Endovascular aortic aneurysm repair of complex aortic aneurysms requires incorporation of side branches using specially designed aortic stent grafts with fenestrations, directional branches, or ...parallel stent grafts. These techniques have been increasingly used and reported in the literature. The purpose of this document is to clarify and to update terminology, classification systems, measurement techniques, and end point definitions that are recommended for reports dealing with endovascular repair of complex abdominal and thoracoabdominal aortic aneurysms involving the renal and mesenteric arteries.
The Association Research Circulation Osseous (ARCO) presents the 2019 revised staging system of osteonecrosis of the femoral head (ONFH) based on the 1994 ARCO classification.
In October 2018, ARCO ...established a task force to revise the staging system of ONFH. The task force involved 29 experts who used a web-based survey for international collaboration. Content validity ratios for each answer were calculated to identify the levels of agreement. For the rating queries, a consensus was defined when more than 70% of the panel members scored a 4 or 5 rating on a 5-point scale.
Response rates were 93.1%-100%, and through the 4-round Delphi study, the 1994 ARCO classification for ONFH was successfully revised. The final consensus resulted in the following 4-staged system: stage I—X-ray is normal, but either magnetic resonance imaging or bone scan is positive; stage II—X-ray is abnormal (subtle signs of osteosclerosis, focal osteoporosis, or cystic change in the femoral head) but without any evidence of subchondral fracture, fracture in the necrotic portion, or flattening of the femoral head; stage III—fracture in the subchondral or necrotic zone as seen on X-ray or computed tomography scans. This stage is further divided into stage IIIA (early, femoral head depression ≤2 mm) and stage IIIB (late, femoral head depression >2 mm); and stage IV—X-ray evidence of osteoarthritis with accompanying joint space narrowing, acetabular changes, and/or joint destruction. This revised staging system does not incorporate the previous subclassification or quantitation parameters, but the panels agreed on the future development of a separate grading system for predicting disease progression.
A staging system has been developed to revise the 1994 ARCO classification for ONFH by an expert panel-based Delphi survey. ARCO approved and recommends this revised system as a universal staging of ONFH.
Objectives Increased utilization of computed tomography angiography (CTA) has increased the radiologic diagnosis of penetrating atherosclerotic ulcers (PAUs), which are defined as the ulceration of ...atherosclerotic plaque through the internal elastic lamina into the aortic media. However, the presentation, treatment indications, and natural history of this disease process remain unclear. Methods The radiology database at a single university hospital was searched retrospectively for the CTA diagnosis of PAU from January 2003 to June 2009. All scans were interpreted by a cardiovascular radiologist. Information on PAU characteristics and need for surgical repair due to PAU disease was collected. PAU stability or progression was assessed by follow-up CTA, if available. Only PAUs in the aortic arch, descending thoracic aorta, and abdominal aorta were included. Results Three hundred eighty-eight PAUs were diagnosed by CTA interpretation. PAU location was in the aortic arch in 27 (6.8%) cases, the descending thoracic aorta in 243 (61.2%) cases, and the abdominal aorta in 118 (29.7%) cases. Two hundred twenty-four (57.7%) PAUs were isolated (without saccular aneurysm or intramural hematoma); 108 (27.8%) PAUs had associated saccular aneurysms; and 56 (14.4%) PAUs had associated intramural hematoma. Rupture was present in 16 (4.1%) cases. Fifty (12.9%) PAUs underwent repair with thoracic endovascular aortic repair (TEVAR) (n = 30), endovascular aneurysm repair (EVAR) (n = 10), or open surgery (n = 10); primary indications for repair were saccular aneurysm (n = 26), rupture (n = 16), and persistent or recurrent symptoms (n = 8). Even if initially treated conservatively with resolution of pain, symptomatic PAU disease was more likely to require repair than asymptomatic PAU disease (36.2% vs 7.8%, P < .001). Follow-up CTA was available for 87 PAUs, 20 (23.0%) of which demonstrated radiographic disease progression at a mean follow-up of 8.4 ± 10.3 months. Symptomatic PAU disease was more likely to progress than asymptomatic disease (42.9% vs 16.7%, P = .029). Conclusions For PAUs diagnosed on CTA at a single institution, 4.1% were ruptured and 12.9% underwent repair. Close follow-up imaging appears to be indicated for PAUs, particularly in the case of symptomatic disease, which is more likely to require repair and to undergo radiographic progression.
Objective The purpose of this study was to assess the incidence, risk factors, and clinical manifestations of spinal cord ischemia (SCI) after thoracic endovascular aortic repair (TEVAR). Methods A ...retrospective review of a prospectively collected database was performed for all patients undergoing TEVAR at a single academic institution between July 2002 and June 2010. Preoperative demographics, procedure-related variables, and clinical details related to SCI were examined. Logistic regression analysis was performed to identify risk factors for the development of SCI. Results Of the 424 patients who underwent TEVAR during the study period, 12 patients (2.8%) developed SCI. Mean age of this cohort with SCI was 69.6 years (range, 44-84 years), and 7 were women. One-half of these patients had prior open or endovascular aortic repair. Indication for surgery was either degenerative aneurysm (n = 8) or dissection (n = 4). Six TEVARs were performed electively, with the remaining done either urgently or emergently due to contained rupture (n = 2), dissection with malperfusion (n = 2), or severe back pain (n = 2). All 12 patients underwent extent C endovascular coverage. Multivariate regression analysis demonstrated chronic renal insufficiency to be independently associated with SCI (odds ratio OR, 4.39; 95% confidence interval CI, 1.2-16.6; P = .029). Onset of SCI occurred at a median of 10.6 hours (range, 0-229 hours) postprocedure and was delayed in 83% (n = 10) of patients. Clinical manifestations of SCI included lower extremity paraparesis in 9 patients and paraplegia in 3 patients. At SCI onset, average mean arterial pressure (MAP) and lumbar cerebrospinal fluid (CSF) pressure was 77 mm Hg and 10 mm Hg, respectively. Therapeutic interventions increased blood pressure to a significantly higher average MAP of 99 mm Hg ( P = .001) and decreased lumbar CSF pressure to a mean of 7 mm Hg ( P = .30) at the time of neurologic recovery. Thirty-day mortality was 8% (1 of 12 patients). The single patient who expired, never recovered any lower extremity neurologic function. All patients surviving to discharge experienced either complete (n = 9) or incomplete (n = 2) neurologic recovery. At mean follow-up of 49 months, 7 of 9 patients currently alive continued to exhibit complete, sustained neurologic recovery. Conclusion Spinal cord ischemia after TEVAR is an uncommon, but important complication. Preoperative renal insufficiency was identified as a risk factor for the development of SCI. Early detection and treatment of SCI with blood pressure augmentation alone or in combination with CSF drainage was effective in most patients, with the majority achieving complete, long-term neurologic recovery.
Objective Thoracic endovascular aortic repair (TEVAR) has become a widely established treatment for a variety of thoracic aortic pathologic diseases despite limited long-term data to support its use. ...We compared the long-term outcomes of TEVAR with the 3 commercially available stents grafts for thoracic aortic aneurysms to results in control subjects undergoing open surgery. Methods Demographic, clinical radiographic parameters were collected prospectively on patients enrolled in trials assessing the Gore TAG (55), Medtronic Talent (36) and Cook TX2 (15) devices. Outcomes were compared with 45 contemporaneous open controls. Detailed clinical and radiographic information was available for analysis. Standard univariate, survival, and regression methods were used. Results During the study period (1995-2007) 106 patients were enrolled in TEVAR trials and there were 45 open controls. TEVAR patients were older and had significantly more comorbidities including diabetes and renal failure. TEVAR patients had 2.3 ± 1.3 devices implanted. Mortality (2.6% TEVAR, 6.7% open; P = .1), paralysis/paraparesis (3.9% TEVAR, 7.1% open; P = .2), and prolonged intubation more than 24 hours (9% TEVAR, 24% open; P = .02) tended to be more common in the open controls. Overall survival at 10 years was similar between groups (log rank P = .5). Multivariate predictors of late mortality included age, chronic obstructive pulmonary disease, diabetes, and chronic renal failure. Use of TEVAR versus open surgery did not influence mortality (hazard ratio, 0.9 95% confidence interval, 0.4-1.6). Over 5 years of radiographic follow-up in the TEVAR group, mean aortic diameter decreased from 61 to 55 mm. Freedom from reintervention on the treated segment was 85% in TEVAR patients at 10 years. Conclusions TEVAR is a safe and effective procedure to treat thoracic aortic aneurysms with improved perioperative and similar long-term results as open thoracic aortic repair. TEVAR-treated aneurysm diameters initially decrease and then stabilize over time.
Objective The management of infected aortic endografts is a challenging endeavor. Treatment of this problem has not been well defined as it is fairly uncommon. However, the incidence is increasing. ...This study examines the results of treatment at a single center for this morbid process. Methods A retrospective review was performed of patients treated for infected abdominal or thoracic endograft infection following previous abdominal or thoracic endovascular aneurysm repair. Data was reviewed for patient demographics, details of initial endograft implantation, presentation and timeline of subsequent infection, management of infected grafts, and outcomes during follow-up. Results Overall, 18 patients were treated for infected endografts (thoracic: six, abdominal:12). Three patients were treated between 2000 and 2006, corresponding to a 0.6% institutional incidence of endograft infection (3/473). There were no transfers for infected endografts from outside institutions. From 2006 to 2011, 15 patients underwent treatment. Six were institutional cases of infections (6/945, 0.6% infection rate), however, there was an increase in transfers (n = 9). Median time to presentation with infection from endograft implant was 90 days, with over one-half (61%) presenting within the first 3 months. Tissue and/or blood cultures were positive in 12/16 growing Escherichia coli (n = 1), group A streptococcus (n = 3), methicillin-resistant Staphylococcus aureus (n = 3), or polymicrobial infections (n = 7). The other four patients were culture negative with computed tomography evidence of gas surrounding the endograft and clinical sepsis. Ten patients (abdominal: eight, thoracic: two) were treated with endograft explantation. The remaining eight patients were considered too high-risk for explant or refused open surgery and were therefore managed conservatively without explant (abdominal: four, thoracic: four). At a mean follow-up of 24.7 months, aneurysm-related mortality was 38.9% (n = 7) and was higher for patients presenting with aortoenteric or aortobronchial fistulas (n = 6/10, 60%) ( P = .04) and for thoracic stent infections (n = 5/6; 83%) ( P = .03). The only survivor of a thoracic infection was managed surgically. Overall survival for patients with abdominal endografts (n = 12) was similar between the eight patients managed surgically (n = 6/8; 75%) and the four selected for medical management (n = 4/4; 100%) ( P = .39). All survivors remain on long-term suppressive antibiotics. Two additional patients died of unrelated causes during follow-up. Conclusions Endograft infection is a rare but increasing complication after abdominal or thoracic endovascular aneurysm repair, which carries significant associated morbidity and mortality. Most endograft infections occurred in proximity to other types of infection, suggesting that bacterial seeding of the endograft was the source. Aortoenteric and aortobronchial fistulas are common presentations, which portend a significantly worse prognosis. Thoracic endograft infections, which have the highest rate of fistulization, have the worst outcomes. Surgical excision continues to be standard of care but conservative management with intravenous antibiotics may be of benefit in certain patients with abdominal endograft infections.
Objectives Extracorporeal membrane oxygenation and extracorporeal cardiopulmonary support (ECMO/CPS) are potentially life-saving techniques for patients with cardiopulmonary collapse. Complications ...include lower extremity ischemia from femoral artery cannulation. We examined the outcomes of patients placed on ECMO/CPS, including the rate of limb ischemia. Methods All instances of ECMO/CPS over a 3-year period (2006-2009) at a single university hospital were examined retrospectively for cannulation strategy, perfusion strategy, mortality, and limb ischemia. Potential predictors of limb ischemia with femoral artery cannulation were age, gender, body surface area (BSA), body mass index (BMI), and arterial cannula size. Results Fifty-eight patients were placed on ECMO/CPS. Of these, 43 patients (74%) had femoral arterial cannulation. In 10 patients, the superficial femoral artery (SFA) was cannulated prophylactically (without antecedent limb ischemia) and perfused in the antegrade direction from a branch of the ECMO/CPS circuit. In 7 of the remaining 33 patients (21%), limb ischemia developed requiring decannulation with fasciotomy (n = 4) or additional cannulation of the SFA with branching of the ECMO/CPS circuit (n = 3). One patient with ipsilateral leg ischemia required eventual amputation. Patients with limb ischemia were significantly younger than those who did not develop limb ischemia ( P = .001). BSA, BMI, and cannula size did not predict limb ischemia. Overall 30-day mortality following the initiation of ECMO/CPS was 79%. There was no correlation between limb ischemia and mortality. Conclusions Younger patients may be at increased risk for lower extremity arterial insufficiency with femoral cannulation for ECMO/CPS. Prophylactic or expectant SFA cannulation are reasonable approaches.
Retrograde open mesenteric stenting (ROMS) through laparotomy was introduced as an alternative to surgical bypass in patients with acute mesenteric ischemia (AMI). The purpose of this study was to ...evaluate the indications and outcomes of ROMS for treatment of AMI and chronic mesenteric ischemia.
We reviewed the clinical data and outcomes of all consecutive patients treated by ROMS in seven academic centers from 2001 to 2013. ROMS was performed through laparotomy with retrograde access into the target mesenteric artery and stent placement using a retrograde or antegrade approach. End points were early (<30 days) and late mortality, morbidity, patency rates, and freedom from symptom recurrence and reintervention.
There were 54 patients, 13 male and 41 female, with a mean age of 72 ± 11 years. Indications for ROMS were AMI in 44 patients (81%) and subacute-on-chronic mesenteric ischemia with flush mesenteric occlusion in 10 patients (19%). A total of 56 target mesenteric vessels were stented, including 52 superior mesenteric arteries and 4 celiac axis lesions, with a mean treatment length of 42 ± 26 mm. Retrograde mesenteric access was used in all patients, but 16 patients also required a simultaneous antegrade brachial approach. The retrograde puncture was closed primarily in 34 patients and with patch angioplasty in 17 patients; 1 patient had manual compression. Bowel resection was needed in 29 patients (66%) with AMI because of perforation or gangrene. Technical success was achieved in all (98%) except one patient for whom ROMS failed, who was treated by bypass. Early mortality was 45% (20/44) for AMI and 10% (1/10) for subacute-on-chronic mesenteric ischemia (P = .04). Early morbidity was 73% for AMI and 50% for subacute-on-chronic mesenteric ischemia (P = .27). Patient survival for the entire cohort was 43% ± 9% at 2 years. Primary patency and secondary patency at 2 years were 76% ± 8% and 90% ± 8%, respectively. Freedom from symptom recurrence and freedom from reinterventions were 72% ± 8% and 74% ± 8% at the same interval.
ROMS offers an alternative to bypass or percutaneous stenting in patients with AMI who require abdominal exploration and in those who have flush mesenteric occlusions and have failed to respond to or are considered unsuitable for stenting by a percutaneous approach. Despite high technical success, mortality remains elevated in patients with AMI. Patency rates and freedom from symptom recurrence and reinterventions are comparable to the results achieved with stenting using percutaneous technique.
Non-traumatic osteonecrosis of the femoral head (ONFH) usually affects adults younger than 50 years and frequently leads to femoral head collapse and subsequent arthritis of the hip. It is becoming ...more prevalent along with increasing use of corticosteroids for the adjuvant therapy of leukemia and other myelogenous diseases as well as management of organ transplantation. This review updated knowledge on the pathogenesis, classification criteria, staging system, and treatment of ONFH.
Objective This study assessed the vascular distribution of stroke after thoracic endovascular aortic repair (TEVAR) and its relationship to perioperative death and neurologic outcome. Methods A ...retrospective review was performed for patients undergoing TEVAR between 2001 and 2010. Aortic arch hybrid and abdominal debranching cases were excluded. Demographics, operative variables, and neurologic complications were examined. Stroke was defined as any new focal or global neurologic deficit lasting >24 hours with radiographic confirmation of acute intracranial pathology. Results Perioperative stroke occurred in 20 of 530 patients (3.8%) undergoing TEVAR. The cohort was 55% male and a mean age of 75.2 ± 8.9 years (range, 57-90 years). Among patients with perioperative strokes, the indication for surgery was degenerative aneurysm in 14 (mean diameter, 6.8 cm), acute type B dissection in four, penetrating atherosclerotic aneurysm in one, and aortic transection in one. Cases were performed urgently or as an emergency in 60%. The proximal landing zone was zone 2 in 11 or zone 3 in nine. All strokes were embolic. The vascular distribution of stroke involved the anterior cerebral (AC) circulation in eight (zone 2, n = 5) and the posterior cerebral (PC) circulation in 12 (zone 2, n = 6). Laterality of cerebral infarction included five right-sided, eight left-sided, and seven bilateral strokes. Nine strokes were diagnosed <24 hours after operation. There was no difference in baseline demographics, aortic pathology, acuity, zone coverage, preoperative left subclavian artery revascularization, number of stents, or estimated blood loss between stroke groups based on vascular distribution. Independent risk factors for any perioperative stroke were chronic renal insufficiency (odds ratios OR, 4.65; 95% confidence interval CI, 1.22-17.7; P = .02) and history of prior stroke (OR, 4.92; 95% CI, 1.69-14.4; P = .004); the risk factor for AC stroke was prior stroke (OR, 7.67; 95% CI, 1.25-46.9; P = .03) and the risk factors for PC stroke were age (OR, 1.11; 95% CI, 1.00-1.23; P = .04), prior stroke (OR, 7.53; 95% CI, 1.78-31.8; P = .006), zone 2 coverage (OR, 6.11; 95% CI, 1.15-32.3; P = .03), and penetrating atherosclerotic ulcer (OR, 32.7; 95% CI, 1.33-807.2; P = .03). Overall in-hospital mortality was 20% (n = 4), with those sustaining PC strokes observed to trend toward increased mortality (33% vs 0%; P = .12). Patients with AC strokes were more likely than those with PC strokes to achieve complete recovery of neurologic deficits before discharge (75% vs 17%; P = .02). Conclusions Perioperative stroke after TEVAR is primarily an embolic event. Although infrequent, stroke was associated with significant morbidity and death, particularly among those with strokes involving the PC circulation.
PDF
