed PTA (P<0.001); 54% in general population. Primary patency, amputation rate and mortality were respectively: 72.5% (P<0.001) – 6.8% (P 0.5) – 13.8% (P 0.005) in dialysed patients; 74.5% (P<0.001) – 5.1% (P>0.5) – 4% (P 0.5) in patients with previous failed PTA; 93.6% – 3.5% – 2.1% in general population. Conclusions: In patients with ESRD, and in patients after failed EV therapy, the subsequent open surgery had to be more distal and technically demanding. Its results were significantly worse than in the general population, with an increase of redo. Our data suggested that EV should not be attempted as the first choice in every patient affected by CLI, and we believe that OS still is the primary treatment for the most advanced clinical situations, particularly in presence of ESRD and extensive loss of tissue, and of a very diseased arterial bed.
Department of Vascular Surgery from the Hospital Universitari Son Dureta, Palma de Mallorca, Spain Objectives: For the last years it has been an increasing using of endovascular strategies for diffuse aorto-iliac occlusive disease. That is the reason why the TASC definitions have been modified. Study the results of the endovascular treatment in TASC C and D aorto-iliac occlusive disease defined by the TASC II classification. Methods: Retrospective study including 40 patients from February 2003 to February 2008. Lesion classification is made according to the intraoperative angiography. Technical success, complications, ankle-brachial index (ABI), primary patency and limb salvage rates were analyzed. Statistic analysis was made with Kaplan–Meier survival time. Results: The mean aged of the patients was 58.2 years (S.D.±10.1). Twenty-six patients presented TASC D lesions and 14 TASC C. Eight patients had critical leg ischemia. The technical success rate was 82.5% (33/40). In five cases recanalization were not possible. Another two patients presented an arterial thrombosis during the procedure and open surgery was necessary. In another case an iliac arterial rupture was resolved with an endograft. All this complications were in TASC D lesions. The mean preoperative ABI was 0.45 (S.D.±0.22) and the postoperative was 0.89 (S.D.±0.15). The mean follow-up period from the successful procedures was 17.1 months. Primary patency rates were 93.3%, 89.6% and 79.3% at 6, 12 and 18 months. During the follow-up period 2 TASC C patients and 3 TASC D presented occlussions. Limb salvage rate was 98.4%. Conclusions: Endovascular treatment of TASC C aorto-iliac occlusive disease has better results. The successful procedures have acceptable primary patency rates.
C8-1 THE MODIFIED BENTALL (BUTTON-BENTALL) TECHNIQUE: AN EXCELLENT OPERATION WITH EXCELLENT RESULTS S. Calvi, A. Dell'Amore, M. Pagliaro, A. Tripodi, M.D. Giglio, G. Noera, A. Albertini, M. Lamarra Villa Maria Cecilia Hospital, Cotignola, Italy Objectives: We describe our experience with the modified Bentall (Button-Bentall) Technique over a five years period, showing how this technique is a simple, standard option, safe for the patient and with excellent results. Methods: Between January 1999 and December 2006, 227 consecutive patients (191 males and 36 females) mean age of 63.13 years had aortic root replacement with a composite valved graft for dilatation or dissection of the aortic root. The aneurysmal disease was predominant (201 patients, 88.5%). Aortic dissection affected the remaining 26 patients (11.5%). The ‘button modification’ of the Bentall operation was performed in all patients, using different composite valved grafts. Eighty-four patients had a Sorin Carbonart graft; 58 patients received a St. Jude Medical prosthesis, while a Carbomedics model was used in 64 patients. An on-site tailored composite graft has been prepared in the remaining 21 cases, suturing the properly biological or mechanical valve prosthesis to an Hemashield or Gelweave Valsalva tubular graft. Results: Thirty-day mortality rate was 3.5% (8 of 227 patients). Four of these patients had critical preoperative conditions (dissection or impending rupture of the aorta). Mean cardiopulmonary bypass time was 95.11 min and mean aortic cross-clamp time was 73.52 min. At eight years the actuarial survival rate is 88.1% and the freedom from reoperation is 100%. Conclusions: The modified Bentall Technique is rapidly becoming a safe standardized operation, with excellent results in terms of mortality and complications.
Cardiovascular Clinic Bad Neustadt, Germany Objectives: To improve hemodynamic characteristics of the mechanical conduit, we routinely use our own modification in which valve prosthesis is placed inside a Dacron tube leaving a margin of the Dacron below the valve for suturing to the aortic annulus. This composite graft allows the use of mechanical valve prosthesis larger than the annulus and a safe anastomosis with the aortic annulus or aortoventricular junction even in case of extended tissue destruction. Methods: Between August 2000 and August 2006, a total of 262 patients (22 [9%] with acute aortic dissection and 46 [18%] with previous cardiac surgery) underwent aortic root replacement using this graft. In 35 patients with destroyed aortic annulus due to endocarditis or previous cardiac surgery the composite graft has been anastomosed to the altered of fragile tissue of aortoventricular junction or even to the sewing cuff of the mitral valve prosthesis. Cumulative follow-up time was 691 patient-years and was 100% complete. Mean follow-up was 2.64±1.91 years (range 0.1–6). Results: The median size of aortic annulus in this patient group was 23 mm, for which a standard conduit with a valve prosthesis having a GOA of about 2.55 cm2 and an estimated EOA of about 2.03 cm2 would have been possible. However, the median GOA and EOA of the valve prostheses implanted (St. Jude Regent 25), was 4.02 and 3.34 cm2, respectively. An expected prosthesis-patient mismatch could be avoided in 21 patients. No blood transfusion during the entire hospital stay was required for 150 patients (69%). There were 2 (0.8%) early and 11 (4.2%) late deaths. Nine of deceased patients had had previous cardiac surgery, which was identified as an independent predictor for mortality. Only five patients (1.9%) suffered valve-related events during the follow-up. The actuarial event-free survival at five years was 90% for all patients. Conclusions: The modified, self-assembled mechanical valve composite graft with a supraannular position of the valve inside the tube provides improved hemodynamic and hemostatic characteristics leading to excellent early and mid-term results and therefore, has been established as a standard substitute for complete aortic root replacement in our clinic.
Bakoulev Scientific Center for Cardiovascular Surgery, Moscow, Russian Federation Objectives: Description of our experience with and the particularities of surgical treatment of type 1 dissecting aortic aneurysm. Methods: Over 900 radical operations on the ascending aorta (AA) and the aortic arch have been performed in Bakoulev Center. From 1990 to December 2007, surgical correction of type 1 dissecting aortic aneurysm was performed in 260 patients. Their mean age was 46±11.3 years, there were 207 men (78%), and 53 women (22%). The causes of the disease were: media necrosis in 51.4%, atherosclerosis in 23.1%, Marfan and Shereshevsky-Turner syndromes in 14.7% of patients. Bicuspid aortic valve was present in 20.5%, tricuspid in 79.5% of patients. The correction of dissecting aortic aneurysm consisted in ascending aorta replacement in accordance with Bentall-DeBono technique in 83.1%; supracoronary replacement with aortic root reconstruction in 16.9% of patients. In 27.7% of them aortic arch replacement was performed. The operations involving the aortic arch were carried out under deep hypothermia; brain protection was assured with antegrade brain perfusion with brachiocephalic trunk and left common carotid artery catheterization, or antegrade unilateral perfusion through the right subcalvia artery, or retrograde brain perfusion. Results: Total hospital mortality was 12.3% (32 patients). The deaths were causes by: acute heart failure, multi-organ failure, cerebral circulation disturbances. Mean duration of the follow-up was 8.3±4.4 years (6 months to 17 years). The outcomes of 56% of patients are known. In the long-term after surgery on the ascending aorta seven patients underwent aortic arch replacement, and ten interventions on the thoraco-abdominal aorta. Conclusions: Indications for aortic arch replacement at surgical treatment aortic of type 1 dissecting aortic aneurysms depends on a sharpness of disease, presence of the extension of dissection on brachiocephalic vessels and conditions of the thoraco-abdominal aorta.
National Amosov Institute of Cardiovascular Surgery, Kiev, Ukraine Objectives: To determine possibilities of correction of poststenotic aneurysm of ascending aorta (PAAA) by means of different methods. Methods: During 1999–2007 years 112 patients (patients) with aortic stenoses (AS) and PAAA were operated in Institute. The average age was 57.2±6.3 (21–71) years. At all group 41 (36.6%) patients were in III NYHA class and 71 (63.4%) patients – in IV. The following operations were performed: aortic valve replacement (AVR)+wrapping of AA – 54 (63.5%) patients (group A), AVR+resection of AA+wrapping of AA 16 (18.8%) patients (group B), AVR+resection of AA+plasty of sinotubular junction (STJ) in zone of non-coronary cusp+wrapping of AA 12 (14.1%) patients (group C), AVR+plasty of STJ+wrapping of AA 3 (3.5%) patients (group D)). In all cases group A–D after AVR nylon tape (diameter 1 cm) was wrapping AA by 5–7 tours and fixation between them and in proximal and distal part of AA. Control group E is 39 patients with PAAA (diameter of AA >5.5 cm) was performed Benthal operation and Wheat operation in three patients. All operations were performed with CPB, moderate hypothermia (28–34°C), retrograde St. Thomas cardioplegia. Results: No hospital deaths among group A–D in hospital period and during remote period (average 4.2±0.9 years). Echo examination of diameter of AA for group A: preoperative 4.9±0.5 cm, postoperative (6–7 days) 4.0±0.4 cm, remote period 4.1±0.3 cm; for group B: preoperative 5.2±0.6 cm, postoperative – 3.8±0.3 cm, remote period 3.9±0.4 cm; for group C: preoperative 5.4±0.5 cm, postoperative – 3.7±0.4 cm, remote period 3.8±0.3 cm; for group D: preoperative 5.4±0.4 cm, postoperative 3.9±0.5 cm, remote period 4.0±0.2 cm. In group E: hospital mortality – 7.6% (n=3/39) for Benthal operation and 1 (2.9%) death at remote period (P<0.05). Cross-clamping time 74.4±9.2 min (group A–D) and 114.4±19.2 min (group E) (P<0.05). Blood loss 274.4±39.4 ml (group A–D) and 645.4±79.2 ml (group E) (P<0.05). Staying in ICU 54.4±6.4 h (group A–D) and 84.4±9.2 h (group E) (P<0.05). Conclusions: On the basis of clinical experience we recommend the expedient method of complex reconstruction of PAAA during AVR without prostheses of AA.
Bakoulev Scientific Center for Cardiovascular Surgery, Moscow, Russian Federation Objectives: Description of the results of ascending aorta replacement with the preservation of the aortic valve. Methods: Aortic valve was preserved during surgical treatment of the ascending aortic (AA) aneurysms in 70 patients. Thirty-four patients underwent supracoronary AA replacement, 17 supracoronary replacement with aortic root reconstruction, five aortic root remodeling with aortic valve preservation in accordance with M. Yacoub technique, and in 14 patients aortic root and ascending aorta replacement with aortic valve reimplantation were performed (T. David technique). In 24 patients (34.3%) the intervention was extended onto the aortic arch. In 14 cases the operations was preformed for urgent indications (acute aortic dissection). Mean age of the operated patients was 49.2±14.8 years (5–77 years). Intraoperative criteria for valve preservation while using M. Yacoub or T. David technique were: absence of the free cusp(s) edge prolapse and good coaptation of the cusps with the commissures being put in the normal position. In the presence of anatomically normal cusps and unchanged aortic sinuses walls we performed supracoronary replacement o the ascending aorta; in cases of dissection extension onto the commissures apexes it was complemented by aortic root reconstruction. Results: Hospital mortality was 7.1% (5 patients). Mean duration of the follow-up was 19±21 months (6 months–8 years). In the long-term follow-up aortic regurgitation in all patients does not exceed the 1st degree, except for one female patient operated in the acute stage of the dissection (M. Yacoub technique); control EchoCG performed six months after the operation revealed aortic regurgitation up to the 3rd degree. She is under dynamic observation. Aortic root dilatation with aortic insufficiency up to 3rd degree was revealed in one patient eight years after supracoronary replacement of the ascending aorta with aortic root reconstruction. This patient underwent re-replacement of the ascending aorta and the aortic valve in accordance with Bentall technique. Conclusions: The results of valve-preserving operations performed in aortic aortic aneurysms suggest the possibility of successful restoration of aortic valve function. Long-term results are stabile.
1Cardiac Surgery Department, S Orsola Malpighi Hospital, Bologna, Italy; 2Department of Cardio Anaesthesiology, S Orsola Malpighi Hospital, Bologna, Italy Objectives: Outstanding progress in the aortic surgery has allowed extending the surgical indications to extremely complex cases such as reoperations on the thoracic aorta. The aim of this study is to retrospectively evaluate the results in reoperations on the thoracic aorta using the antegrade selective cerebral perfusion (ASCP). Methods: Between November 1996 and December 2006, seventy-seven patients (mean age 57.6 years) underwent complex reoperation on the thoracic aorta using ASCP. Previous surgery was defined as any previous cardiac or thoracic aorta repair. Reoperation was indicated for progression of chronic aneurysm of the distal aorta in 45 patients, post dissection aneurysm in 30 patients, type A acute dissection in 6, and for pseudoaneurysm and infection in one patient each. Reoperations were performed, on average, 8.9 years after the initial operation. The extension of aortic replacement included mainly the ascending aorta and aortic arch (37 patients, 48.1%). In seven patients the entire thoracic aorta was replaced. The most frequent associated surgical procedure was composite graft replacement in 35 patients (45.5%). Results: The mean duration of cardiopulmonary bypass was 228.3±70.9 min, aortic cross-clamping was 153.9±53.7 min and ASCP time was 78.3±49.9 min. In-hospital mortality was 16.9% (n=13). Multivariate analysis indicated cardiopulmonary bypass time as the only independent risk factor for hospital death (P=0.007, odds 1.01/min). Permanent neurologic dysfunction occurred in three patients (4.6%) and temporary neurologic dysfunction in seven patients (10.9%). Estimated survival at 1.5 and 10 years was 81.5, 74.8 and 63.2%. Conclusions: Despite extreme underlying disease, complex reoperations on the thoracic aorta can be performed safely with satisfactory early and long-term results.
University of Siena, Italy Objectives: Reduction ascending aortoplasty is an alternative to ascending aorta replacement. This study was designed to evaluate the long-term survival and freedom from reoperation following aortoplasty. The postoperative stability of the aorta and preservation of its elastic property (Windkessel function) were investigated by CT. Methods: From March 1993 to November 2003, 34 patients (mean age 65.7 years) with dilatation of the ascending aorta underwent reduction aortoplasty without external support in association with other cardiac procedures: aortic valve replacement in 31 patients, mitral valve surgery in 2, and CABG in 1. The ascending aorta diameter was measured before and at a median follow-up of 70.2 months in all patients. Postoperative Windkessel function was calculated by ECG-modulated CT–scans and compared with a group of five healthy individuals. Risk factors for survival and freedom from reoperation were determined by Cox regression. Results: Perioperative mortality rate was 2.9%. The actuarial survival estimates at 1, 5 and 10 years were 94.1%, 88.1% and 78.3%, respectively. Only the ICU length of stay was a significant predictor of mortality. Ascending aorta redilatation requiring reoperation occurred in four patients (11.7%). Actuarial freedom from reoperation at 1, 5 and 10 years was 100, 96.7 and 78.2%, respectively. Maximal ascending aorta diameter was 48.9±4.0 mm preoperatively and 44.6±5.4 mm at follow-up. Preoperative diameter was not a significant predictor of redilatation. The mean diastolic-systolic augmentation (Windkessel function) assessed by CT was 1.1±0.6 mm, significantly lower than in the control group (2.7±0.2, t=4.643, P=0.0004). Conclusions: Recurrent dilatation of the ascending aorta does not require reoperation in the first five years after aortoplasty. Longer term follow-up is critical to assess its durability. On the basis of our study the procedure may be indicated for high risk patients with limited life expectancy.
Department of Cardiac Surgery, Cardiovascular Sciences Department, Glenfield Hospital, University of Leicester, UK Objectives: To evaluate the surgical experience and the early clinical outcome of a novel prefabricated stentless valved-conduit (BioValsalva) that does not required anticoagulation and exploits the excellent hemodynamic performance of stentless valves and the presence of sinuses of Valsalva. Methods: Between December 2006 and December 2007, 17 patients of age 65±10 years underwent aortic valve, root and ascending aorta replacement with the BioValsalva valved-conduit. The prosthesis incorporates a stentless porcine aortic valve (Elan, Vascutek) suspended within a triple-layered vascular conduit (Triplex, Vascutek) constructed with sinuses of Valsalva. The Triplex vascular graft structure consists of an inner woven polyester layer, a middle elastomeric membrane to mimic elasticity of the aortic wall and an outer polytetrafluoroethylene layer. All patients had ascending aorta aneurysms with a mean diameter >50 mm, 15 patients had annuloaortic ectasia and pure aortic regurgitation resulting from degenerative valve disease unsuitable for repair, two patients had severe aortic stenosis. Logistic EuroSCORE was 15.8±7.6% (range 6.4–34.4%). Two sizes of the BioValsalva were used: 26 mm and 28 mm conduits with 25 mm and 27 mm valves, respectively. The sewing ring of the BioValsalva conduit was anastomosed to the aortic annulus using a variety of techniques depending on the aortic anatomy. Six patients with large aneurysm of the ascending aorta required deep hypothermic circulatory arrest. Results: There was no perioperative mortality. There were no myocardial infarctions, cardiac failure or cerebrovascular events. The mean cardiopulmonary bypass and ischemic times were 162±55 and 107±29 min, respectively. The mediastinal drainage was 422±169 ml, and mean transfusion requirement for packed red cells, platelets and fresh frozen plasma were 1.6, 1.0 and 1.1 units per patient, respectively. Three patients did not require any blood product transfusion. One patient was reopened for bleeding from the Dacron conduit replacement of the distal ascending aorta. Postoperative CT-scans of the aorta and transthoracic echocardiography in all patients demonstrated well-functioning prosthetic aortic valves without regurgitation, with small residual peak gradients (17.4±6.8 mmHg), and presence of sinuses of Valsalva. Conclusions: The BioValsalva composite stentless-valved-conduit possesses excellent hemodynamic performance, and is safe to implant with associated low morbidity. In addition, the conduit material is hemostatic and reduces bleeding, and also facilitates implantation lending itself well to a variety of insertion techniques. Use of this composite valved-conduit, with incorporation of sinuses of Valsalva into the neoaortic root may improve the function and durability of the stentless valve.
1SACCO University Hospital, Milan, Italy; 2Bioengineering Department, Politecnico di Milano, Italy Objectives: The Aortic Interleaflets Triangles Annuloplasty (AITA), first described by Cabrol in 1969, was a simple technique to achieve an Aortic Root Functional Unit (F.U.) stabilization, improving leaflet coaptation and functional reserve after Aortic Valve leaflet repair. In collaboration with the Politecnico of Milan Bioengineering Department we developed three finite-elements computational models of the F.U.: a normal root, a root with a dilatated annulus and a AITA repaired root in order to compare these models with our clinical practice and to identify the best interleaflets triangles height where to perform the plasty. Methods: From September 2003 to February 2008, 105 patients (pts) were treated with an association of aortic leaflet repairing techniques. In 95 patients (90.5%) a AITA was performed. All patients were submitted to: pre and post-operative echocardiography. The AITA simulation on a finite elements dilatated annulus root model was able to identify the 48% of the interleaflet triangles height (ITH) as the best place to perform the procedure in order to maximize the coaptation area, to minimize the regurgitant orifice and the transvalvular gradient. Using the regression relationship equation of the model applied to our post-operative virtual basal ring echo data, we were able to calculate the Estimated Height (EH) of our AITA. Results: Postoperatively the diameters of the Functional Unit decreased as follow: annulus from 23.4±3.93 to 20.1±1.8 mm (P<0.05), sinuses from 41.53±6.347 to 38.2±4.0 mm (P<0.01) and STJ from 41.3±6.47 to 35.25±5.95 mm (P=ns). The mean ITH was 11.18±1.74 mm and the mean EH obtained from the equation EH=(34.427-post-op annulus diameter)/2.6833 was 5.34±0.6 that is the 47.76% of the ITH comparable to the 48% of the computational model. The leaflet coaptation length after AITA increased from 2.73±1.25 to 7.56±2.36 mm (P<0.001) and in the model the leaflet coaptation area from 8% to 48%. Conclusions: So far, the AITA seems to be a valuable technique to increase leaflet coaptation length in aortic valve repair and in silico models seem to be able to predict the principles of the phenomena but not the individual complexity.
C9-1 P-CIRCUIT TECHNIQUE FOR CORONARY REVASCULARIZATION: FIVE-YEAR EXPERIENCE S. Prapas, I. Panagiotopoulos, V. Kotsis, D. Protogeros, I. Linardakis, A. Michalopoulos Henry Dynant Hospital, Athens, Greece Objectives: To evaluate the feasibility/effectiveness of the P-circuit technique as method of choice for patients requiring coronary revascularization.
Methods: From 2/2001 to 11/2005 1359 patients underwent coronary revascularization with the use of P-circuit consisting, of: (1) beating heart, (2) OPCAB, (3) aorta no-touch, (4) use of composite grafts, and (5) total arterial revascularization. The hi-risk subgroups were studied for pre-op, intraoperative and postoperative variables with Fisher's exact, Results: There were three ICU deaths in the first seven days after surgery. Hospital mortality was 1.5% (21 patients). There were various early postoperative complications as renal failure, pulmonary complications, prolonged mechanical ventilation, superficial sternal wound infection, atrial fibrillation, reexploration, postoperative IABP psychological complications and Gastrointestinal complications. The incidence of these complications varied from very low incidence as in psychological complications (0.6%) and reexploration and sternal wound infection (0.7%, 1%, respectively) to a high incidence as for atrial fibrillation (20%) passing through a medium risk of other complications. The incidence of overall events during the mid-term follow-up period (from 4 to 60 months) as recatheterization, reintervention and mid-term mortality were 2.4, 0.6 and 4.8, respectively. Conclusions: The P-circuit technique can be the method of choice for all high risk patient sub-groups requiring surgical revascularization and is accomplished with low morbidity and mortality rates.
Department of Cardiac Surgery, Erasme Hospital, Brussels, Belgium Objectives: We report our comparative experience of On-pump and Off-pump coronary artery revascularization using the EuroSCORE to calculate the risk of preoperative mortality. Methods: A single center clinical study was conducted prospectively between October 2005 and October 2007. It compared the short (30 days), six months, and one year clinical outcomes of on- and-off pump coronary revascularization in high risk patients (>5) according to the EuroSCORE system. Results: One hundred and forty-seven consecutive patients were divided into 70 on-pump and 76 off-pump procedures based on the intention to treat. Mean predictive logistic EuroSCORE was 8±4% for the on-pump group and 13.4±13% for the off-pump group (P<0.0001). Mean number of distal anastomoses were similar. Postoperative mortality was 7.1% and 5.2%, respectively (P=NS). The off-pump group exhibited less atrial fibrillation, blood products transfusion and pulmonary complications as a shorter ICU stay and lower cost. No major adverse event was reported during the follow-up that averaged 24.5±13.8 months. Angina recurrence was one patient in each group. Conclusions: In an era when the limitations of prospective randomized trials have been recognized and rather than trying to smooth the large differences between groups by making a propensity analysis of our results, we assume that the demonstration that OPCAB provides the same mortality and a lower morbidity and cost to high risk patients when compared to high risk patients in the same hands with the same revascularization pattern is one more major indication to recommend OPCAB in high risk. This advocates for a widespread usage of this technique in high risk patients.
Cardiac Surgery Department, Hospital Juan Canalejo, La Coruña, Spain Objectives: The aim of this study is to review and present our experience in performing off-pump CABG surgery using bilateral internal thoracic artery grafts in octogenarian patients. We analysed the early outcome of surgery in this group of patients in terms of morbidity and mortality in order to find out whether this type of surgery in such a high-risk group had a higher incidence of perioperative complications or not. Methods: In the period between April 1998 and December 2007, sixty four octogenarian patients were submitted to off-pump CABG surgery using bilateral internal thoracic artery grafts. A retrospective study was conducted in which data was gathered from an electronic data base storing system. Demographic data and other risk factors were identified. Risk was calculated by applying both additive EuroSCORE and Parsonet 95 scales for all patients. Details of the surgical intervention and postoperative period were registered as well. Results: The mean age was 81.8±1.8 years. Male to female ratio was about 4 to 1. The main associated cardiovascular risk factors were: arterial hypertension (64.1%), smoking (34.4%) and diabetes mellitus (31.2%). Other risk factors were: peripheral vascular disease (17.2%), chronic renal failure (9.4%), previous cerebrovascular accidents (6.2%) and finally previous cardiac suegical interventions (3.1%). The mean scores of both EuroSCORE and Parsonet 95 were 7.1±1.9 and 6.1±2.3, respectively. Moreover, significant main left coronary trunk lesions were found in 51.6% of patients. The mean left ventricular ejection fraction was 57.3±12.3. Unstable angina was the main presenting symptom in 70.3% of patients and 12 patients (18.7%) had a recent acute myocardial infarction. Urgent surgery was performed in 15.6% of patients. The mean number of grafts was 2.6±0.6 vessels with a mean total coronary artery occlusion time of 27.9±9.6 min. The global morbidity rate was 60.9%. The main postoperative complications were: respiratory (25%), atrial fibrillation (17.2%), deterioration of renal function (15.6%) and neurological (14.1%). Sternal wound infection occurred in only 4.7% of patients. The mortality rate was 6.2%. The mean of stay in intensive care unit was 2.4±1.9 days while the mean of total hospital stay was 7.6+/3.7 days. Conclusions: Off-pump CABG using bilateral internal thoracic artery grafts had a high rate of postoperative morbidity while mortality rate was fairly low. Adequate preoperative optimisation and perioperative care of the octogenarian patient who will be submitted to coronary surgery are of paramount importance in order to reduce the perioperative morbidity and mortality rates.
Saint Petersburg State Pavlov Medical University, Russian Federation Objectives: Little is known about efficiency of intracoronary delivery of autologous bone marrow mononuclear cells (ABMMC) in patients with non-acute ischemic heart disease. Methods: Autologous transplantation of ABMMC was performed in 105 patients with non-acute ischemic heart disease. Intramyocardial delivery was used as adjunctive therapy to coronary artery bypass grafting, as well as intracoronary infusion during coronary angioplasty in 10 and 2 patients, respectively. For 88 patients with counterindications to open heart and/or endovascular surgery, the ABMMC suspension was injected intracoronarily during coronary angiography, with 0.4–0.6x10 billion nucleated cells, including 0.1–0.16x10 billion mononuclear and 0.5–1.8x10 million CD34+cells, being introduced for each patient. Results: The patients were followed for 36 months. We observed clinical improvement in 82 patients. Five patients died. A significant reduction in the number of angina episodes and nitroglycerin consumption was noted in 70% patients after one year passed. Single-photon emission computer tomography revealed a significant improvement in the initially non- and/or hypoperfusable myocardium area(s). Positron emission tomography demonstrated an appreciable improvement in both myocardial viability and perfusion. Echocardiography revealed some decrease in end-diastolic and end-systolic volume of left ventricle as well as an increase of global ejection fraction in patients with initially dilated left ventricle. Conclusions: Autologous bone marrow cell therapy can be considered to be a distinct strategy for chronic human ischemic heart disease as an efficient and safe approach to the restoration of the myocardium perfusion and myocardial viability.
1Cardiothoracic Surgery Department, Cairo University, Egypt; 2Anesthesia Department, Ein Shams University, Cairo, Egypt Objectives: The purpose of this study is to evaluate and to compare the intraoperative surgical results of on-pump and off-pump coronary surgery in the domain of graft dysfunction using the transit time flow measurement (TTFM).
Methods: Two hundred patients undergoing isolated CABG via median sternotomy performed by the same surgical team in the same centre were included in the study. One hundred were done on-pump and one hundred were done on beating heart representing group (A) and group (B) respectively. TTFM was routinely performed for assessment of graft patency during each operation. Preoperative, intraoperative, and postoperative variables were collected and expressed as means±S.D. Comparison of the two groups was performed using the independent two-sample t-test, the independent two-ratio test (Z-test), and the independent Fisher's Results: The clinical features of the two groups were comparable. We assessed patency of 462 grafts in 200 patients using TTFM. Revision was required for 18 grafts in 18 patients based on unsatisfactory TTFM finding, four of which were from group (A), and the remaining fourteen from group (B). Incidence of overall mortality (P<0.05), peri and postoperative myocardial infarction (P<0.05), and IABP insertion (P<0.05) were significantly lower in group (A) than group (B). Conclusions: We believe That TTFM seems to be a crucial tool in the assessement of graft function and that it allows to decrease graft failure during the operation. Our results suggest that detection of graft dysfunction using intraoperative TTFM improves the surgical outcome irrespective of the technique used in CABG as it is a matter of indications.
1Department of Cardiovascular Surgery, Villa Maria Cecilia Hospital, Cotignola, Lugo, Italy; 2Department of Cardiac Surgery, Salus Hospital Reggio Emilia, Italy Objectives: Nowadays is worldwide accepted the benefit of arterial revascularization in term of survival and grafts patency in the treatment of ischemic heart disease. A lot of different techniques to achieve a complete revascularization have been reported. We analized the results of arterial revscularization using the bilateral internal mammary arteries in the treatment of multivessel coronary disease. Methods: Between January 2001 to December 2007, 913 consecutive patients underwent to coronary artery by-pass (CABG) with double mammary grafting. Two configuration were used: the Y-graft construction and in the situ technique. The patients were studied retrospectively by collecting data from hospital records and followed for 0–7 years. Results: The mean age was 62±2.2 years, 698 were male. The in-hospital mortality was 0.6%, no difference was reported between the Y-graft or the in situ technique. The incidence of perioperative infarction was 0.3% and reoperation for bleeding was required in the 8% of the population, deep sternal infection rate was 0.5%. Actuarial survival rate at three years was 98.3%, the freedom from reoperation was 98% and the freedom from re-catheterization was 96%. Conclusions: As previously described in literature the use of two arterial conduits provide increasing survival benefit for coronary disease and reduce the risk of reintervention even in older people. In our experience the use of bilateral mammary arteries provide a simple technique that allow us to obtain in the majority of the patients a complete revascularization with very low perioperative risk and good results during the follow-up time.
Cardiac Surgery Division, Casa di Cura Montevergine Mercogliano AV, Italy Objectives: Off-pump coronary artery bypass surgery (OPCAB) is currently used as an alternative to conventional on-pump surgery (CAB), but there are still very little data available on its systematic use. The aim of this study is to evaluate early and mid-term results on 2156 consecutive patients. Methods: From March 2003 to December 2007, 2156 patients (male/female 1745/411; mean age 64.5±9.9) underwent coronary artery surgery. Indication for OPCAB was systematic in all the patients and only 5.4% were converted to CPB without receiving cross-clamp and cardioplegic arrest. Acute coronary sindrome and congestive heart failure were not considered absolute contraindications to OPCAB. All procedures were performed by three staff-surgeons. Disposable devices for coronary stabilisation and intra-coronary shunts were used. The data, prospectively collected, were retrospectively analyzed. Results: The number of graft-per-patient was 2.6±0.8 (min 1, max 6). Left internal thoracic artery (ITA) was used in 98% of patients. Sixty-six percent of patients received more than one arterial graft (bilateral ITA, and left radial artery). Mean postoperative extubation time was 8.4±6.6 h, mean 24-h bleeding was 450 ±230 ml, and mean length of postoperative hospital stay was 5.2±4.5 days. Operative 30-day mortality was 0.8% in elective and 2.1% in emergency surgery. There was no difference on mortality in the group converted to on pump surgery. Follow-up time was 95.4% complete. The actuarial survival and freedom from new revascularisation at 12, 36, 55 months was 96.9, 95.2, 88.7 and 97.6, 96.4, 92.8, respectively. Age, congestive heart failure, peripheral vascular disease, BPCO and obesity were risk factors for mid-term mortality. Survival free of any cardiac events (cardiac death, myocardial infarction, unstable angina, heart failure or reintervention) was 86±2.8%. Conversion to on pump was not predictor of mid-term mortality or the need for repeat revascularisation. Conclusions: Systematic OPCAB is possible and safe, with good early and mid-term results, respecting the criteria of complete revascularisation, the use of arterial conduits and also feasibility and reliability in routine use.
Univeristy Hospital of Wales, Cardiff, UK Objectives: There is a growing difficulty to balance the quality of the services provided with the need for surgical training. Aim of the study was to assess the effect of training on outcome in coronary artery bypass grafting (CABG). Methods: Between January 2000 and December 2003, 1862 consecutive patients underwent isolated CABG. One thousand three hundred and sixty-four (73.3%) were operated by consultant surgeons (group A) and 498 (26.7%) by trainee (group B). Comparison of clinical characteristics, in hospital mortality and morbidity as well as mid-term mortality was made between both groups. All data were prospectively entered into a database. Mean follow-up was 2120.2 days (S.D. 422.9). Results: Patients operated by consultants surgeons had higher Parsonnet score 7.3 (S.D. 6.1) vs. 6.8 (S.D. 5.5) (P=0.044), addictive EuroSCORE 4.0 (S.D. 3.2) vs. 3.7 (S.D. 2.8) (P=0.026) and logistic EuroSCORE 5.2 (S.D. 8.1) vs. 4.1 (6.6) (P=0.005). However, their patients were younger 63.6 (S.D. 9.2) vs. 64.5 (S.D. 8.9) (P=0.029) and more likely to be male 1132 (83%) vs. 396 (79.5%) (P=0.042). Trainee surgeons were less likely to operate on patients with previous cardiac surgery 61 (4.5%) vs. 13 (2.6%) (P=0.034), poor EF 115 (8.4%) vs. 29 (5.4%) (P=0.03) or with preoperative IABP 78 (5.7%) vs. 7 (1.4%) (P<0.001). Patients in group A had more grafts per patient 3.3 (S.D. 0.9) vs. 3.0 (S.D. 0.7) (P<0.001), shorter bypass time 89.1 (S.D. 34.9) vs. 95.6 (S.D. 27.7) (P<0.001) and longer ITU stay 2.3 days (S.D. 3.1) vs. 1.7 (S.D. 0.9) (P=0.002). There were no other differences in postoperative period. In hospital 36 (2.6%) vs. 9 (1.8%) (P=0.15) and mid-term mortality 89 (6.5%) vs. 29 (5.9%) (P=0.29) were also comparable. Conclusions: Training does not adversely affect the early and mid-term outcomes of CABG.
Department of Cardiac Surgery and Transplantation, Silesian Center for Hart Disease, Zabrze, Poland Objectives: The main goal of this study was to assess safety and efficacy of surgical revascularization in patients with left main disease performed on a beating heart (OPCAB). Furthermore, early results of such procedure were analyzed and compared with outcomes of the regular, on-pump CABG. Methods: Between January 1, 2004 and August 31, 2005 among 1726 patients operated on coronary artery disease, 382 patients had left main disease (50%). Patients were non-randomly assigned to receive surgical revascularization performed of a beating heart (OPCAB, n=117) and facilitating extracorporeal circulation (CABG n=265). Results: Beating heart technique was used more extensively in high risk patients (EuroSCORE: OPCAB vs. CABG: 4.73±3.01 vs. 3.8±2.87, respectively; P=0.004) with history of stroke or/and cerebrovascular disease (OPCAB 17.9% vs. 9.1% CABG P<0.05) including stroke (OPCAB 7.7% vs. 3.0% CABG P<0.05). However, patients operated on pump received higher number of grafts per patient (OPCAB 2.35±0.72 vs. 3.06±0.85 CABG P=0.001) due to more extensive nature of coronary disease (3 vessel disease OPCAB 19.7% vs. 33.2% CABG P<0.05). There were no statistical differences in number of perioperative myocardial infarction (CABG 3.0% vs. OPCAB 5.1%; NS), postoperative stroke (CABG 1.5% vs. OPCAB 2.6%; NS) or death (CABG 3.4% vs. OPCAB; 3.4% NS). Conclusions: Comparison of early results of conventional and off-pump coronary artery bypass grafting in patients with left main stenosis showed a selection of high risk patients with prior stroke and/or cerebrovascular disease being grafted without CPB may account for the low incidence of neurological complications, post and perioperative myocardial infarct or death in both groups. Coronary artery bypass grafting using off-pump technique is safe, feasible and effective in patients with critical left main stenosis.
1Second Department of Cardiac Surgery, Medical University of Silesia, Katowice, Poland; 2Department of Cardiology, Medical University of Silesia, Katowice, Poland Objectives: It was recently shown that perivascular tissue (PVT) of human internal thoracic artery (ITA) releases potent, soluable anticontractile factor. The nature of this factor and its influence on other vascular beds used in coronary surgery remains unknown. The aim of the study was to assess anticontractile properties of perivascular tissue of human ITA and its effect on contractility of saphenous vein (SV) and radial artery (RA). Methods: Human ITA, SV and RA rings were studied in-vitro. Concentration response curves to serotonin (10-9–10-4M) were constructed. Maximal response (Emax) and pD2=-logEC50 were calculated from regression analysis. In every experiment two preparations of studied vessel devoid of perivascular tissue were analyzed in two separate tissue baths. Reactivity of ITA was compared first (n=10). In bioassay experiments fragment of ITA from one patient was skeletonized and divided into two preparations. The first one was incubated alone, the other together with PVT remaining from skeletonization that was floating freely in the bath. Both fragments were simultaneously contracted with serotonin. PVT was then transferred from one to the other bath and concentration-response curves were reconstructed. Next, the same protocol was applied for SV (n=12) and RA (n=8) using PVT remaining from ITA skeletonization from the same patient. One averaged concentration-response regression curve was obtained for every type of vessels studied with PVT in the bath and one when PVT was not present. Parameters of regression analysis were compared using Student's t-test. Results: Perivascular tissue significantly attenuated ITA contractile response to serotonin (Emax 41±5 vs. 20±3 mN, PVT(-) vs. PVT(+), respectively; P<0.001). PVT presence in the bath did not change ITA sensitivity (EC50) to serotonin; pD2: 6.2±0.3 vs. 5.8±0.3, respectively, P=0.3. Factor released by ITA's PVT failed to change saphenous vein and radial artery contractility to serotonin. Saphenous vein: Emax 91±6 vs. 100±6 mN; P=0.33. Radial artery: Emax 123±11 vs. 128±13 mN, PVT(+) vs. PVT(-), respectively; P=0.73. Saphenous vein and radial artery sensitivity to serotonin both with and without perivascular tissue were not changed (saphenous vein: pD2: 7.1±0.2 vs. 6.8±0.2, P=0.2; radial artery: 6.8±0.2 vs. 6.5±0.3, P=0.5, tissue vs. no tissue present, respectively). Conclusions: Periarterial tissue of ITA releases soluable factor that significantly attenuates ITA contractility and might therefore prevent ITA spasm. This factor does not affect contractility of saphenous vein and radial artery. This may suggest that factor released by PVT is a vessel-specific agent.
C10-1 REINTUBATION AFTER CARDIAC SURGERY N. Koumallos, A. Paschalis, C. Antoniades, M. Garipi, N. Sfyras, V. Gata, G. Koulaxouzidis, G. Economopoulos Department of Cardiothoracic, Hippokration Hospital, Athens, Greece Objectives: After cardiac surgery procedures, weaning from mechanical ventilation and endotracheal extubation usually proceeds uncomplicatedly. Failure of the patient to tolerate extubation may reflect premature extubation or may be a marker of a sicker patient. In this study we evaluate the determinants, characteristics, and outcomes of the patients who were reintubated in the early postoperative period following cardiac surgery. Methods: The study population consisted of 320 patients (aged 66.1±0.95 year-old), undergoing cardiac surgery with cardiopulmonary bypass. We enrolled the patients who needed reintubation during their stay in the ICU and tried to correlate patient characteristics, operation characteristics, and biochemical markers with the possibility of reintubation. Results: Twenty-nine patients (9%) needed reintubation during their stay in the ICU. The possibility of reintubation was positively correlated with age (rho=0.229, P=0.007), obstructive pulmonary disease (rho=0.409, P=0.001), cardiopulmonary bypass time (rho=0.183, P=0.032), renal failure (rho=0.322, P=0.0001), white blood cell count (rho=0.291, P=0.001), fever (rho=0.381, P=0.0001) and atrial fibrillation (0.323, P=0.0001). Patients who were reintubated had much higher mortality compared with the control group (rho=0.556, P=0.0001). Conclusions: Older patients with pulmonary disease are more vulnerable to reintubation especially after operations that need prolonged by pass time. Postoperative complications especially infections and renal failure also contribute to this situation.
Krasnodar Regional Clinical Hospital, Krasnodar, Russian Federation Objectives: The aim this study was to assess preconditioning properties of Sevoflurane in patients undergoing coronary surgery with normothermic cardiopulmonary bypass and to compare with propofol – fentanyl technique. Methods: Elective coronary surgery patients were randomly assigned to two different anesthetic protocols (n=50 each). In sevorane group anesthesia was induced with Sevorane® 1.7–2.1 MAC, Pipecuronium 0.03 mg kg-1; maintenance of anesthesia was 1.5–2.1 MAC Sevorane®; maintenance of anesthesia during CPB (2.5 l/min/m2 Terumo® Advanced Perfusion System 1) was 1.0–1.3 MAC Sevorane®. Volatile anesthetic was delivered into oxygenator in composition of gas mixture. In control group anesthesia during surgery maintained by a continuous infusion of Fentanyl 5 µg kg–1 h-1 and Propofol 2 mg kg–1 h-1, Pipecuronium 0.03 mg kg-1. We used antegrade cardioplegia Custodiol® 20 ml/kg. Postoperative analgesia was achieved by Fentanyl (PCA). We assessed the time respiratory support, length of stay in the ICU, necessity and duration inotrope therapy, determined the intraoperative BIS, hemodynamic profile, oxygen delivery and consumption, IL1, IL2, IL4, IL6, IL8, TNF, Oxystat, patient S100, NS Enolaze, Troponin I, CKMB, Glucose, Lactate, Cortisol. These samples were obtained before surgery (baseline), after administration heparin (Th), after administration protamin (Tp), at arrival in the intensive care unit (T0), after 2 h (T2), and 24 h (T24). Results: Stroke volume and LVSWI were remained unchanged in the Sevorane group but were decreased transiently after cardiopulmonary bypass in the propofol group. Duration of stay in the intensive care unit was lower in the Sevorane group than in the propofol group 6.3±1.6 h vs. 18.2±1.5 h (P<0.05); time respiratory support 18±6 min vs. 212±44 min (P<0.05). Intraoperative and postoperative troponin I levels and CKMB concentrations in the Sevorane group were lower than in the propofol group (P<0.01). IL1 (P<0.01), IL2 (P<0.05), IL4 (P<0.05), IL6 (P>0.05), IL8 (P<0.05), TNF (P<0.05), and Oxystat (P<0.05) concentrations were lower in the Sevorane group than in control group. Cortisol levels in the Sevorane group were significantly lower than in the propofol group (P<0.01). Conclusions: Our results indicated that use of Sevorane technique in patients undergoing coronary artery surgery with CPB, has more clinically significant cardioprotective effects then propofol technique.
Gulhane Military Academy of Medicine, Istanbul, Turkey Objectives: Postoperative atrial fibrillation (AF) occurs in up to 50% of cardiac surgery patients and represents the most common postoperative arrhythmic complication. Elective cardioversion, a short but painful procedure, remains an option for patients who do not convert to sinus rhythm with medical therapy. Combinations of remifentanil (a potent analgesic with a short elimination time) with propofol (a hypnotic agent) or midazolam (a sedative agent) produce a synergistic interaction. This study was undertaken to compare these combinations in terms of effectiveness and pain relief when given as sedoanalgesia for elective cardioversion. Methods: In this prospective, randomized trial, 60 adult patients with postoperative AF after coronary artery bypass grafting were given a single dose of propofol 1 mg/kg combined with remifentanil 0.1 µg/kg (group 1), or midazolam 0.05 mg/kg combined with remifentanil 0.1 µg/kg (group 2). Cardiorespiratory parameters were monitored and recorded. Results: Demographic data were similar (P>0.05) and sufficient sedoanalgesia and successful cardioversion were achieved in both groups. Hemodynamic parameters revealed no significant differences between groups (P>0.05); however, induction time, time to eye opening, recuperation time, and time to full recovery of psychomotor function were faster in group 1 than in group 2 (P<0.05). Conclusions: The remifentanil/propofol combination provided sufficient analgesia, satisfactory hemodynamic stability, and mild respiratory depression, along with faster recovery and discharge times from the intensive care unit.
Silesian Center for Heart Diseases, Zabrze, Poland Objectives: Acute kidney impairment (AKI) requiring renal replacement therapy (RRT) is an infrequent but dangerous complication of cardiac surgery. Its development is associated with high mortality and morbidity. A recently published simple risk stratification algorithm has been developed and validated in USA and Canada, but its discriminatory power has never been tested in Europe. We wanted to cross-validate the newly developed risk stratification algorithm in a group of patients operated on in a single cardiac centre in Poland. Methods: From the hospital database we selected 1421 patients fulfilling identical inclusion and exclusion criteria as in the Canadian derivation cohort. In each patient eligible for analysis we calculated simplified renal index (SRI) and assessed its predictive power for RRT. Results: After surgery 33 (2.3%) patients developed AKI and subsequently underwent RRT. The SRI precisely predicted risk of postoperative RRT in our group. Patients with low (0–1), medium (2–3) and high values of SRI (4 and more) were found to have increasingly higher risk for RRT (1.1%, 3.2% and 12.5%, respectively). The area under the ROC curve for the SRI as the predictor for RRT was 0.73 (95% CI, 0.62 0.81) and did not differ significantly from the values obtained in the original paper. Conclusions: The new Canadian risk stratification algorithm is very effective in the discrimination of patients at high risk for development of AKI with the need of renal replacement therapy in the East European population.
Hippocratio General Hospital of Athens, Greece Objectives: Preoperative anemia as an important risk factor for morbidity and mortality after cardiac surgery has not been well documented. It is well known that it has a significant role in perioperative transfusions, which are definitely associated with adverse outcomes. Our aim is to assess if preoperative anemia could be significantly associated with adverse effects after cardiac surgery with cardiopulmonary bypass (CPB). Methods: In our study we enrolled 219 patients who underwent cardiac surgery with CPB between January 2006 and December 2006. We collected data about patients’ history, physical examination, demographics, laboratory tests, type of surgery, postoperative complications and length of stay. None of the patients received preoperative transfusion. Nine patients were excluded due to missing data and eight of them were excluded due to their unstable condition. Results: The 202 patients group was consisted of 58% of patients underwent isolated coronary artery bypass graft surgery (CABG), 22% underwent single valve procedure, 10% combined CABG and valve surgery and 10% other types of operations. The prevalence of preoperation anemia, defined as hemoglobin <12 g/dl, was 33.6%. The mean preoperative hemoglobin (Hb) concentration was 12.7 g/dl. A statistic analysis was performed and the results show that low Hb levels are significantly associated with adverse outcome. Anemic patients undergoing cardiac surgery have higher mortality rates (rho=–0.327, P=0.003) and higher levels of amylase (rho=–0.24, P=0.032) and billirubin (rho=–0.304, P=0.006) due to, probably, dysfunction of the liver and pancreas. Conclusions: Preoperative anemia in patients undergoing cardiac surgery with CPB is significantly associated with adverse outcomes. The increased hemodilution in CPB is probably associated with inadequate oxygen delivery causing ischemic and/or inflammatory organ injury. Further studies must investigate whether treading the preoperation Hb would improve the outcome of anemic patients undergoing cardiac surgery.
Mount Sinai Medical Center, New York, USA Objectives: This study was designed to investigate the incidence of, and the survival impact of major complications in patients following cardiac surgery. In addition, we determined independent predictors of hospital mortality in order to create a model that could serve as a tool for the prediction of survival in this patient population. Methods: We retrospectively analyzed prospectively collected data of 6641 patients (mean age 64±14 years, n=2499; 38% female) who underwent cardiac surgery between January 1998 and December 2006. Six major complications were studied: respiratory failure, sepsis, renal failure, mediastinitis, gastrointestinal event, and stroke. Their impact on hospital mortality, hospital length of stay and late survival using multivariate regression models was determined. Results: A total of 1354 complications were observed in 826 (12.4%) patients. The most frequent complication was respiratory failure (n=634; 9.5%) followed by sepsis (n=202; 3%) and stroke (n=163; 2.5%), renal failure (n=145; 2.2%), mediastinitis (n=111; 1.7%), gastrointestinal complications (n=99; 1.5%). Hospital mortality increased with the number of complications (control group-no complication: 1.6% (n=92/5815); single: 12% (n=58/485), double: 25.5% (n=52/204), three or more: 40% (n=55/137)). Ten preoperative and five postoperative predictors of hospital mortality were identified and included into the logistic model which accurately predicted outcome in the study population and the validation cohort (c-statistic: 0.866 and 0.892, P=0.716). Length of stay was 9±10 days, 28±27 days, 46±40 days and 64±48 days in control group and those patients with 1, 2, and 3 or more complications, respectively (P=0.001). Long-term survival was significantly decreased with the increasing number of complications and total length of stay Conclusions: With a worsening in the risk profile of patients undergoing cardiac surgery, an increasing number of patients develop major complication(s) leading to increased hospital stay and mortality, which is proportional to the number and severity of these complications. Our predictive model based on pre- and postoperative variables allowed us to determine with accuracy the hospital mortality in critically ill patients after cardiac surgery.
QEII Health Science Centre, Halifax, Canada Objectives: Patients with renal dysfunction are prone to develop more deterioration in their renal function or acute renal failure after cardiopulmonary bypass. To prevent or reduce the incidence of post cardiac surgery renal failure and therefore, its morbidity and mortality, the protective effect of perioperative Dopamine and Lasix was tested in this study. Methods: One hundred and twenty patients with renal dysfunction (Creatinine level more than one and a half above normal value (High normal value: 110 mmol/l) and not on dialysis were included in the study. Other criteria include: EF >30%, coronary artery disease required two or more coronary artery bypass grafts. The patients were divided in to two well statistically matched groups of 60 patients each. Group (I): given Dopamine I.V. 2.5–5 Ug/kg/min at the beginning of the surgery, followed by Lasix 5–10 mg/min postoperatively on the arrival to the Intensive care unit. Group (II) did not receive Lasix drip, Dopamine drip was needed in 14 patients in this group for hemodynamic reasons. Creatinine and Urea levels as well as the need for dialysis were monitored in both groups. Statistical analysis of the results was conducted and the statistical significant values were determined with a P<0.05. Results: 1) Creatinine and Urea rise occurred in all patients. The degree of the rise was 6–55% in group (I) and 11–157% in group (II), P<0.001. 2) Hemodialysis was needed in two patients in group (I), and in nine patients of group (II) P<0.001. Conclusions: The data of this study indicates that the use of perioperative I.V. Dopamine and Lasix has a significant renal protective effect in this kind of patients.
Tabriz University of Medical Sciences, Iran Objectives: Catheter related infection (CRI) is one of the most serious complications of the use of central venous catheters (CVCs) and arterial catheters (ACs), with an incidence of 2–30/1000 days in different studies. No prospective study has evaluated the rate of CRI in cardiac surgery intensive care unit (SICU) in Iran. Since 2006, we have had a through program for the insertion and care of all catheters used at cardiac SICU. Our purpose was to study the incidence of catheter tip colonization, CRI, their risk factors, and to compare these data with other studies. Methods: We studied prospectively 183 catheters in 150 patients in relation to insertion data and catheter characteristics, catheterization time and microbiological cultures. These catheters were in place for >48 h over a 16 months period. Risk factors were analyzed by multivariate analysis. Results: The analysis included 115 CVCs, 65 ACs and 3 PACs inserted in 150 patients. The median time of catheter placement was four days. The incidence of positive tip culture was 9.8% and ten microorganism isolated from 18 colonized catheters. Thirteen Gram-negative bacilli, four Gram-positive cocci and one yeast were isolated. Escherchia coli was the dominant isolated (27.7%). From multivariant analysis, >6 days of catheterization and insertion site were the variables associated with significantly increased risk of catheter colonization. Conclusions: Gram-negative bacilli and Gram-positive cocci are the commenest microorganisms colonizing CVC and AC from cardiac SICU patients. Duration of catheterization and catheter insertion site were independent risk factors of catheter related infection.
V5-1 WILL FEMORO-POPLITEAL BYPASS BECOME OBSOLETE? A STUDY OF INFRA-INGUINAL STENTING IN PERIPHERAL ARTERIAL OCCLUSIVE DISEASE P.W.H. Collins1, R. O'Neill2, T. Richards1, S. Habib2, S. Whitaker2, B.D. Braithwaite1 1Department of Vascular and Endovascular Surgery, Queens Medical Centre, Nottingham, UK; 2Department Interventional Radiology, Queens Medical Centre, Nottingham, UK Objectives: Traditionally, long intra-inguinal arterial occlusions have been treated by surgical by-pass. Recent advances in self-expanding Nitinol stent technology have made stenting of such lesions technically possible, with encouraging long-term patency rates. The aims of this study were to examine the feasibility and long-term outcome following infra-inguinal, intra-arterial stenting in peripheral arterial occlusive disease. Methods: Patients undergoing infra-inguinal, intra-luminal arterial stenting in a single specialist endovascular centre were followed-up for one year (mean 6 months [SD5]) or until primary end-point of stent occlusion or death. Demographic, technical and out-come data was entered prospectively on a database. Patency was confirmed by Duplex ultrasound examination, resolution of symptoms and/or ulcer healing. Results: One hundred legs were stented (M:F 59: 41, median age 75 [41–97], Fontaine stage IIb [41%], III [16%], IV [43%], diabetic [26%]) between November 2004 and Jan 2007. Median lesion length (range) was 21 cm (4–66). TASC II classification (n): A (5), B (16), C (32), D (47). Stenting was performed for rescue of failed angioplasty in 88%. Recanalisation rates of 97% were achieved (sub-intimal in 80%). Patency at six months and one year was 75% and 65%, respectively. Mortality rate at one year was 27%. Fourteen percent required major amputation. Conclusions: Intra-luminal stenting of long infra-inguinal occlusive lesions is feasible with good primary success rates. Patency appears durable. Stenting of the SFA and popliteal arteries should be considered as a viable alternative to femoro-popliteal bypass for limb salvage, particularly in patients with high anaesthetic risk.
Vakif Gureba Hospital, Cardiovascular Surgery Clinic, Istanbul, Turkey Objectives: Aorta-femoral artery bypass operation is the first choice for the treatment of aortoiliac occlusive disease. This operation can be done succesfully with increasing experience. Prosthetic aortic graft infection is a devastated complication of this procedure with increasing mortality and morbidity. Methods: Between October 2001–March 2007, 452 patients were treated for aortoiliac occlusive disease using bifurcated vascular graft. Twenty-one patients, nine from our clinic and 12 patients from other centers were treated for aortic graft infection. Ten of these patient had aortbifemoral bypass operation and 11 had aortbifemoral bypass and femoropopliteal bypass operation before. Treatment was performed complete prosthetic excision and revascularisation with either autolog or bioprotesis if needed. The surgical approach was transperitoneal for 15 patients and retroperitoneal for six patients. The objective criteria for revascularisation was the femoral artery backflow. Nine patients with inadequate back flow were treated with aorto femoral by pass using saphenous vein, and obturatuar by pass was performed in two patients. Four patient had adequate femoral backflow and only saphenous patchplasty were performed. Five patients with critical limb ischemia had an additional saphenous vein bypass. Two of these patients had aortofemoral bypass using bioprotesis after the saphenous vein graft failure. Results: One patient with high creatinine level died in the early postoperative period. Two patients had amputations due to inadequate arterial flow. Five patients had reoperation with syntetic vascular protesis after infection healed. Conclusions: Aortofemoral prosthetic graft infection is a distressing complication for surgeons and patients. Autogenous saphenous vein graft for reconstruction of the aorta and femoral artery is a good option for these patients. Bioprotesis also relies as an alternative method in whom autolog graft is not an option. We believe that vascular graft infections can be treated with successful results in experienced centers.
Scientific Institute IRCCS San Raffaele, Milan, Italy Objectives: The aim of this prospective study was to evaluate the performance of bifurcated, longitudinally extensible (stretch), expanded polytetrafluoroethylene (ePTFE) grafts implanted in patients with aortoiliac or aortofemoral occlusive atherosclerotic disease. Methods: Between October 1991 and December 2005, 822 patients (708 men, 114 women; mean age, 63.8 years) underwent aortoiliac or aortofemoral reconstruction using a bifurcated ePTFE stretch graft. Preoperatively, all patients had ultrasonographic and arteriographic evaluations and were divided into groups according to the TASC II morphological stratification of iliac lesions. Seventy-seven patients (9.4%) had type B lesions, 314 (38.2%) patients had type C lesions and 431 (52.4%) were classified as type D lesions. Endarterectomy of the aorta was required in 172 patients (21%); femoral arteries were endarterectomized in 222 (27%). Femoropopliteal bypass grafting was performed in 18 patients, aortorenal bypass in 12, and mesenteric artery grafting in 1. Results: One patient died perioperatively of a myocardial infarction. Perioperative morbidity included cardiac (2.2% of patients), respiratory (0.9%), and gastrointestinal complications (1.2%), as well as acute renal insufficiency (1.3%). Seven patients had bleeding requiring surgical revision within the first 24 h after surgery. There were four cases (0.5%) of immediate graft thrombosis and five (0.6%) of single-limb graft thrombosis. During a mean follow-up time of 37 months (range, 1–162 months), 58 patients (7.1%) were lost to follow-up and 205 patients (24.9%) died. The primary and secondary graft-patency rates during the observation period were 90.6% and 97.9%, respectively. Twelve late graft occlusions resolved after thrombectomy alone. Eleven cases of single-limb late thrombosis resolved after thrombectomy and profundoplasty. Limb-salvage rate during the observation period in patients who underwent operation for critical limb ischemia was 84.5%. There were nine postoperative graft infections (1.1% infection rate) in the series. Conclusions: Our long-term experience with ePTFE stretch grafts in aortoiliac and aortofemoral reconstruction shows that these prostheses have an high rate of patency and a low rate of graft-related complications. The physical characteristics of the grafts may help to reduce postoperative graft infection.
Seconda Universita Degli Studi Di Napoli Scuola Di Specializzazione In Chirurgia Vascolare Dir A Matarazzo, Italy Objectives: Patient with critical ischemia who are not candidate for invasive revascularization have impending limb loss. About 30% of patients with critical limb ischemia cannot be treated by any methods and the only option is amputation. we showed that metabolic intervention with antioxidant and L-arginine can enhance beneficial effects with implantation of bone marrow cells (BMCs). We performed a long-term controlled trial to assess the safety and efficacy of intrarterial autologous implantation of bone marrow cells (BMC) infusion with oral vitamin E and C and L-arginine in patients with Chronic peripheral arterial disease. Methods: We enrolled 18 patient with critical limb ischemia. All patient had intermittent claudication, rest pain, ischemic ulcers and were not candidates for surgical revascularization. Exclusion criteria were malignant disease, myocardial infarction or brain infarction, sever heart failure. Total mononucleated cells obtained from the patient ranged from 13.3 to 60.3 x1000000000 µm. The infusomat fmS braun infusion pump was used. Two doses of implantation of bone marrow cells (BMCs) (time 0 and 45 days) were injected in the common femoral artery of the affected leg. After 30 days the patients received 400 UI vitamin E, 1 g of vitamin C and 2 g of L-arginine. The end point were the leg savage, improvement of ulcers, improvement of pain. After admission (T0) all patient were seen at 3-6-12-18 (T1-2-3-4) months. Results: Patients treated safely and no serious reaction, were observed during this study: at T1, T2 time point follow-up the ABI value increased in 10 patients and 13 patients at T4. Twelve showed a decreased of the pain score at T3 and T4. The improvement of the pain free walking distance was consistent at T2, T3, T4. Laser Doppler index, which reflect microcirculation, were also significantly improved between T3, T4 after treatment. Similarly, an improvement of the venousarteriolar reflex activation was observed with Laser Doppler evaluation which resulted normalized completely in eight cases. More important after one year the number of neocapillaries increased significantly in tibia toe and foot. Finally, angiographic evaluation illustrated collateral vessel formation at six months. Conclusions: Results showed significant improvements in the ABI, ulcers healing, maximum walking distance, microcirculation blood flow. Methabolic intervention with antioxidants and L-arginine could help the differentiation of BMCs. In the study we show that BMC arterial infusion together with metabolic intervention is a long-term safe and effective therapeutic procedures in improving major clinical indexes and enhancing neovascularization capacity represent a promising therapeutic approach.
Saint Petersburg Pavlov State Medical University, Russian Federation Objectives: The effects of clopidogrel, an antiplateled agent, on painfree and maximal walking distances (PWD, MWD) and ankle brachial index (ABI) in patients (patients) with PAOD were assessed in a long-term controlled trial. Methods: The patients with typical intermittent claudication for six months or more were selected in this trial, standardized PWD 200 m or less, ABI at worst leg 0.7 or less with further decrease after exercise. Six hundred and fifty-nine patients received clopidogrel (75 mg b. i. d.) (first group) and 572 patients received Aspirin (250 mg i.d.) (second group) from 28 to 122 months (medium 77 months). Results: Analysis of the results in an intention to treat approach showed progressive enhancement of both PWD and MWD in the first group, consistently greater than in the second group (P<005 to 0.001). ABI values at rest and after exercise moderately but consistently increased in the first group and decreased in the second, with significant intergroup differences (P<0.01 to 0.001). Gastrointestinal bleeding was observed in 12 (1.8%) patients of the first group and in 61 (10.7%) patients of the second group (P<0.05). Amputations took place in long-term period in 21 (3.2%) patients of first group and in 43 (7.5%) patients of the second group (P<0.05). Myocardial infarction was observed in 48 (7.2%) patients of the first group and in 61 (10.7%) patients of the second group (P<0.001). Stroke occurred in 61 (9.2%) patients of the first group and in 84 (14.7%) patients of the second group (P<0.01). Conclusions: The results demonstrate that Clopidogrel is effective in modifying the natural course of intermittent claudication and improving the flow conditions in the legs of these patients.
Siyami Ersek Thoracic and Cardiovascular Surgery Center, Istanbul, Turkey Objectives: This report summarizes our institutional experience with axillofemoral bypass and evaluates the patency rates and risk of graft occlusion after axillofemoral bypass. Methods: During 2001 and 2007, 27 patients received axillo femoral extra anatomic bypass for chronic severe aortailiac occlusive disease in our institution. Patient demographics, risk factors, indication for surgery and outcomes were recorded. The follow-up was performed with a median of 38 months. Results: All of the patients were men who were between the ages of 50 to 77 years with a mean of 65 years. Ten of the 27 patients returned with claudication readmitted in the first 16 months. Five of these patients had gangrene in the distal lower extremity. Of the 10 patients seven received embolectomy but in only four a succesful outcome was gained. Seven patients had graft occlusions with rest pain and in three of these further distal bypass was performed. Of the 17 patients, three had graft infection. For the rest, medical treatment was the choice. Three of the patients died because of cardiac or non-cardiac problems. Only seven of the patients were found with a patent axillo femoral graft. The risk factors were determined as elder age, diabetes and renal failure. Conclusions: The patency of axillo femoral extra anatomic bypass graft operation is cruical in some patients and may be the only way for lomb salvage. Nevertheless, long-term results in means of patency and relief of symptoms, are not satisfactory.
Emergency Medicine Research Institute, Saint-Petersburg, Russian Federation Objectives: Critical limb ischemia is still one of the most dramatic artery diseases, which still have very high level of disability. Subintimal balloon angioplasty has proved to be validate and efficient kind of treatment. Present research is made to define opportunities of subintimal balloon angioplasty in treatment of patients with critical limb ischemia. Methods: At cardiovascular surgical clinic 650 patients with critical limb ischemia were on treatment and research. Subintimal angioplasty (SA) of peripheral arteries was applied as surgical procedure for 43 (6.6%) patients. Average age of these patients was 72 years. Duration of period of critical limb ischemia was more than three months. Degree of ischemia was 4–5 categories on Rutherford and 3–4 categories on Fontein–Pokrovsky. In total 57 procedures of subintimal balloon angioplasty of the following arteries were done: 12 – iliac, superficial femoral and tibial arteries, 35 - superficial femoral and distal arteries of the leg and 10 – tibioperonel trunk and tibial arteries. Results: During the first month after the procedure the reconstructed arteries were possible in 76.2% (n=28) of patients. Thrombosis in the zone of subintimal angioplasty in the early postoperative period was observed in 23.8% (n=9) of the patients. Succesfull thrombectomies from iliac and femoral segments and thrombectomies from femoral and popliteal segments were performed in five of these patients, in the rest of these patients- iliac and femoral prosthetics with femoroprofundoplasty (2 cases) or endarterectomy from iliac and femoral segment in combination with femoroprofundoplasty (2 cases). Amputation at the level of the middle of the thigh was necessary in 4 patients (10.5%), below knee amputation in 1 case (2.3%), amputation of the foot in 1 case (2.3%). Due to ischemic stroke died one of our patients. Conclusions: The applied new technological method of treatment of occlusion and stenotic defects of peripheral arteries of the leg demands further investigation of its effectiveness in patients with critical limb ischemia. This method obviously reduces risk of lethal outcome during and after surgical procedure and gives a chance to reduce rate of disability in patients with critical limb ischemia. Our first positive results testify perspectivity of this method.
Thoracic and Cardiovascular Surgery Department and the University of Limoges, France Objectives: Peripheral arterial disease (PAD) is associated with poor cardiovascular (CV) prognosis. It is unknown whether this prognosis could differ according to PAD lesions topography. Methods: We reviewed the data of all patients who underwent a first lower limbs angiography between January 2000 and December 2005 in our hospital. Arterial stenoses >50% were located by two experienced vascular physicians. Following events were collected until 04/2007: death, non-fatal myocardial infarction or stroke, coronary or carotid revascularisation. The primary outcome combined all adverse events. Results: We studied 400 PAD cases (age 68.3±12.3 year, 77.5% males). Aorto-iliac disease (AI-PAD) and infra-iliac disease were noted in 211 (52.8%) and 251 (62.8%) cases, respectively. Male sex and smoking were more prevalent in AI-PAD while older age, diabetes, hypertension, renal failure and critical ischemia were significantly more prevalent in infra-iliac disease (P<0.05). During the follow-up period, the event-free survival curves differed according to PAD topography. Adjusted to age, sex, CV disease history and risk factors, critical ischemia and treatments, AI-PAD was significantly associated to worse prognosis (primary outcome: OR=3.28, death: OR=3.18, P<0.002). Conclusions: The association between CV risk factors and PAD differs according to the lesions localization. This is the first study reporting the worse general prognosis of aorto-iliac disease vs. distal PAD, independent of risk factors and comorbidities.
1Vascular Surgery Department, A Perrino Hospital, Brindisi, Italy; 2Cardiovascular Department, Anthea Hospital, Bari, Italy Objectives: Patients with lower limb arterial disease in advanced Leriche–Fontan class may have disappointing results after surgical revascularization. Despite maximal medical therapy and best standard-of-care surgical treatment, coexistence of diabetes mellitus or necrotic lesions represent a marker of suboptimal results in terms of relief of symptoms and risk of amputation. Herein we present a combined treatment strategy comprising surgical revascularization and locoregional intraarterial infusion of prostanoid iloprost trometamol. Methods: Ten patients in either Fontane class III (6 individuals) or class IV (4 individuals), aged 65 to 80 years and having surgical indication were prospectively enrolled. All patients received preoperative iloprost infusion (1.5 ng/kg/min for 6 h during 12 consecutive days). Supraarticular femoro-popliteal bypass surgery was performed in six cases (Goretex stented prosthesis in five and autologous great saphenous vein in 1) and infraarticular operation was done in the remaining four cases (Goretex stented prosthesis in two and autologous great saphenous vein in 2). Intraoperatively, iloprost trometamol 3.000 ng were infused through the graft. One month after the operation, an additional iloprost infusion (1 ng/kg/min during 6 consecutive days) was performed. Echo-Doppler evaluation of the blood flow, flow velocity and resistance index in the posterior tibial artery and in the pedidial artery was accomplished at the following timepoints: before treatment with iloprost, 30 min after release of the arterial clamps, six days and one month postoperatively. Results: Follow-up was 100% complete. An average 20% decrease in resistance index was observed between timepoint one and timepoint 4 (from 0.55 to 0.45, average measurements). Distal flow was increased by an average of 50%. Patients reported relief of symptoms (ischemic pain), increased walking distance and complete resolution of necrotic areas. Improvement in lower limb motility and sensitivity was also reported by all study subjects. Conclusions: The combined treatment of surgical revascularization and the presented infusional protocol of iloprost trometamol achieves optimal results in patients with advanced lower limb arterial disease (Leriche–Fontane class III or IV). Clinically significant improvements of blood flow, ischemic symptoms and limb function are associated with this combined treatment strategy. Evaluation in larger patients subsets is prompted.
1Department of Vascular Surgery, Benfratelli Civic Hospital, Palermo, Italy; 2Department of Vascular Radiology, Benfratelli Civic Hospital, Palermo, Italy Objectives: Isolated Iliac Artery Aneurysms (IIAA) are rare with an incidence <2%. Up to date there is no consensus about some aspects of their management. We retrospectively reviewed our experience. Methods: From January 1995 to December 2006 we treated 23 IIAA in 18 patients. Parametrical variables were analyzed by two test and continuous variables by t-student test. Results: All 18 patients were men with a mean age of 69 years (S.D.±9.2). The mean diameter was 5.1 cm (range 3–8 cm). Eight patients (44.5%) had elective and 10 patients (55.5%) had urgent treatment to repair IIAA with mean diameter, respectively, of 5.4 cm and 4.9 cm, respectively (P>0.05). They were involved 18 (78%) Common ilac arteries, 1 (4.5%) external iliac artery and 4 (17.5%) internal iliac arteries. Ten patients (55.5%) complained of abdominal symptoms because the rupture or fissuration of the IIAA. Three patients (13%) presented a bilateral aneurysm. At the admittance, 1 patients (4.5%) was shocked. An aorto-bifemoral graft and aorto-biliac graft were performed in 2 patients (11%) and in 2 patients (11%), respectively. A common iliac graft, a common iliac to external-internal graft, a common iilac-external graft with ipogastric artery exclusion and IIAA ligation. There were three postoperative deaths due to cardiac failure in patients with coronaropathy, with 16.5% cumulative postoperative mortality rate. All the postoperative deaths were in symptomatic patients with 30% ruptured IIAA postoperative mortality rate. In the postoperative period they survived: 8 out 8 (100%) asymptomatic patients vs. 7 patients out 10 (70%) symptomatics, (P<0.05); 2 out 4 patients (50%) with bilateral IIAA vs. 13 out 14 patients (93%) with monolateral aneurysm (P<0.05); 6 out 9 patients (66.5%) with ruptured IIAA vs. 9 out 9 patients (100%) with intact IIAA (P<0.05); 2 out 4 patients (50%) treated by bifurcated aortic reconstruction vs. 11 out 12 (92%) patients treated by iliac reconstruction; 13 out 16 patients (81%) treated surgically vs. 2 out 2 patients (100%) treated by endovascular approach (P<0.05). Conclusions: IIAA are not frequent but are burdened with high mortality rate in case of rupture (30% in our experience). Postoperative follow-up is basic not only for the reconstruction patency surveillance but also for the potential enlargement of the aorta and the controlateral iliac artery.
V5bis-1 SHORT LEUKOCYTE TELOMERE LENGTH IS ASSOCIATED WITH ABDOMINAL AORTIC ANEURYSM G. Atturu, S. Brouilette, N.J. Samani, N.J.M. London, M.J. Bown, R. Sayers University of Leicester, Leicester, UK Objectives: Telomeres are specialised DNA structures present at the ends of chromosomes. The telomere length shortens with each cell division and represents cellular biological age. A variety of environmental, haemodynamic and genetic factors has been implicated in the pathogenesis of abdominal aortic aneurysm (AAA). The aim of this study was to determine the relationship between abdominal aortic aneurysm and white cell telomere length. Methods: Peripheral blood samples were collected from 112 male patients with AAA and 112 age matched screened male controls. Genomic DNA was extracted from the buffy coat and digested with restriction enzymes (Rsa 1 and Hinf 1). The DNA fragments were separated on 0.5% agarose gel electrophoresis at 150 vs. for one hour and 50 vs. for 18 h and then transferred to a nylon membrane using southern blotting. The DNA fragments were hybridised with a telomere repeat specific Digoxigenin (DIG) labelled probe and incubated with DIG specific antibody coupled with alkaline phosphatase. The telomere length was then measured using a chemilumiscence technique with telo TAGGG telomere length assay kit (Roche applied science). Data was analysed using student's t-test and Pearson correlation using SPSS v14.0. Results: Median age of cases and controls was 66 years (range 60 to 87 years). The mean white cell telomere length was significantly lower in patients with AAA (5486 base pairs (bp)) compared to controls (5827 bp). The difference in telomere length between the cases and controls was 340 base pairs (95% confidence interval 463 bp to 217 bp) (P=0.000). There was a significant negative correlation between the size of AAA and telomere length (larger AAA had shorter telomere length) 9R=–0.274, n=112, P=0.009). Conclusions: Patients with abdominal aortic aneurysms have significantly shorter telomere lengths compared to healthy controls. In patients with AAA, aortic size is negatively associated with telomere length. This suggests that cellular biological aging may have a role in the pathogenesis and progression of AAA.
Ege University Medical Faculty, Department of Cardiovascular Surgery, Izmir, Turkey Objectives: Infrarenal clamping of the aorta which seems possible in the preoperative evaluation can not be performed everytime in the repair of ruptured abdominal aortic aneurysm, because of CT technique, differences in interpretation and inadequate cooperation of the patient. Aim of our study was to evaluate comparatively the results and safety of routine hiatal clamping as a first choice with those of infrarenal clamping. Methods: The records of 122 patients with mean age of 69.4±9.2 years who had undergone ruptured abdominal aortic aneurysm repair between 1994–2007 were evaluated retrospectively. Hiatal clamping and infrarenal clamping were performed in 96 patients and 26 patients, respectively. By univariate and multivariate statistical analyses of respiratory, renal, gastrointestinal, cardiac complications, relaparotomy, infection, mortality, cell saver usage, blood and blood product requirements, and hospitalization time were evaluated comparatively between two groups. Results: Overall mortality was 40 (32.8%) and there was not any difference between two groups. Univariate analyses revealed that hospitalization time (P=0.008), postoperative respiratory complications (P=0.006), blood requirement (P=0.009), and cell-saver usage (P<0.001) were significantly higher in the hiatal clamping group. Multivariate analysis was also performed, since cell saver usage which had been found higher in the hiatal group, was also found related to postoperative respiratory complications (P=0.042), and prolonged hospitalization time (P=0.04). Prolonged renal ischemia time (>30 min) of hiatal group was an independent risk factor for renal complications (P=0.04), blood usage (P=0.005), and mortality (P<0.001) in this group. If hospital mortalities were excluded, 5-year and 10-year cumulative survivals were 59.94%, 5.66% and 39.18%, 6.13%, respectively. Cross-clamp level had not a significant effect on long-term survival. Cardiac event in follow-up was only independent predictor of late deaths and long-term survival. Conclusions: Hiatal clamping which is performed without any delay for infrarenal aortic exploration is not a significant risk factor in the repair of ruptured abdominal aortic aneurysm, provided clamping time is under 30 min. It can be performed safely and provides more comfortable operative conditions.
Department of General Vascular and Transplant Surgery, Medical University of Warsaw, Poland; Second Department of Radiology, Medical University of Warsaw, Poland Objectives: Atherosclerosis or severe calcification of recipient iliac arteries is considered contraindication for kidney transplantation. On the other hand, it is common in end stage kidney disease patients on dialysis. Nowadays, since renal transplantation is increasingly successful, extended indications are accepted on the waiting list including patients with severe atherosclerosis. This requires vascular procedure prior to kidney transplantation or during the same operation. The aim of the study was to present our experience with aorto-iliac reconstruction prior to kidney transplantation. Methods: There were eight atherosclerotic, uremic patients refereed to our Department as a candidates for kidney transplantation. All were refused waiting list inclusion due to occlusive lesions of iliac arteries or distal part of the aorta. There were seven male and one female, age 45–62 years, all current or past smokers. Preoperative assessment consisted of Doppler ultrasound and angio-CT scan. Reconstruction of blood supply was performed with aorto-bi-iliac in five, aorto-bi-femoral in two and ilio-femoral graft in one patient under general anesthesia. Results: There was no major postoperative complications. Patients were discharged and placed on a special waiting list. Six of them received kidney allograft including one living-related transplantation. All procedures were made with transplanted kidney artery anastomosis to the side of the prosthesis. No patient developed signs of arterial graft infection. In postoperative period there was no arterial or renal allograft related complications except delayed kidney function in two cases. Remaining two patients are still on waiting list four and six months after vascular procedure. Conclusions: Adequate vascular reconstruction in uremic patients with severe atherosclerotic lesions of iliac vessels allows safe and durable kidney transplantation.
Scientific Institute IRCCS San Raffaele, Milan, Italy Objectives: Abdominal surgery in patients with advanced liver disease has been reported to be associated with high morbidity and mortality rates. However, the surgical risk of infrarenal aortic aneurysm (AAA) repair in cirrhotics remains ill defined. We reviewed our experience to investigate the predictors of the outcome in cirrhotic patients after elective AAA open repair. Methods: Between January 2001 and March 2006, 1189 patients underwent elective open repair of infrarenal AAA and 24 (2%) had a biopsy-proven cirrhosis (23 M; 1 F; mean age 68±7 years). The latter were retrospectively stratified according to the Child-Turcotte-Pugh (CTP) score and the Model for End-Stage Liver Disease (MELD) score. Operative variables and perioperative complications were recorded and compared to those of concurrent non-cirrhotic controls matched by gender, age, aneurysm size and type of reconstruction. Prognostic value of CTP and MELD scores was evaluated. Results: No intraoperative or 30-day deaths were recorded. No significant differences in terms of major perioperative complications (P=0.74) were observed between cirrhotic patients and controls. Operative time (162±49 min vs. 126±33 min, P=0.006) was significantly longer in cirrhotics. Intraoperative blood transfusion requirements were higher in the study group (273±352 ml vs. 89±214 ml, P=0.045). Hospital length of stay was nearly doubled in cirrhotic patients (11.0±2.8 days vs. 5.7±1.5 days; P<0.0001). Twenty-two cirrhotic patients were classified as Child A and two as Child B. Median MELD score was 8 (range 6–14). Child B class was a predictor of higher intraoperative blood transfusion requirement (340±297 ml vs. 35±98 ml, P=0.0041). At a mean follow-up of 27±24 months, five deaths were recorded (20.8%). Both Child B patients died within six months. Child's class B and a MELD score >10 were associated with reduced mid-term survival rates (P<0.0001 and P=0.02, respectively). Conclusions: In our experience, open AAA repair in cirrhotics was safely performed with an acceptable increase of the magnitude of the operation. However, the reduced life expectancy of subgroups of patients identified by means of prognostic models raises a word of caution in patient selection.
Department of Cardiovascular Sciences, Vascular Surgery Group, University of Leicester, Leicester, UK Objectives: Abdominal aortic aneurysm (AAA) expansion has both prognostic and surgical decision implications. Aneurysm diameter is an independent predictor of all cause mortality in people with AAA. People with higher AAA diameters are at significant risk from rupture. Hence the current practice of surgical intervention at a diameter of 5.5 cm. Previous attempts at modelling AAA expansion have assumed a linear process and ignored the highly correlated nature of repeated measurements. Our objective is therefore, to model AAA expansion process using a hierarchical non-linear mixed effects regression methodology. Methods: We recruited 354 white male caucasians with confirmed abdominal aortic aneurysms (AAA) into our study. We followed them up over a period of time and repeatedly measured their AAA maximum diameters with ultrasound and CT-scans. The maximum infra-renal aneurysm diameter was recorded at the time of measurement. People whose aneurysms exceeded 5.5 cm or became symptomatic were offered surgery. The minimum and maximum periods of follow-up were nine months and seven years, respectively. The minimum and maximum time-points of observations per person were 3 and 10. The data was organized in a longitudinal data format and missing data were assumed to be missing completely at random and therefore, were ignored. We used maximum likelihood methods accounting for the correlation between repeated measurements in individual patients. The choice of a non-linear multivariate regression technique was informed by the fact that a quadratic linear regression model out-performed a simple linear regression model in terms of information criteria. We adjusted for covariates such as sex, hypertension, smoking, ischaemic heart disease and chronic obstructive pulmonary disease (COPD). Results: The AAA diameter at baseline was 3.036 cm (0.05) and the rate of expansion was 0.14 cm/year (0.008) P<0.0001. At baseline, people with hypertension have AAA that are 9% higher in diameter as compared with normotensives. However, smoking accounts for a 5% increase in baseline AAA diameter and copd, 3% (P<0.001). Using empirical bayes estimates we were also able to predict individual AAA diameters from their data. The individual specific variance was 11%. Conclusions: Abdominal aortic aneurysm expansion shows inherent between-individual and within-individual variability and it is inappropriate to model this ‘stochastic’ behaviour with linear approaches. Using non-linear mixed effects regression methods we have been able to model AAA expansion and extract individual specific diameters. Our findings are consistent with the commonly quoted ‘small’ AAA expansion rates.
Vascular Surgery Department, Bassano del Grappa, Italy Objectives: Elective surgical standard treatment of abdominal aortic aneurysm presents more difficulties when expert surgeons undergo at the same time into correction of visceral arteries lesions or into internal iliac arteries (especially in their distal tract when aneurismatic) or inferior mesenteric artery revascularization (as to prevent intestinal ischemia). Also visceral or vascular system congenital abnormalities (e.g. posterior left renal vein, abnormal or double vena cava, extra renal arteries etc.) and retroperitoneal inflammatory diseases make surgical repair harder. This study evaluated morbidity and mortality on perioperative outcome (30-day) in elective open abdominal aortic aneurysm repair on patients affected by abdominal aortic aneurism associated with visceral or vascular abnormalities/lesions or undergoing to inferior mesenteric artery or internal iliac artery rivascolarization if compared with patients undergoing only open aneurysm repair. Methods: Between January 2002 and December 2007, 190 patients with abdominal aortic aneurysm underwent open abdominal aortic aneurysm repair. Preoperative check-up screening consisted of thoraco-abdominal CT with intravenous contrast material, followed by angiography if aorto-iliac disease or abdominis angina existed. Patients were separated into two groups: group 1 (n=45, 23%), defined as complicated and group 2 (n=145, 77%) defined as standard. All patients had retroperitoneal approach and Dacron woven grafts were used for aorta and internal iliac arteries; Great Saphenous vein or polytetrafluoroethylene were used to repair visceral arteries. In Group 1, 10 patients (5.2%) underwent at the same time open aneurysm repair and inferior mesenteric artery revascularization by directly re-grafting this on aortic graft; 20 patients (10.5%) underwent open aortic surgery and Internal Iliac artery Dacron bypass grafting; 4 patients (2%) underwent open aortic surgery and renal artery revascularization; 4 patients (2%) underwent open aortic surgery and Superior Mesenteric artery revascularization; 5 patients (2.6%) underwent open aortic surgery and Inferior Mesenteric artery and Internal Iliac artery revascularization; 2 patients (1.05%) underwent open aneurysm repair and Celiac artery revascularization. In Group 2, 65 patients (34.2%) underwent open aortic surgery with prosthetic-graft replacement, 80 patients (42.1%) underwent open aortic surgery with aorto-bisiliac graft replacement. Results: No differences there have been between group 1 and group 2 about morbidity and mortality (Log rank-test P>0.05). Conclusions: Perioperative mortality and morbidity of open aortic surgery done by expert surgeons in patients with complicated abdominal aortic aneurysm are the same if compared with patients affected only by abdominal aortic aneurism without other complications. The only difference stays in operation time which is longer in first case.
Tabriz University of Medical Sciences, Iran Objectives: Abdominal aortic aneurysm occurs as a result of degenerative change in arterial wall. We evaluated prospectively multifarious signs and feature in prognosis of 31 patients with Abdominal aortic aneurysm in Imam Hospital from 2000 to 2005. Methods: In this analytic descriptive study, patients categorized into three groups; unruptured (10), unstable ruptured (9) and stable ruptured (12). All patients operated transperitoneally. Early postoperative mortality, morbidity and other prognostic factors were documented. Results: Mean age was 67.1±8.9 years. Early mortality was 77% of unstable ruptured, 25% of stable ruptured and 10% of unruptured group. Significant relation found between mortality and systolic blood pressure in admission and presence of dysfunction. Mean hospital and ICU stay were 9.1±5.6 and 4.1±2, respectively. Distal embolization and renal failure were the main postoperative complications. Conclusions: Incidence of abdominal aortic aneurysm has been increases. Mortality increases with ruptured aneurysms. It seems evaluation for early detection and operation to be an extremity.
V6-1 THORACIC AORTA ENDOGRAFT AS AN ADJUNCT TO RESECTION OF A LOCALLY INVASIVE TUMOR: A NEW INDICATION TO ENDOGRAFT S. Lepidi1, P. Frigatti1, M. Antonello1, G. Marulli2, F. Rea2, F. Grego1, G.P. Deriu1 1Division of Vascular Surgery, Department of Cardiac Thoracic and Vascular Sciences, University of Padova, Italy; 2Division of Thoracic Surgery, Department of Cardiac Thoracic and Vascular Sciences, University of Padova, Italy Objectives: A 61-year-old male had a recurrent metastasis from porocarcinoma localized in the left lung and infiltrating the aortic wall. In 1995, the patient underwent a surgical resection of an eccrine porocarcinoma (EP), a malignant tumor arising from the sweat gland, localized in the neck region. In 1999, he underwent a left lower lobectomy for a single lung metastasis from EP. In December 2005, the patient presented with dyspnoea and persistent cough. CT-scan showed the presence of a mass occluding the left main bronchus and infiltrating the wall of descending aorta. Surgical excision of cancer was not feasible without concomitant resection of the infiltrated aortic wall and thoracic aorta repair. Traditional repair consisting in resection and graft interposition, also utilizing a cardiopulmonary bypass, presented a significant morbidity and mortality risk in a patient undergoing a redo thoracotomy and completion left pneumonectomy. Methods: A thoracic endovascular graft (Zenith TX2 Thoracic TAA, Cook, Brisbane, Australia) 28 mm diameter and 120 mm length was placed distal to the left subclavian artery, covering the area involved by cancer infiltration with a safe proximal and distal 4 cm margin of normal aorta. The following day the patient underwent a completion left pneumonectomy together with resection of the infiltrated area of thoracic aorta, avoiding aortic clamping, resection and vascular graft anastomoses. The removed area included the adventitia and almost the full thickness the media, about 3 cm wide of 0.25 of aorta circumference. Margins were negative of tumor at frozen section examination. Results: The final pathology confirmed the relapsing EP with infiltration into the adventitia of the aortic wall. The postoperative course was uneventful and the patient was discharged on X° day. Adjuvant radiotherapy was delivered (total dose: 60 Gy) in the area of hilum and aortic invasion. The patient is well and free of disease 24 months after surgery. Conclusions: Our experience showed that an aortic endograft can be a useful and safe tool to allow a combined resection of the lung and the infiltrated aortic wall without the need for thoracic aorta cross-clamping and graft replacement, potentially reducing morbidity and mortality associated with surgery. Further studies are necessary with longer follow-up to evaluate the potential of this technique, but we believe that, when a limited area of descending thoracic aorta is involved by tumor and the resected wall need to be replaced with a prosthetic graft, the use of endograft could represent an appropriate option.
Department of Vascular Surgery, Graz Medical University, Austria Objectives: Mycotic aneurysms and infections of the arterial wall in carotid arteries are extremely rare. There are seven cases of carotid pseudoaneurysms and infection by Salmonellae in the literature. Methods: We report a patient with infection of the arterial wall by salmonellae and perivascular abscess formation. A 77-year-old male was admitted to the ENT department due to unilateral swelling of the neck and fever. Ultrasound and CT-angiography showed a contrast-enhancing tumor of the right-sided carotid bifurcation. In addition, there was a hemodynamically significant stenosis of the right internal carotid artery. Results: Intraoperatively an abscess at the carotid bifurcation with arrosion of the vagal nerve was found. After abscess drainage the infected arterial wall was resected. The internal carotid artery was reconstructed by venous interposition. Microbiology assessment of the intraoperative sample showed Salmonellae group D. The postoperative course was uneventful except for an ipsilateral laryngeal nerve palsy with moderate hoarseness. Ultrasound investigation four weeks postoperatively showed no abnormalities. Phoniatric training continues. Conclusions: Perivascular abscess of the carotid bifurcation with infection of the arterial wall by Salmonellae without aneurysm or pseudoaneurysm formation is possible. Operative treatment by experienced vascular surgeons with the option of replacement of the carotid artery is recommended.
Vascular Surgery Division, Hospital Clinic, University of Barcelona, Spain Objectives: Secondary repair of thoracic aorta surgery represents a challenging clinical situation. Endovascular treatment can simplify such approach. Methods: An asymptomatic 42-year-old male was surgically treated due to an aortic coarctation 24 years before his admission. A big descending thoracic aortic anastomotic pseudoaneurysm was detected in a plain X-rays examination and the patient was referred to our institution. Associated arch dysplasia predicted a challenging approach. Two step repair was planned. First, a left carotid-subclavian artery and proximal ligature were performed for intentional coverage of the left subclavian artery to achieve a better proximal anchor and fixation for the stent-graft. In the second step, two days later, a thoracic endovascular repair was applied with a Bolton® Relay endovascular graft using a transfemoral access. Successful exclusion of the aneurysm was achieved. Patient was discharged 36 h later without any complication. Results: A false aneurysm at the repair site of aortic coarctation is a very common complication in patients surgically treated with a Dacron patch. It would be repaired as soon as possible to avoid major complications. We consider endovascular therapy as a first choice in patients with aortic arch abnormalities or previous surgery due to less mortality and morbility. Conclusions: 1. Aortic arch dysplasia represents a challenge for endovascular repair. 2. Preoperative planning must be careful and supraortic trunk transposition should be applied to prevent accidental ostial coverage.
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April 25th, 2008 2nd...
April 25th, 2008 2nd...
2-tests and multivariate regression analysis. P<0.05 was considered statistically significant.