Tracheal Compression Caused by a Mediastinal Hematoma After Interrupted Aortic Arch Surgery.

PubMed

Hua, Qingwang; Lin, Zhiyong; Hu, Xingti; Zhao, Qifeng

2017-08-03

Congenital abnormalities of the aortic arch include interrupted aortic arch (IAA), coarctation of the aorta (CoA), and double aortic arch (DAA). Aortic arch repair is difficult and postoperative complications are common. However, postoperative tracheobronchial stenosis with respiratory insufficiency is an uncommon complication and is usually caused by increased aortic anastomotic tension. We report here a case of tracheal compression by a mediastinal hematoma following IAA surgery. The patient underwent a repeat operation to remove the hematoma and was successfully weaned off the ventilator.In cases of tracheobronchial stenosis after aortic arch surgery, airway compression by increased aortic anastomotic tension is usually the first diagnosis considered by clinicians. Other causes, such as mediastinal hematomas, are often ignored. However, the severity of symptoms with mediastinal hematomas makes this an important entity.

A case of complete double aortic arch visualized by transthoracic echocardiography.

PubMed

Saito, Naka; Kato, Shingo; Saito, Noritaka; Nakachi, Tatsuya; Fukui, Kazuki; Iwasawa, Tae; Kosuge, Masami; Kimura, Kazuo

2017-08-01

A case of double aortic arch that was well visualized using transthoracic echocardiography is reported. A 38-year-old man underwent transthoracic echocardiography for the evaluation of dyspnea. A suprasternal view of transthoracic echocardiography showed the ascending aorta bifurcate to left and right aortic arches, with blood flow from the ascending aorta to bilateral aortic arches. The diagnosis of right side-dominant double aortic arch was made, and the patient's symptom was conceivably related to compression of the trachea due to a vascular ring. This report indicates the potential usefulness of transthoracic echocardiography for noninvasive detection of double aortic arch in adults. © 2017, Wiley Periodicals, Inc.

A geometric reappraisal of proximal landing zones for thoracic endovascular aortic repair according to aortic arch types.

PubMed

Marrocco-Trischitta, Massimiliano M; de Beaufort, Hector W; Secchi, Francesco; van Bakel, Theodorus M; Ranucci, Marco; van Herwaarden, Joost A; Moll, Frans L; Trimarchi, Santi

2017-06-01

This study assessed whether the additional use of the aortic arch classification in type I, II, and III may complement Ishimaru's aortic arch map and provide valuable information on the geometry and suitability of proximal landing zones for thoracic endovascular aortic repair. Anonymized thoracic computed tomography scans of healthy aortas were reviewed and stratified according to the aortic arch classification, and 20 of each type of arch were selected. Further processing allowed calculation of angulation and tortuosity of each proximal landing zone. Data were described indicating both proximal landing zone and type of arch (eg, 0/I). Angulation was severe (>60°) in 2/III and in 3/III. Comparisons among the types of arch showed an increase in proximal landing zones angulation (P < .001) and tortuosity (P = .009) depending on the type of arch. Comparisons within type of arch showed no change in angulation and tortuosity across proximal landing zones within type I arch (P = .349 and P = .409), and increases in angulation and tortuosity toward more distal proximal landing zones within type II (P = .003 and P = .043) and type III (P < .001 in both). The aortic arch classification is associated with a consistent geometric pattern of the aortic arch map, which identifies specific proximal landing zones with suboptimal angulation for stent graft deployment. Arches II and III also appear to have progressively less favorable anatomy for thoracic endovascular aortic repair compared with arch I. Copyright © 2016 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.

Endovascular Retrieval of Entrapped Elephant Trunk Graft During Complex Hybrid Aortic Arch Repair

DOE Office of Scientific and Technical Information (OSTI.GOV)

Damodharan, Karthikeyan, E-mail: drdkarthik@hotmail.com; Chao, Victor T. T., E-mail: victor.chao.t.t@singhealth.com.sg; Tay, Kiang Hiong, E-mail: tay.kiang.hiong@singhealth.com.sg

Entrapment of the elephant trunk graft within the false lumen is a rare complication of surgical repair of an aortic dissection. This is normally retrieved by emergent open surgery. We describe a technique of endovascular retrieval of the dislodged graft, during hybrid aortic arch repair. The elephant trunk was cannulated through and through from a femoral access and the free end of the wire was snared and retrieved from a brachial access. The wire was externalised from both accesses and was used to reposition the graft into the true lumen using a body flossing technique.

Aneurysm of an Aberrant Right Subclavian Artery Successfully Excluded by a Thoracic Aortic Stent Graft with Supra-aortic Bypass of Three Arch Vessels

DOE Office of Scientific and Technical Information (OSTI.GOV)

Munneke, Graham J.; Loosemore, Thomas M.; Belli, Anna-Maria

2005-06-15

An aberrant right subclavian artery (ARSA) arising from a left-sided aortic arch is the fourth most common aortic arch anomaly. Aneurysmal dilatation of the ARSA requires treatment because of the associated risk of rupture. We present a case where supra-aortic bypass of the arch vessels was performed to facilitate exclusion of the aneurysm by a thoracic aortic stent graft.

[Persistence of the 5th aortic arch associated with interruption of the aortic arch].

PubMed

Houssa, Mahdi Ait; Atmani, Noureddine; Bamous, Mehdi; Abdou, Abdessamad; Nya, Fouad; Seghrouchni, Anis; Amahzoune, Brahim; El Bekkali, Youssef; Drissi, Mohamed; Boulahya, Abdelatif

2017-01-01

We report a case of persistence of the 5th aortic arch associated with total interruption of the aortic arch. This clinical case shows the diagnostic pitfall of the persistence of the 5th aortic arch and its beneficial hemodynamic effect. Preoperative clinical picture was misleading, due to the persistence of femoral pulses and clinical signs of left-to-right shunt via a wide ductus arteriosus. The diagnosis was intraoperatively adjusted on the basis of blood pressure monitoring using catheter placed into the femoral artery.

Vocal cord paralysis after aortic arch surgery: predictors and clinical outcome.

PubMed

Ohta, Noriyuki; Kuratani, Toru; Hagihira, Satoshi; Kazumi, Ken-Ichiro; Kaneko, Mitsunori; Mori, Takahiko

2006-04-01

This study is retrospective cohort study of data on vocal cord paralysis after aortic arch surgery collected during 14 years at a general hospital. We investigated factors in the development of vocal cord paralysis after aortic arch surgery and the effect of vocal cord paralysis on clinical course and outcome. We reviewed data for 182 patients who underwent aortic arch surgery for aortic arch aneurysm and aortic dissection between 1989 and 2003, of whom 58 patients had proximal aortic repair, 62 had distal arch repair, and 62 had total arch repair. We assessed factors associated with the development of vocal cord paralysis and examined in detail the clinical outcome of patients with vocal cord paralysis. Postoperative vocal cord paralysis occurred in 40 patients. Multiple logistic regression analysis revealed the following risk factors with odds ratios (OR) for vocal cord paralysis: extension of procedures into distal arch (OR, 17.0), chronic dilatation of the aorta at the left subclavian artery (OR, 9.14), and total arch repair (OR, 4.24). Adoption of open-style stent-grafts reduced the incidence of vocal cord paralysis (OR, 0.031). The postoperative occurrence of vocal cord paralysis itself emerges as an independent predictor of pulmonary complications (OR, 4.12) and leads to a longer duration of hospital stay. The risk of vocal cord paralysis after aortic arch surgery depends on surgical factors, such as aneurysmal involvement of the distal arch, or the application of newer, less invasive surgical procedures. Vocal cord paralysis after aortic arch surgery itself, under aggressive postoperative respiratory management, did not increase aspiration pneumonia but was associated with postoperative complications leading to higher hospital mortality and prolonged hospitalization.

Absent right common carotid artery associated with aberrant right subclavian artery.

PubMed

Uchino, Akira; Uwabe, Kazuhiko; Osawa, Iichiro

2018-06-01

Rarely, the external and internal carotid arteries arise separately from the brachiocephalic trunk and right subclavian artery (SA) or the aortic arch and reflect the absence of a common carotid artery (CCA). We report a 45-year-old man with absent right CCA associated with aberrant right SA, an extremely rare combination, diagnosed by computed tomography (CT) angiography during follow-up for postoperative aortic dissection. Retrospective careful observation of preoperative postcontrast CT revealed the absent right CCA. Previously reported arch variations associated with absent CCA include cervical aortic arch, double aortic arch, and right aortic arch.

Frozen elephant trunk reconstruction for right-sided aortic arch with aberrant left subclavian artery and aneurysm of the descending aorta: a case report.

PubMed

Kokotsakis, John; Jarral, Omar A; Harling, Leanne; Tsipas, Panteleimon; Athanasiou, Thanos

2016-05-05

A 59-year old man being investigated for back pain was found to have aneurysmal dilatation of a right-sided aortic arch and descending thoracic aorta together with an aberrant left subclavian artery. He underwent repair of this utilising the frozen elephant trunk technique, which dealt with all three pathologies in one-stage. He made an unremarkable recovery and was discharged home on the 8th post-operative day. This case report further demonstrates the flexibility and safety of the frozen elephant trunk in dealing with complex aortic pathology as a single-stage procedure.

Hybrid endovascular repair in aortic arch pathologies: a retrospective study.

PubMed

Ma, Xiaohui; Guo, Wei; Liu, Xiaoping; Yin, Tai; Jia, Xin; Xiong, Jiang; Zhang, Hongpeng; Wang, Lijun

2010-11-18

The aortic arch presents specific challenges to endovascular repair. Hybrid repair is increasingly evolving as an alternative option for selected patients, and promising initial results have been reported. The aim of this study was to introduce our experiences and evaluate mid-term results of supra aortic transpositions for extended endovascular repair of aortic arch pathologies. From December 2002 to January 2008, 25 patients with thoracic aortic aneurysms and dissections involving the aortic arch were treated with hybrid endovascular treatment in our center. Of the 25 cases, 14 were atherosclerotic thoracic aortic aneurysms and 11 were thoracic aortic dissection. The hybrid repair method included total-arch transpositions (15 cases) or hemi-arch transpositions (10 cases), and endovascular procedures. All hybrid endovascular procedures were completed successfully. Three early residual type-I endoleaks and one type-II endoleak were observed. Stroke occurred in three patients (8%) during the in-hospital stage. The perioperative mortality rate was 4%; one patients died post-operatively from catheter related complications. The average follow-up period was 15 ± 5.8 months (range, 1-41 months). The overall crude survival rate at 15 months was 92% (23/25). During follow-up, new late endoleaks and stent-raft related complications were not observed. One case (4%) developed a unilateral lower limb deficit at 17 days and was readmitted to hospital. In conclusion, the results are encouraging for endovascular aortic arch repair in combination with supra-aortic transposition in high risk cases. Aortic endografting offers good mid-term results. Mid-term results of the hybrid approach in elderly patients with aortic arch pathologies are satisfying.

The effect of demographic features on aortic arch anatomy and its role in the etiology of cerebrovascular disease.

PubMed

İnanç, Yılmaz; İnanç, Yusuf; Ay, Halil

2018-01-01

The aim of this study was to retrospectively evaluate the distribution of aortic arches, the relationship with demographic characteristics, and the results of carotid and vertebral artery stenting procedures in patients diagnosed with cerebrovascular disease through the intra-arterial digital subtraction angiography (DSA) technique. A retrospective examination was performed on 288 patients diagnosed with cerebrovascular disease, who underwent DSA in the Department of Neurology of Gaziantep University Medical Faculty and Kahramanmaraş¸ Sütçü Imam University Medical Faculty. The patients were examined in respect of demographic features and aortic arch anatomic structure characteristics. All demographic characteristics, DSA, carotid, and vertebral artery stent results were recorded. The patients comprised 60.1% males and 39.9% females with a mean age of 58.25 years. Type 2 aortic arch was found in 175 (60.7%) patients, Type 2 aortic arch in 99 (34.3%) patients, and Type 3 aortic arch in 14 (4.8%) patients. The right carotid artery stenosis rate was found to be higher in patients with Type 2 aortic arch ( P =0.013). When the patients were evaluated according to the presence of a bovine arch, there was no significant difference in terms of age, carotid, and vertebral artery lesions ( P >0.05). The aortic arch and its branching properties were not found to have a direct effect on increased risk of cerebrovascular disease or stenting rates. This study can be considered to raise awareness for new studies to demonstrate the effect of aortic arch anatomic differences on cerebrovascular diseases.

The effect of demographic features on aortic arch anatomy and its role in the etiology of cerebrovascular disease

PubMed Central

İnanç, Yılmaz; İnanç, Yusuf; Ay, Halil

2018-01-01

Purpose The aim of this study was to retrospectively evaluate the distribution of aortic arches, the relationship with demographic characteristics, and the results of carotid and vertebral artery stenting procedures in patients diagnosed with cerebrovascular disease through the intra-arterial digital subtraction angiography (DSA) technique. Methods A retrospective examination was performed on 288 patients diagnosed with cerebrovascular disease, who underwent DSA in the Department of Neurology of Gaziantep University Medical Faculty and Kahramanmaraş¸ Sütçü Imam University Medical Faculty. The patients were examined in respect of demographic features and aortic arch anatomic structure characteristics. All demographic characteristics, DSA, carotid, and vertebral artery stent results were recorded. Results The patients comprised 60.1% males and 39.9% females with a mean age of 58.25 years. Type 2 aortic arch was found in 175 (60.7%) patients, Type 2 aortic arch in 99 (34.3%) patients, and Type 3 aortic arch in 14 (4.8%) patients. The right carotid artery stenosis rate was found to be higher in patients with Type 2 aortic arch (P=0.013). When the patients were evaluated according to the presence of a bovine arch, there was no significant difference in terms of age, carotid, and vertebral artery lesions (P>0.05). Conclusion The aortic arch and its branching properties were not found to have a direct effect on increased risk of cerebrovascular disease or stenting rates. This study can be considered to raise awareness for new studies to demonstrate the effect of aortic arch anatomic differences on cerebrovascular diseases. PMID:29302189

Multimodal optical measurement in vitro of surface deformations and wall thickness of the pressurized aortic arch

NASA Astrophysics Data System (ADS)

Genovese, Katia; Humphrey, Jay D.

2015-04-01

Computational modeling of arterial mechanics continues to progress, even to the point of allowing the study of complex regions such as the aortic arch. Nevertheless, most prior studies assign homogeneous and isotropic material properties and constant wall thickness even when implementing patient-specific luminal geometries obtained from medical imaging. These assumptions are not due to computational limitations, but rather to the lack of spatially dense sets of experimental data that describe regional variations in mechanical properties and wall thickness in such complex arterial regions. In this work, we addressed technical challenges associated with in vitro measurement of overall geometry, full-field surface deformations, and regional wall thickness of the porcine aortic arch in its native anatomical configuration. Specifically, we combined two digital image correlation-based approaches, standard and panoramic, to track surface geometry and finite deformations during pressurization, with a 360-deg fringe projection system to contour the outer and inner geometry. The latter provided, for the first time, information on heterogeneous distributions of wall thickness of the arch and associated branches in the unloaded state. Results showed that mechanical responses vary significantly with orientation and location (e.g., less extensible in the circumferential direction and with increasing distance from the heart) and that the arch exhibits a nearly linear increase in pressure-induced strain up to 40%, consistent with other findings on proximal porcine aortas. Thickness measurements revealed strong regional differences, thus emphasizing the need to include nonuniform thicknesses in theoretical and computational studies of complex arterial geometries.

Contemporary patterns of surgery and outcomes for aortic coarctation: An analysis of the Society of Thoracic Surgeons Congenital Heart Surgery Database

PubMed Central

Ungerleider, Ross M.; Pasquali, Sara K.; Welke, Karl F.; Wallace, Amelia S.; Ootaki, Yoshio; Quartermain, Michael D.; Williams, Derek A.; Jacobs, Jeffrey P.

2013-01-01

Objective The objective of this study was to describe characteristics and early outcomes across a large multicenter cohort undergoing coarctation or hypoplastic aortic arch repair. Methods Patients undergoing coarctation or hypoplastic aortic arch repair (2006–2010) as their first cardiovascular operation in the Society of Thoracic Surgeons Congenital Heart Surgery Database were included. Group 1 patients consisted of those with coarctation or hypoplastic aortic arch without ventricular septal defect (coarctation or hypoplastic aortic arch, isolated); group 2, coarctation or hypoplastic aortic arch with ventricular septal defect (coarctation or hypoplastic aortic arch, ventricular septal defect); and group 3, coarctation or hypoplastic aortic arch with other major cardiac diagnoses (coarctation or hypoplastic aortic arch, other). Results The cohort included 5025 patients (95 centers): group 1, 2705 (54%); group 2, 840 (17%); and group 3, 1480 (29%). Group 1 underwent coarctation or hypoplastic aortic arch repair at an older age than groups 2 and 3 (groups 1, 2, and 3, 75%, 99%, and 88% < 1 year old, respectively; P<.0001). The most common operative techniques for coarctation or hypoplastic aortic arch repair (group 1) were end-to-end (33%) or extended end-to-end (56%) anastomosis. Overall mortality was 2.4%, and was 1%, 2.5%, and 4.8% for groups 1, 2, and 3 respectively (P < .0001). Ventricular septal defect management strategies for group 2 patients included ventricular septal defect closure (n = 211, 25%), pulmonary artery band (n = 89, 11%), or no intervention (n = 540, 64%) without significant difference in mortality (4%, 1%, 2%; P = .15). Postoperative complications occurred in 36% of patients overall and were more common in groups 2 and 3. There were no occurrences of spinal cord injury (0/973). Conclusions In the current era, primary coarctation or hypoplastic aortic arch repair is performed predominantly in neonates and infants. Overall mortality is low, although those with concomitant defects are at risk for higher morbidity and mortality. The risk of spinal cord injury is lower than previously reported. PMID:23098750

Selective Cerebro-Myocardial Perfusion in Complex Neonatal Aortic Arch Pathology: Midterm Results.

PubMed

Hoxha, Stiljan; Abbasciano, Riccardo Giuseppe; Sandrini, Camilla; Rossetti, Lucia; Menon, Tiziano; Barozzi, Luca; Linardi, Daniele; Rungatscher, Alessio; Faggian, Giuseppe; Luciani, Giovanni Battista

2018-04-01

Aortic arch repair in newborns and infants has traditionally been accomplished using a period of deep hypothermic circulatory arrest. To reduce neurologic and cardiac dysfunction related to circulatory arrest and myocardial ischemia during complex aortic arch surgery, an alternative and novel strategy for cerebro-myocardial protection was recently developed, where regional low-flow perfusion is combined with controlled and independent coronary perfusion. The aim of the present retrospective study was to assess short-term and mid-term results of selective and independent cerebro-myocardial perfusion in neonatal aortic arch surgery. From April 2008 to August 2015, 28 consecutive neonates underwent aortic arch surgery under cerebro-myocardial perfusion. There were 17 male and 11 female, with median age of 15 days (3-30 days) and median body weight of 3 kg (1.6-4.2 kg), 9 (32%) of whom with low body weight (<2.5 kg). The spectrum of pathologies treated was heterogeneous and included 13 neonates having single-stage biventricular repair (46%), 7 staged biventricular repair (25%), and 8 single-ventricle repair (29%). All operations were performed under moderate hypothermia and with a "beating heart and brain." Average cardiopulmonary bypass time was 131 ± 64 min (42-310 min). A period of cardiac arrest to complete intra-cardiac repair was required in nine patients (32%), and circulatory arrest in 1 to repair total anomalous pulmonary venous connection. Average time of splanchnic ischemia during cerebro-myocardial perfusion was 30 ± 11 min (15-69 min). Renal dysfunction, requiring a period of peritoneal dialysis was observed in 10 (36%) patients, while liver dysfunction was noted only in 3 (11%). There were three (11%) early and two late deaths during a median follow-up of 2.9 years (range 6 months-7.7 years), with an actuarial survival of 82% at 7 years. At latest follow-up, no patient showed signs of cardiac or neurologic dysfunction. The present experience shows that a strategy of selective and independent cerebro-myocardial perfusion is safe, versatile, and feasible in high-risk neonates with complex congenital arch pathology. Encouraging outcomes were noted in terms of cardiac and neurological function, with limited end-organ morbidity. © 2018 International Center for Artificial Organs and Transplantation and Wiley Periodicals, Inc.

The evolution of amphibian metamorphosis: insights based on the transformation of the aortic arches of Pelobates fuscus (Anura)

PubMed Central

Kolesová, Hana; Lametschwandtner, Alois; Roček, Zbyněk

2007-01-01

In order to gain insights into how the aortic arches changed during the transition of vertebrates to land, transformations of the aortic arches during the metamorphosis of Pelobates fuscus were investigated and compared with data from the early development of a recent ganoid fish Amia calva and a primitive caudate amphibian Salamandrella keyserlingi. Although in larval Pelobates, as in other non-pipid anurans, the gill arches serve partly as a filter-feeding device, their aortic arches maintain the original piscine-like arrangement, except for the mandibular and hyoid aortic arches which were lost. As important pre-adaptations for breathing of atmospheric oxygen occur in larval Pelobates (which have well-developed, though non-respiratory lungs and pulmonary artery), transformation of aortic arches during metamorphosis is fast. The transformation involves disappearance of the ductus Botalli, which results in a complete shunting of blood into the lungs and skin, disappearance of the ductus caroticus, which results in shunting of blood into the head through the arteria carotis interna, and disappearance of arch V, which results in shunting blood to the body through arch IV (systemic arch). It is supposed that the branching pattern of the aortic arches of permanently water-dwelling piscine ancestors, of intermediate forms which occasionally left the water and of primitive tetrapods capable of spending longer periods of time on land had been the same as in the prematamorphic anuran larvae or in some metamorphosed caudates in which the ductus caroticus and ductus Botalli were not interrupted, and arch V was still complete. PMID:17367494

The evolution of amphibian metamorphosis: insights based on the transformation of the aortic arches of Pelobates fuscus (Anura).

PubMed

Kolesová, Hana; Lametschwandtner, Alois; Rocek, Zbynek

2007-04-01

In order to gain insights into how the aortic arches changed during the transition of vertebrates to land, transformations of the aortic arches during the metamorphosis of Pelobates fuscus were investigated and compared with data from the early development of a recent ganoid fish Amia calva and a primitive caudate amphibian Salamandrella keyserlingi. Although in larval Pelobates, as in other non-pipid anurans, the gill arches serve partly as a filter-feeding device, their aortic arches maintain the original piscine-like arrangement, except for the mandibular and hyoid aortic arches which were lost. As important pre-adaptations for breathing of atmospheric oxygen occur in larval Pelobates (which have well-developed, though non-respiratory lungs and pulmonary artery), transformation of aortic arches during metamorphosis is fast. The transformation involves disappearance of the ductus Botalli, which results in a complete shunting of blood into the lungs and skin, disappearance of the ductus caroticus, which results in shunting of blood into the head through the arteria carotis interna, and disappearance of arch V, which results in shunting blood to the body through arch IV (systemic arch). It is supposed that the branching pattern of the aortic arches of permanently water-dwelling piscine ancestors, of intermediate forms which occasionally left the water and of primitive tetrapods capable of spending longer periods of time on land had been the same as in the prematamorphic anuran larvae or in some metamorphosed caudates in which the ductus caroticus and ductus Botalli were not interrupted, and arch V was still complete.

Asymptomatic Interrupted Aortic Arch, Severe Tricuspid Regurgitation, and Bicuspid Aortic Valve in a 76-Year-Old Woman.

PubMed

Tajdini, Masih; Sardari, Akram; Forouzannia, Seyed Khalil; Baradaran, Abdolvahab; Hosseini, Seyed Mohammad Reza; Kassaian, Seyed Ebrahim

2016-10-01

Interrupted aortic arch is a rare congenital abnormality with a high infancy mortality rate. The principal finding is loss of luminal continuity between the ascending and descending portions of the aorta. Because of the high mortality rate in infancy, interrupted aortic arch is very rare among adults. In this report, we describe the case of a 76-year-old woman with asymptomatic interrupted aortic arch, severe tricuspid regurgitation, and bicuspid aortic valve. To our knowledge, she is the oldest patient ever reported with this possibly unique combination of pathologic conditions. In addition to reporting her case, we review the relevant medical literature.

Body surface area as a key determinant of aortic root and arch dimensions in a population-based study.

PubMed

Wang, Yan-Li; Wang, Qing-Ling; Wang, Liang; Wu, Ying-Biao; Wang, Zhi-Bin; Cameron, James; Liang, Yu-Lu

2013-02-01

The associations between the aortic dimensions (of the aortic sinus, aortic annulus and aortic arch) and physiological variables have not been established in the Chinese population. The present study examined the associations among physiological variables to determine the aortic root and arch dimensions echocardiographically. The diameters of the aortic sinus, annulus and arch were measured in 1,010 subjects via 2-D echocardiography with a 3.5-MHz transducer in a trans-thoracic position. The images of the aortic sinus and aortic annulus were obtained from a standard parasternal long-axis view. The maximum diameter of the valve orifice was measured at the end of systole. The aortic arch dimension was visualized in the long-axis using a suprasternal notch window and the maximum transverse diameter was measured. Epidata 3.0, Excel 2007 and SPSS version 17.0 were used to collect and analyze the data. A total of 1,010 subjects were enrolled. The mean age was 55.0±17.0 years (range of 18 to 90 years). The body surface area (BSA) was the best predictor of all the studied physiological variables and may be used to predict aortic sinus, annulus and arch dimensions independently (r=0.54, 0.37 and 0.39, respectively). Gender, blood pressure, age and BSA are significant predictors of the aortic dimensions. Of these, BSA was the best predictor.

Single center experience of aortic bypass graft for aortic arch obstruction in children.

PubMed

Shinkawa, Takeshi; Chipman, Carl; Holloway, Jessica; Tang, Xinyu; Gossett, Jeffrey M; Imamura, Michiaki

2017-01-01

The purpose of this study is to access the outcomes of aortic bypass graft placement in children. This is a retrospective review of all children having aortic bypass graft placement for aortic arch obstruction for the first time between 1982 and 2013 at a single institution. The actuarial survival and the freedom from aortic arch reoperation were calculated and compared between the groups. Seventy consecutive children underwent aortic bypass graft placements. The median age and body weight at the operation were 14 days and 3.6 kg. There were 7 early deaths, 6 late deaths, and 7 heart transplants during the median follow-up of 10.8 years (0.0-31.5 years). The actuarial transplant free survival was 64.7 % at 20 years and the freedom from aortic arch reoperation was 50.5 % at 10 years. Between the children younger than 1 year old and older than 1 year old, there were significant differences in actuarial transplant free survival (56.4 vs. 100 % at 15 years, p = 0.0042) and in the freedom from aortic arch reoperation (18.7 vs. 100 % at 10 years, p < 0.001). The children who received aortic bypass graft larger than 16 mm in size had no aortic arch reoperation at 15 years. The aortic bypass graft placement for aortic arch obstruction can be done with low mortality and morbidity for children who can receive bypass graft larger than 16 mm in size. However, it should be avoided for the neonates and infants except selected situations.

Fenestrated endovascular repair of aortic arch aneurysm in patients with bovine arch using the Najuta stent graft.

PubMed

Toya, Naoki; Ohki, Takao; Fukushima, Soichiro; Shukuzawa, Kota; Ito, Eisaku; Akiba, Tadashi

2018-06-01

We describe the case of a 74-year-old man with a thoracic aortic aneurysm with a bovine arch who underwent fenestrated endovascular repair of aortic arch aneurysm using the Najuta stent graft (Kawasumi Laboratories, Inc, Tokyo, Japan). He has had a previous endovascular aneurysm repair and femoropopliteal bypass for abdominal aortic aneurysm combined with peripheral arterial disease. The Najuta stent graft was inserted and deployed at zone 0 with delicate positional adjustment of the fenestration of the stent graft to the brachiocephalic trunk. There was no endoleak or complication. His postoperative course was uneventful. At 7-month follow-up, complete exclusion of the aneurysm was noted. The Najuta stent graft repair of aortic arch aneurysms is a safe and effective treatment option for patients with a bovine arch.

Regional cerebral perfusion for surgical correction of neonatal aortic arch obstruction.

PubMed

Zhang, Hui; Cheng, Pei; Hou, Jia; Li, Lei; Liu, Hu; Liu, Ruifang; Ji, Bingyang; Luo, Yi

2009-05-01

One-stage repair of aortic arch obstruction and associated cardiac anomalies is a surgical challenge in infants.The purpose of the present study is to review the current outcome using regional cerebral perfusion (RCP) during a procedure correcting interrupted aortic arch (IAA) and also isolated aortic coarctation (CoA) and CoA combined with hypoplastic aortic arch (CoA-HyAA) in our center. Between January 2007 and July 2008, 24 infant patients with interrupted aortic arch (IAA) (n=3), isolated aortic coarctation (iCoA) (n=9) and aortic coarctation with hypoplastic aortic arch (CoA-HyAA) (n=12) underwent one-stage surgical correction in our hospital. End-to-end anastomosis was employed in 12 infants (IAA n=3 and iCoA n=9); for the other 12 patients with CoA-HyAA, an end-to-end extended anastomosis was used in 8 cases, end-to-side anastomosis in 2 cases, and composite heterologous pericardial patch in 2 cases. RCP with 40 mL/kg/min through the innominate artery during aortic arch reconstruction was employed for all pediatric patients. One single-dose histidine-ketoglutarate-tryptophan (HTK) solution was used for myocardial protection during CPB. Cardiopulmonary bypass time and aortic cross-clamp time were 165.6+/-32.4 min and 81.7+/-30.0 min, respectively. The mean regional cerebral perfusion time was 31.0+/-10.6 min; lowest nasopharyngeal temperature was 19.1+/-1.1 degrees C. Operative mortality rate in both groups was 8.3%. Mean follow-up was 10.5+/-4.8 months. There was no late mortality or postoperative neurologic, renal or hepatic complications. All patients are asymptomatic and are developing normally. One-stage total arch repair using the RCP technique is an excellent method that may minimize neurologic and renal complications. Our surgical strategy for arch anomaly has a low rate of residual and recurrent coarctation when performed in these infants.

Double aortic arch presenting with a foreign object in the oesophagus: a case report and imaging diagnosis.

PubMed

Yang, Xiuzhen; Ye, Jingjing; Gao, Zhan

2017-10-01

In this article, we report a rare case of double aortic arch. The case presented initially with a foreign object in the oesophagus. The patient was a 2-year-old boy, who was referred with primary symptoms of tussis (15 days) and emesis (2 days). He had a history of ingesting a coin. Routine chest X-ray indicated a rounded, metal foreign object in the upper oesophagus. A half-Yuan coin was removed by gastroduodenoscopy. Echocardiographic imaging suggested that the patient had double aortic arch, which was subsequently diagnosed by CT angiography with three-dimensional reconstruction. The right subclavian artery arose from the right loop of the double aortic arch. The left subclavian artery as well as left and right common carotid arteries had distinct origins from the left aortic arch. Imaging also indicated atresia of the distal left arch. The patient underwent corrective surgery and made a full recovery. Despite the rarity, double aortic arch should be considered when patients present with a foreign object in the oesophagus. Echocardiography and CT angiography can inform the diagnosis.

The Infant with Aortic Arch Hypoplasia and Small Left Heart Structures: Echocardiographic Indices of Mitral and Aortic Hypoplasia Predicting Successful Biventricular Repair.

PubMed

Plymale, Jennifer M; Frommelt, Peter C; Nugent, Melodee; Simpson, Pippa; Tweddell, James S; Shillingford, Amanda J

2017-08-01

In infants with aortic arch hypoplasia and small left-sided cardiac structures, successful biventricular repair is dependent on the adequacy of the left-sided structures. Defining accurate thresholds of echocardiographic indices predictive of successful biventricular repair is paramount to achieving optimal outcomes. We sought to identify pre-operative echocardiographic indices of left heart size that predict intervention-free survival in infants with small left heart structures undergoing primary aortic arch repair to establish biventricular circulation (BVC). Infants ≤2 months undergoing aortic arch repair from 1999 to 2010 with aortic and/or mitral valve hypoplasia, (Z-score ≤-2) were included. Pre-operative and follow-up echocardiograms were reviewed. Primary outcome was successful biventricular circulation (BVC), defined as freedom from death, transplant, or single ventricular conversion at 1 year. Need for catheter based or surgical re-intervention (RI), valve annular growth, and significant late aortic or mitral valve obstruction were additional outcomes. Fifty one of 73 subjects (79%) had successful BVC and were free of RI at 1 year. Seven subjects failed BVC; four of those died. The overall 1 year survival for the cohort was 95%. Fifteen subjects underwent a RI but maintained BVC. In univariate analysis, larger transverse aorta (p = 0.006) and aortic valve (p = 0.02) predicted successful BVC without RI. In CART analysis, the combination of mitral valve (MV) to tricuspid valve (TV) ratio ≤0.66 with an aortic valve (AV) annulus Z-score ≤-3 had the greatest power to predict BVC failure (sensitivity 71%, specificity 94%). In those with successful BVC, the combination of both AV and MV Z-score ≤-2.5 increased the odds of RI (OR 3.8; CI 1.3-11.4). Follow-up of non-RI subjects revealed improvement in AV and MV Z-score (median AV annulus changed over time from -2.34 to 0.04 (p < 0.001) and MV changed from -2.88 to -1.41 (p < 0.001), but residual mitral valve stenosis and aortic arch obstruction were present in one-third of subjects. In this cohort of infants requiring initial aortic arch repair with concomitant small left heart structures, successful BVC can be predicted from combined echocardiographic indices. In this complex population, 1 year survival is high, but the need for RI and the presence of residual lesions are common.

Three-dimensional printed prototypes refine the anatomy of post-modified Norwood-1 complex aortic arch obstruction and allow presurgical simulation of the repair.

PubMed

Kiraly, Laszlo; Tofeig, Magdi; Jha, Neerod Kumar; Talo, Haitham

2016-02-01

Three-dimensional (3D) printed prototypes of malformed hearts have been used for education, communication, presurgical planning and simulation. We present a case of a 5-month old infant with complex obstruction at the neoaortic to transverse arch and descending aortic junction following the neonatal modified Norwood-1 procedure for hypoplastic left heart syndrome. Digital 3D models were created from a routine 64-slice CT dataset; then life-size solid and magnified hollow models were printed with a 3D printer. The solid model provided further insights into details of the anatomy, whereas the surgical approach and steps of the operation were simulated on the hollow model. Intraoperative assessment confirmed the anatomical accuracy of the 3D models. The operation was performed in accordance with preoperative simulation: sliding autologous flaps achieved relief of the obstruction without additional patching. Knowledge gained from the models fundamentally contributed to successful outcome and improved patient safety. This case study presents an effective use of 3D models in exploring complex spatial relationship at the aortic arch and in simulation-based planning of the operative procedure. © The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

[Angiographic evaluation of branching pattern and anatomy of the aortic arch].

PubMed

Ergun, Onur; Tatar, İdil Güneş; Birgi, Erdem; Durmaz, Hasan Ali; Akçalar, Seray; Kurt, Aydın; Hekimoğlu, Baki

2015-04-01

The study aimed to investigate anatomical variations in branching pattern and anatomy of the aortic arch, and the prevalence of each type. Between September 2011 and November 2013, angiographic studies of 270 patients (144 male, 126 female) were analyzed retrospectively for variations in branching pattern and anatomy of the aortic arch. Patient mean age was 59.8 years (range, 13-88). Branching variations were found and divided into subtypes. Patients were also classified according to arch anatomy. Incidence of variations and types of aortic arch were statistically analysed. Analysis of the 270 patients revealed six types of branching pattern. Type I, classical pattern arch with three branches (TB, LCC, LS), was observed in 198 cases (73.3%). Type II (bovine arch), the most commonly observed variation, in which LCC originates from TB, was observed in 58 cases (21.5%). Type III, in which the left vertebral artery arises from the arch, was seen in seven cases (2.6%). Type IV, a combination of types II and III, was observed in three cases (1.1%). Type V, common origin of common carotids, LS and aberrant RS, was found in three cases (1.1%). Type VI (avian type), arch with only two branches, was observed in one case (0.4%). When patients were classified according to aortic arch anatomy, Type 1, Type 2 and Type 3 were observed in 195, 40 and 35 patients respectively. Knowledge of the variations and anatomy of the aortic arch is essential during interventional procedures and neck-thorax surgery.

Selective Heart, Brain and Body Perfusion in Open Aortic Arch Replacement.

PubMed

Maier, Sven; Kari, Fabian; Rylski, Bartosz; Siepe, Matthias; Benk, Christoph; Beyersdorf, Friedhelm

2016-09-01

Open aortic arch replacement is a complex and challenging procedure, especially in post dissection aneurysms and in redo procedures after previous surgery of the ascending aorta or aortic root. We report our experience with the simultaneous selective perfusion of heart, brain, and remaining body to ensure optimal perfusion and to minimize perfusion-related risks during these procedures. We used a specially configured heart-lung machine with a centrifugal pump as arterial pump and an additional roller pump for the selective cerebral perfusion. Initial arterial cannulation is achieved via femoral artery or right axillary artery. After lower body circulatory arrest and selective antegrade cerebral perfusion for the distal arch anastomosis, we started selective lower body perfusion simultaneously to the selective antegrade cerebral perfusion and heart perfusion. Eighteen patients were successfully treated with this perfusion strategy from October 2012 to November 2015. No complications related to the heart-lung machine and the cannulation occurred during the procedures. Mean cardiopulmonary bypass time was 239 ± 33 minutes, the simultaneous selective perfusion of brain, heart, and remaining body lasted 55 ± 23 minutes. One patient suffered temporary neurological deficit that resolved completely during intensive care unit stay. No patient experienced a permanent neurological deficit or end-organ dysfunction. These high-risk procedures require a concept with a special setup of the heart-lung machine. Our perfusion strategy for aortic arch replacement ensures a selective perfusion of heart, brain, and lower body during this complex procedure and we observed excellent outcomes in this small series. This perfusion strategy is also applicable for redo procedures.

Double Aortic Arch With Previously Undescribed Head and Neck Vessel Branching.

PubMed

Hashemi, Sassan; Parks, W James; Sallee, Denver; Slesnick, Timothy

2017-04-01

Vascular ring in the form of a double aortic arch is a rare anomaly that can cause airway compression. It occasionally occurs with unusual head and neck vessel branching. A 5-year-old boy with chronic respiratory symptoms was referred because of a tracheal indentation on his chest x-ray. Magnetic resonance imaging showed a double aortic arch with arch origins of a common carotid, vertebral, and subclavian on the right and internal and external carotids, vertebral, and subclavian arteries on the left. Our case represents, to our knowledge, the first report of a double aortic arch with 7 separate vessels arising from the transverse arches. Copyright © 2016 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.

Aortic Arch Morphology and Aortic Length in Patients with Dissection, Traumatic, and Aneurysmal Disease.

PubMed

Alberta, H B; Takayama, T; Smits, T C; Wendorff, B B; Cambria, R P; Farber, M A; Jordan, W D; Patel, V; Azizzadeh, A; Rovin, J D; Matsumura, J S

2015-12-01

To assess aortic arch morphology and aortic length in patients with dissection, traumatic injury, and aneurysm undergoing TEVAR, and to identify characteristics specific to different pathologies. This was a retrospective analysis of the aortic arch morphology and aortic length of dissection, traumatic injury, and aneurysmal patients. Computed tomography imaging was evaluated of 210 patients (49 dissection, 99 traumatic injury, 62 aneurysm) enrolled in three trials that received the conformable GORE TAG thoracic endoprosthesis. The mean age of trauma patients was 43 ± 19.6 years, 57 ± 11.7 years for dissection and 72 ± 9.6 years for aneurysm patients. A standardized protocol was used to measure aortic arch diameter, length, and take-off angle and clockface orientation of branch vessels. Differences in arch anatomy and length were assessed using ANOVA and independent t tests. Of the 210 arches evaluated, 22% had arch vessel common trunk configurations. The aortic diameter and the distance from the left main coronary (LMC) to the left common carotid (LCC) were greater in dissection patients than in trauma or aneurysm patients (p < .001). Aortic diameter in aneurysm patients was greater compared with trauma patients (p < .05). The distances from the branch vessels to the celiac artery (CA) were greater in dissection and aneurysm patients than in trauma patients (p < .001). The take-off angle of the innominate (I), LCCA, and left subclavian (LS) were greater, between 19% and 36%, in trauma patients than in dissection and aneurysm patients (p < .001). Clockface orientation of the arch vessels varies between pathologies. Arch anatomy has significant morphologic differences when comparing aortic pathologies. Describing these differences in a large sample of patients is beneficial for device designs and patient selection. Copyright © 2015 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.

Supravalvular aortic stenosis in adult with anomalies of aortic arch vessels and aortic regurgitation

PubMed Central

Valente, Acrisio Sales; Alencar, Polyanna; Santos, Alana Neiva; Lobo, Roberto Augusto de Mesquita; de Mesquita, Fernando Antônio; Guimarães, Aloyra Guedis

2013-01-01

The supravalvular aortic stenosis is a rare congenital heart defect being very uncommon in adults. We present a case of supravalvular aortic stenosis in adult associated with anomalies of the aortic arch vessels and aortic regurgitation, which was submitted to aortic valve replacement and arterioplasty of the ascending aorta with a good postoperative course. PMID:24598962

Saccular aortic aneurysm that resembled a mediastinal neoplasm

PubMed Central

Nose, Naohiro; Kataoka, Hiroumi; Hamada, Masakatsu; Kosako, Yukio; Matsuno, Yasuji; Ishii, Takahiro

2012-01-01

INTRODUCTION Saccular aortic arch aneurysms in unusual sites may be misdiagnosed as a neoplasm. We present the case of a rare saccular aortic arch aneurysm between trachea and esophagus that resembled a mediastinal neoplasm in the preoperative findings. PRESENTATION OF CASE A 63-year-old male with an abnormal mediastinal shadow on chest X-ray was referred to the hospital. An axial plain computed tomogram of the chest revealed mediastinal soft tissue next to the right side of the aortic arch resembling a neoplasm originating from the gap between the trachea and the esophagus. The coronal view constructed by enhanced 64-row multi detector computed tomography revealed the soft tissue was an aneurysm arising from the inner side of the aortic arch. An aortic arch replacement was performed via a median sternotomy. DISCUSSION A thoracic aortic aneurysm sometimes behaves like a mediastinal neoplasm. The multiple cross-sectional image from multidetector computed tomography was useful for the correct diagnosis of such an aneurysm. CONCLUSION The possibility of an aneurysm should be considered whenever a mass in contact with the aortic wall is identified. PMID:22995656

Right Cervical Aortic Arch and Pseudocoarctation of the Aorta Associated with Aneurysms and Steal Phenomena: US, CTA, and MRA Findings

DOE Office of Scientific and Technical Information (OSTI.GOV)

Tanju, Sumru, E-mail: sumrutanju@yahoo.com; Ustuner, Evren; Erden, Ilhan

A 55-year-old woman presented with right cervical aortic arch with pseudocoarctation of the aorta further complicated by the presence of multiple aneurysms and a high-grade stenosis at the origin of the left subclavian trunk from the aorta causing a discrepancy in blood pressure between the right and left arms. The branching pattern and the resulting complex steal syndromes involving the left carotid and the subclavian system are unique. The computed tomography angiography, magnetic resonance angiography, and Doppler ultrasound findings are described.

Brain protection in aortic arch aneurysm: antegrade or retrograde?

PubMed

Harky, Amer; Fok, Matthew; Bashir, Mohamad; Estrera, Anthony L

2018-01-03

During open aortic arch repair, there is an interruption of cerebral perfusion and to prevent neurological sequelae, the hypothermic circulatory arrest has been established to provide sufficient brain protection coupled with adjuncts including retrograde and antegrade cerebral perfusion. To date, brain protection during open aortic arch repair is a contested topic as to which provides superior brain protection with little evidence existing to suggest supremacy of one modality over the other. This article reviews current literature reflecting on key and emerging studies in brain protection and their associated outcomes in patients undergoing open aortic arch surgery.

Aortic Arch Aneurysms: Treatment with Extra anatomical Bypass and Endovascular Stent-Grafting

DOE Office of Scientific and Technical Information (OSTI.GOV)

Kato, Noriyuki; Shimono, Takatsugu; Hirano, Tadanori

2002-10-15

Endovascular repair of thoracic aortic aneurysms is emerging as an attractive alternative to surgical graft replacement. However,patients with aortic arch aneurysms are often excluded from the target of endovascular repair because of lack of suitable landing zones, especially at the proximal ones. In this paper we describe our method for treating patients with aortic arch aneurysms using a combination of extra anatomical bypass surgery and endovascular stent-grafting.

Angiotensin converting enzyme inhibitors and aortic arch obstructive malformations.

PubMed

Maliheh, Kadivar; Abdorrazagh, Kiani; Armen, Kocharian; Reza, Shabanian

2006-10-01

We describe two newborn infants with aortic arch obstructive malformations who became anuric after initiation of captopril. Since angiotensin converting enzyme inhibitors can alter renal blood flow by reduction in angiotensin II and blocking autoregulation phenomenon, it is important to use them with great caution in neonates with aortic arch obstructive malformations, while monitoring their renal function closely.

Abnormal aortic arch morphology in Turner syndrome patients is a risk factor for hypertension.

PubMed

De Groote, Katya; Devos, Daniël; Van Herck, Koen; Demulier, Laurent; Buysse, Wesley; De Schepper, Jean; De Wolf, Daniël

2015-09-01

Hypertension in Turner syndrome (TS) is a multifactorial, highly prevalent and significant problem that warrants timely diagnosis and rigorous treatment. The objective of this study was to investigate the association between abnormal aortic arch morphology and hypertension in adult TS patients. This was a single centre retrospective study in 74 adult TS patients (age 29.41 ± 8.91 years) who underwent a routine cardiac MRI. Patients were assigned to the hypertensive group (N = 31) if blood pressure exceeded 140/90 mmHg and/or if they were treated with antihypertensive medication. Aortic arch morphology was evaluated on MRI images and initially assigned as normal (N = 54) or abnormal (N = 20), based on the curve of the transverse arch and the distance between the left common carotid-left subclavian artery. We additionally used a new more objective method to describe aortic arch abnormality in TS by determination of the relative position of the highest point of the transverse arch (AoHP). Logistic regression analysis showed that hypertension is significantly and independently associated with age, BMI and abnormal arch morphology, with a larger effect size for the new AoHP method than for the classical method. TS patients with hypertension and abnormal arch morphology more often had dilatation of the ascending aorta. There is a significant association between abnormal arch morphology and hypertension in TS patients, independent of age and BMI, and not related to other structural heart disease. We suggest that aortic arch morphology should be included in the risk stratification for hypertension in TS and propose a new quantitative method to express aortic arch morphology.

Advances in aortic disease management: a year in review.

PubMed

Garg, Vinay; Ouzounian, Maral; Peterson, Mark D

2016-03-01

The medical and surgical management of aortic disease is continually changing in search for improved outcomes. Our objective is to highlight recent advances in a few select areas pertaining to aortic disease and aortic surgery: the genetics of aortopathy, medical therapy of aortic aneurysms, advances in cardiac imaging, and operative strategies for the aortic arch. As our understanding of the genetic basis for aortopathy continues to improve, routine genetic testing may be of value in assessing patients with genetically triggered forms of aortic disease. With regard to medical advances, treating patients with Marfan syndrome with either losartan or atenolol at an earlier stage in their disease course improves outcomes. In addition, novel imaging indices such as wall shear stress and aortic stiffness assessed by MRI may become useful markers of aortopathy and warrant further study. With regard to the optimal technique for cerebral perfusion in aortic arch surgery, high-quality data are still lacking. Finally, in patients with complex, multilevel aortic disease, the frozen elephant trunk is a viable single-stage option compared with the conventional elephant trunk, although with an increased risk for spinal cord injury. Based on recent advances, continued studies in genetics, cardiac imaging, and surgical trials will further elucidate the etiology of aortopathy and ultimately guide management, both medically and surgically.

Aortic Elongation and Stanford B Dissection: The Tübingen Aortic Pathoanatomy (TAIPAN) Project.

PubMed

Lescan, M; Veseli, K; Oikonomou, A; Walker, T; Lausberg, H; Blumenstock, G; Bamberg, F; Schlensak, C; Krüger, T

2017-08-01

Aortic elongation has not yet been considered as a potential risk factor for Stanford type B dissection (TBD). The role of both aortic elongation and dilatation in patients with TBD was evaluated. The aortic morphology of a healthy control group (n = 236) and patients with TBD (n = 96) was retrospectively examined using three dimensional computed tomography imaging. Curved multiplanar reformats were used to examine aortic diameters at defined landmarks and aortic segment lengths. Diameters at all landmarks were significantly larger in the TBD group. The greatest diameter difference (56%) was measured in dissected descending aortas (p < .001). The segment with the most considerable difference between the study groups with regard to elongation was the non-dissected aortic arch of patients with TBD (36%; p < .001). Elongation in the aortic arch was accompanied by a diameter increase of 21% (p < .001). In receiver-operating curve analysis, the area under the curve was .85 for the diameter and .86 for the length of the aortic arch. In addition to dilatation, aortic arch elongation is associated with the development of TBD. The diameter and length of the non-dissected aortic arch may be predictive for TBD and may possibly be used for risk assessment in the future. This study provides the basis for further prospective evaluation of these parameters. Copyright © 2017 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.

Anomalous Origin of the Left Vertebral Artery from the Aortic Arch

PubMed Central

Einstein, Evan H.; Song, Linda H.; Villela, Natalia L. A.; Fasani-Feldberg, Gregory B.; Jacobs, Jonathan L.; Kim, Dolly O.; Nathawat, Akshay; Patel, Devika; Bender, Roger B.; Peters, Daniel F.

2016-01-01

Anatomic anomalies of the aortic arch have implications for clinical practice if their significance is understood. Our case study involves a cadaveric finding of the left vertebral artery originating directly from the aortic arch. Although this anatomical variation has been documented, the prevalence of this anomaly may be generally underestimated. After noting this anomaly, we analyzed 27 cases and found that four female cadavers had the left vertebral artery originating from the aortic arch rather than the left subclavian artery. With a prevalence rate of 14.8%, it would seem that this anomaly is more significant than previously thought, which could have implications for surgical practice. PMID:27757404

Anomalous Origin of the Left Vertebral Artery from the Aortic Arch.

PubMed

Einstein, Evan H; Song, Linda H; Villela, Natalia L A; Fasani-Feldberg, Gregory B; Jacobs, Jonathan L; Kim, Dolly O; Nathawat, Akshay; Patel, Devika; Bender, Roger B; Peters, Daniel F

2016-04-01

Anatomic anomalies of the aortic arch have implications for clinical practice if their significance is understood. Our case study involves a cadaveric finding of the left vertebral artery originating directly from the aortic arch. Although this anatomical variation has been documented, the prevalence of this anomaly may be generally underestimated. After noting this anomaly, we analyzed 27 cases and found that four female cadavers had the left vertebral artery originating from the aortic arch rather than the left subclavian artery. With a prevalence rate of 14.8%, it would seem that this anomaly is more significant than previously thought, which could have implications for surgical practice.

Quantification of motion of the thoracic aorta after ascending aortic repair of type-A dissection.

PubMed

Suh, Ga-Young; Fleischmann, Dominik; Beygui, Ramin E; Cheng, Christopher P

2017-05-01

To quantify cardiac and respiratory deformations of the thoracic aorta after ascending aortic graft repair. Eight patients were scanned with cardiac-resolved computed tomography angiography during inspiratory/expiratory breath-holds. Aortic centerlines and lumen were extracted to compute the arclength, curvature, angulation, and cross-section shape. From systole to diastole, the angle of graft [Formula: see text] arch increased by 2.4[Formula: see text] ± 1.8[Formula: see text] (P < 0.01) and the angle of arch [Formula: see text] descending aorta decreased by 2.4[Formula: see text] ± 2.6[Formula: see text] (P < 0.05), while the effective diameter of the proximal arch decreased by 2.4 ± 1.9% (P < 0.01), a greater change than those of the graft or distal arch (P < 0.05). From inspiration to expiration, the angle of graft [Formula: see text] arch increased by 2.8[Formula: see text] ± 2.6[Formula: see text] (P < 0.02) with the peak curvature increase (P < 0.05). Shorter graft length was correlated with greater cardiac-induced graft [Formula: see text] arch angulation, and longer graft length was correlated with greater respiratory-induced arch [Formula: see text] descending aorta angulation (R [Formula: see text] 0.50). The thoracic aorta changed curvature and angulation with cardiac and respiratory influences, driven by aortic root and arch motion. The thoracic aortic geometry and deformation are correlated with the ascending aortic graft length.

How to Perfuse: Concepts of Cerebral Protection during Arch Replacement

PubMed Central

Habertheuer, Andreas; Wiedemann, Dominik; Kocher, Alfred; Laufer, Guenther; Vallabhajosyula, Prashanth

2015-01-01

Arch surgery remains undoubtedly among the most technically and strategically challenging endeavors in cardiovascular surgery. Surgical interventions of thoracic aneurysms involving the aortic arch require complete circulatory arrest in deep hypothermia (DHCA) or elaborate cerebral perfusion strategies with varying degrees of hypothermia to achieve satisfactory protection of the brain from ischemic insults, that is, unilateral/bilateral antegrade cerebral perfusion (ACP) and retrograde cerebral perfusion (RCP). Despite sophisticated and increasingly individualized surgical approaches for complex aortic pathologies, there remains a lack of consensus regarding the optimal method of cerebral protection and circulatory management during the time of arch exclusion. Many recent studies argue in favor of ACP with various degrees of hypothermic arrest during arch reconstruction and its advantages have been widely demonstrated. In fact ACP with more moderate degrees of hypothermia represents a paradigm shift in the cardiac surgery community and is widely adopted as an emergent strategy; however, many centers continue to report good results using other perfusion strategies. Amidst this important discussion we review currently available surgical strategies of cerebral protection management and compare the results of recent European multicenter and single-center data. PMID:26713319

Influences on Early and Medium-Term Survival Following Surgical Repair of the Aortic Arch

PubMed Central

Bashir, Mohamad; Field, Mark; Shaw, Matthew; Fok, Matthew; Harrington, Deborah; Kuduvalli, Manoj; Oo, Aung

2014-01-01

Objectives: It is now well established by many groups that surgery on the aortic arch may be achieved with consistently low morbidity and mortality along with relatively good survival compared to estimated natural history for a number of aortic arch pathologies. The objectives of this study were to: 1) report, compare, and analyze our morbidity and mortality outcomes for hemiarch and total aortic arch surgery; 2) examine the survival benefit of hemiarch and total aortic arch surgery compared to age- and sex-matched controls; and 3) define factors which influence survival in these two groups and, in particular, identify those that are modifiable and potentially actionable. Methods: Outcomes from patients undergoing surgical resection of both hemiarch and total aortic arch at the Liverpool Heart and Chest Hospital between June 1999 and December 2012 were examined in a retrospective analysis of data collected for The Society for Cardiothoracic Surgeons (UK). Results: Over the period studied, a total of 1240 patients underwent aortic surgery, from which 287 were identified as having undergone hemi to total aortic arch surgery under deep or moderate hypothermic circulatory arrest. Twenty three percent of patients' surgeries were nonelective. The median age at the time of patients undergoing elective hemiarch was 64.3 years and total arch was 65.3 years (P = 0.25), with 40.1% being female in the entire group. A total of 140 patients underwent elective hemiarch replacement, while 81 underwent elective total arch replacement. Etiology of the aortic pathology was degenerative in 51.2% of the two groups, with 87.1% requiring aortic valve repair in the elective hemiarch group and 64.2% in the elective total arch group (P < 0.001). Elective in-hospital mortality was 2.1% in the hemiarch group and 6.2% (P = 0.15) in the total arch group with corresponding rates of stroke (2.9% versus 4.9%, P = 0.47), renal failure (4.3% versus 6.2%, P = 0.54), reexploration for bleeding (4.3% versus 4.9%, P > 0.99), and prolonged ventilation (8.6% versus 16.1%, P = 0.09). Overall mortality was 20.9% at 5 years, while it was 15.7% in the elective hemiarch and 25.9% in the total arch group (P = 0.065). Process control charts demonstrated stability of annualized mortality outcomes over the study period. Survival curve was flat and parallel compared to age- and sex-matched controls beyond 2 years. Multivariate analysis demonstrated the following independent factors associated with survival: renal dysfunction [hazard ratio (HR) = 3.11; 95% confidence interval (CI) = 1.44-6.73], New York Heart Association (NYHA) class ≥ III (HR = 2.25; 95% CI = 1.38-3.67), circulatory arrest time > 100 minutes (HR = 2.92; 95% CI = 1.57-5.43), peripheral vascular disease (HR = 2.44; 95% CI = 1.25-4.74), and concomitant coronary artery bypass graft operation (HR = 2.14; 95% CI = 1.20-3.80). Conclusions: Morbidity, mortality, and medium-term survival were not statistically different for patients undergoing elective hemi-aortic arch and total aortic arch surgery. The survival curve in this group of patients is flat and parallel to sex- and age-matched controls beyond 2 years. Multivariate analysis identified independent influences on survival as renal dysfunction, NYHA class ≥ III, circulatory arrest time (> 100 min), peripheral vascular disease, and concomitant coronary artery bypass grafting. Focus on preoperative optimization of some of these variables may positively influence long-term survival. PMID:26798716

Evaluation and Influence of Brachiocephalic Branch Re-entry in Patients With Type A Acute Aortic Dissection.

PubMed

Yasuda, Shota; Imoto, Kiyotaka; Uchida, Keiji; Karube, Norihisa; Minami, Tomoyuki; Goda, Motohiko; Suzuki, Shinichi; Masuda, Munetaka

2016-12-22

Stanford type A acute aortic dissection (A-AAD) extends to the brachiocephalic branches in some patients. After ascending aortic replacement, a remaining re-entry tear in the distal brachiocephalic branches may act as an entry and result in a patent false lumen in the aortic arch. However, the effect of brachiocephalic branch re-entry concomitant with A-AAD remains unknown.Methods and Results:Eighty-five patients with A-AAD who underwent ascending aortic replacement in which both preoperative and postoperative multiple-detector computed tomography (MDCT) scans could be evaluated were retrospectively studied. The presence of a patent false lumen in at least one of the brachiocephalic branches on preoperative MDCT was defined as brachiocephalic branch re-entry, and 41 patients (48%) had this. Postoperatively, 47 of 85 (55%) patients had a patent false lumen in the aortic arch. False lumen remained patent after operation in 34 out of the 41 (83%) patients with brachiocephalic branch re-entry, as compared to that in 13 of the 44 (30%) patients without such re-entry (P<0.001). Brachiocephalic branch re-entry was a significant risk factor for a late increase in the aortic arch diameter greater than 10 mm (P=0.047). Brachiocephalic branch re-entry in patients with A-AAD is related to a patent false lumen in the aortic arch early after ascending aortic replacement and is a risk factor for late aortic arch enlargement.

Loss of unc45a precipitates arteriovenous shunting in the aortic arches

PubMed Central

Anderson, Matthew J.; Pham, Van N.; Vogel, Andreas M.; Weinstein, Brant M.; Roman, Beth L.

2008-01-01

Aortic arch malformations are common congenital disorders that are frequently of unknown etiology. To gain insight into the factors that guide branchial aortic arch development, we examined the process by which these vessels assemble in wild type zebrafish embryos and in kurzschlusstr12 (kus tr12) mutants. In wild type embryos, each branchial aortic arch first appears as an island of angioblasts in the lateral pharyngeal mesoderm, then elaborates by angiogenesis to connect to the lateral dorsal aorta and ventral aorta. In kustr12 mutants, angioblast formation and initial sprouting are normal, but aortic arches 5 and 6 fail to form a lumenized connection to the lateral dorsal aorta. Blood enters these blind-ending vessels from the ventral aorta, distending the arteries and precipitating fusion with an adjacent vein. This arteriovenous malformation (AVM), which shunts nearly all blood directly back to the heart, is not genetically programmed, as its formation correlates with blood flow and aortic arch enlargement. By positional cloning, we have identified a nonsense mutation in unc45a in kustr12 mutants. Our results are the first to ascribe a role for Unc45a, a putative myosin chaperone, in vertebrate development, and identify a novel mechanism by which an AVM can form. PMID:18462713

Neonatal repair of right interrupted aortic arch with cerebro-myocardial perfusion technique.

PubMed

Takeuchi, Koh; Masuzawa, Akihiro; Kobayashi, Jotaro; Tsuchiya, Keiji

2011-10-01

Right interrupted aortic arch and descending aorta is exceedingly rare and most likely cause respiratory presentation, since patent ductus arteriosus (PDA) courses over the right mainstem bronchus. We report a case of successful neonatal biventricular repair of a right interrupted aortic arch (type B), with an aberrant right subclavian artery ventricular septal defect (VSD) in a 2.7 kg term neonate with DiGeorge syndrome. Patient presented in severe respiratory distress and acidosis at one day old. Two-dimensional (2D) echocardiography revealed aortic arch interruption beyond the common carotid arteries with large perimembranous outlet VSD. Aortic annulus diameter was 4.8 mm and there was no left ventricle (LV) outflow tract obstruction. Three-dimensional (3D) CT-scan confirmed these findings and identified a right-sided ductal arch that continued over the right mainstem bronchus into a right-sided descending aorta and aberrant right subclavian artery. Brachiocephalic perfusion and ductal perfusion was employed for cooling during cardiopulmonary bypass. Under deep hypothermia (27 °C rectal temperature), selective cerebro-myocardial perfusion was used for successful aortic arch repair without sacrificing the aberrant right subclavian artery. A direct tension-free anastomosis was attained. Her postoperative course was uneventful and her respiratory symptoms disappeared postoperatively. Early surgical correction is mandatory for these patients with unique anatomy and presentation.

Anatomic variations of the branches of the aortic arch in a Peruvian population.

PubMed

Huapaya, Julio Arturo; Chávez-Trujillo, Kristhy; Trelles, Miguel; Dueñas Carbajal, Roy; Ferrandiz Espadin, Renato

2015-07-31

Previous publications from two countries in South America found one anatomical variation not previously reported in the rest of the world, which in turn give some clues with regard to a racial difference. The objective of the present study is to describe variations in the anatomical distribution of the branches of the aortic arch in a Peruvian population. To describe variations in the anatomical distribution of the branches of the aortic arch in a Peruvian population. A descriptive study of patients who underwent a tomography angiography of the aorta was performed. We analyzed the reports that showed the description of the variations of the branches of the aortic arch based on the eight types currently described in the literature. From 361 analyzed reports, 282 patients (78.12%) had a normal aortic arch configuration (type I; aortic arch gives rise to the brachiocephalic trunk, left common carotid and left subclavian arteries); followed by type II (left common carotid artery as a branch of the aorta) with 41 patients (11.36%); and type IX (common ostium for the brachiocephalic trunk and the left common carotid artery) with 25 patients (6.93%). The latter and two other types are new variations. Aortic Arch Type I, Type II and Type IX were the most frequent variations in this Peruvian study. Additionally, we also found two more new types that have not been previously described in the literature. Further investigation regarding these variations is needed in order to assess a racial factor in South America and possible relationships with clinical or surgical events.

Concomitant Reconstruction of Arch Vessels during Repair of Aortic Dissection

PubMed Central

Nezic, Dusko; Vukovic, Petar; Jovanovic, Marko; Lozuk, Branko; Jagodic, Sinisa; Djukanovic, Bosko

2014-01-01

Surgery for acute aortic dissection is challenging, especially in cases of cerebral malperfusion. Should we perform only the aortic repair, or should we also reconstruct the arch vessels when they are severely affected by the disease process? Here we present a case of acute aortic dissection with multiple tears that involved the brachiocephalic artery and caused cerebral and right upper-extremity malperfusion. The patient successfully underwent complete replacement of the brachiocephalic artery and the aortic arch during deep hypothermic circulatory arrest, with antegrade cerebral protection. We have found this technique to be safe and reproducible for use in this group of patients. PMID:25120398

Concomitant reconstruction of arch vessels during repair of aortic dissection.

PubMed

Micovic, Slobodan; Nezic, Dusko; Vukovic, Petar; Jovanovic, Marko; Lozuk, Branko; Jagodic, Sinisa; Djukanovic, Bosko

2014-08-01

Surgery for acute aortic dissection is challenging, especially in cases of cerebral malperfusion. Should we perform only the aortic repair, or should we also reconstruct the arch vessels when they are severely affected by the disease process? Here we present a case of acute aortic dissection with multiple tears that involved the brachiocephalic artery and caused cerebral and right upper-extremity malperfusion. The patient successfully underwent complete replacement of the brachiocephalic artery and the aortic arch during deep hypothermic circulatory arrest, with antegrade cerebral protection. We have found this technique to be safe and reproducible for use in this group of patients.

Total Arch versus Hemiarch Replacement for Type A Acute Aortic Dissection: A Single-Center Experience.

PubMed

Lio, Antonio; Nicolò, Francesca; Bovio, Emanuele; Serrao, Andrea; Zeitani, Jacob; Scafuri, Antonio; Chiariello, Luigi; Ruvolo, Giovanni

2016-12-01

We retrospectively evaluated early and intermediate outcomes of aortic arch surgery in patients with type A acute aortic dissection (AAD), investigating the effect of arch surgery extension on postoperative results. From January 2006 through July 2013, 201 patients with type A AAD underwent urgent corrective surgery at our institution. Of the 92 patients chosen for this study, 59 underwent hemiarch replacement (hemiarch group), and 33 underwent total arch replacement (total arch group) in conjunction with ascending aorta replacement. The operative mortality rate was 22%. Total arch replacement was associated with a 33% risk of operative death, versus 15% for hemiarch ( P =0.044). Multivariable analysis found these independent predictors of operative death: age (odds ratio [OR]=1.13/yr; 95% confidence interval [CI], 1.04-1.23; P =0.002), body mass index >30 kg/m 2 (OR=9.9; 95% CI, 1.28-19; P =0.028), postoperative low cardiac output (OR=10.6; 95% CI, 1.18-25; P =0.035), and total arch replacement (OR=8.8; 95% CI, 1.39-15; P =0.021) The mean overall 5-year survival rate was 59.3% ± 5.5%, and mean 5-year freedom from distal reintervention was 95.4% ± 3.2% ( P =NS). In type A AAD, aortic arch surgery is still associated with high operative mortality rates; hemiarch replacement can be performed more safely than total arch replacement. Rates of distal aortic reoperation were not different between the 2 surgical strategies.

Aortic Arch Plaques and Risk of Recurrent Stroke and Death

PubMed Central

Di Tullio, Marco R.; Russo, Cesare; Jin, Zhezhen; Sacco, Ralph L.; Mohr, J.P.; Homma, Shunichi

2010-01-01

Background Aortic arch plaques are a risk factor for ischemic stroke. Although the stroke mechanism is conceivably thromboembolic, no randomized studies have evaluated the efficacy of antithrombotic therapies in preventing recurrent events. Methods and Results The relationship between arch plaques and recurrent events was studied in 516 patients with ischemic stroke, double–blindly randomized to treatment with warfarin or aspirin as part of the Patent Foramen Ovale in Cryptogenic Stroke Study (PICSS), based on the Warfarin-Aspirin Recurrent Stroke Study (WARSS). Plaque thickness and morphology was evaluated by transesophageal echocardiography. End-points were recurrent ischemic stroke or death over a 2-year follow-up. Large plaques (≥4mm) were present in 19.6% of patients, large complex plaques (those with ulcerations or mobile components) in 8.5 %. During follow-up, large plaques were associated with a significantly increased risk of events (adjusted Hazard Ratio 2.12, 95% Confidence Interval 1.04-4.32), especially those with complex morphology (HR 2.55, CI 1.10-5.89). The risk was highest among cryptogenic stroke patients, both for large plaques (HR 6.42, CI 1.62-25.46) and large-complex plaques (HR 9.50, CI 1.92-47.10). Event rates were similar in the warfarin and aspirin groups in the overall study population (16.4% vs. 15.8%; p=0.43). Conclusions In patients with stroke, and especially cryptogenic stroke, large aortic plaques remain associated with an increased risk of recurrent stroke and death at two years despite treatment with warfarin or aspirin. Complex plaque morphology confers a slight additional increase in risk. PMID:19380621

Endovascular Repair of a Right-Sided Descending Thoracic Aortic Aneurysm Associated with a Right Aortic Arch and a Left Subclavian Artery Arising from a Kommerell's Diverticulum

DOE Office of Scientific and Technical Information (OSTI.GOV)

Klonaris, Chris, E-mail: chris_klonaris@yahoo.com; Avgerinos, Efthimios D.; Katsargyris, Athanasios

2009-07-15

This case report describes the endovascular repair of a right-sided descending thoracic aortic aneurysm associated with a right aortic arch and an aberrant left subclavian artery. A 76-year-old male with multiple comorbidities was incidentally found to have a right-sided descending thoracic aortic aneurysm with a maximum diameter of 6.2 cm. Additionally, there was a right aortic arch with a retroesophageal segment and separate arch branches arising in the following order: left common carotid artery, right common carotid artery, right subclavian artery, and left subclavian artery that was aberrant, arising from a Kommerrell's diverticulum. The aneurysm was successfully excluded by deploymentmore » of a Zenith TX1 36 x 32 x 20-mm stent-graft using wire traction technique via the left femoral and right brachial arteries in order to deal with two severe aortic angulations. At 18-month follow-up the patient was doing well, with aneurysm sac shrinkage to 5.9 cm and no signs of endoleak or migration. Endovascular repair of right-sided descending thoracic aortic aneurysms with a right arch and aberrant left subclavian artery is feasible, safe, and effective. In such rare configurations, which demand considerably increased technical dexterity and center experience, endovascular repair emerges as an attractive therapeutic option.« less

Incidence of Branching Patterns Variations of the Arch in Aortic Dissection in Chinese Patients

PubMed Central

Tapia, G. Pullas; Zhu, Xiaohua; Xu, Jing; Liang, Pan; Su, Gang; Liu, Hai; Liu, Yang; Shu, Liliang; Liu, Shuiqi; Huang, Chen

2015-01-01

Abstract Several authors have described anatomic variations of the aortic arch in 13% to 20% of the patients who do not have aortic disease. However, few studies have evaluated these patterns in the thoracic aortic dissection (TAD). In the authors’ knowledge, this is the first survey that specifically investigates the frequency of these variations in a broad, nonselected group of Chinese patients with aortic dissection. Furthermore, it compares this group with a group of patients without aortic disease. The objective of this study was to define the variation frequency of the aortic arch branches pattern using the tomographic studies of 525 Chinese patients with a diagnosis of TAD. The Stanford classification was used to set the site of the initial tear of the dissection. In addition, we performed an epidemiological analysis of the aortic arch anatomic variations in TAD, and its possible implications for surgical or endovascular treatment. The general hypothesis proposal asserted that Chinese patients with dissection of the aorta have a similar incidence of variations of the aortic arch to the patients without aortic disease. A retrospective study of cases and controls was carried out using the tomographic studies (CT) of all patients admitted to the First Affiliated Hospital of Zhengzhou University, located at Henan-China, with a confirmed diagnosis of aortic dissection from January 2012 until December 2014. The group of cases consisted of 525 patients: 374 men and 151 women, with a mean age of 52.27 years (range, 20–89). The average age of the patients with Stanford A and B aortic dissection was 49.46 and 53.67, respectively. The control group consisted of 525 unselected patients without TAD who underwent a CT scan of the chest due to other indications. This group consisted of 286 men and 239 women, with a mean age of 53.60 years (range, 18–89). All the patients with aneurysm or dissection were excluded from the control group. We performed a statistical analysis of demographic data. The study found 7 different patterns of the aortic arch on both groups of cases and controls. Within the 525 patients with TAD were observed 85 (16.19%) anatomical variations, while the control group showed 112 variations (21.33%); P = 0.033. The most common anatomical variant was the bovine arch, found in 62 (11.80%) cases of TAD compared with 77 (14.66%) in the control group; P = 0.172. Anatomical variations were observed in 14.32% of the patients with Stanford A dissection and 17.09% of the patients with Stanford B dissection; P = 0.425. Patients with Stanford A dissection showed the pattern of bovine arch in 23 (13.21%) of 174 cases. In contrast, the patients with Stanford B dissection showed it in 39 (11.11%) of 351 cases; P = 0.481. The anatomical variant defined as vertebral artery of direct origin of the aortic arch was more frequent in the patients with Stanford B dissection (5.12%). The patients with Stanford A dissection presented this pattern in 1.14% of the cases; P = 0.025. This study observed an increased frequency of aortic dissection in the subgroup from 41 to 60 years old. In the subgroup from 41 to 60 years old without TAD, a greater frequency of anatomical variations were found than in the patients with TAD (20.81% vs 14.23%; P = 0.050). The same fashion was seen in patients older than 80 years (27.27% vs 0%; P = 0.030). The anatomical variations of the aortic arch with TAD occurred in 14.97% of the male patients and 19.20% of the female patients compared to 21.67% to 20.92% in the control group; P = 0.026 and P = 0.681, respectively. The aortic arch variations were found less frequently in the TAD group than in the control group in the present Chinese series. The bovine arch was considered the variant pattern of the major frequency in the patients with TAD and the control group. The anatomical variant of 4 branches, defined as vertebral artery of direct origin of the aortic arch, was more frequent in patients with Stanford B aortic dissection than in the patients with Stanford A. This finding might show an association between the geometry of the aortic arch and the site of onset of first intimal tear of dissection. PMID:25929931

Incidence of branching patterns variations of the arch in aortic dissection in Chinese patients.

PubMed

Tapia, G Pullas; Zhu, Xiaohua; Xu, Jing; Liang, Pan; Su, Gang; Liu, Hai; Liu, Yang; Shu, Liliang; Liu, Shuiqi; Huang, Chen

2015-05-01

Several authors have described anatomic variations of the aortic arch in 13% to 20% of the patients who do not have aortic disease. However, few studies have evaluated these patterns in the thoracic aortic dissection (TAD). In the authors' knowledge, this is the first survey that specifically investigates the frequency of these variations in a broad, nonselected group of Chinese patients with aortic dissection. Furthermore, it compares this group with a group of patients without aortic disease.The objective of this study was to define the variation frequency of the aortic arch branches pattern using the tomographic studies of 525 Chinese patients with a diagnosis of TAD. The Stanford classification was used to set the site of the initial tear of the dissection. In addition, we performed an epidemiological analysis of the aortic arch anatomic variations in TAD, and its possible implications for surgical or endovascular treatment. The general hypothesis proposal asserted that Chinese patients with dissection of the aorta have a similar incidence of variations of the aortic arch to the patients without aortic disease.A retrospective study of cases and controls was carried out using the tomographic studies (CT) of all patients admitted to the First Affiliated Hospital of Zhengzhou University, located at Henan-China, with a confirmed diagnosis of aortic dissection from January 2012 until December 2014. The group of cases consisted of 525 patients: 374 men and 151 women, with a mean age of 52.27 years (range, 20-89). The average age of the patients with Stanford A and B aortic dissection was 49.46 and 53.67, respectively. The control group consisted of 525 unselected patients without TAD who underwent a CT scan of the chest due to other indications. This group consisted of 286 men and 239 women, with a mean age of 53.60 years (range, 18-89). All the patients with aneurysm or dissection were excluded from the control group. We performed a statistical analysis of demographic data.The study found 7 different patterns of the aortic arch on both groups of cases and controls. Within the 525 patients with TAD were observed 85 (16.19%) anatomical variations, while the control group showed 112 variations (21.33%); P = 0.033. The most common anatomical variant was the bovine arch, found in 62 (11.80%) cases of TAD compared with 77 (14.66%) in the control group; P = 0.172. Anatomical variations were observed in 14.32% of the patients with Stanford A dissection and 17.09% of the patients with Stanford B dissection; P = 0.425. Patients with Stanford A dissection showed the pattern of bovine arch in 23 (13.21%) of 174 cases. In contrast, the patients with Stanford B dissection showed it in 39 (11.11%) of 351 cases; P = 0.481. The anatomical variant defined as vertebral artery of direct origin of the aortic arch was more frequent in the patients with Stanford B dissection (5.12%). The patients with Stanford A dissection presented this pattern in 1.14% of the cases; P = 0.025. This study observed an increased frequency of aortic dissection in the subgroup from 41 to 60 years old. In the subgroup from 41 to 60 years old without TAD, a greater frequency of anatomical variations were found than in the patients with TAD (20.81% vs 14.23%; P = 0.050). The same fashion was seen in patients older than 80 years (27.27% vs 0%; P = 0.030). The anatomical variations of the aortic arch with TAD occurred in 14.97% of the male patients and 19.20% of the female patients compared to 21.67% to 20.92% in the control group; P = 0.026 and P = 0.681, respectively.The aortic arch variations were found less frequently in the TAD group than in the control group in the present Chinese series. The bovine arch was considered the variant pattern of the major frequency in the patients with TAD and the control group. The anatomical variant of 4 branches, defined as vertebral artery of direct origin of the aortic arch, was more frequent in patients with Stanford B aortic dissection than in the patients with Stanford A.This finding might show an association between the geometry of the aortic arch and the site of onset of first intimal tear of dissection.

Blunt Traumatic Aortic Injury of Right Aortic Arch in a Patient with an Aberrant Left Subclavian Artery

PubMed Central

Yeo, Daryl Li-Tian; Haider, Sajjad; Zhen, Claire Alexandra Chew

2015-01-01

Right-sided aortic arch (RAA) is a rare congenital developmental variant present in about 0.1 percent of the population. This anatomical anomaly is commonly associated with congenital heart disease and complications from compression of mediastinal structures. However, it is unknown if patients are at a higher risk of blunt thoracic aortic injury (BTAI). We report a case of a 20-year-old man admitted to the hospital after being hit by an automobile. Computed tomographic scan revealed an RAA with an aberrant left subclavian artery originating from a Kommerell’s diverticulum. A pseudo-aneurysm was also seen along the aortic arch. A diagnosis of blunt traumatic aortic injury was made. The patient was successfully treated with a 26mm Vascutek hybrid stentgraft using the frozen elephant trunk technique. A literature review of the pathophysiology of BTAI was performed to investigate if patients with right-sided aortic arch are at a higher risk of suffering from BTAI. Results from the review suggest that although theoretically there may be a higher risk of BTAI in RAA patients, the rarity of this condition has prevented large studies to be conducted. Previously reported cases of BTAI in RAA have highlighted the possibility that the aortic isthmus may be anatomically weak and therefore prone to injury. We have explored this possibility by reviewing current literature of the embryological origins of the aortic arch and descending aorta. PMID:25745378

Mechanical cause for acute left lung atelectasis after neonatal aortic arch repair with arterial switch operation: Conservative management.

PubMed

Maddali, Madan Mohan; Kandachar, Pranav Subbaraya; Al-Hanshi, Said; Al Ghafri, Mohammed; Valliattu, John

2017-01-01

Respiratory complications due to mechanical obstruction of the airways can occur following pediatric cardiac surgery. Clinically significant intrathoracic vascular compression of the airway can occur when extensive dissection and mobilization of arch and neck vessels is involved as in repair of interrupted aortic arch. This case report describes a neonate who underwent interrupted aortic arch repair along with an arterial switch operation and developed a left lung collapse immediately after tracheal extubation. Fiber-optic bronchoscopy revealed vascular compression as the real culprit. The child was successfully managed conservatively.

Successful Conservative Treatment of a Kommerell Aneurysm Associated With Right-Sided Aortic Arch.

PubMed

Lococo, Filippo; Tusini, Nicola; Brandi, Loris; Leuzzi, Giovanni; Galeone, Carla; Paci, Massimiliano; Rapicetta, Cristian

2016-08-01

Right-side aortic arch is a rare congenital aortic anomaly occurring in 0.05% to 0.1% of the general population. Approximately, half of these cases may be associated with an aberrant left subclavian artery and occasionally with aneurysmatic change at its origin known as Kommerell diverticulum or aneurysm (KA). Herein we report a challenging case of a right-side aortic arch associated with KA incidentally observed in a 73-year-old male with metastatic lung cancer. After careful multidisciplinary discussion, a conservative strategy of care was successfully adopted. © The Author(s) 2016.

Hemiarch versus total aortic arch replacement in acute type A dissection: a systematic review and meta-analysis

PubMed Central

Poon, Shi Sum; Theologou, Thomas; Harrington, Deborah; Kuduvalli, Manoj; Oo, Aung

2016-01-01

Background Despite recent advances in aortic surgery, acute type A aortic dissection remains a surgical emergency associated with high mortality and morbidity. Appropriate management is crucial to achieve satisfactory outcomes but the optimal surgical approach is controversial. The present systematic review and meta-analysis sought to access cumulative data from comparative studies between hemiarch and total aortic arch replacement in patients with acute type A aortic dissection. Methods A systematic review of the literature using six databases. Eligible studies include comparative studies on hemiarch versus total arch replacement reporting short, medium and long term outcomes. A meta-analysis was performed on eligible studies reporting outcome of interest to quantify the effects of hemiarch replacement on mortality and morbidity risk compared to total arch replacement. Result Fourteen retrospective studies met the inclusion criteria and 2,221 patients were included in the final analysis. Pooled analysis showed that hemiarch replacement was associated with a lower risk of post-operative renal dialysis [risk ratio (RR) =0.72; 95% confidence interval (CI): 0.56–0.94; P=0.02; I2=0%]. There was no significant difference in terms of in-hospital mortality between the two groups (RR =0.84; 95% CI: 0.65–1.09; P=0.20; I2=0%). Cardiopulmonary bypass, aortic cross clamp and circulatory arrest times were significantly longer in total arch replacement. During follow up, no significant difference was reported from current studies between the two operative approaches in terms of aortic re-intervention and freedom from aortic reoperation. Conclusions Within the context of publication bias by high volume aortic centres and non-randomized data sets, there was no difference in mortality outcomes between the two groups. This analysis serves to demonstrate that for those centers doing sufficient total aortic arch activity to allow for publication, excellent and equivalent outcomes are achievable. Conclusions on differences in longer term outcome data are required. We do not, however, advocate total arch as a primary approach by all centers and surgeons irrespective of patient characteristics, but rather, a tailored approach based on surgeon and center experience and patient presentation. PMID:27386403

Pathogenesis of solitary right aortic arch: a mass effect hypothesis based on observations of serial human embryonic sections.

PubMed

Jin, Zhe W; Yamada, Tomonori; Kim, Ji H; Rodríguez-Vázquez, José F; Murakami, Gen; Arakawa, Keiji

2017-03-01

In general, solitary right aortic arch carries the left-sided ductus arteriosus communicating between the left subclavian and pulmonary arteries or the right-sided ductus connecting the descending aorta to the left pulmonary artery. Serial sections of fifteen 5- to 6-week-old embryos and ten 8- to 9-week-old fetuses suggested that the pathogenesis was unrelated to inversion due to dysfunction in gene cascades that control the systemic left/right axis. With inversion, conversely, the ductus or the sixth pharyngeal arch artery should connect to the right pulmonary artery. The disappearance of the right aortic arch started before the caudal migration of the aortic attachment of the ductus. Sympathetic nerve ganglia developed immediately posterior to both aortae, with a single embryonic specimen showing a large ganglion at the midline close to the union of the aortic arches. These ganglia may interfere with blood flow through the distal left arch, resulting in the ductus ending at the descending aorta behind the oesophagus. In another fetus examined, a midline shift of the ductus course resulted in the trachea curving posteriorly. Therefore, solitary right arch is likely to accompany abnormalities of the surrounding structures. The timing and site of the obstruction should be different between types: an almost midline obstruction near the aortic union needed for the development of the left-sided ductus and a distal obstruction near the left subclavian arterial origin needed for the development of the right-sided ductus. A mass effect of the sympathetic ganglia may explain the pathogenesis of any type of anomalous ductus arteriosus shown in previous reports of the solitary right arch.

Oesophageal foreign body and a double aortic arch: rare dual pathology.

PubMed

O'Connor, T E; Cooney, T

2009-12-01

We report the rare case of an oesophageal foreign body which lodged above the site of oesophageal compression by a double aortic arch. Case report and a review of the literature surrounding the classification, embryology, diagnosis and management of vascular rings and slings. An eight-month-old male infant presented with symptoms of tracheal compression following ingestion of an oesophageal foreign body. Following removal of the oesophageal foreign body, the infant's symptoms improved initially. However, subsequent recurrence of respiratory symptoms lead to a repeat bronchoscopy and the diagnosis of a coexisting double aortic arch, causing tracheal and oesophageal compression. To our knowledge, this is only the second reported case of a double aortic arch being diagnosed in a patient following removal of an oesophageal foreign body.

Identification of Aortic Arch-Specific Quantitative Trait Loci for Atherosclerosis by an Intercross of DBA/2J and 129S6 Apolipoprotein E-Deficient Mice

PubMed Central

Kayashima, Yukako; Makhanova, Natalia A.; Matsuki, Kota; Tomita, Hirofumi; Bennett, Brian J.; Maeda, Nobuyo

2015-01-01

The genetic background of apolipoprotein E (apoE) deficient mice influences atherosclerotic plaque development. We previously reported three quantitative trait loci (QTL), Aath1–Aath3, that affect aortic arch atherosclerosis independently of those in the aortic root in a cross between C57BL6 apoEKO mice (B6-apoE) and 129S6 apoEKO mice (129-apoE). To gain further insight into genetic factors that influence atherosclerosis at different vascular locations, we analyzed 335 F2 mice from an intercross between 129-apoE and apoEKO mice on a DBA/2J genetic background (DBA-apoE). The extent of atherosclerosis in the aortic arch was very similar in the two parental strains. Nevertheless, a genome-wide scan identified two significant QTL for plaque size in the aortic arch: Aath4 on Chromosome (Chr) 2 at 137 Mb and Aath5 on Chr 10 at 51 Mb. The DBA alleles of Aath4 and Aath5 respectively confer susceptibility and resistance to aortic arch atherosclerosis over 129 alleles. Both QTL are also independent of those affecting plaque size at the aortic root. Genome analysis suggests that athero-susceptibility of Aath4 in DBA may be contributed by multiple genes, including Mertk and Cd93, that play roles in phagocytosis of apoptotic cells and modulate inflammation. A candidate gene for Aath5 is Stab2, the DBA allele of which is associated with 10 times higher plasma hyaluronan than the 129 allele. Overall, our identification of two new QTL that affect atherosclerosis in an aortic arch-specific manner further supports the involvement of distinct pathological processes at different vascular locations. PMID:25689165

Growth of left ventricular outflow tract and predictors of future re-intervention after repair for ventricular septal defect and aortic arch obstruction.

PubMed

Jijeh, Abdulraouf; Ismail, Muna; Alhabshan, Fahad

2017-09-01

Ventricular septal defect and aortic arch obstruction are usually associated with a narrow left ventricular outflow tract. The aim of the present study was to analyse the growth and predictors of future obstruction of the left ventricular outflow tract after surgical repair. We carried out a retrospective review of patients who underwent repair for ventricular septal defect and aortic arch obstruction - coarctation or interrupted aortic arch - between July, 2002 and June, 2013. Echocardiographic data were reviewed, and the need for re-intervention was evaluated. A total of 89 patients were included in this study. A significant left ventricular outflow tract growth was noticed after surgical repair. Preoperatively, the mean left ventricular outflow tract Z-score was -1.46±1 (range -5.5 to 1.1) and increased to a mean value of -0.7±1.3 (range -2.7 to 3.2) at last follow-up (p=0.0001), demonstrating relevant growth of the left ventricular outflow tract after repair for ventricular septal defect and aortic arch obstruction. After primary repair, 11 patients (12.3%) required re-intervention with surgical repair for left ventricular outflow tract obstruction after a mean period of 36±21 months. There were no significant differences in age, weight, and indexed aortic valve and left ventricular outflow tract measurements between those who developed obstruction and those who did not. Significant left ventricular outflow tract growth is expected after repair of ventricular septal defect and aortic arch obstruction. Small aortic valve and left ventricular outflow tract at diagnosis are not risk factors to predict the need for surgical re-intervention for left ventricular outflow tract obstruction in future.

Best surgical option for arch extension of type B aortic dissection: the open approach

PubMed Central

Kim, Joon Bum

2014-01-01

Arch extension of aortic dissection (AD) is reported to occur in 4-25% of patients presenting with acute type B AD. The DeBakey and Stanford classifications do not specifically account for this subset, however, recent studies have demonstrated that the prognosis of patients with arch extension in acute type B AD is virtually identical to that of others with type B AD. In this sense, it seems reasonable to extend the general management principles that are applied to classic acute type B AD even to patients with arch extension. This may be because even in patients with arch extension, most complications occur at locations distal to the arch, and therefore treatment of these patients is similar to that of complicated type B AD, namely thoracic endovascular aortic repair (TEVAR). Conversely, 10% of patients with acute type B AD and arch extension develop complications that are directly related to the arch pathology. This clinical scenario generally necessitates surgical arch repair through a sternotomy approach. The frozen elephant trunk technique combined with arch repair is a very reasonable option to treat this unique clinical entity that involves relatively distal locations of the aortic diseases. Combined arch and descending aorta replacement through thoracotomy is an alternative option particularly when the anatomical features of the target lesions are not suitable for a sternotomy approach or TEVAR. Nonetheless, the reported mortality associated with this approach has been exceedingly high. Hybrid arch repair is another consideration in treating these patients to reduce the treatment-related mortality and morbidity, especially when the arch pathology is limited to the distal part. Nevertheless, the safety and efficacy of this procedure in cases with more extensive arch involvement needs to be assessed in further studies in comparison with other treatment modalities. PMID:25133105

Aortic arch repair under moderate hypothermic circulatory arrest with or without antegrade cerebral perfusion based on the extent of repair

PubMed Central

Park, Sung Jun; Jeon, Bo Bae; Kim, Hee Jung

2018-01-01

Background For aortic-arch repair, moderate hypothermic circulatory arrest (HCA) have shown favorable outcomes over conventional deep HCA when coupled with antegrade cerebral perfusion (ACP); however, recent studies have shown that ACP may not be essential when circulatory arrest time is less than 30 minutes. This study aims to evaluate the stratified arch repair strategy of moderate HCA with or without ACP based on the extent of procedure. Methods Consecutive 138 patients (63 female; mean age, 60.2±15.7 years) undergoing open arch repair due to acute aortic syndrome (n=69) or chronic aneurysm (n=69) from January 2012 through April 2017 were enrolled in this study. Stratified neuroprotective strategy was employed according to the extent of repair: hemi-arch repair (n=93) was performed under moderated HCA alone and total-arch repair (n=45) under moderate HCA combined with unilateral ACP. Results Median total circulatory arrest and total procedural times were 8.0 minutes [interquartile range (IQR), 6.0–10.0] and 233.0 minutes (IQR, 196.0–290.0 minutes), respectively in the hemi-arch group, and 25.0 minutes (IQR, 12.0–33.0 minutes) and 349.0 minutes (IQR, 276.0–406.0 minutes), respectively in the total-arch group. Early mortality occurred in 2 patients (1.4%) who underwent hemi-arch repair for acute aortic dissection. There was no permanent neurological injury, but 2 cases (1.4%) of temporary neurologic deficit in the hemi-arch group. Other complications included re-exploration for bleeding in 6 (4.3%), postoperative extracorporeal life support in 5 (3.6%) and new-dialysis in 6 (4.3%). Conclusions Stratified cerebral perfusion strategy using moderate hypothermia for aortic-arch surgery based on the extent of arch repair showed satisfactory safety and reasonable efficiency. PMID:29707342

Persistent truncus arteriosis associated with interruption of the aortic arch.

PubMed

Nath, P H; Zollikofer, C; Castaneda-Zuniga, W; Formanek, A; Amplatz, K

1980-09-01

Five patients with a combination of truncus arteriosus and interruption of the aortic arch are reported. The combination of those defects significantly increases the surgical risk. This rare cardiac malformation can only be diagnosed radiographically. An aberrant right subclavian artery is present in 25% of patients. It is helpful in suspecting the diagnosis from plain films of the chest. The diagnosis can be made from a ventriculogram, but usually a truncogram is necessary to define the anatomy of the aortic arch.

Arterial Cannulation and Cerebral Perfusion Strategies for Aortic Arch Operations.

PubMed

Foley, Lisa S; Yamanaka, Katsuhiro; Reece, T Brett

2016-12-01

Neurologic injuries following aortic arch operations can be devastating, with stroke occurring in up to 12% of elective operations and significant cerebral dysfunction occurring in up to 25% of cases. The primary challenge unique to aortic arch operations involves interruption of direct perfusion of the brachiocephalic vessels during arch reconstruction. For this reason, neuroprotection is paramount. The 2 main modes of protection are (1) reducing metabolic demand through hypothermia and (2) limiting, or even eliminating, the ischemic period. Preoperative selection of the cerebral perfusion plan for each operation is imperative to maintain maximal diffuse cerebral protection and prevent focal neurologic events. © The Author(s) 2016.

Blood flow characteristics in the aortic arch

NASA Astrophysics Data System (ADS)

Prahl Wittberg, Lisa; van Wyk, Stevin; Mihaiescu, Mihai; Fuchs, Laszlo; Gutmark, Ephraim; Backeljauw, Philippe; Gutmark-Little, Iris

2012-11-01

The purpose with this study is to investigate the flow characteristics of blood in the aortic arch. Cardiovascular diseases are associated with specific locations in the arterial tree. Considering atherogenesis, it is claimed that the Wall Shear Stress (WSS) along with its temporal and spatial gradients play an important role in the development of the disease. The WSS is determined by the local flow characteristics, that in turn depends on the geometry as well as the rheological properties of blood. In this numerical work, the time dependent fluid flow during the entire cardiac cycle is fully resolved. The Quemada model is applied to account for the non-Newtonian properties of blood, an empirical model valid for different Red Blood Cell loading. Data obtained through Cardiac Magnetic Resonance Imaging have been used in order to reconstruct geometries of the the aortic arch. Here, three different geometries are studied out of which two display malformations that can be found in patients having the genetic disorder Turner's syndrome. The simulations show a highly complex flow with regions of secondary flow that is enhanced for the diseased aortas. The financial support from the Swedish Research Council (VR) and the Sweden-America Foundation is gratefully acknowledged.

Pregnancy with aortic dissection in Ehler-Danlos syndrome. Staged replacement of the total aorta (10-year follow-up).

PubMed

Babatasi, G; Massetti, M; Bhoyroo, S; Khayat, A

1997-10-01

Pregnancy complicated by aortic dissection in patients with hereditary disorder of connective tissue presents interesting considerations including management of caesarean section with the unexpected need for cardiac surgery in emergency. Generalizations can be made on management principles with long-term follow-up requiring an aggressive individualized approach by a multidisciplinary team. A 33-year-old parturient presenting an aortic dissection at 37 weeks gestation required prompt diagnosis of Ehlers-Danlos syndrome in combination with correct surgical therapy resulted in the survival of both the mother and infant. During the 10-year follow-up, multiple complex dissection required transverse aortic arch and thoracoabdominal aortic replacement.

Retrograde Ascending Aortic Dissection after Stent Grafting for Stanford Type B Aortic Dissection with Severe Limb Ischemia.

PubMed

Higuchi, Yoshiro; Tochii, Masato; Takami, Yoshiyuki; Kobayashi, Akihiro; Yanagisawa, Tsutomu; Amano, Kentaro; Sakurai, Yusuke; Ishida, Michiko; Ishikawa, Hiroshi; Hattori, Koji; Takagi, Yasushi

2017-03-24

We report a rare case of retrograde Stanford type A aortic dissection after endovascular repair for complicated Stanford type B aortic dissection. A 45-year-old man presented with a sudden onset of back pain and was transferred to our hospital. Computed tomography demonstrated acute Stanford type B aortic dissection with lower limb ischemia. Emergency endovascular surgery was planned for repair of the Stanford type B aortic dissection. The patient suddenly developed recurrent chest pain 10 days after the initial procedure. Computed tomography revealed retrograde Stanford type A aortic dissection involving the ascending aorta and aortic arch. The patient underwent a successful emergency total aortic arch replacement.

Suppressive effect of pitavastatin on aortic arch dilatation in acute stanford type B aortic dissection: analysis of STANP trial.

PubMed

Masaki, Naoki; Kumagai, Kiichiro; Sasaki, Konosuke; Matsuo, Satoshi; Motoyoshi, Naotaka; Adachi, Osamu; Akiyama, Masatoshi; Kawamoto, Shunsuke; Tabayashi, Koichi; Saiki, Yoshikatsu

2018-04-06

Medical therapy for patients with uncomplicated acute type B aortic dissection (ABAD) is essentially accepted for its excellent early outcome; however, long-term outcomes have not been satisfactory due to aorta-related complications. This trial was performed to investigate the efficacy of a statin as an additive that may enhance the effectiveness of conventional medical treatment in patients with ABAD. This was a multi-center, prospective, and randomized comparative investigation of patients with uncomplicated ABAD. Fifty patients with ABAD compatible with inclusion criteria were randomly assigned to two groups and then received administration of pitavastatin (group P) or not (group C). We followed up the patients for 1 year from study onset. Two patients demised during the follow-up period (both were in group C). In addition, aorta-related interventions were performed in two patients (entry closure for aortic dissection by endovascular repair in one patient in each group). Aortic arch diameters at 1 year in group P tended to be smaller than in group C (P = 0.17), and the rate of change of the aortic arch diameters from onset to 1 year was significantly lower in group P (P = 0.046). Multivariate analysis identified patency of the false lumen was detected as a risk factor for aortic arch dilatation (P = 0.02), and pitavastatin intake was a negative risk factor (P = 0.03). Pitavastatin treatment, in addition to the standard antihypertensive therapy, may have a suppressive effect on aortic arch dilatation in patients with ABAD.

The long-term outcomes of partial arch repair using the frozen elephant trunk technique for distal arch aortic aneurysm.

PubMed

Sueda, Taijiro; Takahashi, Shinya; Katayama, Keijiro; Morita, Shohei; Watanabe, Masazumi; Kurosaki, Tatsuya

2018-06-22

The purpose of this study was to evaluate the long-term results of partial arch repair using the frozen elephant trunk (FET) technique for distal arch aortic aneurysm and to examine the late complications. Thirty-eight patients with true distal arch aortic aneurysms were repaired with FET introduced through an incision in the proximal arch aorta. Follow-up computed tomography was performed every 6 or 12 months in 36 surviving patients. The maximum dimension of the excluded aneurysmal space was measured to determine whether the aneurysmal space had decreased or disappeared. Late complications were also evaluated during the long-term follow-up. There was 1 hospital death (2.6%) and 1 (2.6%) case of paraplegia. There were 2 late sudden deaths (5.2%) thought to be due to aneurysm rupture and arrhythmia. Postoperative serial-computed tomography showed shrinkage of the excluded aneurysmal space in 33 of 36 patients. Late aneurysmal formation occurred in the anastomotic site in three patients. One patient underwent thoracic endovascular stent grafting 10 years after surgery, 1 patient had total arch replacement 9 years after surgery, and 1 died due to rupture. Frozen elephant trunk was found to be a useful alternative for treating true distal arch aortic aneurysm. However, we must be alert for late aneurysmal formation at the incision site.

Double aortic arch and persistent left vena cava in a white lion cub (Panthera leo).

PubMed

Goldin, J P; Lambrechts, N E

1999-03-01

A 4-mo-old female white lion (Panthera leo) cub was presented with a 2-wk history of persistent postprandial regurgitation, mild dyspnea, and poor weight gain. The cub was weak and thin but otherwise alert. Survey and contrast radiography revealed a large dilated esophagus cranial to the heart base, with an esophageal filling defect present at the level of the fourth thoracic vertebra. A vascular ring anomaly was tentatively diagnosed. Exploratory thoracotomy revealed a double aortic arch and a persistent left vena cava. The left aortic arch was ligated and divided, and recovery was uneventful. A single episode of regurgitation occurred within the first postoperative month, and the cub gained 5.5 kg in weight during the same time period. Neither double aortic arch nor persistent left vena cava has been reported in a nondomestic felid.

[Feasibility and possibility of Inoue stent graft for thoracic aortic aneurysms].

PubMed

Marui, Akira; Kimura, Takeshi; Tazaki, Junichi; Sakata, Ryuzo; Inoue, Kanji

2011-01-01

Open surgical repair is a traditional treatment for patients with thoracic aortic aneurysms. Despite recent advances in surgical techniques and anesthetic management, the surgical repair of thoracic aortic aneurysms is still associated with significant mortality and morbidity. Endovascular aneurysm repair of thoracic aortic aneurysms is emerging as an alternative method for repair in selected patients. Although endovascular stent grafting is less invasive than open surgical repair, involvement of branch vessels and precipitous curvature of the aortic arch limits the application of stent grafting. Inoue stent graft system consists of soft nitinol ring-type stent which enables very flexible stent graft, and it can well comply with the precipitous curvature of the aortic arch. The system also provides a stent graft with a side branch to manage the left subclavian artery. This system does not require the surgical revascularization of the left subclavian artery. In this report, we show the feasibility and possibility of Inoue stent graft system to manage the aortic arch aneurysm.

Thoracic Endovascular Aortic Repair Combined with Assistant Techniques and Devices for the Treatment of Acute Complicated Stanford Type B Aortic Dissections Involving Aortic Arch.

PubMed

Zhang, Tianhua; Jiang, Weiliang; Lu, Haitao; Liu, Jianfeng

2016-04-01

The present study retrospectively reviewed and evaluated the effectiveness of thoracic endovascular aortic repair (TEVAR) combined with assistant techniques and devices for the treatment of acute complicated Stanford type B aortic dissections involving aortic arch. Fifty-six patients with acute complicated Stanford type B aortic dissection involving aortic arch were treated with TEVAR combined with hybrid procedure, chimney-graft technique, and branched stent grafts from January 2009 to March 2014. Seventeen patients undergone TEVAR combined with hybrid technique. Technical success was achieved in 94.1% with 5.8% of early mortality. Strokes occurred in a patient developing paraplegia, who completely recovered after lumbar drainage. Cardiocirculatory and pulmonary complications, bypass dysfunction or severe endoleak was not observed. Thirty patients undergone TEVAR combined with chimney technique with 100% technical success rate. Chimney-stent compression was observed in 1 patient, and another bare stent was deployed inside the first one. Three patients (10%) died during the study period. Immediate postoperative type I endoleak was detected in 4 cases (13.3%). TEVAR assisted by Castor branched aortic stent grafts in 9 patients was successful. Mortality during perioperative period and 30 days after TEVAR was null. No serious complications such as strokes, acute myocardial infarction, and ischemia of arms occurred. The results indicate that TEVAR combined with hybrid technique, chimney technique, and branched stent grafts is proven to be a technically feasible and effective treatment for acute complicated Stanford type B aortic dissection involving aortic arch in small cohort. Copyright © 2016 Elsevier Inc. All rights reserved.

Blunt traumatic aortic injuries of the ascending aorta and aortic arch: a clinical multicentre study.

PubMed

Mosquera, Victor X; Marini, Milagros; Muñiz, Javier; Gulias, Daniel; Asorey-Veiga, Vanesa; Adrio-Nazar, Belen; Herrera, José M; Pradas-Montilla, Gonzalo; Cuenca, José J

2013-09-01

To report the clinical and radiological characteristics, management and outcomes of traumatic ascending aorta and aortic arch injuries. Historic cohort multicentre study including 17 major trauma patients with traumatic aortic injury from January 2000 to January 2011. The most common mechanism of blunt trauma was motor-vehicle crash (47%) followed by motorcycle crash (41%). Patients sustaining traumatic ascending aorta or aortic arch injuries presented a high proportion of myocardial contusion (41%); moderate or greater aortic valve regurgitation (12%); haemopericardium (35%); severe head injuries (65%) and spinal cord injury (23%). The 58.8% of the patients presented a high degree aortic injury (types III and IV). Expected in-hospital mortality was over 50% as defined by mean TRISS 59.7 (SD 38.6) and mean ISS 48.2 (SD 21.6) on admission. Observed in-hospital mortality was 53%. The cause of death was directly related to the ATAI in 45% of cases, head and abdominal injuries being the cause of death in the remaining 55% cases. Long-term survival was 46% at 1 year, 39% at 5 years, and 19% at 10 years. Traumatic aortic injuries of the ascending aorta/arch should be considered in any major thoracic trauma patient presenting cardiac tamponade, aortic valve regurgitation and/or myocardial contusion. These aortic injuries are also associated with a high incidence of neurological injuries, which can be just as lethal as the aortic injury, so treatment priorities should be modulated on an individual basis. Copyright © 2012 Elsevier Ltd. All rights reserved.

DOE Office of Scientific and Technical Information (OSTI.GOV)

Zanchetta, Mario, E-mail: emodinacit@ulss15.pd.it; Rigatelli, Gianluca; Pedon, Luigi

To assess the accuracy and efficacy of intravascular ultrasound guidance obtained by an intracardiac ultrasound probe during complex aortic endografting. Between November 1999 and July 2002, 19 patients (5 female, 14 male; mean age 73.5 {+-} 2.1 years) underwent endovascular repair of thoracic (n = 10), complex abdominal (n = 6) and concomitant thoraco-abdominal (n = 3) aortic aneurysm. The most suitable size and configuration of the stent-graft were chosen on the basis of preoperative computed tomographic angiography (CTA) or magnetic resonance angiography (MRA). Intraoperative intravascular ultrasound imaging was obtained using a 9 Fr, 9 MHz intracardiac echocardiography (ICE) probe,more » 110 cm in length, inserted through a 10 Fr precurved long sheath. The endografts were deployed as planned by CTA or MRA. Before stent-graft deployment, the ICE probe allowed us to view the posterior aortic arch and descending thoraco-abdominal aorta without position-related artifacts, and to identify both sites of stent-graft positioning. After stent-graft deployment, the ICE probe allowed us to detect the need for additional modular components to internally reline the aorta in 11 patients, and to discover 2 incomplete graft expansions subsequently treated with adjunctive balloon angioplasty. In 1 patient, the ICE probe supported the decision that the patient was ineligible for the endovascular exclusion procedure. The ICE probe provides accurate information on the anatomy of the posterior aortic arch and thoracic and abdominal aortic aneurysms and a rapid identification of attachment sites and stent-graft pathology, allowing refinement and improvement of the endovascular strategy.« less

Pulsatile flows and wall-shear stresses in models simulating normal and stenosed aortic arches

NASA Astrophysics Data System (ADS)

Huang, Rong Fung; Yang, Ten-Fang; Lan, Y.-K.

2010-03-01

Pulsatile aqueous glycerol solution flows in the models simulating normal and stenosed human aortic arches are measured by means of particle image velocimetry. Three transparent models were used: normal, 25% stenosed, and 50% stenosed aortic arches. The Womersley parameter, Dean number, and time-averaged Reynolds number are 17.31, 725, and 1,081, respectively. The Reynolds numbers based on the peak velocities of the normal, 25% stenosed, and 50% stenosed aortic arches are 2,484, 3,456, and 3,931, respectively. The study presents the temporal/spatial evolution processes of the flow pattern, velocity distribution, and wall-shear stress during the systolic and diastolic phases. It is found that the flow pattern evolving in the central plane of normal and stenosed aortic arches exhibits (1) a separation bubble around the inner arch, (2) a recirculation vortex around the outer arch wall upstream of the junction of the brachiocephalic artery, (3) an accelerated main stream around the outer arch wall near the junctions of the left carotid and the left subclavian arteries, and (4) the vortices around the entrances of the three main branches. The study identifies and discusses the reasons for the flow physics’ contribution to the formation of these features. The oscillating wall-shear stress distributions are closely related to the featured flow structures. On the outer wall of normal and slightly stenosed aortas, large wall-shear stresses appear in the regions upstream of the junction of the brachiocephalic artery as well as the corner near the junctions of the left carotid artery and the left subclavian artery. On the inner wall, the largest wall-shear stress appears in the region where the boundary layer separates.

Aberrant left subclavian artery occlusion in right-sided aortic artery associated with left cerebral infarction: A case report.

PubMed

Tempaku, Akira; Kuroiwa, Terumasa; Nishio, Akimasa

2018-06-01

Purpose Right-sided aortic arch is a rare vessel anomaly with an incidence of 0.1% worldwide. Supra-aortic branches form a mirror image of the left-sided aortic arch or an aberrant left subclavian artery associated with Kommerell diverticulum. Most patients are diagnosed by a difference in blood pressure in each upper extremity or by the presence of left subclavian steal syndrome in their younger age. The diagnosis of onset of ischemic stroke in middle age is rare. Methods We present the case of a female patient who presented with an ischemic stroke in the left posterior circulation area. She had no history of congenital heart malformation. We performed head magnetic resonance imaging, cerebral angiography, and enhanced computed tomography of the aortic arch and major branches. Results The patient had a right-sided aortic arch and an aberrant left subclavian artery. The left subclavian artery was occluded at the proximal portion with a fibrous string. Collateral flow in the anterior cervical subcutaneous area supported left limb perfusion. Conclusion An atheromatous change reduced shunt flow via collateral networks at the anterior cervical region. Congenital subclavian steal supported the ischemic stroke.

Total aortic arch replacement with the frozen elephant trunk technique: 10-year follow-up single-centre experience.

PubMed

Ius, Fabio; Fleissner, Felix; Pichlmaier, Maximilian; Karck, Matthias; Martens, Andreas; Haverich, Axel; Shrestha, Malakh

2013-11-01

Since August 2001, the frozen elephant trunk (FET) technique has been used at our institution to treat degenerative or dissecting aneurysms involving the aortic arch and descending aorta as a potential 'single-stage' procedure. The aim of this study was to review our FET experience and to present the 10-year results. Between August 2001 and January 2012, 131 patients underwent FET implant with three different prostheses: the custom-made Chavan-Haverich (n = 66), the Jotec E-vita (n = 30) and the Vascutek Thoraflex (n = 35) prostheses. Concomitant procedures included aortic valve-sparing operations (David, n = 17) and aortic root replacement (Bentall, n = 25). Patient records and the first postoperative and last available computer tomography (CT) were retrospectively reviewed. Incidence of rethoracotomy for bleeding, stroke, spinal cord injury, prolonged ventilatory support (>96 h) and acute renal failure requiring dialysis were 18, 11, 1, 41 and 16%, respectively. In-hospital mortality was 15%. The mean follow-up was 42 ± 37 (range 1-134 months). At 1, 5 and 10 years, survivals were 82 ± 3, 72 ± 5 and 58 ± 8%, respectively. Freedoms from distal aortic operation were 81 ± 4, 67 ± 5 and 43 ± 13%, respectively. Thirty-six patients underwent 40 distal aortic operations, either open surgical (n = 22, 55%) or endovascular (n = 18, 45%). Chronic aortic dissection was identified as an independent risk factor for distal aortic operation (odds ratio = 3.8; 95% confidence interval 1.5-9.3; P = 0.004). At last CT control, false-lumen thrombosis rates up to 93% were achieved around the stent graft. An FET concept adds to the armament of the surgeon in the treatment of complex and diverse aortic arch pathologies. The preoperative patient risk profile explains the postoperative morbidity and in-hospital mortality. The FET can potentially be still a 'one-stage' procedure in selected patients. However, the extension of FET to patients with extensive aortic aneurysms has led to an increase in second-stage procedures.

Thoracic Endovascular Aortic Repair With Single/Double Chimney Technique for Aortic Arch Pathologies.

PubMed

Wang, Tun; Shu, Chang; Li, Ming; Li, Quan-Ming; Li, Xin; Qiu, Jian; Fang, Kun; Dardik, Alan; Yang, Chen-Zi

2017-06-01

To summarize a single-center experience using the single/double chimney technique in association with thoracic endovascular aortic repairs (TEVAR) for aortic arch pathologies. From November 2007 to March 2016, 122 patients (mean age 50.4±12.7 years, range 29-80; 92 men) with aortic arch pathologies underwent TEVAR combined with single (n=101) or double (n=21) chimney grafts to reconstruct the supra-aortic branches: 21 innominate arteries, 114 left common carotid arteries, and 8 left subclavian arteries (LSA). Pathologies included type B aortic dissection (n=47), aortic arch dissection (n=49), retrograde type A aortic dissection (n=8), thoracic aortic aneurysm (n=7), penetrating aortic arch ulcer (n=9), and post-TEVAR type I endoleak (n=2). Follow-up examinations included computed tomography at 0.5, 3, 6, and 12 months and yearly thereafter. The aortic stent-grafts were deployed in zone 0 (n=21), zone 1 (n=93), and zone 2 (n=8). One (0.8%) of the 122 patients died at 4 days due to a perforated peptic ulcer. Type Ia endoleaks were found intraoperatively in 13 (10.7%) patients, including 3 with the double chimney technique. Type II endoleaks occurred in 6 (4.9%) patients; 3 were treated with duct occluders in the LSA. Postoperative chimney graft migration occurred in 1 (0.8%) patient with double chimneys; additional stent-grafts were deployed in both chimneys. Median follow-up was 32.3 months, during which 1 (0.8%) patient died after a stroke at 3 months. Chimney stent-graft patency was observed in the remaining 120 patients. Two (1.7%) secondary TEVARs were performed for distal aortic dissection. Nine asymptomatic type Ia endoleaks and 1 type II endoleak persisted in follow-up; a type II endoleak in 1 patient with Marfan syndrome sealed in 52 months. TEVAR with the chimney technique provides a safe, minimally invasive alternative with good chimney graft patency and low postoperative mortality during midterm follow-up. The double chimney technique should be used judiciously owing to its potential complications.

Vascular ring presenting as dysphagia in an adult woman: a case report.

PubMed

Powell, B L

2017-01-01

A 48-year-old woman was seen in a surgical outpatient clinic with a 2 year history of progressive dysphagia with occasional regurgitation, partially controlled with a proton pump inhibitor. Primary investigations of pH testing and gastroscopy were normal, although a barium swallow study revealed significant hold-up at the aortic arch impression and a posterior right-sided oesophageal impression suggestive of a right-sided aortic arch. A follow-up computed tomography angiogram discovered a vascular ring encircling the trachea and oesophagus, formed by a right-sided aortic arch with aberrant aortic branches, and a Kommerell's diverticulum. It was deemed that the patient's symptoms were related to this vascular ring. The patient underwent stage-one surgery - an extra-anatomic bypass of the double aortic arch and right subclavian artery - and 4 months later a stent graft insertion over the origin of the diverticulum with the aim of complete symptomatic relief. This case presents a common symptom familiar to any clinician (dysphagia), which has been caused by a rare pathology. It is even more unusual that this should present itself in adulthood.

Mechanism of smart baroreception in the aortic arch

NASA Astrophysics Data System (ADS)

Kember, G. C.; Armour, J. A.; Zamir, M.

2006-09-01

A mechanism is proposed by which the patch of baroreceptors along the inner curvature of the arch of the aorta can sense hemodynamic events occurring downstream from the aortic arch, in the periphery of the arterial tree. Based on a solution of equations governing the elastic movements of the aortic wall, it is shown that the pressure distribution along the patch of baroreceptors has the same functional form as the distribution of strain along the patch. The significance of these findings are discussed, particularly as they relate to the possibility of a neuromechanical basis of essential hypertension.

Aortic Arch Pulse Wave Velocity Assessed by Magnetic Resonance Imaging as a Predictor of Incident Cardiovascular Events: The MESA (Multi-Ethnic Study of Atherosclerosis).

PubMed

Ohyama, Yoshiaki; Ambale-Venkatesh, Bharath; Noda, Chikara; Kim, Jang-Young; Tanami, Yutaka; Teixido-Tura, Gisela; Chugh, Atul R; Redheuil, Alban; Liu, Chia-Ying; Wu, Colin O; Hundley, W Gregory; Bluemke, David A; Guallar, Eliseo; Lima, Joao A C

2017-09-01

The predictive value of aortic arch pulse wave velocity (PWV) assessed by magnetic resonance imaging for cardiovascular disease (CVD) events has not been fully established. The aim of the present study was to evaluate the association of arch PWV with incident CVD events in MESA (Multi-Ethnic Study of Atherosclerosis). Aortic arch PWV was measured using magnetic resonance imaging at baseline in 3527 MESA participants (mean age, 62±10 years at baseline; 47% men) free of overt CVD. Cox regression was used to evaluate the risk of incident CVD (coronary heart disease, stroke, transient ischemic attack, or heart failure) in relation to arch PWV adjusted for age, sex, race, and CVD risk factors. The median value of arch PWV was 7.4 m/s (interquartile range, 5.6-10.2). There was significant interaction between arch PWV and age for outcomes, so analysis was stratified by age categories (45-54 and >54 years). There were 456 CVD events during the 10-year follow-up. Forty-five to 54-year-old participants had significant association of arch PWV with incident CVD independent of CVD risk factors (hazard ratio, 1.44; 95% confidence interval, 1.07-1.95; P =0.018; per 1-SD increase for logarithmically transformed PWV), whereas >54-year group did not ( P =0.93). Aortic arch PWV assessed by magnetic resonance imaging is a significant predictor of CVD events among middle-aged (45-54 years old) individuals, whereas arch PWV is not associated with CVD among an elderly in a large multiethnic population. © 2017 American Heart Association, Inc.

Evaluation of robotic endovascular catheters for arch vessel cannulation.

PubMed

Riga, Celia V; Bicknell, Colin D; Hamady, Mohamad S; Cheshire, Nicholas J W

2011-09-01

Conventional catheter instability and embolization risk limits the adoption of endovascular therapy in patients with challenging arch anatomy. This study investigated whether arch vessel cannulation can be enhanced by a remotely steerable robotic catheter system. Seventeen clinicians with varying endovascular experience cannulated all arch vessels within two computed tomography-reconstructed pulsatile flow phantoms (bovine type I and type III aortic arches), under fluoroscopic guidance, using conventional and robotic techniques. Quantitative (catheterization times, catheter tip movements, vessel wall hits, catheter deflection) and qualitative metrics (Imperial College Complex Endovascular Cannulation Scoring Tool [IC3ST]) performance scores were compared. Robotic catheterization techniques resulted in a significant reduction in median carotid artery cannulation times and the median number of catheter tip movements for all vessels. Vessel wall contact with the aortic arch wall was reduced to a median of zero with robotic catheters. During stiff guidewire exchanges, robotic catheters maintained stability with zero deflection, independent of the distance the catheter was introduced into the carotid vessels. Overall IC3ST performance scores (interquartile range) were significantly improved using the robotic system: Type I arch score was 26/35 (20-30.8) vs 33/35 (31-34; P = .001), and type III arch score was 20.5/35 (16.5-28.5) vs 26.5/35 (23.5-28.8; P = .001). Low- and medium-volume interventionalists demonstrated an improvement in performance with robotic cannulation techniques. The high-volume intervention group did not show statistically significant improvement, but cannulation times, movements, and vessel wall hits were significantly reduced. Robotic technology has the potential to reduce the time, risk of embolization and catheter dislodgement, radiation exposure, and the manual skill required for carotid and arch vessel cannulation, while improving overall performance scores. Copyright © 2011 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.

Safety and efficacy of retrograde cerebral perfusion as an adjunct for cerebral protection during surgery on the aortic arch.

PubMed

Girardi, Leonard N; Shavladze, Nikolay; Sedrakyan, Art; Neragi-Miandoab, Siyamek

2014-12-01

The best adjunct for cerebral protection during aortic arch reconstruction remains controversial. Retrograde cerebral perfusion (RCP) as an adjunct to profound hypothermic circulatory arrest (PHCA) extends the tolerable period of brain ischemia by flushing emboli and air from the cerebral circulation while maintaining hypothermia. We examined our experience with RCP to determine its efficacy in patients undergoing complex arch reconstruction. We retrospectively evaluated 879 patients undergoing arch reconstruction using RCP from July 1997 to March 2013. Perioperative risk factors were analyzed as predictors of neurologic injury and mortality. Survival for the type of arch reconstruction and for the interval of PHCA was calculated. Of the 879 patients, 671 underwent hemiarch and 208 total arch replacement. The mean age was 65 ± 13.3 years, and 61.6% were men. The total arch patients had longer mean periods of PHCA (39 vs 21 minutes, P < .001) and RCP (37 vs 19 minutes, P < .001). However, the incidence of transient neurologic dysfunction (3.0% vs 2.4%, P < .813) and permanent neurologic dysfunction (1.3% vs 1.9%, P < .519) was similar for both techniques. Mortality was greater in the hemiarch group (4.8% vs 0.5%, P < .003). Patients requiring >40 minutes of PHCA had outcomes similar to those requiring less. The 1-, 5-, and 10-year survival was similar, regardless of the procedure performed or interval of PHCA. RCP is a safe and effective adjunct for cerebral protection during arch surgery. Patients requiring more extensive arch reconstruction are not at greater risk of permanent neurologic dysfunction or perioperative mortality. Copyright © 2014 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

Combined open proximal and stent-graft distal repair for distal arch aneurysms: an alternative to total debranching.

PubMed

Zierer, Andreas; Sanchez, Luis A; Moon, Marc R

2009-07-01

We present herein a novel, combined, simultaneous open proximal and stent-graft distal repair for complex distal aortic arch aneurysms involving the descending aorta. In the first surgical step, the transverse arch is opened during selective antegrade cerebral perfusion, and a Dacron graft (DuPont, Wilmington, DE) is positioned down the descending aorta in an elephant trunk-like fashion with its proximal free margin sutured circumferentially to the aorta just distal to the left subclavian or left common carotid artery. With the graft serving as the new proximal landing zone, subsequent endovascular repair is performed antegrade during rewarming through the ascending aorta.

A review of the surgical management of right-sided aortic arch aneurysms

PubMed Central

Barr, James G.; Sepehripour, Amir H.; Jarral, Omar A.; Tsipas, Pantelis; Kokotsakis, John; Kourliouros, Antonios; Athanasiou, Thanos

2016-01-01

Aneurysms and dissections of the right-sided aortic arch are rare and published data are limited to a few case reports and small series. The optimal treatment strategy of this entity and the challenges associated with their management are not yet fully investigated and conclusive. We performed a systematic review of the literature to identify all patients who underwent surgical or endovascular intervention for right aortic arch aneurysms or dissections. The search was limited to the articles published only in English. We focused on presentation and critically assessed different management strategies and outcomes. We identified 74 studies that reported 99 patients undergoing surgical or endovascular intervention for a right aortic arch aneurysm or dissection. The median age was 61 years. The commonest presenting symptoms were chest or back pain and dysphagia. Eighty-eight patients had an aberrant left subclavian artery with only 11 patients having the mirror image variant of a right aortic arch. The commonest pathology was aneurysm arising from a Kommerell's diverticulum occurring in over 50% of the patients. Twenty-eight patients had dissections, 19 of these were Type B and 9 were Type A. Eighty-one patients had elective operations while 18 had emergency procedures. Sixty-seven patients underwent surgical treatment, 20 patients had hybrid surgical and endovascular procedures and 12 had totally endovascular procedure. There were 5 deaths, 4 of which were in patients undergoing emergency surgery and none in the endovascular repair group. Aneurysms and dissections of a right-sided aortic arch are rare. Advances in endovascular treatment and hybrid surgical and endovascular management are making this rare pathology amenable to these approaches and may confer improved outcomes compared with conventional extensive repair techniques. PMID:27001673

Bilateral aortic origins of the vertebral arteries with right vertebral artery arising distal to left subclavian artery: case report.

PubMed

Al-Okaili, Riyadh; Schwartz, Eric D

2007-02-01

Bilateral aortic origins of the vertebral arteries are a rare anatomic variant, with fewer than 20 cases reported in the literature. This particular variant has only been reported twice. A 35-year-old woman presented to the emergency department after trauma to the head and a witnessed convulsion. Subsequent workup included MRI/MRA, which resulted in identification of the anomaly. The clinical importance of aortic arch anomalies lies in that it may be a source of misinterpretation, as one may conclude occlusion of the vertebral artery if the aberrant origin is not included in the MRA or CTA imaging parameters. Therefore, it is important to scan through the entire aortic arch to just below the level of the ligamentum arteriosum when performing these noninvasive modalities. In addition, vertebral arteries arising from the aortic arch have an increased risk of dissection.

A statistical shape modelling framework to extract 3D shape biomarkers from medical imaging data: assessing arch morphology of repaired coarctation of the aorta.

PubMed

Bruse, Jan L; McLeod, Kristin; Biglino, Giovanni; Ntsinjana, Hopewell N; Capelli, Claudio; Hsia, Tain-Yen; Sermesant, Maxime; Pennec, Xavier; Taylor, Andrew M; Schievano, Silvia

2016-05-31

Medical image analysis in clinical practice is commonly carried out on 2D image data, without fully exploiting the detailed 3D anatomical information that is provided by modern non-invasive medical imaging techniques. In this paper, a statistical shape analysis method is presented, which enables the extraction of 3D anatomical shape features from cardiovascular magnetic resonance (CMR) image data, with no need for manual landmarking. The method was applied to repaired aortic coarctation arches that present complex shapes, with the aim of capturing shape features as biomarkers of potential functional relevance. The method is presented from the user-perspective and is evaluated by comparing results with traditional morphometric measurements. Steps required to set up the statistical shape modelling analyses, from pre-processing of the CMR images to parameter setting and strategies to account for size differences and outliers, are described in detail. The anatomical mean shape of 20 aortic arches post-aortic coarctation repair (CoA) was computed based on surface models reconstructed from CMR data. By analysing transformations that deform the mean shape towards each of the individual patient's anatomy, shape patterns related to differences in body surface area (BSA) and ejection fraction (EF) were extracted. The resulting shape vectors, describing shape features in 3D, were compared with traditionally measured 2D and 3D morphometric parameters. The computed 3D mean shape was close to population mean values of geometric shape descriptors and visually integrated characteristic shape features associated with our population of CoA shapes. After removing size effects due to differences in body surface area (BSA) between patients, distinct 3D shape features of the aortic arch correlated significantly with EF (r = 0.521, p = .022) and were well in agreement with trends as shown by traditional shape descriptors. The suggested method has the potential to discover previously unknown 3D shape biomarkers from medical imaging data. Thus, it could contribute to improving diagnosis and risk stratification in complex cardiac disease.

``Smart'' baroreception along the aortic arch, with reference to essential hypertension

NASA Astrophysics Data System (ADS)

Kember, G. C.; Zamir, M.; Armour, J. A.

2004-11-01

Beat-to-beat regulation of heart rate is dependent upon sensing of local stretching or local “disortion” by aortic baroreceptors. Distortions of the aortic wall are due mainly to left ventricular output and to reflected waves arising from the arterial tree. Distortions are generally believed to be useful in cardiac control since stretch receptors or aortic baroreceptors embedded in the adventitia of the aortic wall, transduce the distortions to cardiovascular neural reflex pathways responsible for beat-to-beat regulation of heart rate. Aortic neuroanatomy studies have also found a continuous strip of mechanosensory neurites spread along the aortic inner arch. Although their purpose is now unknown, such a combined sensing capacity would allow measurement of the space and time dependence of inner arch wall distortions due, among other things, to traveling waves associated with pulsatile flow in an elastic tube. We call this sensing capability-“smart baroreception.” In this paper we use an arterial tree model to show that the cumulative effects of wave reflections, from many sites far downstream, have a surprisingly pronounced effect on the pressure distribution in the root segment of the tree. By this mechanism global hemodynamics can be focused by wave reflections back to the aortic arch, where they can rapidly impact cardiac control via smart baroreception. Such sensing is likely important to maintain efficient heart function. However, alterations in the arterial tree due to aging and other natural processes can lead in such a system to altered cardiac control and essential hypertension.

Machine-learning phenotypic classification of bicuspid aortopathy.

PubMed

Wojnarski, Charles M; Roselli, Eric E; Idrees, Jay J; Zhu, Yuanjia; Carnes, Theresa A; Lowry, Ashley M; Collier, Patrick H; Griffin, Brian; Ehrlinger, John; Blackstone, Eugene H; Svensson, Lars G; Lytle, Bruce W

2018-02-01

Bicuspid aortic valves (BAV) are associated with incompletely characterized aortopathy. Our objectives were to identify distinct patterns of aortopathy using machine-learning methods and characterize their association with valve morphology and patient characteristics. We analyzed preoperative 3-dimensional computed tomography reconstructions for 656 patients with BAV undergoing ascending aorta surgery between January 2002 and January 2014. Unsupervised partitioning around medoids was used to cluster aortic dimensions. Group differences were identified using polytomous random forest analysis. Three distinct aneurysm phenotypes were identified: root (n = 83; 13%), with predominant dilatation at sinuses of Valsalva; ascending (n = 364; 55%), with supracoronary enlargement rarely extending past the brachiocephalic artery; and arch (n = 209; 32%), with aortic arch dilatation. The arch phenotype had the greatest association with right-noncoronary cusp fusion: 29%, versus 13% for ascending and 15% for root phenotypes (P < .0001). Severe valve regurgitation was most prevalent in root phenotype (57%), followed by ascending (34%) and arch phenotypes (25%; P < .0001). Aortic stenosis was most prevalent in arch phenotype (62%), followed by ascending (50%) and root phenotypes (28%; P < .0001). Patient age increased as the extent of aneurysm became more distal (root, 49 years; ascending, 53 years; arch, 57 years; P < .0001), and root phenotype was associated with greater male predominance compared with ascending and arch phenotypes (94%, 76%, and 70%, respectively; P < .0001). Phenotypes were visually recognizable with 94% accuracy. Three distinct phenotypes of bicuspid valve-associated aortopathy were identified using machine-learning methodology. Patient characteristics and valvular dysfunction vary by phenotype, suggesting that the location of aortic pathology may be related to the underlying pathophysiology of this disease. Copyright © 2017 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

Hybrid treatment of aortic arch disease

PubMed Central

Metzger, Patrick Bastos; Rossi, Fabio Henrique; Moreira, Samuel Martins; Issa, Mario; Izukawa, Nilo Mitsuru; Dinkhuysen, Jarbas J.; Spina Neto, Domingos; Kambara, Antônio Massamitsu

2014-01-01

Introduction The management of thoracic aortic disease involving the ascending aorta, aortic arch and descending thoracic aorta are technically challenging and is an area in constant development and innovation. Objective To analyze early and midterm results of hybrid treatment of arch aortic disease. Methods Retrospective study of procedures performed from January 2010 to December 2012. The end points were the technical success, therapeutic success, morbidity and mortality, neurologic outcomes, the rate of endoleaks and reinterventions. Results A total of 95 patients treated for thoracic aortic diseases in this period, 18 underwent hybrid treatment and entered in this study. The average ages were 62.3 years. The male was present in 66.7%. The technical and therapeutic success was 94.5% e 83.3%. The perioperative mortality rate of 11.1%. There is any death during one-year follow- up. The reoperation rates were 16.6% due 2 cases of endoleak Ia and one case of endoleak II. There is any occlusion of anatomic or extra anatomic bypass during follow up. Conclusion In our study, the hybrid treatment of aortic arch disease proved to be a feasible alternative of conventional surgery. The therapeutic success rates and re- interventions obtained demonstrate the necessity of thorough clinical follow-up of these patients in a long time. PMID:25714205

Separate origins of the left internal and external carotid arteries from the aortic arch and cervical internal carotid artery aneurysm in a patient with Noonan syndrome.

PubMed

Tahir, Rizwan Ahmad; Asmaro, Karam; Pabaney, Aqueel; Kole, Max; Nypaver, Timothy; Marin, Horia

2016-07-20

Distinct origins of the external carotid artery and the internal carotid artery (ICA) from the aortic arch have been rarely described, and represent an aberrant development of the aortic arches during fetal life. This anatomical variation is usually discovered incidentally; infrequently, an aneurysm of the cervical ICA might accompany this rare configuration. We describe one such case in a patient with Noonan syndrome who presented with pulsatile neck mass. The diagnostic features and management of the aneurysm and a review of the literature are presented. 2016 BMJ Publishing Group Ltd.

Endovascular Treatment of Distal Aortic Arch Aneurysm Associated with Coarctation of Aorta in a Jehovah's Witness

PubMed Central

Mannacio, Vito A.; Di Tommaso, Ettorino; Pinna, Giovanni B.; Fontana, Immacolata; Iannelli, Gabriele

2017-01-01

Late aneurysm formation in the proximal aorta or distal aortic arch is a recognized sequela of untreated stenosis of the aortic isthmus and is associated with substantial risk of aortic rupture. We describe the case of a 44-year-old man with untreated coarctation of the aorta who presented with a prestenotic dissecting thoracic aortic aneurysm. He declined surgery because he was a Jehovah's Witness. Instead, we performed emergency endovascular aortic repair in which 2 stent-grafts were placed in the descending aorta. Our experience suggests that this procedure is a useful and safe alternative to open surgery in patients who have aneurysms associated with coarctation of the aorta. PMID:29276439

Congenital anomalies of the left brachiocephalic vein detected in adults on computed tomography.

PubMed

Yamamuro, Hiroshi; Ichikawa, Tamaki; Hashimoto, Jun; Ono, Shun; Nagata, Yoshimi; Kawada, Shuichi; Kobayashi, Makiko; Koizumi, Jun; Shibata, Takeo; Imai, Yutaka

2017-10-01

Anomalous left brachiocephalic vein (BCV) is a rare and less known systemic venous anomaly. We evaluated congenital anomalies of the left BCV in adults detected during computed tomography (CT) examinations. This retrospective study included 81,425 patients without congenital heart disease who underwent chest CT. We reviewed the recorded reports and CT images for congenital anomalies of the left BCV including aberrant and supernumerary BCVs. The associated congenital aortic anomalies were assessed. Among 73,407 cases at a university hospital, 22 (16 males, 6 females; mean age, 59 years) with aberrant left BCVs were found using keyword research on recorded reports (0.03%). Among 8018 cases at the branch hospital, 5 (4 males, 1 female; mean age, 67 years) with aberrant left BCVs were found using CT image review (0.062%). There were no significant differences in incidences of aberrant left BCV between the two groups. Two cases had double left BCVs. Eleven cases showed high aortic arches. Two cases had the right aortic arch, one case had an incomplete double aortic arch, and one case was associated with coarctation. Aberrant left BCV on CT examination in adults was extremely rare. Some cases were associated with aortic arch anomalies.

Hybrid treatment of a huge complex aortic pseudo-aneurysm subsequent to a coarctation.

PubMed

Rizza, Antonio; Barletta, Valentina; Palmieri, Cataldo; Berti, Sergio

2017-07-01

Endovascular treatment of pseudo-aneurysms subsequent to a pre-existing aortic coarctation is becoming a well-accepted technical solution especially in patients presenting anatomical challenges involving the aortic arch. We report the case of a 65-year-old woman with a huge pseudo-aneurysm of the descending thoracic aorta. Diagnostic imaging assessment documented also the presence of an aneurysmatic aberrant right subclavian artery. Due to patient's anatomical arterial condition, we decided to treat the aneurysm applying a hybrid approach. © The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Total aortic arch replacement with the elephant trunk technique: single-centre 30-year results.

PubMed

Shrestha, Malakh; Martens, Andreas; Krüger, Heike; Maeding, Illona; Ius, Fabio; Fleissner, Felix; Haverich, Axel

2014-02-01

The combined disease of the aortic arch and the descending aorta (aneurysms and dissection) remains a surgical challenge. Various approaches have been used to treat this complex pathology. In the two-stage operation, at the first-stage operation, the aortic arch is replaced through a median sternotomy. Later, at the second-stage operation, the descending thoracic aorta is replaced through a lateral thoracotomy. The elephant trunk (ET) technique was introduced by H.G. Borst at our centre in March 1982, greatly simplifying the second-phase operation. We present our 30-year experience. From March 1982 to March 2012, 179 patients (112 males, age 56.4±12.6 years) received an ET procedure for the combined disease of the aortic arch and the descending aorta (91 aneurysms, 88 dissections (47 acute)). Fifty-six of these patients had undergone previous cardiac operations. Concomitant procedures were performed if necessary. The cerebral protection was done either by deep (till 1999) or moderate hypothermic circulatory arrest and selective antegrade cerebral perfusion (SACP, after 1999). Cardiopulmonary bypass (CPB) and X-clamp times were 208.5±76.5 min and 123.7±54.8 min, respectively. The intraoperative mortality and 30-day mortality during the first-stage operation were 1.7% (3/179) and 17.3% (31/179, 15 with AADA), respectively. Perioperative stroke was 7.9% (n=14/176). Postoperative recurrent nerve palsy was present in 18.2% (32/176) and paraplegia in 5.6% (10/176). The second-stage completion operation was performed as early as possible. Fifty-seven second-stage completion procedures were performed, either surgically (n=50) or through interventional techniques (n=7). The intraoperative and 30-day mortality after the second-stage completion procedures were 5.2% (3/57) and 7.0% (4/57), respectively. The stroke, recurrent nerve palsy and paraplegia rates were 0, 0 and 7% (4/54), respectively. The ET technique has greatly facilitated the two-stage approach to the surgical treatment of combined diseases of the aortic arch and descending aorta. The initial learning curve, acute dissections, re-do and concomitant procedures partially explain the higher mortality rate. Despite the development of new hybrid techniques, there is still a role for the classical ET in selected patients, particularly in the context of proven long-term results and cost effectiveness.

Combined Open and Endovascular Repair for Aortic Arch Pathology

PubMed Central

Kang, Woong Chol; Ahn, Tae Hoon; Lee, Kyung Hoon; Moon, Chan Il; Han, Seung Hwan; Park, Chul-Hyun; Park, Kook-Yang; Kang, Jin Mo; Kim, Jung Ho

2010-01-01

Background and Objectives We describe our experience with combined open and endovascular repair in patients who have aortic arch pathology. Subjects and Methods This study is a retrospective analysis of 7 patients who underwent combined open and endovascular repair for aortic arch pathology. Medical records and radiographic information were reviewed. Results A total of 7 consecutive patients (5 men, 71.4%) underwent thoracic stent graft implantation. The mean age was 59.9±16.7 years. The indication for endovascular repair was aneurysmal degeneration in 5 patients, and rupture or impending rupture in 2 patients. In all 7 cases, supra-aortic transposition of the great vessels was performed successfully. Stent graft implantation was achieved in all cases. Surgical exposure of the access vessel was necessary in 2 patients. A total of 9 stent grafts were implanted (3 stent grafts in one patient). The Seal thoracic and the Valiant endovascular stent graft were implanted in 6 patients and 1 patient, respectively. There were no post-procedure deaths or neurologic complications. In 2 patients, bleeding and injury of access vessel were noted after the procedure. Postoperative endoleak was noted in 1 patient. One patient died at 10 months after the procedure due to a newly developed ascending aortic dissection. No patients required secondary intervention during the follow-up period. The aortic diameter decreased in 4 patients. In 3 patients, including 1 patient with endoleak, there was no change in aortic diameter. Conclusion Our experience suggests that combined open and endovascular repair for aortic arch pathology is safe and effective, with few complications. PMID:20830254

Loss of pulse pressure amplification between the ascending and descending aorta in patients after an aortic arch repair.

PubMed

Murakami, Tomoaki; Shiraishi, Masahiro; Nawa, Tomohiro; Takeda, Atsuhito

2017-03-01

One of the most important problems in patients with an aortic coarctation after an aortic arch repair is future cardiovascular disease. We previously reported the enhancement of the aortic pressure wave reflection in patients and hypothesized that the enhancement was caused by a new pressure wave reflection generated from the repaired site. To prove the hypothesis, we analyzed the pressure waveform in the ascending and descending aorta and examined their pulse pressure (PP) amplification. Fifteen patients after an aortic arch repair without a recoarctation were enrolled. The ascending and descending aorta pressure waveforms were recorded by a pressure sensor mounted catheter. The pressures were compared with those of age-matched controls. The patient's age was 7.3 ± 2.7 years, and they underwent the aortic arch repair at 30.1 ± 29.0 days. The ascending aorta SBP (106.1 ± 12.7 mmHg) was higher than in the control patients (97.9 ± 14.3) (P = 0.015). The PP at the ascending aorta in the patients (41.3 ± 7.8) was wider than that in the controls (36.4 ± 5.0) (P = 0.010). There was no difference concerning the PP at the descending aorta between the patients (41.0 ± 7.7) and controls (40.5 ± 6.5). The difference in the PP between the descending and ascending aorta (PP at the descending aorta - PP at the ascending aorta) in the patients was -0.3 ± 1.7 and 5.1 ± 2.9 in the controls (P < 0.0001). The ascending aortic PP was augmented in the patients after the aortic arch repair. It could be one of the causes of future cardiovascular disease.

[Right-side aortic arch with aberrant left subclavian artery and Kommerell's diverticulum. A cause of vascular ring].

PubMed

Tamayo-Espinosa, Tania; Erdmenger-Orellana, Julio; Becerra-Becerra, Rosario; Balderrabano-Saucedo, Norma; Segura-Standford, Begoña

The right-side aortic arch may be associated with aberrant left subclavian artery, in some cases this artery originates from an aneurismal dilation of the aorta called Kommerell's diverticulum. A report is presented on 2 cases of vascular ring formed by a right-side aortic arch, anomalous left subclavian artery, Kommerell's diverticulum and left patent ductus arteriosus. A review the literature was also performed as regards the embryological development and the imaging methods used to help in the diagnosis of this rare vascular anomaly. Copyright © 2017 Instituto Nacional de Cardiología Ignacio Chávez. Publicado por Masson Doyma México S.A. All rights reserved.

Interrupted Aortic Arch Type B in A Patient with Cat Eye Syndrome

PubMed Central

Belangero, Sintia Iole Nogueira; Bellucco, Fernanda Teixeira da Silva; Cernach, Mirlene C. S. P.; Hacker, April M.; Emanuel, Beverly S.; Melaragno, Maria Isabel

2010-01-01

We report a patient with cat eye syndrome and interrupted aortic arch type B, a typical finding in the 22q11.2 deletion syndrome. Chromosomal analysis and fluorescent in situ hybridization (FISH) showed a supernumerary bisatellited isodicentric marker chromosome derived from chromosome 22. The segment from 22pter to 22q11.2 in the supernumerary chromosome found in our patient does not overlap with the region deleted in patients with the 22q11.2 deletion syndrome. However, the finding of an interrupted aortic arch type B is unusual in CES, although it is a frequent heart defect in the 22q11 deletion syndrome. PMID:19629279

Intimal re-layering technique for type A acute aortic dissection-reconstructing the intimal layer continuity to induce remodeling of the false channel.

PubMed

Neri, Eugenio; Tucci, Enrico; Tommasino, Giulio; Guaccio, Giulia; Ricci, Carmelo; Lucatelli, Pierleone; Cini, Marco; Ceresa, Roberto; Benvenuti, Antonio; Muzzi, Luigi

2018-01-01

Residual false channel is common after repair of type A acute aortic dissection (TAAAD). Starting from our recent series of TAAAD patients we carried out a retrospective analysis, regarding the failure of primary exclusion at the time of the initial operation. We classified the location of the principal entry tears perfusing the residual false channel. The proposed technique represents our attempt to correct the mechanism of false channel perfusion during primary repair. We describe a new technique designed to address some limitations of standard hemiarch aortic replacement. Its goal are: (I) to reinforce the intimal layer at the arch level; (II) to eliminate inter-luminal communications at the arch level using suture lines around the arch vessels; (III) to provide an elephant trunk configuration for further interventions. Between August 2016 and January 2018, 11 patients underwent emergency surgery using this technique; 7 were men; the median age was 74 years. All patients were treated using systemic circulatory arrest under moderate hypothermia (26 °C) and selective cerebral perfusion. All patients had supra-coronary repair; 1 patient had aortic valve replacement + CABG. In the first two patients a manual suture around supra-aortic trunks was used; the subsequent seven patients were treated with a mechanical suture bladeless device. CT scan follow up was performed in all survivors with controls before discharge 3 months and 1 year after operation. No patient died in the operating room and no neurologic deficit was observed in this initial experience. One patient died in POD 5th for low cardiac output syndrome. Median ICU stay was 3 days (IQR, 2-6 days). Hospital mean length of stay was 15.2±8 days. Median cardiopulmonary bypass time was 130 min (IQR, 110-141 min); median arrest time for re-layering was 17 min (IQR, 16-20 min); median total arrest was 36 min (IQR, 29-39 min). Distal aortic anastomosis was performed in zone 0 in 4 patients, zone 1, with innominate replacement, in 5 patients, in zone 2, with branches to innominate and left common carotid arteries, in 2 patients. Median follow up (closing date 06/01/2018) was 443 days (IQR, 262-557 days); no late deaths occurred. No dehiscence at the level of stapler or manual sutures was observed. Proximal 1/3 of the thoracic aorta false channel was obliterated in all cases but one; in 3 cases complete exclusion of the false channel was obtained after operation. In one case stent graft completion was required. This technique combines the advantages of arch replacement to the simplicity of anterior hemiarch repair. This study demonstrates the safety of the procedure and the possibility to induce aortic remodeling without complex arch replacement.

Carotid Artery Dissection and Ischemic Stroke Originating from Localized Aortic Arch Dissection.

PubMed

Kamimura, Teppei; Nomura, Eiichi; Hara, Naoyuki; Maetani, Yuta; Agari, Dai; Ichimura, Kouichi; Yoshida, Hideo; Yamawaki, Takemori

2016-11-01

Aortic dissection is an infrequent but important cause of acute ischemic stroke (AIS), and must not be overlooked because of a possible worse outcome, especially with the use of an intravenous recombinant tissue plasminogen activator. We report a case of left carotid artery dissection and AIS originating from localized aortic arch dissection, pathologically caused by cystic medial necrosis in the tunica media. Copyright © 2016 National Stroke Association. Published by Elsevier Inc. All rights reserved.

Effect of cannula shape on aortic wall and flow turbulence: hydrodynamic study during extracorporeal circulation in mock thoracic aorta.

PubMed

Minakawa, Masahito; Fukuda, Ikuo; Yamazaki, Junichi; Fukui, Kozo; Yanaoka, Hideki; Inamura, Takao

2007-12-01

This study was designed to analyze flow pattern, velocity, and strain on the aortic wall of a glass aortic model during extracorporeal circulation, and to elucidate the characteristics of flow pattern in four aortic cannulas. Different patterns of large vortices and helical flow were made by each cannula. The high-velocity flow (0.6 m/s) was observed in end-hole cannula, causing high strain rate tensor (0.3~0.4 without unit) on the aortic arch. In dispersion cannula, a decreased strain rate tensor (less than 0.1) was found on the outer curvature of the aortic arch. In Soft-flow cannula (3M Cardiovascular, Ann Arbor, MI, USA), further decreased flow velocity (0.2 m/s) and strain (less than 0.2) were observed. In Select 3D cannula (Medtronic, Inc., Minneapolis, MN, USA), a high strain (0.4~0.5) was observed along the inner curvature of the aortic arch. In conclusion, end-hole cannula should not be used in atherosclerotic aorta. Particular attention should be paid both for selection of cannulas and cannulation site based on this result.

Canadian Cardiovascular Society/Canadian Society of Cardiac Surgeons/Canadian Society for Vascular Surgery Joint Position Statement on Open and Endovascular Surgery for Thoracic Aortic Disease.

PubMed

Appoo, Jehangir J; Bozinovski, John; Chu, Michael W A; El-Hamamsy, Ismail; Forbes, Thomas L; Moon, Michael; Ouzounian, Maral; Peterson, Mark D; Tittley, Jacques; Boodhwani, Munir

2016-06-01

In 2014, the Canadian Cardiovascular Society (CCS) published a position statement on the management of thoracic aortic disease addressing size thresholds for surgery, imaging modalities, medical therapy, and genetics. It did not address issues related to surgical intervention. This joint Position Statement on behalf of the CCS, Canadian Society of Cardiac Surgeons, and the Canadian Society for Vascular Surgery provides recommendations about thoracic aortic disease interventions, including: aortic valve repair, perfusion strategies for arch repair, extended arch hybrid reconstruction for acute type A dissection, endovascular management of arch and descending aortic aneurysms, and type B dissection. The position statement is constructed using Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology, and has been approved by the primary panel, an international secondary panel, and the CCS Guidelines Committee. Advent of endovascular technology has improved aortic surgery safety and extended the indications of minimally invasive thoracic aortic surgery. The combination of safer open surgery with endovascular treatment has improved patient outcomes in this rapidly evolving subspecialty field of cardiovascular surgery. Copyright © 2016 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.

Computer-aided patch planning for treatment of complex coarctation of the aorta

NASA Astrophysics Data System (ADS)

Rietdorf, Urte; Riesenkampff, Eugénie; Kuehne, Titus; Huebler, Michael; Meinzer, Hans-Peter; Wolf, Ivo

2009-02-01

Between five and eight percent of all children born with congenitally malformed hearts suffer from coarctations of the aorta. Some severe coarctations can only be treated by surgical repair. Untreated, this defect can cause serious damage to organ development or even lead to death. Patch repair requires open surgery. It can affect patients of any age: newborns with severe coarctation and/or hypoplastic aortic arch as well as older patients with late diagnosis of coarctation of the aorta. Another patient group are patients of varying age with re-coarctation of the aorta or hypoplastic aortic arch after surgical and/or interventional repair. If anatomy is complex and interventional treatment by catheterization, balloon angioplasty or stent placement is not possible, surgery is indicated. The choice of type of surgery depends not only on the given anatomy but also on the experience the surgical team has with each method. One surgical approach is patch repair. A patch of a suitable shape and size is sewed into the aorta to expand the aortic lumen at the site of coarctation. At present, the shape and size of the patch are estimated intra-operatively by the surgeon. We have developed a software application that allows planning of the patch pre-operatively on the basis of magnetic resonance angiographic data. The application determines the diameter of the coarctation and/or hypoplastic segment and constructs a patch proposal by calculating the difference to the normal vessel diameter pre-operatively. Evaluation of MR angiographic datasets from 12 test patients with different kinds of aortic arch stenosis shows a divergence of only (1.5+/-1.2) mm in coarctation diameters between manual segmentations and our approach, with comparable time expenditure. Following this proposal the patch can be prepared and adapted to the patient's anatomy pre-operatively. Ideally, this leads to shorter operation times and a better long-term outcome with a reduced rate of residual stenosis and re-stenosis and aneurysm formation.

Contemporary results of open aortic arch surgery.

PubMed

Thomas, Mathew; Li, Zhuo; Cook, David J; Greason, Kevin L; Sundt, Thoralf M

2012-10-01

The success of endovascular therapies for descending thoracic aortic disease has turned attention toward stent graft options for repair of aortic arch aneurysms. Defining the role of such techniques demands understanding of contemporary results of open surgery. The outcomes of open arch procedures performed on a single surgical service from July 1, 2001 to August 30, 2010, were examined as defined per The Society of Thoracic Surgeons national database. During the study period, 209 patients (median age, 65 years; range, 26-88) underwent arch operations, of which 159 were elective procedures. In 65 the entire arch was replaced, 22 of whom had portions of the descending thoracic aorta simultaneously replaced via bilateral thoracosternotomy. Antegrade cerebral perfusion was used in 78 patients and retrograde cerebral perfusion in 1. Operative mortality was 2.5% in elective circumstances and 10% in emergency cases (P = .04). The stroke rate was 5.0% when procedures were performed electively and 11.8% when on an emergency basis (P = .11). Procedure-specific mortality rates were 5.5% for elective and 10% for emergency procedures with total arch replacement, and 1.0% for elective and 10% for emergency procedures with hemiarch replacement. Stratified by extent, neurologic event rates were 5.5% for elective and 10% for emergency procedures with total arch and 4.8% for elective and 12.5% for emergency procedures with hemiarch replacement. Open aortic arch replacement can be performed with low operative mortality and stroke rates, especially in elective circumstances, by a team with particular focus on the procedure. The results of novel endovascular therapies should be benchmarked against contemporary open series performed in such a setting. Copyright © 2012 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.

Impact of Retrograde Arch Extension in Acute Type B Aortic Dissection on Management and Outcomes.

PubMed

Nauta, Foeke J H; Tolenaar, Jip L; Patel, Himanshu J; Appoo, Jehangir J; Tsai, Thomas T; Desai, Nimesh D; Montgomery, Daniel G; Mussa, Firas F; Upchurch, Gilbert R; Fattori, Rosella; Hughes, G Chad; Nienaber, Christoph A; Isselbacher, Eric M; Eagle, Kim A; Trimarchi, Santi

2016-12-01

Optimal management of acute type B aortic dissection with retrograde arch extension is controversial. The effect of retrograde arch extension on operative and long-term mortality has not been studied and is not incorporated into clinical treatment pathways. The International Registry of Acute Aortic Dissection was queried for all patients presenting with acute type B dissection and an identifiable primary intimal tear. Outcomes were stratified according to management for patients with and without retrograde arch extension. Kaplan-Meier survival curves were constructed. Between 1996 and 2014, 404 patients (mean age, 63.3 ± 13.9 years) were identified. Retrograde arch extension existed in 67 patients (16.5%). No difference in complicated presentation was noted (36.8% vs 31.7%, p = 0.46), as defined by limb or organ malperfusion, coma, rupture, and shock. Patients with or without retrograde arch extension received similar treatment, with medical management in 53.7% vs 56.5% (p = 0.68), endovascular treatment in 32.8% vs 31.1% (p = 0.78), open operation in 11.9% vs 9.5% (p = 0.54), or hybrid approach in 1.5% vs 3.0% (p = 0.70), respectively. The in-hospital mortality rate was similar for patients with (10.7%) and without (10.4%) retrograde arch extension (p = 0.96), and 5-year survival was also similar at 78.3% and 77.8%, respectively (p = 0.27). The incidence of retrograde arch dissection involves approximately 16% of patients with acute type B dissection. In the International Registry of Acute Aortic Dissection, this entity seems not to affect management strategy or early and late death. Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Endovascular Treatment of Various Aortic Pathologies: Review of the Latest Data and Technologies.

PubMed

Maeda, Koji; Ohki, Takao; Kanaoka, Yuji

2018-06-01

The technologies and innovations applicable to endovascular treatment for complex aortic pathologies have progressed rapidly over the last two decades. Although the initial outcomes of an endovascular aortic repair have been excellent, as long-term data became available, complications including endoleaks, endograft migration, and endograft infection have become apparent and are of concern. Previously, the indication for endovascular therapy was restricted to descending thoracic aortic aneurysms and abdominal aortic aneurysms. However, its indication has expanded along with the improvement of techniques and devices, and currently, it has become possible to treat pararenal aortic aneurysms and Crawford type 4 thoracoabdominal aortic aneurysm (TAAA) using the off-the-shelf devices. Additionally, custom-made devices allow for the treatment of arch or more extensive TAAAs. Endovascular treatment is applied not only to aneurysms but also to acute/chronic dissections. However, long-term outcomes are still unclear. This article provides an overview of available devices and the results of endovascular treatment for various aortic pathologies.

Bovine aortic arch with supravalvular aortic stenosis.

PubMed

Idhrees, Mohammed; Cherian, Vijay Thomas; Menon, Sabarinath; Mathew, Thomas; Dharan, Baiju S; Jayakumar, K

2016-09-01

A 5-year-old boy was diagnosed to have supravalvular aortic stenosis (SVAS). On evaluation of CT angiogram, there was associated bovine aortic arch (BAA). Association of BAA with SVAS has not been previously reported in literature, and to best of our knowledge, this is the first case report of SVAS with BAA. Recent studies show BAA as a marker for aortopathy. SVAS is also an arteriopathy. In light of this, SVAS can also possibly be a manifestation of aortopathy associated with BAA. Copyright © 2015 Cardiological Society of India. Published by Elsevier B.V. All rights reserved.

Visualization of Monocytic Cells in Regressing Atherosclerotic Plaques by Intravital 2-Photon and Positron Emission Tomography-Based Imaging-Brief Report.

PubMed

Li, Wenjun; Luehmann, Hannah P; Hsiao, Hsi-Min; Tanaka, Satona; Higashikubo, Ryuji; Gauthier, Jason M; Sultan, Deborah; Lavine, Kory J; Brody, Steven L; Gelman, Andrew E; Gropler, Robert J; Liu, Yongjian; Kreisel, Daniel

2018-05-01

Aortic arch transplants have advanced our understanding of processes that contribute to progression and regression of atherosclerotic plaques. To characterize the dynamic behavior of monocytes and macrophages in atherosclerotic plaques over time, we developed a new model of cervical aortic arch transplantation in mice that is amenable to intravital imaging. Vascularized aortic arch grafts were transplanted heterotropically to the right carotid arteries of recipient mice using microsurgical suture techniques. To image immune cells in atherosclerotic lesions during regression, plaque-bearing aortic arch grafts from B6 ApoE-deficient donors were transplanted into syngeneic CX 3 CR1 GFP reporter mice. Grafts were evaluated histologically, and monocytic cells in atherosclerotic plaques in ApoE-deficient grafts were imaged intravitally by 2-photon microscopy in serial fashion. In complementary experiments, CCR2 + cells in plaques were serially imaged by positron emission tomography using specific molecular probes. Plaques in ApoE-deficient grafts underwent regression after transplantation into normolipidemic hosts. Intravital imaging revealed clusters of largely immotile CX 3 CR1 + monocytes/macrophages in regressing plaques that had been recruited from the periphery. We observed a progressive decrease in CX 3 CR1 + monocytic cells in regressing plaques and a decrease in CCR2 + positron emission tomography signal during 4 months. Cervical transplantation of atherosclerotic mouse aortic arches represents a novel experimental tool to investigate cellular mechanisms that contribute to the remodeling of atherosclerotic plaques. © 2018 American Heart Association, Inc.

Neurodevelopmental Outcomes Following Regional Cerebral Perfusion with Neuromonitoring for Neonatal Aortic Arch Reconstruction

PubMed Central

Andropoulos, Dean B.; Easley, R. Blaine; Brady, Ken; McKenzie, E. Dean; Heinle, Jeffrey S.; Dickerson, Heather A.; Shekerdemian, Lara S.; Meador, Marcie; Eisenman, Carol; Hunter, Jill V.; Turcich, Marie; Voigt, Robert G.; Fraser, Charles D.

2013-01-01

Background In this study we report magnetic resonance imaging (MRI) brain injury, and 12 month neurodevelopmental outcomes, when regional cerebral perfusion (RCP) is utilized for neonatal aortic arch reconstruction. Methods Fifty seven neonates receiving RCP during aortic arch reconstruction were enrolled in a prospective outcome study. RCP flows were determined by near-infrared spectroscopy and transcranial Doppler monitoring. Brain MRI were performed preoperatively and 7 days postoperatively. Bayley Scales of Infant Development III was performed at 12 months. Results Mean RCP time was 71 ± 28 minutes (range 5–121), mean flow 56.6 ± 10.6 ml/kg/min. New postoperative MRI brain injury was seen in 40% of patients. For 35 RCP patients at age 12 months, mean Bayley III composite standard scores were: Cognitive = 100.1 ± 14.6,(range 75–125); Language = 87.2 ± 15.0, (range 62–132); Motor = 87.9 ± 16.8, (range 58–121).Increasing duration of RCP was not associated with adverse neurodevelopmental outcomes. Conclusions Neonatal aortic arch repair with RCP utilizing a neuromonitoring strategy results in 12-month cognitive outcomes that are at reference population norms; language and motor outcomes are lower than the reference population norms by 0.8–0.9 standard deviation. This largest RCP group with neurodevelopmental outcomes published to date demonstrates that this technique is effective and safe in supporting the brain during neonatal aortic arch reconstruction. PMID:22766302

A Feasibility Study of a New Unibody Branched Stent Graft Applied to Reconstruct the Canine Aortic Arch.

PubMed

Li, W; Zhai, S; Xu, K; Li, Q; Zhong, H; Li, T; Zhang, Z

2018-06-01

The aim was to evaluate the feasibility and safety of a new unibody branched stent graft for the reconstruction of the canine aortic arch. The unibody branched stent grafts included single branched stent grafts and double branched stent grafts. The main stent graft and branched limbs were sutured together. The branched stent grafts were folded into the introducer system, which consisted of a double channel catheter, a detachable sleeve, and an introducer sheath. The branched stent grafts were introduced and deployed into the aortic arch by the delivery system. Twenty adult mongrel dogs were used for the experiments. Ten dogs were implanted with single branched stent grafts; the other 10 were implanted with double branched stent grafts. The surviving animals were followed up for 3 months. Computed tomography angiography (CTA) was performed to observe the status of the branched stent grafts. All the unibody branched stent grafts were successfully implanted into the canine aortic arches. The technical success rate was 100%. There was no cerebral infarction, paraplegia or incision infection. CTA showed that all the branched stent grafts were patent; there was no endoleak or stent migration. The unibody branched stent graft system could be used to reconstruct the aortic arch. The animal experimental procedures demonstrated the safety and feasibility of the unibody branched stent graft system. Copyright © 2018 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.

Hypothermia and cerebral protection strategies in aortic arch surgery: a comparative effectiveness analysis from the STS Adult Cardiac Surgery Database.

PubMed

Englum, Brian R; He, Xia; Gulack, Brian C; Ganapathi, Asvin M; Mathew, Joseph P; Brennan, J Matthew; Reece, T Brett; Keeling, W Brent; Leshnower, Bradley G; Chen, Edward P; Jacobs, Jeffrey P; Thourani, Vinod H; Hughes, G Chad

2017-09-01

Hypothermic circulatory arrest is essential to aortic arch surgery, although consensus regarding optimal cerebral protection strategy remains lacking. We evaluated the current use and comparative effectiveness of hypothermia/cerebral perfusion (CP) strategies in aortic arch surgery. Using the Society of Thoracic Surgeons Database, cases of aortic arch surgery with hypothermic circulatory arrest from 2011 to 2014 were categorized by hypothermia strategy-deep/profound (D/P; ≤20°C), low-moderate (L-M; 20.1-24°C), and high-moderate (H-M; 24.1-28°C)-and CP strategy-no CP, antegrade (ACP), retrograde (RCP) or both ACP/RCP. After adjusting for potential confounders, strategies were compared by composite end-point (operative mortality or neurologic complication). Of the 12 521 aortic arch repairs with hypothermic circulatory arrest, the most common combined strategies were straight D/P without CP (25%), D/P + RCP (16%) and D/P + ACP (14%). Overall rates of the primary end-point, operative mortality and stroke were 23%, 12% and 8%, respectively. Among the 7 most common strategies, the 2 not utilizing CP (straight D/P and straight L-M) appeared inferior, associated with significantly higher risk of the composite end-point (odds ratio: 1.6; P < 0.01); there was no significant difference in composite outcome between the remaining strategies (D/P + ACP, D/P + RCP, L-M + ACP, L-M + RCP and H-M + ACP). In a comparative effectiveness study of cerebral protection strategies for aortic arch repair, strategies without adjunctive CP, including the most commonly utilized strategy of straight D/P hypothermia, appeared inferior to those utilizing CP. There was no clearly superior strategy among remaining techniques, and randomized trials are needed to define best practice. © The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

CXCL12-CXCR4 signalling plays an essential role in proper patterning of aortic arch and pulmonary arteries.

PubMed

Kim, Bo-Gyeong; Kim, Yong Hwan; Stanley, Edward L; Garrido-Martin, Eva M; Lee, Young Jae; Oh, S Paul

2017-11-01

Chemokine CXCL12 (stromal derived factor 1: SDF1) has been shown to play important roles in various processes of cardiovascular development. In recent avian studies, CXCL12 signalling has been implicated in guidance of cardiac neural crest cells for their participation in the development of outflow tract and cardiac septum. The goal of this study is to investigate the extent to which CXCL12 signalling contribute to the development of aortic arch and pulmonary arteries in mammals. Novel Cxcl12-LacZ reporter and conditional alleles were generated. Using whole mount X-gal staining with the reporter allele and vascular casting techniques, we show that the domain branching pattern of pulmonary arteries in Cxcl12-null mice is completely disrupted and discordant with that of pulmonary veins and airways. Cxcl12-null mice also displayed abnormal and superfluous arterial branches from the aortic arch. The early steps of pharyngeal arch remodelling in Cxcl12-null mice appeared to be unaffected, but vertebral arteries were often missing and prominent aberrant arteries were present parallel to carotid arteries or trachea, similar to aberrant vertebral artery or thyroid ima artery, respectively. Analysis with computed tomography not only confirmed the results from vascular casting studies but also identified abnormal systemic arterial supply to lungs in the Cxcl12-null mice. Tie2-Cre mediated Cxcr4 deletion phenocopied the Cxcl12-null phenotypes, indicating that CXCR4 is the primary receptor for arterial patterning, whereas Cxcl12 or Cxcr4 deletion by Wnt1-Cre did not affect aortic arch patterning. CXCL12-CXCR4 signalling is essential for the correct patterning of aortic arches and pulmonary arteries during development. Superfluous arteries in Cxcl12-null lungs and the aortic arch infer a role of CXCL12 in protecting arteries from uncontrolled sprouting during development of the arterial system. Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2017. For Permissions, please email: journals.permissions@oup.com.

Is Decellularized Porcine Small Intestine Sub-mucosa Patch Suitable for Aortic Arch Repair?

PubMed Central

Corno, Antonio F.; Smith, Paul; Bezuska, Laurynas; Mimic, Branko

2018-01-01

Introduction: We reviewed our experience with decellularized porcine small intestine sub-mucosa (DPSIS) patch, recently introduced for congenital heart defects. Materials and Methods: Between 10/2011 and 04/2016 a DPSIS patch was used in 51 patients, median age 1.1 months (5 days to 14.5 years), for aortic arch reconstruction (45/51 = 88.2%) or aortic coarctation repair (6/51 = 11.8%). All medical records were retrospectively reviewed, with primary endpoints interventional procedure (balloon dilatation) or surgery (DPSIS patch replacement) due to patch-related complications. Results: In a median follow-up time of 1.5 ± 1.1 years (0.6–2.3years) in 13/51 patients (25.5%) a re-intervention, percutaneous interventional procedure (5/51 = 9.8%) or re-operation (8/51 = 15.7%) was required because of obstruction in the correspondence of the DPSIS patch used to enlarge the aortic arch/isthmus, with median max velocity flow at Doppler interrogation of 4.0 ± 0.51 m/s. Two patients required surgery after failed interventional cardiology. The mean interval between DPSIS patch implantation and re-intervention (percutaneous procedure or re-operation) was 6 months (1–17 months). While there were 3 hospital deaths (3/51 = 5.9%) not related to the patch implantation, no early or late mortality occurred for the subsequent procedure required for DPSIS patch interventional cardiology or surgery. The median max velocity flow at Doppler interrogation through the aortic arch/isthmus for the patients who did not require interventional procedure or surgery was 1.7 ± 0.57 m/s. Conclusions: High incidence of re-interventions with DPSIS patch for aortic arch and/or coarctation forced us to use alternative materials (homografts and decellularized gluteraldehyde preserved bovine pericardial matrix). PMID:29900163

External carotid compression: a novel technique to improve cerebral perfusion during selective antegrade cerebral perfusion for aortic arch surgery.

PubMed

Grocott, Hilary P; Ambrose, Emma; Moon, Mike

2016-10-01

Selective antegrade cerebral perfusion (SACP) involving cannulation of either the axillary or innominate artery is a commonly used technique for maintaining cerebral blood flow (CBF) during the use of hypothermic cardiac arrest (HCA) for operations on the aortic arch. Nevertheless, asymmetrical CBF with hypoperfusion of the left cerebral hemisphere is a common occurrence during SACP. The purpose of this report is to describe an adjunctive maneuver to improve left hemispheric CBF during SACP by applying extrinsic compression to the left carotid artery. A 77-yr-old male patient with a history of aortic valve replacement presented for emergent surgical repair of an acute type A aortic dissection of a previously known ascending aortic aneurysm. His intraoperative course included cannulation of the right axillary artery, which was used as the aortic inflow during cardiopulmonary bypass and also allowed for subsequent SACP during HCA. After the onset of HCA, the innominate artery was clamped at its origin to allow for SACP. Shortly thereafter, however, the left-sided cerebral oxygen saturation (SrO2) began to decrease. Augmenting the PaO2, PaCO2 and both SACP pressure and flow failed to increase left hemispheric SrO2. Following the use of ultrasound guidance to confirm the absence of atherosclerotic disease in the carotid artery, external pressure was applied partially compressing the artery. With the carotid compression, the left cerebral saturation abruptly increased, suggesting pressurization of the left cerebral hemispheric circulation and augmentation of CBF. Direct ultrasound visualization and cautious partial compression of the left carotid artery may address asymmetrical CBF that occurs with SACP during HCA for aortic arch surgery. This strategy may lead to improved symmetry of CBF and corresponding cerebral oximetry measurements during aortic arch surgery.

Developments in parallel grafts for aortic arch lesions.

PubMed

Kolvenbach, Ralf R; Rabin, Asaf; Karmeli, Ron; Alpaslan, Alper; Schwierz, Elizabeth

2016-06-01

Due to the shortage of commercially available off the shelf aortic arch grafts since the last years parallel grafts or chimney grafts have played an increasing role in the treatment of patients with aortic arch lesions. Although there are still issues with type endoleaks and gutters between the chimney graft and the aortic stent-graft remaining. We report our results with the Medtronic thoracic graft in combination with long self-expanding parallel grafts, to ensure an overlapping zone of more than 7 cm between the different grafts. Alternatively, sandwich configurations are used where a direct contact between the parallel graft and the aortic wall is avoided. We have placed a total of 65 parallel grafts into supra-aortic branches. In 21 cases chimney grafts were placed into the carotid artery, in most cases into the left common carotid artery. In 36 cases chimney grafts were placed into left subclavian artery. A maximum number of 4 parallel grafts were placed for total endovascular debranching. In addition, in 8 patients a parallel graft had to be placed into the innominate artery. There was a patency of 69% for all subclavian artery chimney grafts versus 73% for carotid artery parallel grafts. Of note is a stroke rate of 5.2% in all these cases. Only 2 of the patients with an occluded left subclavian artery chimney graft required a bypass procedure for arm claudication or ischemia. We had a primary type I endoleak rate of 28%. In almost 25% secondary interventions were required mainly to treat type I leaks, in those cases where the leak did not resolve spontaneously. The overall mortality rate was 3.5%. The results of parallel graft in the aortic arch are promising, but of major concern is still the high rate of type I endoleaks as well as the neurological complication rate, most probably due to catheter manipulation in patients with severe atherosclerotic arch lesions.

Neurodevelopmental outcomes after regional cerebral perfusion with neuromonitoring for neonatal aortic arch reconstruction.

PubMed

Andropoulos, Dean B; Easley, R Blaine; Brady, Ken; McKenzie, E Dean; Heinle, Jeffrey S; Dickerson, Heather A; Shekerdemian, Lara S; Meador, Marcie; Eisenman, Carol; Hunter, Jill V; Turcich, Marie; Voigt, Robert G; Fraser, Charles D

2013-02-01

In this study we report magnetic resonance imaging (MRI) brain injury and 12-month neurodevelopmental outcomes when regional cerebral perfusion (RCP) is used for neonatal aortic arch reconstruction. Fifty-seven neonates receiving RCP during aortic arch reconstruction were enrolled in a prospective outcome study. RCP flows were determined by near-infrared spectroscopy and transcranial Doppler monitoring. Brain MRI was performed preoperatively and 7 days postoperatively. Bayley Scales of Infant Development III was performed at 12 months. Mean RCP time was 71 ± 28 minutes (range, 5 to 121 minutes) and mean flow was 56.6 ± 10.6 mL/kg/min. New postoperative MRI brain injury was seen in 40% of patients. For 35 RCP patients at age 12 months, mean Bayley Scales III Composite standard scores were: Cognitive, 100.1 ± 14.6 (range, 75 to 125); Language, 87.2 ± 15.0 (range, 62 to 132); and Motor, 87.9 ± 16.8 (range, 58 to 121). Increasing duration of RCP was not associated with adverse neurodevelopmental outcomes. Neonatal aortic arch repair with RCP using a neuromonitoring strategy results in 12-month cognitive outcomes that are at reference population norms. Language and motor outcomes are lower than the reference population norms by 0.8 to 0.9 standard deviations. The neurodevelopmental outcomes in this RCP cohort demonstrate that this technique is effective and safe in supporting the brain during neonatal aortic arch reconstruction. Copyright © 2013 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Truncus arteriosus with aortic arch interruption: cardiovascular magnetic resonance findings in the unrepaired adult

PubMed Central

2010-01-01

Truncus arteriosus (TA) is a rare congenital condition defined as a single arterial vessel arising from the heart that gives origin to the systemic, pulmonary and coronary circulations. We discuss the unique case of a 28 year-old female patient with unrepaired TA and interruption of the aortic arch who underwent cardiovascular magnetic resonance (CMR). PMID:20307275

Effect of lifelong antibiotic treatment for aortic arch prosthesis infection.

PubMed

Rupprecht, Leopold; Grosse, Jirka; Hellwig, Dirk; Schmid, Christof

2017-11-01

A patient who underwent multiple aortic operations suffered persistent infection of the ascending aorta and arch prosthesis and was finally treated with lifelong antibiotics. An 8-year follow-up with positron emission computed tomography is reported. © The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

[Efficacy of coarctation resection and aortoplasty with autologous pulmonary artery patch strategy for treating coarctation of the aorta combined with hypoplastic aortic arch in infants].

PubMed

Ma, Z L; Yan, J; Li, S J; Hua, Z D; Yan, F X; Wang, X; Wang, Q

2018-03-24

Objective: To investigate the outcomes of coarctation resection and aortoplasty with autologous pulmonary artery patch for treating coarctation of the aorta combined with hypoplastic aortic arch in infants. Methods: Clinical data of 21 infants with coarctation of the aorta and hypoplastic aortic arch, who underwent coarctation resection and aortoplasty with autologous pulmonary artery patch in Fuwai hospital from January 2009 to June 2016 were retrospectively analyzed. The age of the patients was 4 (2, 5) months,and the body weight of the patients was (5.3±1.6) kg. The patients were followed up to observe the surgery effect. Results: No perioperative death and serious complications occurred. When the patients were discharged,the systolic blood pressure of the right upper limb was lower than the preoperative systolic blood pressure ((85.7±5.9) mmHg(1 mmHg=0.133 kPa) vs. (100.7±16.6) mmHg, P< 0.001),and the systolic blood pressure of the right lower limb was higher than the preoperative systolic blood pressure ((98.7±13.3) mmHg vs. (85.6±20.8) mmHg, P< 0.001). The pressure gradient of aortic coarctation detected by echocardiography was lower than the preoperative pressure gradient ((13.1±3.8) mmHg vs. (46.2±17.1) mmHg, P< 0.001). No restenosis was detected by echocardiography at discharge. Follow-up data were obtained in 19 patients, and the follow-up time was 18 (8, 45) months.The patients grew well, and no death occurred. Restenosis occurred in 3 cases, 1 patient underwent aortic balloon dilatation and the remaining 2 patients were under follow up observation. Computed tomography angiography showed that the morphology of aortic arch was normal without signs of aortic aneurysm. Conclusion: Coarctation resection with autologous pulmonary artery patch aortoplastystrategy is considered as a safe and effective surgical method for management of infant coarctation with hypoplastic aortic arch, and this surgery method is related with satisfactory early and mid-term outcomes in this patient cohort.

Separate origins of the left internal and external carotid arteries from the aortic arch and cervical internal carotid artery aneurysm in a patient with Noonan syndrome.

PubMed

Tahir, Rizwan Ahmad; Asmaro, Karam; Pabaney, Aqueel; Kole, Max; Nypaver, Timothy; Marin, Horia

2017-04-01

Distinct origins of the external carotid artery and the internal carotid artery (ICA) from the aortic arch have been rarely described, and represent an aberrant development of the aortic arches during fetal life. This anatomical variation is usually discovered incidentally; infrequently, an aneurysm of the cervical ICA might accompany this rare configuration. We describe one such case in a patient with Noonan syndrome who presented with pulsatile neck mass. The diagnostic features and management of the aneurysm and a review of the literature are presented. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

Multidetector Computed Tomography for Congenital Anomalies of the Aortic Arch: Vascular Rings.

PubMed

García-Guereta, Luis; García-Cerro, Estefanía; Bret-Zurita, Montserrat

2016-07-01

The development of multidetector computed tomography has triggered a revolution in the study of the aorta and other large vessels and has replaced angiography in the diagnosis of congenital anomalies of the aortic arch, particularly vascular rings. The major advantage of multidetector computed tomography is that it permits clear 3-dimensional assessment of not only vascular structures, but also airway and esophageal compression. The current update aims to summarize the embryonic development of the aortic arch and the developmental anomalies leading to vascular ring formation and to discuss the current diagnostic and therapeutic role of multidetector computed tomography in this field. Copyright © 2016 Sociedad Española de Cardiología. Published by Elsevier España, S.L.U. All rights reserved.

Aortic arch shape is not associated with hypertensive response to exercise in patients with repaired congenital heart diseases.

PubMed

Ntsinjana, Hopewell N; Biglino, Giovanni; Capelli, Claudio; Tann, Oliver; Giardini, Alessandro; Derrick, Graham; Schievano, Silvia; Taylor, Andrew M

2013-11-12

Aortic arch geometry is linked to abnormal blood pressure (BP) response to maximum exercise. This study aims to quantitatively assess whether aortic arch geometry plays a role in blood pressure (BP) response to exercise. 60 age- and BSA-matched subjects--20 post-aortic coarctation (CoA) repair, 20 transposition of great arteries post arterial switch operation (ASO) and 20 healthy controls--had a three-dimensional (3D), whole heart magnetic resonance angiography (MRA) at 1.5 Tesla, 3D geometric reconstructions created from the MRA. All subjects underwent cardiopulmonary exercise test on the same day as MRA using an ergometer cycle with manual BP measurements. Geometric analysis and their correlation with BP at peak exercise were assessed. Arch curvature was similarly acute in both the post-CoA and ASO cases [0.05 ± 0.01 vs. 0.05 ± 0.01 (1/mm/m²); p = 1.0] and significantly different to that of normal healthy controls [0.05 ± 0.01 vs. 0.03 ± 0.01 (1/mm/m²), p < 0.001]. Indexed transverse arch cross sectional area were significantly abnormal in the post-CoA cases compared to the ASO cases (117.8 ± 47.7 vs. 221.3 ± 44.6; p < 0.001) and controls (117.8 ± 47.7 vs. 157.5 ± 27.2 mm²; p = 0.003). BP response to peak exercise did not correlate with arch curvature (r = 0.203, p = 0.120), but showed inverse correlation with indexed minimum cross sectional area of transverse arch and isthmus (r = -0.364, p = 0.004), and ratios of minimum arch area/ descending diameter (r = -0.491, p < 0.001). Transverse arch and isthmus hypoplasia, rather than acute arch angulation plays a role in the pathophysiology of BP response to peak exercise following CoA repair.

Intimal re-layering technique for type A acute aortic dissection—reconstructing the intimal layer continuity to induce remodeling of the false channel

PubMed Central

Tucci, Enrico; Tommasino, Giulio; Guaccio, Giulia; Ricci, Carmelo; Lucatelli, Pierleone; Cini, Marco; Ceresa, Roberto; Benvenuti, Antonio; Muzzi, Luigi

2018-01-01

Background Residual false channel is common after repair of type A acute aortic dissection (TAAAD). Starting from our recent series of TAAAD patients we carried out a retrospective analysis, regarding the failure of primary exclusion at the time of the initial operation. We classified the location of the principal entry tears perfusing the residual false channel. The proposed technique represents our attempt to correct the mechanism of false channel perfusion during primary repair. We describe a new technique designed to address some limitations of standard hemiarch aortic replacement. Its goal are: (I) to reinforce the intimal layer at the arch level; (II) to eliminate inter-luminal communications at the arch level using suture lines around the arch vessels; (III) to provide an elephant trunk configuration for further interventions. Methods Between August 2016 and January 2018, 11 patients underwent emergency surgery using this technique; 7 were men; the median age was 74 years. All patients were treated using systemic circulatory arrest under moderate hypothermia (26 °C) and selective cerebral perfusion. All patients had supra-coronary repair; 1 patient had aortic valve replacement + CABG. In the first two patients a manual suture around supra-aortic trunks was used; the subsequent seven patients were treated with a mechanical suture bladeless device. CT scan follow up was performed in all survivors with controls before discharge 3 months and 1 year after operation. Results No patient died in the operating room and no neurologic deficit was observed in this initial experience. One patient died in POD 5th for low cardiac output syndrome. Median ICU stay was 3 days (IQR, 2–6 days). Hospital mean length of stay was 15.2±8 days. Median cardiopulmonary bypass time was 130 min (IQR, 110–141 min); median arrest time for re-layering was 17 min (IQR, 16–20 min); median total arrest was 36 min (IQR, 29–39 min). Distal aortic anastomosis was performed in zone 0 in 4 patients, zone 1, with innominate replacement, in 5 patients, in zone 2, with branches to innominate and left common carotid arteries, in 2 patients. Median follow up (closing date 06/01/2018) was 443 days (IQR, 262–557 days); no late deaths occurred. No dehiscence at the level of stapler or manual sutures was observed. Proximal 1/3 of the thoracic aorta false channel was obliterated in all cases but one; in 3 cases complete exclusion of the false channel was obtained after operation. In one case stent graft completion was required. Conclusions This technique combines the advantages of arch replacement to the simplicity of anterior hemiarch repair. This study demonstrates the safety of the procedure and the possibility to induce aortic remodeling without complex arch replacement. PMID:29780728

Minimally Invasive Transverse Aortic Constriction in Mice.

PubMed

Zaw, Aung Moe; Williams, Connor M; Law, Helen K W; Chow, Billy Kwok Chong

2017-03-14

Minimally invasive transverse aortic constriction (MTAC) is a more desirable method for the constriction of the transverse aorta in mice than standard open-chest transverse aortic constriction (TAC). Although transverse aortic constriction is a highly functional method for the induction of high pressure in the left ventricle, it is a more difficult and lengthy procedure due to its use of artificial ventilation with tracheal intubation. TAC is oftentimes also less survivable, as the newer method, MTAC, neither requires the cutting of the ribs and intercostal muscles nor tracheal intubation with a ventilation setup. In MTAC, as opposed to a thoracotomy to access to the chest cavity, the aortic arch is reached through a midline incision in the anterior neck. The thyroid is pulled back to reveal the sternal notch. The sternum is subsequently cut down to the second rib level, and the aortic arch is reached simply by separating the connective tissues and thymus. From there, a suture can be wrapped around the arch and tied with a spacer, and then the sternal cut and skin can be closed. MTAC is a much faster and less invasive way to induce left ventricular hypertension and enables the possibility for high-throughput studies. The success of the constriction can be verified using high-frequency trans-thoracic echocardiography, particularly color Doppler and pulsed-wave Doppler, to determine the flow velocities of the aortic arch and left and right carotid arteries, the dimension of the blood vessels, and the left ventricular function and morphology. A successful constriction will also trigger significant histopathological changes, such as cardiac muscle cell hypertrophy with interstitial and perivascular fibrosis. Here, the procedure of MTAC is described, demonstrating how the resulting flow changes in the carotid arteries can be examined with echocardiography, gross morphology, and histopathological changes in the heart.

Hybrid endovascular repair for aortic arch pathology: intermediate outcomes and complications: a retrospective analysis.

PubMed

Kang, Woong Chol; Shin, Eak Kyun; Park, Chul-Hyun; Kang, Jin Mo; Ko, Young-Guk; Choi, Donghoon; Youn, Young Nam; Shim, Won-Heum

2013-08-01

To evaluate the outcomes of hybrid endovascular repair for aortic arch pathology. This study was a retrospective analysis involving patients who underwent hybrid endovascular repair for aortic arch pathologies. Twenty-one patients (16 men; mean age, 64.7 ± 16.2 years) with aortic arch pathologies were treated by hybrid endovascular repair. The indications for treatment included increased aneurysm size in 16 cases (71.4%), rupture or impending aneurysmal rupture in 5 cases (23.8%), and rapid growth of aortic dissection (≥ 10 mm/y) in 1 case (4.8%). Supra-aortic vessel transposition and stent-graft implantation were achieved in all cases. Two types of stent-graft was used, as follows: the Seal thoracic stent-graft in 14 patients (66.7%); and the Valiant stent grafts in 7 patients (33.3%). Perioperative complications affected 5 patients (23.8%), as follows: bleeding (n = 4, 19.0%); stroke (n = 3, 14.3%); renal failure (n = 2, 9.5%); vascular injury (n = 1, 4.8%), and respiratory failure (n = 1, 4.8%). Two patients died within 30 days (9.5%). Technical success was achieved in 15 patients (71.5%). Early endoleaks were noted in 4 patients (19.0%). One patient died during follow-up (mean, 21.3 ± 11.6 months) due to a de novo intramural hematoma. Persistent early endoleaks were noted in 4 patients (19.0%); 2 of the 4 patients were successfully managed with implantation of additional stent-grafts. No late onset endoleaks were noted. The death-free survival and reintervention-free survival rates during follow-up were 85.7% and 90.5%, respectively. Hybrid treatment with supra-aortic vessel transposition and endovascular repair may be an option in frail patients in who open procedures is too risky. © 2013 Wiley Periodicals, Inc.

Endovascular Repair of Thoracoabdominal and Arch Aneurysms in Patients with Connective Tissue Disease Using Branched and Fenestrated Devices.

PubMed

Clough, Rachel E; Martin-Gonzalez, Teresa; Van Calster, Katrien; Hertault, Adrien; Spear, Rafaëlle; Azzaoui, Richard; Sobocinski, Jonathan; Haulon, Stéphan

2017-10-01

Prophylactic open surgery is the standard practice in patients with connective tissue and thoracoabdominal aortic aneurysm (TAAA) and aortic arch disease. Branched and fenestrated devices offer a less invasive alternative but there are concerns regarding the durability of the repair and the effect of the stent graft on the fragile aortic wall. The aim of this study is to evaluate mid-term outcomes of fenestrated and/or branched endografting in patients with connective tissue disease. All patients with connective tissue disease who underwent TAAA or arch aneurysm repair using a fenestrated and/or branched endograft in a single, high-volume center between 2004 and 2015 were included. Ruptured aneurysms and acute aortic dissections were excluded from this study, but not chronic aortic dissections. In total, 427 (403 pararenal and TAAAs, and 24 arch aneurysms) endovascular interventions were performed during the study period. Of these, 17 patients (4%) (16 TAAAs, 1 arch) had connective tissue disease. All patients were classified as unfit for open repair. The mean age was 51 ± 8 years. Thirteen patients with TAAA were treated with a fenestrated, 1 with a branched, and 2 with a combined fenestrated/branch device. A double inner branch device was used to treat the arch aneurysm. The technical success rate was 100% with no incidence of early mortality, spinal cord ischemia, stroke, or further dissection. Postoperative deterioration in renal function was seen in 3 patients (18.8%) and no hemodialysis was required. The mean follow-up was 3.4 years (0.3-7.4). Aneurysm sac shrinkage was seen in 35% of patients (6/17) and the sac diameter remained stable in 65% of patients (11/17). No sac or sealing zone enlargement was observed in any of the patients and there were no conversions to open repair. Reintervention was required in 1 patient at 2 years for bilateral renal artery occlusion (successful fibrinolysis). One type II endoleak (lumbar) is under surveillance and 1 type III (left renal stent) sealed spontaneously. One patient died at 2 years after the procedure from nonaortic causes (endocarditis). The favorable mid-term outcomes in this series that demonstrate fenestrated and/or branched endografting should be considered in patients with connective tissue and TAAA and aortic arch disease, which are considered unfit for open surgery. All patients require close lifetime surveillance at a center specializing in aortic surgery, with sufficient experience in both open and endovascular aortic surgery, so that if endovascular treatment failure occurs it can be recognized early and further treatment offered. Copyright © 2017 Elsevier Inc. All rights reserved.

Is Previous Cardiac Surgery a Risk Factor for Short and Mid-term Mortality Following Total Aortic Arch Replacement in Patients with Stanford Type A Aortic Dissection?

PubMed

Ge, Yi-Peng; Li, Cheng-Nan; Chen, Lei; Liu, Wei; Cheng, Li-Jian; Liu, Yong-Min; Zheng, Jun; Ma, Wei-Guo; Zhu, Jun-Ming; Sun, Li-Zhong

2015-11-01

The aim of this study was to evaluate if the previous cardiac surgery (PCS) is the risk factor for short- and mid-term mortality following total aortic arch replacement in patients with Stanford type A aortic dissection. Between February 2009 and February 2012, a total of 384 patients who suffered Stanford type A aortic dissection involving aortic arch underwent total aortic arch replacement with frozen elephant trunk. Of these patients, 36 patients had PCS. Logistic regression was used to identify if the previous cardiac surgery was the risk factor for in-hospital mortality. Propensity score-matching (1:1 match) was used to yield patients from the primary surgery group who matched PCS group with respect to pre-operative clinical characteristics and post-operative complications. Survival analysis and differences between the two groups were performed by the Kaplan-Meier estimate and the log-rank test. The overall in-hospital mortality was 8%. Logistic multiple regression identified that cardiopulmonary bypass time≥ 300minutes (OR=12.05, p<0.001) and surgical period from symptom onset shorter than one week (OR=2.43, p=0.04) were final risk factors for in-hospital mortality and PCS was not the final risk factor. Of 36 patients with PCS, three patients died in the hospital and 33 patients were discharged from the hospital. Of these 33 patients, 32 patients matched primary surgery group successfully. During the follow-up period, two patients died in PCS group, one patient died in primary surgery group. The mean follow-up time was 35.38±14.12 months. The five-year survival was 96% for the primary surgery group. Previous cardiac surgery group five-year survival was 73%. Five-year survival was not significantly different between the two groups (p=0.84 log-rank test). PCS is not the risk factor for short- and mid-term mortality following total aortic arch replacement in patients with Stanford type A aortic dissection. Copyright © 2015 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.

Anomalous Origin of the Right Vertebral Artery: Incidence and Significance.

PubMed

Maiti, Tanmoy Kumar; Konar, Subhas Kanti; Bir, Shyamal; Nanda, Anil; Cuellar, Hugo

2016-05-01

Detailed knowledge about anatomic variations of the aortic arch and its multiple branches is extremely important to endovascular and diagnostic radiologists. It is often hypothesized that anomalous origin and distribution of large aortic vessels may alter the cerebral hemodynamics and potentially lead to a vascular pathology. In this article, we describe a case of anomalous origin of the right vertebral artery, which was detected during an intervention. We further reviewed the available literature of anomalous origin of the right vertebral artery. The probable embryologic development and clinical significance are discussed. The incidence of anomalous origin of a vertebral artery seems to be underestimated in recent literature. A careful review of the literature shows more than 100 such cases. The right vertebral artery can arise from the aortic arch or one of its branches. Dual origin of the vertebral artery is not uncommon. The embryologic developmental hypotheses are contradictory and complex. Anomalous origin of the right vertebral artery may not be the sole reason behind a disease process. However, it can certainly lead to a misdiagnosis during diagnostic vascular studies. Detailed information is essential for any surgery or endovascular intervention in this location. Copyright © 2015 Elsevier Inc. All rights reserved.

In situ fenestrations for the aortic arch and visceral segment: advances and challenges.

PubMed

Riga, Celia V; McWilliams, Richard G; Cheshire, Nicholas J W

2011-09-01

The management of complex aortic pathologies remains a major challenge particularly in the emergency setting. Bespoke fenestrated and branch stent graft technology has shown encouraging short- and mid-term results in selected patients. Despite tremendous technological advances in this field however, factors such as the inherent delay in device manufacturing, anatomical and technical challenges, high degree of planning, and cost hinder the wider applications of minimally invasive endovascular therapy. In situ fenestration of aortic stent grafts is an attractive alternative that eliminates the need for preoperative custom tailoring with the potential to widen the therapeutic options available and to offer a bailout option after inadvertent side branch occlusion. This article summarizes the principles of this technique and discusses its current applications.

22q11 deletions in fetuses with malformations of the outflow tracts or interruption of the aortic arch: impact of additional ultrasound signs.

PubMed

Volpe, Paolo; Marasini, Maurizio; Caruso, Gilda; Marzullo, Andrea; Buonadonna, Antonia Lucia; Arciprete, Paolo; Di Paolo, Salvatore; Volpe, Gennaro; Gentile, Mattia

2003-09-01

One hundred and forty-one consecutive cases of malformations of the outflow tracts or interrupted aortic arch (IAA), detected by fetal echocardiography, underwent detailed anatomy scan, karyotyping and fluorescence in situ hybridization analysis (FISH) to detect the prevalence of 22q11 microdeletion and to evaluate neonatal clinical findings and outcome according to the presence of the genetic defect. Then, we sought to investigate whether some prenatal ultrasound findings could help identify fetuses at higher risk of carrying the 22q11 microdeletion. Echocardiography and FISH for the DiGeorge critical region (22q11) were performed in all cases. 22q11 microdeletion was detected in 28 of 141 fetuses (19.8%). Intrauterine growth restriction (IUGR) appeared to be associated with the worst prognosis, being present in 2/2 intrauterine fetal deaths and 5/6 post-natal deaths. IUGR, additional aortic arch anomalies and thymic hypo/aplasia were significantly more frequent in fetuses with 22q11 microdeletion (p=0.011, 0.011 and <0.0001, respectively). Prenatal ultrasound thymus examination, performed on the last 84 fetuses, showed 75% sensitivity and 94% specificity. The combination of 2 predictors, namely, thymus defects and IUGR associated with additional aortic arch anomalies reached more than 90% sensitivity and 100% specificity. Our study demonstrates that 22q11 microdeletion occurs in 20% of malformations of the outflow tracts and IAA type B, as detected in utero, and that this association is significantly predicted by the presence of associated ultrasound findings: thymic hypo/aplasia, IUGR and additional aortic arch anomalies. The feasibility of a correct prenatal diagnosis should enable clinicians to provide the couple with further informative counselling and to plan adequate post-natal medical interventions. Copyright 2003 John Wiley & Sons, Ltd.

Morphometric changes in the aortic arch with advancing age in fetal to mature thoroughbred horses.

PubMed

Endoh, Chihiro; Matsuda, Kazuya; Okamoto, Minoru; Tsunoda, Nobuo; Taniyama, Hiroyuki

2017-03-28

Aortic rupture is a well recognized cause of sudden death in thoroughbred horses. Some microscopic lesions, such as those caused by cystic medial necrosis and medionecrosis, can lead to aortic rupture. However, these microscopic lesions are also observed in normal horses. On the other hand, a previous study of aortic rupture suggested that underlying elastin and collagen deposition disorders might be associated with aortic rupture. Therefore, the purpose of this study was to compare the structural components of the tunica media of the aortic arch, which is composed of elastin, collagen, smooth muscle cells and mucopolysaccharides (MPS), in fetal to mature thoroughbred horses. The percentage area of elastin was greatest in the young horses and subsequently decreased with aging. The percentage area of collagen increased with aging, and the elderly horses (aged ≥20) exhibited significantly higher percentage areas of collagen than the young horses. The percentage area of smooth muscle cells did not change with age. The percentage area of MPS was inversely proportional to the percentage area of elastin. The fetuses exhibited a markedly larger percentage area of MPS than the mature horses. We concluded that the medial changes seen in the aortic arch, which included a reduction in the amount of elastin and increases in the amounts of collagen and MPS, were age-related variations.

Classification and outcomes of extended arch repair for acute Type A aortic dissection: a systematic review and meta-analysis.

PubMed

Smith, Holly N; Boodhwani, Munir; Ouzounian, Maral; Saczkowski, Richard; Gregory, Alexander J; Herget, Eric J; Appoo, Jehangir J

2017-03-01

Distal extent of repair in patients undergoing surgery for acute Type A aortic dissection (ATAAD) is controversial. Emerging hybrid techniques involving open and endovascular surgery have been reported in small numbers by select individual centres. A systematic review and meta-analysis was performed to investigate the outcomes following extended arch repair for ATAAD. A classification system is proposed of the different techniques to facilitate discussion and further investigation. Using Ovid MEDLINE, 38 studies were identified reporting outcomes for 2140 patients. Studies were categorized into four groups on the basis of extent of surgical aortic resection and the method of descending thoracic aortic stent graft deployment; during circulatory arrest (frozen stented elephant trunk) or with normothermic perfusion and use of fluoroscopy (warm stent graft): (I) surgical total arch replacement, (II) total arch and frozen stented elephant trunk, (III) hemiarch and frozen stented elephant trunk and (IV) total arch and warm stent graft. Perioperative event rates were obtained for each of the four groups and the entire cohort using pooled summary estimates. Linearized rates of late mortality and reoperation were calculated. Overall pooled hospital mortality for extended arch techniques was 8.6% (95% CI 7.2-10.0). Pooled data categorized by surgical technique resulted in hospital mortality of 11.9% for total arch, 8.6% total arch and frozen stented elephant trunk, 6.3% hemiarch and frozen stented elephant trunk and 5.5% total arch and 'warm stent graft'. Overall incidence of stroke for the entire cohort was 5.7% (95% CI 3.6-8.2). Rate of spinal cord ischaemia was 2.0% (95% CI 1.2-3.0). Pooled linearized rate of late mortality was 1.66%/pt-yr (95% CI 1.34-2.07) with linearized rate of re-operation of 1.62%/pt-yr (95% CI 1.24-2.05). Perioperative results of extended arch procedures are encouraging. Further follow-up is required to see if long-term complications are reduced with these emerging techniques. The proposed classification system will facilitate future comparison of short- and long-term results of different techniques of extended arch repair for ATAAD. © The Author 2016. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

An Adult Case of Chromosome 22q11.2 Deletion Syndrome Associated with a High-positioned Right Aortic Arch

PubMed Central

Hoshino, Yoichi; Machida, Moriya; Shimano, Shun-ichi; Taya, Teizo

2017-01-01

Chromosome 22q11.2 deletion syndrome (22q11.2 DS) has a very wide phenotypic spectrum that includes dysmorphic features, cardiac anomalies, and hypocalcemia arising from hypoparathyroidism. We herein describe an adult case of 22q11.2 DS with associated hypoparathyroidism and anomalies of the aortic arch. Because the patient had been diagnosed with primary hypoparathyroidism at another hospital, a diagnosis of 22q11.2 DS had been overlooked. A chest X-ray examination revealed widening of the mediastinum caused by a high-positioned right aortic arch, and we subsequently confirmed a diagnosis of 22q11.2 DS using fluorescence in situ hybridization. Because primary hypoparathyroidism is a rare disorder, physicians should be aware of the variable phenotypic features of 22q11.2 DS. PMID:28381757

Mosaic partial deletion of PTPN12 in a child with interrupted aortic arch type A.

PubMed

Duffy, Elizabeth A; Pretorius, Pamela R; Lerach, Stephanie; Lohr, Jamie L; Hirsch, Betsy; Souza, Cleiton M; Veillette, André; Schimmenti, Lisa A

2015-11-01

Congenital heart malformations, including those of the great vessels, are among the most common human birth defects. The goal of this study was to identify the significance of a de novo mosaic PTPN12 partial deletion identified in a newborn with an interrupted aortic arch type A, ventricular septal defect, and pyloric stenosis. PTPN12, a downstream target of the RAS pathway, has a known role in endothelial cell adhesion and migration. Neither genetic nor genomic variants in PTPN12 have been described in a human patient; therefore, we evaluated the effect of ptpn12 in a mouse conditional knockout and zebrafish knockdown model to determine the significance of a loss in gene expression. Observed loss of ptpn12 expression in zebrafish resulted in abnormal branchial arch and tail vasculature patterns, with reduced blood flow throughout the animal. This phenotype was supported by anomalous vasculature in a conditional Ptpn12 mouse knockout. Given the novel co-occurrence of interrupted aortic arch type A, ventricular septal defect, and partial deletion of PTPN12 in the patient, as well as vascular phenotypes in Ptpn12 mouse and ptpn12 zebrafish models, it is likely that PTPN12 has a significant role in cardiovascular development and vessel formation during human embryonic development. Furthermore, the partial deletion of PTPN12 lead to interrupted aortic arch type A in this child and may represent a novel condition caused by a null mutation in the RAS pathway. © 2015 Wiley Periodicals, Inc.

Relay NBS Graft with the Plus Delivery System to Improve Deployment in Aortic Arch with Small Radius Curve

DOE Office of Scientific and Technical Information (OSTI.GOV)

Ferro, Carlo; Rossi, Umberto G., E-mail: urossi76@hotmail.com; Seitun, Sara

The purpose of this report is to describe deployment of the Relay NBS Thoracic Stent Graft with the Plus Delivery System (Bolton Medical, Sunrise, FL) in a flexible resin arch model with a 15-mm radius curve as well as our preliminary clinical results. The Relay NBS graft with the Plus Delivery System was evaluated by way of bench testing, which was performed with stent grafts with diameters ranging from 24 to 46 mm and lengths ranging from 100 to 250 mm in flexible resin arch models with a 15-mm arch radius of curvature. The deployment sequence was analyzed. The Relaymore » NBS graft with the Plus Delivery System was deployed in two patients, respectively, having a 6.5-cm penetrating aortic ulcer of the proximal third of the descending thoracic aorta and a DeBakey type-I aortic dissection with chronic false lumen dilatation after surgery due to an entry site at the distal thoracic aorta. Bench tests showed proper conformation and apposition of the Relay NBS graft with the Plus Delivery System in the flexible resin model. This stent graft was deployed successfully into the two patients with a correct orientation of the first stent and without early or late complications. The Relay NBS graft with the Plus Delivery System ensures an optimal conformation and apposition of the first stent in the aortic arch with a small radius of curvature.« less

[Non-invasive estimation of aortic flow by local electrical impedance changes].

PubMed

Okuda, N; Ohashi, N; Yamada, M; Fujinami, T

1986-09-01

Aortic flow velocity was measured by catheter-tip flow transducer in 25 patients who underwent left cardiac catheterization for non-invasive estimates by the impedance method. Disk electrodes were attached to the skin at the levels of the second thoracic vertebra in the posterior median line and the V8 lead position for electrocardiography. Alternating current, 350 micro-amperes, 50 KHz constant, was applied to the outer electrode, and impedance changes were detected via the inner electrode. The e wave, or height of the first derivative dz/dt wave of the electrical impedance was lower in cases of old myocardial infarction and higher in cases of aortic valve regurgitation, as compared with the values of the healthy control group. The time lag between the start of the upward deflection and the peak value of the dz/dt wave coincided with that of the aortic flow curve as measured at the aortic arch and descending aorta. These time lags were about 20 to 30 msec as compared with the ascending aortic flow curve, and were -20 to -30 msec as compared with the abdominal aortic flow curve. There was a close correlation between the maximum flow velocity measured at the aortic arch and the height of the e waves. The regression equation was: Y = 0.21X - 1.53, r = 0.88, p less than 0.01. These data suggest that the first derivative of electrical impedance change as obtained by the disk electrode method reflects aortic flow at the arch and descending aorta.

Right cervical aortic arch with aberrant left subclavian artery.

PubMed

Tjang, Yanto S; Aramendi, José I; Crespo, Alejandro; Hamzeh, Gadah; Voces, Roberto; Rodríguez, Miguel A

2008-08-01

The combination of right cervical aortic arch, aberrant retroesophageal left subclavian artery originating from a Kommerell's diverticulum, and a ligamentum arteriosum, constitutes a rare form of vascular ring. Two patients aged 21 days and 54 years, who were diagnosed by multislice 3-dimensional computed tomography and magnetic resonance imaging, underwent surgical division of a vascular ring. The adult required resection of a Kommerell's aneurysm and subclavian artery reimplantation.

Retrograde cerebral perfusion (RCP) in aortic arch surgery: efficacy and possible mechanisms of brain protection.

PubMed

Bavaria, J E; Pochettino, A

1997-07-01

Retrograde cerebral perfusion (RCP) was first introduced to treat air embolism during cardiopulmonary bypass (CPB). Its use was reintroduced to extend the safety of hypothermic circulatory arrest (HCA) during operations involving an open aortic arch. RCP seems to prevent cerebral rewarming during HCA. Both clinical and animal data suggest that RCP provides between 10% and 30% of baseline cerebral blood flow when administered through the superior vena cava (SVC) at jugular pressures of 20 to 25 mm Hg. RCP flows producing jugular venous pressures higher than 30 mm Hg may cause cerebral edema. Cerebral blood flow generated by RCP is able to sustain some cerebral metabolic activity, yet is not able to fully meet cerebral energy demands even at temperatures of 12 degrees to 18 degrees C. RCP may further prevent embolic events during aortic arch surgery when administered at moderate jugular vein pressures (< 40 mm Hg). Clinical results suggest that RCP, when applied during aortic arch reconstruction, may extend the safe HCA period and improve morbidity and mortality, especially when HCA times are more than 60 minutes. RCP applied in patients and severe carotid and brachiocephalic occlusive disease may be ineffective, and caution is in order when RCP times are greater than 90 minutes.

Overview of current surgical strategies for aortic disease in patients with Marfan syndrome.

PubMed

Miyahara, Shunsuke; Okita, Yutaka

2016-09-01

Marfan syndrome is a heritable, systemic disorder of the connective tissue with a high penetrance, named after Dr. Antoine Marfan. The most clinically important manifestations of this syndrome are cardiovascular pathologies which cause life-threatening events, such as acute aortic dissections, aortic rupture and regurgitation of the aortic valve or other artrioventricular valves leading to heart failure. These events play important roles in the life expectancy of patients with this disorder, especially prior to the development of effective surgical approaches for proximal ascending aortic disease. To prevent such catastrophic aortic events, a lower threshold has been recommended for prophylactic interventions on the aortic root. After prophylactic root replacement, disease in the aorta beyond the root and distal to the arch remains a cause for concern. Multiple surgeries are required throughout a patient's lifetime that can be problematic due to distal lesions complicated by dissection. Many controversies in surgical strategies remain, such as endovascular repair, to manage such complex cases. This review examines the trends in surgical strategies for the treatment of cardiovascular disease in patients with Marfan syndrome, and current perspectives in this field.

The repair of a type Ia endoleak following thoracic endovascular aortic repair using a stented elephant trunk procedure.

PubMed

Qi, Rui-Dong; Zhu, Jun-Ming; Liu, Yong-Min; Chen, Lei; Li, Cheng-Nan; Xing, Xiao-Yan; Sun, Li-Zhong

2018-04-01

Type Ia endoleaks are not uncommon complications that occur after thoracic endovascular aortic repair (TEVAR). Because aortic arch vessels prevent extension of the landing zone, it is very difficult to manipulate a type Ia endoleak using an extension cuff or stent-graft, especially when the aortic arch is involved. Here, we retrospectively review our experience of surgical treatment of type Ia endoleak after TEVAR using a stented elephant trunk procedure. From July 2010 to August 2016, we treated 17 patients diagnosed with a type Ia endoleak following TEVAR using stented elephant trunk procedure. The mean age of our patients was 52 ± 8 years. The mean interval between TEVAR and the open surgical repair was 38 ± 43 months. All cases of type Ia endoleak (100%) were repaired successfully. There were no in-hospital deaths. One case required reintubation and continuous renal replacement therapy due to renal failure; this patient recovered smoothly before discharge. One other patient suffered a stroke and renal failure and did not fully recover following discharge, or follow-up. During follow-up, there were 3 deaths. Acceptable results were obtained using a stented elephant trunk procedure in patients with a type Ia endoleak after TEVAR. This technique allowed us to repair the proximal aortic arch lesions, surgically correct the type Ia endoleak, and promote false lumen thrombosis in the distal aorta. Implantation of a stented elephant trunk, with or without a concomitant aortic arch procedure, is an alternative approach for this type of lesion. Copyright © 2017 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

Aortic arch reconstruction: deep and moderate hypothermic circulatory arrest with selective antegrade cerebral perfusion.

PubMed

Wu, YanWen; Xiao, LiQiong; Yang, Ting; Wang, Lei; Chen, Xin

2017-07-01

To compare the effects of moderate and deep hypothermic circulatory arrest (DHCA) with selective antegrade cerebral perfusion (SACP) during aortic arch surgery in adult patients and to offer the evidence for the detection of the temperature which provides best brain protection in the subjects who accept aortic arch reconstruction surgery. A total of 109 patients undergoing surgery of the aortic arch were divided into the moderate hypothermic circulatory arrest group (Group I) and the deep hypothermic circulatory arrest group (Group II). We recorded the data of the patients and their cardiopulmonary bypass (CPB) time, aortic clamping time, SACP time and postoperative anesthetized recovery time, tracheal intubation time, time in the intensive care unit (ICU) and postoperative neurologic dysfunction. Patient characteristics were similar in the two groups. There were four patients who died in Group II and 1 patient in Group I. There were no significant differences in aortic clamping time of each group (111.4±58.4 vs. 115.9±16.2) min; SACP time (27.4±5.9 vs. 23.5±6.1) min of the moderate hypothermic circulatory arrest group and the deep hypothermic circulatory arrest group; there were significant differences in cardiopulmonary bypass time (207.4±20.9 vs. 263.8±22.6) min, postoperative anesthetized recovery time (19.0±11.1 vs. 36.8±25.3) hours, extubation time (46.4±15.1 vs. 64.4±6.0) hours; length of stay in the intensive care unit (ICU) (4.7±1.7 vs. 8±2.3) days and postoperative neurologic dysfunction in the two groups. Compared to deep hypothermic circulatory arrest, moderate hypothermic circulatory arrest can provide better brain protection and achieve good clinical results.

MURCS Association: a rare association with patent ductus arteriosus and bicuspid aortic valve.

PubMed

Ramakrishna; Kotecha, Nikunj; Patel, Chetan A; Pipavat, Rushi

2013-11-01

An 18 yr old female referred to us as hypertrophic obstructive cardiomyopathy with bicuspid aortic valve. On Initial history and examination patient also had primary amenorrhoea, differential cyanosis in lower limbs, differential clubbing, polydactyly, syndactyly, high arched foot, pectus carinatum and scoliosis. Oxygen saturation was 94% at room air and complete blood count was suggestive of polycythaemia (Hb 20 g/dl, Hct 60%, Tc-16500, RBC count--6.29 million/cumm, Platelet count--1,88000). Imaging studies were done, ultrasonography showed absent uterus, absent left kidney, right ectopic kidney.X-ray foot showed 6th metatarsal with phalanx. 2D ECHO was suggestive of Patent Ductus Arteriosus with reversal of shunt with severe aortic stenosis and bicuspid aortic valve. All these anomalies form part of a syndrome complex called MURCS ASSOCIATION (Mullerian agenesis/aplasia, renal anomalies, and Cervicothoracic Somite deformities).

[MRI of aortic arch anomalies in children. Initial results].

PubMed

Mamou Mani, T; Lallemand, D; Brunelle, F; Barth, M O

1988-12-01

A prospective study by nuclear magnetic resonance in 7 infants with respiratory disorders and with a barium swallow suggestive of anomalies of the aortic arch was conducted. It allowed the definition of an investigation protocol including sedation, RF coil adapted to infants size, naso-gastric tube placement, thin MR sections. Sequences are T1 weighted with ECG gating in two perpendicular frontal oblique and transverse oblique planes determined on a scout sagittal MR acquisition. Precise determination of the anatomy of the vascular malformation and its relationship with the trachea and esophagus were obtained. After definition of the investigation protocol, MRI was found to be a very effective evaluation technique for aortic arch anomalies. It can be proposed as an alternative to preoperative digital angiography. Its indications remain to be defined in relation to the clinical features and the results of the chest X-ray and barium swallow.

[Mycotic aneurism in aortic arch by Aspergillus fumigatus: contribution of a case and review of the literature].

PubMed

Burón Fernández, M R; Oruezábal Moreno, M J

2005-09-01

The micotic aneurisms by Aspergillus are rare and usually appear in the context of an invasive pulmonary aspergilosis, or by septicum embolism or direct extension from the lungs, for that reason the location the more frequents is in aortic arch and the ascending aorta.8 cases of micotic aneurisms by Aspergillus spp. have been described in literature between 1966 and 2000, being the most frequent location the ascending aorta or the aortic arch. The Aspergillus fumigatus is the isolated species with more frequency, affecting mainly to patients undergoing inmunosupression. The diagnosis of a micotic aneurism requires a high clinical suspicion, given to its peculiarity and the presence of inespecific symptoms, being frequently an accidental finding in an invasive pulmonary aspergilosis.The case of a patient with a micotic aneurism by A. fumigatus appears and we reviewed the similar cases previously disclosed.

Carbon Dioxide in the Aortic Arch: Coronary Effects and Implications in a Swine Study

DOE Office of Scientific and Technical Information (OSTI.GOV)

Culp, William C.; Porter, Thomas R.; Culp, William C.

2003-04-15

Purpose: CO{sub 2} angiography is considered dangerous in the aortic arch where bubbles may cause critical cerebral and cardiac ischemia. We investigated CO{sub 2}distribution, physiologic effects in the heart, methods of detection and treatments. Methods: Eight pigs had CO{sub 2}and iodinated contrast arch angiograms in supine and both lateral decubitus positions. An electrocardiogram, physiologic data and cardiac ultrasound were obtained. Therapies included precordial thumps and rolls to lateral decubitus positions. Results: Supine high descending aorta CO{sub 2} injections floated retrograde up the arch during diastole and preferentially filled the right coronary artery (RCA): mean score 3.5 (of 4), in nominatemore » artery 2.4, left coronary artery 1.2; n = 17; p = 0.0001. Aortic root injections preferentially filled the RCA when the animal was supine, left coronary in the right decubitus position, and showed a diffuse pattern in the left decubitus position. Right decubitus rolls filled both coronaries causing several lethal arrhythmias. Precordialthumps successfully cleared CO{sub 2}. Ultrasound is a sensitive detector of myocardial CO{sub 2}. Conclusion: Arch distribution of CO{sub 2} primarily involves the RCA. Diagnostic ultrasound detects cardiac CO{sub 2} well. Precordial thumps are an effective treatment.« less

Automated measurement of uptake in cerebellum, liver, and aortic arch in full-body FDG PET/CT scans.

PubMed

Bauer, Christian; Sun, Shanhui; Sun, Wenqing; Otis, Justin; Wallace, Audrey; Smith, Brian J; Sunderland, John J; Graham, Michael M; Sonka, Milan; Buatti, John M; Beichel, Reinhard R

2012-06-01

The purpose of this work was to develop and validate fully automated methods for uptake measurement of cerebellum, liver, and aortic arch in full-body PET/CT scans. Such measurements are of interest in the context of uptake normalization for quantitative assessment of metabolic activity and/or automated image quality control. Cerebellum, liver, and aortic arch regions were segmented with different automated approaches. Cerebella were segmented in PET volumes by means of a robust active shape model (ASM) based method. For liver segmentation, a largest possible hyperellipsoid was fitted to the liver in PET scans. The aortic arch was first segmented in CT images of a PET/CT scan by a tubular structure analysis approach, and the segmented result was then mapped to the corresponding PET scan. For each of the segmented structures, the average standardized uptake value (SUV) was calculated. To generate an independent reference standard for method validation, expert image analysts were asked to segment several cross sections of each of the three structures in 134 F-18 fluorodeoxyglucose (FDG) PET/CT scans. For each case, the true average SUV was estimated by utilizing statistical models and served as the independent reference standard. For automated aorta and liver SUV measurements, no statistically significant scale or shift differences were observed between automated results and the independent standard. In the case of the cerebellum, the scale and shift were not significantly different, if measured in the same cross sections that were utilized for generating the reference. In contrast, automated results were scaled 5% lower on average although not shifted, if FDG uptake was calculated from the whole segmented cerebellum volume. The estimated reduction in total SUV measurement error ranged between 54.7% and 99.2%, and the reduction was found to be statistically significant for cerebellum and aortic arch. With the proposed methods, the authors have demonstrated that automated SUV uptake measurements in cerebellum, liver, and aortic arch agree with expert-defined independent standards. The proposed methods were found to be accurate and showed less intra- and interobserver variability, compared to manual analysis. The approach provides an alternative to manual uptake quantification, which is time-consuming. Such an approach will be important for application of quantitative PET imaging to large scale clinical trials. © 2012 American Association of Physicists in Medicine.

Anomalous origin of the left innominate (brachiocephalic) artery in the right aortic arch: How can it be anomalous when the left innominate artery is absent?

PubMed

Raimondi, Francesca; Bonnet, Damien; Geva, Tal; Sanders, Stephen P

2016-01-01

An unusual case of a rare vascular ring, which has been called right aortic arch with aberrant left innominate artery, is presented. The appearance of this case led to the realization that there is really no innominate artery present in this anomaly but only the left dorsal aorta. We present a clarification of the nature and likely development of the vessels present.

Interrupted Aortic Arch Associated with Absence of Left Common Carotid Artery: Imaging with MDCT

DOE Office of Scientific and Technical Information (OSTI.GOV)

Onbas, Omer; Olgun, Hasim; Ceviz, Naci

2006-06-15

Interrupted aortic arch (IAA) is a rare severe congenital heart defect defined as complete luminal and anatomic discontinuity between ascending and descending aorta. Although its association with various congenital heart defects has been reported, absence of left common carotid artery (CCA) in patients with IAA has not been reported previously. We report a case of IAA associated with the absence of left CCA which was clearly shown on multidetector-row spiral CT.

Repair of an aneurysm of the ascending aorta and arch in an infant with Loeys-Dietz syndrome.

PubMed

Jaiswal, Pratiksha; Shetty, Varun; Patel, Ebrahim; Shetty, Deviprasad

2018-05-01

Aortic aneurysms in childhood are rare disease entities and are usually seen in patients with genetic connective tissue disorders such as Marfans, Ehler-Danlos, and Loeys-Dietz syndrome (LDS). Patients affected with LDS present early in life and have a rapid disease progression. We report a case of repair of an ascending and aortic arch aneurysm in an infant with Loeys-Dietz syndrome. © 2018 Wiley Periodicals, Inc.

Long-term Voice Outcomes of Early Thyroplasty for Unilateral Vocal Fold Paralysis Following Aortic Arch Surgery.

PubMed

Kwak, Paul E; Tritter, Andrew G; Donovan, Donald T; Ongkasuwan, Julina

2016-07-01

To describe this institution's experience with and the long-term outcomes of early type 1 thyroplasty for unilateral vocal fold paralysis (UVFP) following surgery on the aortic arch. Retrospective chart review with telephone questionnaire. Academic tertiary care center. Three hundred forty-eight patients with UVFP following surgery on the aortic arch since 1999 were identified; 40 were available for follow-up. The number of revision procedures following initial thyroplasty was ascertained, and the Voice Handicap Index (VHI) was administered by telephone. The hypothesis that early thyroplasty produced voice outcomes and revision rates comparable to injection laryngoplasty was established prior to the initiation of data collection. Six out of the 40 patients (15%) required revision thyroplasty following their initial procedure. Mean VHI of all patients was 36.0 (SD, 27.2). Mean VHI was significantly different in the 18 to 39 age group (13.1) when compared to the 40 to 59 (51.8) and 60+ (37.7) age groups (P = .013). Mean follow-up since initial thyroplasty was 46.5 months (SD, 42.2). In the setting of aortic arch surgery with injury to the recurrent laryngeal nerve, early thyroplasty produces voice outcomes comparable to those achieved in the literature with repeated injection and delayed thyroplasty and can be considered in select populations. © The Author(s) 2016.

Recurrent Laryngeal Nerve Injury and Swallowing Dysfunction in Neonatal Aortic Arch Repair.

PubMed

Pourmoghadam, Kamal K; DeCampli, William M; Ruzmetov, Mark; Kosko, James; Kishawi, Sami; O'Brien, Michael; Cowden, Amanda; Piggott, Kurt; Fakioglu, Harun

2017-11-01

We evaluated the incidence, clinical effect, and recovery rate of vocal cord dysfunction (VCD) and swallowing dysfunction in neonates undergoing aortic arch repair. We retrospectively evaluated 101 neonates who underwent aortic arch reconstruction from 2008 to 2015. Direct flexible laryngoscopy was performed in 89 patients before initiation of postoperative oral feeding after Norwood (n = 63) and non-Norwood (n = 26) arch reconstruction. We defined VCD as immobility of vocal cords or their lack of coaptation and poor mobility. The incidence of VCD after aortic arch repair was 48% (n = 43). There was no significant difference between the VCD and non-VCD groups in postoperative length of stay, extubation failure, cardiopulmonary bypass, cross-clamp, selective cerebral perfusion time, operative death, and The Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery (STAT) Congenital Heart Surgery Mortality Categories. Placement of gastrostomy (p = 0.03) and documented aspiration (p = 0.01) were significantly more common in VCD patients. The incidence of VCD was 41% (n = 26) after Norwood and 65% (n = 17) after non-Norwood repairs (p = 0.06). Gastrostomy was required in 44 Norwood patients vs 9 non-Norwood patients (p = 0.004). Median length of stay was similar in Norwood patients with or without VCD (p = .28) but was significantly longer in non-Norwood patients with VCD vs those without (p = 0.002). At follow-up direct flexible laryngoscopy, VCD recovery was 74% (14 of 19) in the Norwood group and 86% (12 of 14) in the non-Norwood group. The incidence of VCD and swallowing dysfunction in neonates undergoing aortic arch reconstruction is high. Patients with VCD have a significantly higher incidence of gastrostomy placement and aspiration. In the Norwood population, length of stay is not associated with presence or absence of VCD. More than 70% of patients in each group who had direct flexible laryngoscopy follow-up recovered vocal cord function. Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Total Endovascular Aortic Repair in a Patient with Marfan Syndrome.

PubMed

Amako, Mau; Spear, Rafaëlle; Clough, Rachel E; Hertault, Adrien; Azzaoui, Richard; Martin-Gonzalez, Teresa; Sobocinski, Jonathan; Haulon, Stéphan

2017-02-01

The aim of this study is to describe a total endovascular aortic repair with branched and fenestrated endografts in a young patient with Marfan syndrome and a chronic aortic dissection. Open surgery is the gold standard to treat aortic dissections in patients with aortic disease and Marfan syndrome. In 2000, a 38-year-old man with Marfan syndrome underwent open ascending aorta repair for an acute type A aortic dissection. One year later, a redo sternotomy was performed for aortic valve replacement. In 2013, the patient presented with endocarditis and pulmonary infection, which necessitated tracheostomy and temporary dialysis. In 2014, the first stage of the endovascular repair was performed using an inner branched endograft to exclude a 77-mm distal arch and descending thoracic aortic aneurysm. In 2015, a 63-mm thoracoabdominal aortic aneurysm was excluded by implantation of a 4-fenestrated endograft. Follow-up after both endovascular repairs was uneventful. Total aortic endovascular repair was successfully performed to treat a patient with arch and thoraco-abdominal aortic aneurysm associated with chronic aortic dissection and Marfan syndrome. The postoperative images confirmed patency of the endograft and its branches, and complete exclusion of the aortic false lumen. Endovascular repair is a treatment option in patients with connective tissue disease who are not candidates for open surgery. Long-term follow-up is required to confirm these favorable early outcomes. Copyright © 2016 Elsevier Inc. All rights reserved.

Aortic operation after previous coronary artery bypass grafting: management of patent grafts for myocardial protection.

PubMed

Nakajima, Masato; Tsuchiya, Koji; Fukuda, Shoji; Morimoto, Hironobu; Mitsumori, Yoshitaka; Kato, Kaori

2006-04-01

Aortic surgery for progressive aortic valve disease or aortic aneurysm after previous coronary artery bypass grafting (CABG) is a challenging procedure. We report the outcome of aortic reoperation after previous CABG and evaluate our management of patent grafts and our methods for obtaining myocardial protection. From February 2001 to July 2003, 6 patients with progressive aortic valve disease and aneurysm of the thoracic aorta were operated on. The group comprised 3 men and 3 women with a mean age of 67.6 years. There were 4 patients with an aneurysm of the aortic arch, 1 with chronic ascending aortic dissection, and 1 with progressive aortic valve stenosis. The interval between previous CABG and aortic surgery was 74.0 +/- 44.2 months. All reoperations were performed via median resternotomy. Myocardial protection was obtained by hypothermic perfusion of patent in-situ arterial grafts following cold-blood cardioplegia administration via the aortic root under aortic cross clamping. The operative procedure was aortic arch replacement in 4 patients, ascending aortic replacement with double CABG in 1, and aortic valve replacement in 1. All patients survived the reoperation. Postoperative maximum creatine kinase-MB was 49.2 +/- 29.8 and no new Q-waves occurred in the electrocardiogram nor were any new wall motion abnormalities recognized on echocardiography. There were no late deaths during a follow-up of 30.7 months. Reoperative aortic procedures after CABG can be performed safely with myocardial protection via hypothermic perfusion of a patent in-situ arterial graft.

Left aortic arch with right-sided descending aorta associated with sudden neonatal death: a case report.

PubMed

Pampin, J Blanco; Rivero, A Garcia; Tamayo, N Morte; Fonseca, R Hinojal

2003-10-01

We present the case of a 26-day-old female in whom left aortic arch with right-sided descending aorta occurred. The previously healthy newborn baby was found dead on her bed. This anomaly is very uncommon and its clinical presentation as sudden death is also exceptional with only a few cases having been reported in the literature. The pathological findings and embryological origins of this malformation, so-called 'circumflex aorta' are discussed. The pertinent literature is reviewed.

Fgf8 expression in the Tbx1 domain causes skeletal abnormalities and modifies the aortic arch but not the outflow tract phenotype of Tbx1 mutants

PubMed Central

Vitelli, Francesca; Zhang, Zhen; Huynh, Tuong; Sobotka, Angela; Mupo, Annalisa; Baldini, Antonio

2007-01-01

Fgf8 and Tbx1 have been shown to interact in patterning the aortic arch, and both genes are required in formation and growth of the outflow tract of the heart. However, the nature of the interaction of the two genes is unclear. We have utilized a novel Tbx1Fgf8 allele which drives Fgf8 expression in Tbx1-positive cells and an inducible Cre-LoxP recombination system to address the role of Fgf8 in Tbx1 positive cells in modulating cardiovascular development. Results support a requirement of Fgf8 in Tbx1 expressing cells to finely control patterning of the aortic arch and great arteries specifically during the pharyngeal arch artery remodeling process and indicate that the endoderm is the most likely site of this interaction. Furthermore, our data suggest that Fgf8 and Tbx1 play independent roles in regulating outflow tract development. This finding is clinically relevant since TBX1 is the candidate for DGS/VCFS, characterized clinically by variable expressivity and reduced penetrance of cardiovascular defects; Fgf8 gene variants may provide molecular clues to this variability. PMID:16696966

Computational analysis of hybrid Norwood circulation with distal aortic arch obstruction and reverse Blalock-Taussig shunt.

PubMed

Ceballos, Andres; Argueta-Morales, I Ricardo; Divo, Eduardo; Osorio, Ruben; Caldarone, Christopher A; Kassab, Alain J; Decampli, William M

2012-11-01

The hemodynamics characteristics of the hybrid Norwood (HN) procedure differ from those of the conventional Norwood and are not fully understood. We present a multiscale model of HN circulation to understand local hemodynamics and effects of aortic arch stenosis and a reverse Blalock-Taussig shunt (RBTS) on coronary and carotid perfusion. Four 3-dimensional models of four HN anatomic variants were developed, with and without 90% distal preductal arch stenosis and with and without a 4-mm RBTS. A lumped parameter model of the circulation was coupled to a local 3-dimensional computational fluid dynamics model. Outputs from the lumped parameter model provided waveform boundary conditions for the computational fluid dynamics model. A 90% distal arch stenosis reduced pressure and net flow-rate through the coronary and carotid arteries by 30%. Addition of the RBTS completely restored pressure and flow rate to baseline in these vessels. Zones of flow stagnation, flow reversal, and recirculation in the presence of stenosis were rendered more orderly by addition of the RBTS. In the absence of stenosis, presence of the shunt resulted in extensive zones of disturbed flow within the RBTS and arch. We found that a 4-mm × 21-mm RBTS completely compensated for the effects of a 90% discrete stenosis of the distal aortic arch in the HN. Placed preventatively, the RBTS and arch displayed zones with thrombogenic potential showing recirculation and stagnation that persist for a substantial fraction of the cardiac cycle, indicating that anticoagulation should be considered with a prophylactic RBTS. Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

[Right patent ductus arteriosus with an ipsilateral aortic arch: percutaneous closure with amplatzer devices].

PubMed

Santiago, Justo; Acuña, Manuel; Arispe, Elizabeth; Camargo, Ronaldo; Neves, Juliana; Arnoni, Daniel; Fontes, Valmir F; Pedra, Carlos A

2007-03-01

The association of a right aortic arch with an ipsilateral patent ductus arteriosus is rare, especially when there are no other intracardiac anomalies. We report three female patients aged 26, 35 and 9 years with this combination in whom previous attempts at surgical closure by thoracotomy and sternotomy were unsuccessful and who subsequently underwent successful percutaneous closure of the defects using Amplatzer devices. In two patients, although angiography demonstrated the presence of type-A patent ductus arteriosus, it was not possible to determine the minimum diameter accurately and it was necessary to measure it using a sizing balloon. An Amplatzer duct occluder was used in two patients and an Amplatzer muscular ventricular septal defect occluder, in the other. In all patients, full closure was confirmed in the catheterization laboratory and the patients were discharged on the same day with no complications. Percutaneous closure of a right patent ductus arteriosus associated with a right aortic arch is feasible, safe and effective.

Emergent total arch replacement for acute type A aortic dissection with aberrant right subclavian artery in a systemic lupus erythematosus patient.

PubMed

Kitamura, Hideki; Kimura, Arishige; Fukaya, Shunsuke; Okawa, Yasuhide; Komeda, Masashi

2016-01-01

A 50-year-old man with a history of systemic lupus erythematosus and hemodialysis developed acute type A aortic dissection. Computed tomography demonstrated acute type A aortic dissection with chronic distal arch aneurysm and aberrant right subclavian artery that arose from the proximal descending aorta and ran in a retro-esophageal track. Emergent total arch replacement was performed using antegrade cerebral perfusion with circulatory arrest. Both common carotid arteries and the left subclavian artery were chosen as selective cerebral perfusion sites. The right subclavian artery was snared during cerebral perfusion. The right subclavian artery was reconstructed with the right common carotid artery in an end-to-side fashion in the anterior mediastinum. The patient's postoperative course was uneventful, and computed tomography showed excellent blood flow to all four branches. The case description is followed by a discussion of cerebral protection, reconstruction route of the right aberrant subclavian artery and steroids for systemic lupus erythematosus.

Inheritance Analysis of Congenital Left Ventricular Outflow Tract Obstruction Malformations: Segregation, Multiplex Relative Risk, and Heritability

PubMed Central

McBride, Kim L.; Pignatelli, Ricardo; Lewin, Mark; Ho, Trang; Fernbach, Susan; Menesses, Andres; Lam, Wilbur; Leal, Suzanne M.; Kaplan, Norman; Schliekelman, Paul; Towbin, Jeffrey A.; Belmont, John W.

2006-01-01

The left ventricular outflow tract (LVOTO) malformations, aortic valve stenosis (AVS), coarctation of the aorta (COA), and hypoplastic left heart (HLH) constitute a mechanistically defined subgroup of congenital heart defects that have substantial evidence for a genetic component. Evidence from echocardiography studies has shown that bicuspid aortic valve (BAV) is found frequently in relatives of children with LVOTO defects. However, formal inheritance analysis has not been performed. We ascertained 124 families by an index case with AVS, COA, or HLH. A total of 413 relatives were enrolled in the study, of which 351 had detailed echocardiography exams for structural heart defects and measurements of a variety of aortic arch, left ventricle, and valve structures. LVOTO malformations were noted in 30 relatives (18 BAV, 5 HLH, 3 COA, and 3 AVS), along with significant congenital heart defects (CHD) in 2 others (32/413; 7.7%). Relative risk for first-degree relatives in this group was 36.9, with a heritability of 0.71–0.90. Formal segregation analysis suggests that one or more minor loci with rare dominant alleles may be operative in a subset of families. Multiplex relative risk analysis, which estimates number of loci, had the highest maximum likelihood score in a model with 2 loci (range of 1–6 in the lod-1 support interval). Heritability of several aortic arch measurements and aortic valve was significant. These data support a complex but most likely oligogenic pattern of inheritance. A combination of linkage and association study designs is likely to enable LVOTO risk gene identification. This data can also provide families with important information for screening asymptomatic relatives for potentially harmful cardiac defects. PMID:15690347

Favourable Outcomes of Endovascular Total Aortic Arch Repair Via Needle Based In Situ Fenestration at a Mean Follow-Up of 5.4 Months.

PubMed

Shang, Tao; Tian, Lu; Li, Dong-Lin; Wu, Zi-Heng; Zhang, Hong-Kun

2018-03-01

Endovascular repair of aortic arch pathologies remains challenging. Recently, needle based in situ fenestration (ISF) has shown great potential in endovascular total aortic arch repair (ETAAR). This study aimed to evaluate the feasibility, effectiveness, and safety of ETAAR via needle based ISF, and to present initial experience with this technique. Patients who met the inclusion criteria were enrolled in this prospective study. The supra-arch branches were manually punctured in a retrograde manner using liver biopsy needles (18 gauge/30 cm) in the left common carotid artery (LCCA) and brachiocephalic trunk (BCT), and endo-puncture system or aspiration biopsy needles (21-gauge) in the left subclavian artery (LSA). All the branches were revascularised with bridge stents. Routine follow-up occurred at 1, 3, 6, and 12 months post surgery. Ten patients with arch pathologies underwent ETAAR. Revascularisation of three branches was successfully performed in eight patients, but attempts to create ISF in LSA were unsuccessful in two patients because of tortuosity and sharp angle. The time taken to establish ISF in LCCA and BCT was 100.4s and 489.6s, respectively. Bilateral regional cerebral oxygen saturation (RCOS) decreased after the arch endograft deployment (both, p < .001) and recovered to the pre-operative level once both carotid arteries were reconstructed (left, p = .0856; right, p = .6). The right RCOS was higher with the beneficial effect of extracorporeal circulation (after cTAGs deployment, p < .001; after LCCA revascularised, p = .0148) during the ischaemic period. In one case, the left iliac artery ruptured, but no ISF related or neurological complications occurred. An early follow-up (mean 5.44 months) CTA and ultrasound confirmed patency of all the branch grafts without any endoleak or migration CONCLUSIONS: This study demonstrated that ETAAR via needle based ISF, making full use of off the shelf devices and techniques, can be successfully performed in aortic arch pathologies with a favourable early outcome. Copyright © 2017 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.

Heterogeneity in the Segmental Development of the Aortic Tree: Impact on Management of Genetically Triggered Aortic Aneurysms

PubMed Central

Sherif, Hisham M.F.

2014-01-01

An extensive search of the medical literature examining the development of the thoracic aortic tree reveals that the thoracic aorta does not develop as one unit or in one stage: the oldest part of the thoracic aorta is the descending aorta with the aortic arch being the second oldest, developing under influence from the neural crest cell. Following in chronological order are the proximal ascending aorta and aortic root, which develop from a conotruncal origin. Different areas of the thoracic aorta develop under the influence of different gene sets. These parts develop from different cell lineages: the aortic root (the conotruncus), developing from the mesoderm; the ascending aorta and aortic arch, developing from the neural crest cells; and the descending aorta from the mesoderm. Findings illustrate that the thoracic aorta is not a single entity, in developmental terms. It develops from three or four distinct areas, at different stages of embryonic life, and under different sets of genes and signaling pathways. Genetically triggered thoracic aortic aneurysms are not a monolithic group but rather share a multi-genetic origin. Identification of therapeutic targets should be based on the predilection of certain genes to cause aneurysmal disease in specific aortic segments. PMID:26798739

Assessment of aortic stiffness in patients with ankylosing spondylitis using cardiovascular magnetic resonance.

PubMed

Biesbroek, P Stefan; Heslinga, Sjoerd C; van de Ven, Peter M; Peters, Mike J L; Amier, Raquel P; Konings, Thelma C; Maroules, Christopher D; Ayers, Colby; Joshi, Parag H; van der Horst-Bruinsma, Irene E; van Halm, Vokko P; van Rossum, Albert C; Nurmohamed, Michael T; Nijveldt, Robin

2018-05-12

To evaluate aortic stiffness in patients with ankylosing spondylitis (AS) using cardiovascular magnetic resonance (CMR) and to assess its association with AS characteristics and left ventricular (LV) remodeling. In this prospective study, 14 consecutive AS patients were each matched to two controls without cardiovascular symptoms or known cardiovascular disease who underwent CMR imaging for the assessment of aortic arch pulse wave velocity (PWV) at 1.5 Tesla. To enhance comparability of the samples, matching was done with replacement resulting in 20 unique controls. Only AS patients with abnormal findings on screening echocardiography were included in this exploratory study. Cine CMR was used to assess LV geometry and systolic function, and late gadolinium enhancement was performed to determine the presence of myocardial hyperenhancement (i.e., fibrosis). Aortic arch PWV was significantly higher in the AS group compared with the control group (median 9.7 m/s, interquartile range [IQR] 7.1 to 11.8 vs. 6.1 m/s, IQR 4.6 to 7.6 m/s; p < 0.001). PWV was positively associated with functional disability as measured by BASFI (R: 0.62; p = 0.018). Three patients (21%) with a non-ischemic pattern of hyperenhancement showed increased PWV (11.7, 12.3, and 16.5 m/s) as compared to the 11 patients without hyperenhancement (9.0 m/s, IQR 6.6 to 10.5 m/s; p = 0.022). PWV was inversely associated with LV ejection fraction (R: - 0.63; p = 0.015), but was not found to be statistically correlated to LV volumes or mass. Aortic arch PWV was increased in our cohort of patients with AS. Higher PWV in the aortic arch was associated with functional disability, the presence of non-ischemic hyperenhancement, and reduced LV systolic function.

Retrograde Ascending Dissection After Thoracic Endovascular Aortic Repair Combined With the Chimney Technique and Successful Open Repair Using the Frozen Elephant Trunk Technique.

PubMed

Hirano, Koji; Tokui, Toshiya; Nakamura, Bun; Inoue, Ryosai; Inagaki, Masahiro; Maze, Yasumi; Kato, Noriyuki

2018-01-01

The chimney technique can be combined with thoracic endovascular aortic repair (TEVAR) to both obtain an appropriate landing zone and maintain blood flow of the arch vessels. However, surgical repair becomes more complicated if retrograde type A aortic dissection occurs after TEVAR with the chimney technique. We herein report a case involving a 73-year-old woman who developed a retrograde ascending dissection 3 months after TEVAR for acute type B aortic dissection. To ensure an adequate proximal sealing distance, the proximal edge of the stent graft was located at the zone 2 level and an additional bare stent was placed at the left subclavian artery (the chimney technique) at the time of TEVAR. Enhanced computed tomography revealed an aortic dissection involving the ascending aorta and aortic arch. Surgical aortic repair using the frozen elephant trunk technique was urgently performed. The patient survived without stroke, paraplegia, renal failure, or other major complications. Retrograde ascending dissection can occur after TEVAR combined with the chimney technique. The frozen elephant trunk technique is useful for surgical repair in such complicated cases.

[Endovascular repair of primary retrograde Stanford type A aortic dissection].

PubMed

Wu, H W; Sun, L; Li, D M; Jing, H; Xu, B; Wang, C T; Zhang, L

2016-10-01

Objective: To summarize the short- and mid-term results on endovascular repair of primary retrograde Stanford type A aortic dissection with an entry tear in distal aortic arch or descending aorta. Methods: Between December 2009 and December 2014, 21 male patients of primary retrograde Stanford type A aortic dissection with a mean age of (52±9) years received endovascular repair in Department of Cardiothoracic Surgery, Jinling Hospital. Among the 21 cases, 17 patients were presented as ascending aortic intramural hematoma, 4 patients as active blood flow in false lumen and partial thrombosis, 8 patients as ulcer on descending aorta combined intramural hematoma in descending aorta, and 13 patients as typical dissection changes. All patients received endovascular stent-graft repair successfully, with 15 cases in acute phase and 6 cases in chronic phase. Results: Cone stent was implanted in 13 cases, while straight stent in 8 cases, including 1 case of left common carotid-left subclavian artery bypass surgery and 1 case of restrictive bare-metal stent implantation. No perioperative stroke, paraplegia, stent fracture or displacement, limbs or abdominal organ ischemia or other severe complications occured, except for tracheotomy in 2 patients. Active blood flow in ascending aorta or aortic arch disappeared, and intramural hematoma started being absorbed on CT angiography images before discharge. All patients were alive during follow-up (6 to 72 months), and intramural hematoma in ascending aorta and aortic arch was absorbed thoroughly. Type Ⅰ endoleak and ulcer expansion were found in 1 patient, and type Ⅳ endoleak in distal stent was found in another one patient. Secondary ascending aortic dissection was found in 1 case two years later, which was cured by hybrid procedure with cardiopulmonary bypass. Conclusion: Endovascular repair of primary retrograde Stanford type A aortic dissection was safe and effective, which correlated with favorable short- and mid-term results.

Impact of Different Aortic Entry Tear Sites on Early Outcomes and Long-Term Survival in Patients with Stanford A Acute Aortic Dissection.

PubMed

Merkle, Julia; Sabashnikov, Anton; Deppe, Antje Christin; Weber, Saskia; Mader, Navid; Choi, Yeong-Hoon; Liakopoulos, Oliver; Kuhn-Régnier, Ferdinand; Wahlers, Thorsten

2018-06-13

 Stanford A acute aortic dissection (AAD) is a life-threatening emergency. The aim of this study was to compare the impact of three different aortic entry tear sites on early outcomes and long-term survival of patients with Stanford A AAD.  From January 2006 to April 2015, a total of 240 consecutive patients with diagnosed Stanford A AAD underwent emergent, isolated surgical aortic repair in our center. Patients were divided into three groups comprising isolated ascending aorta, proximal aortic arch, and distal aortic arch entry tear site and were followed up for up to 9 years.  Thirty-day mortality as well as major cerebrovascular events were significantly different between the three groups ( p  = 0.007 and p  = 0.048, respectively). Overall cumulative short- and long-term survival of all patients revealed significant differences (Log-Rank p  = 0.002), whereas survival of all patients free from major cerebrovascular events was similar (Log-Rank p  = 0.780). Subgroup analysis of short- and long-term survival of patients showed significant differences in terms of men (Log-Rank p  = 0.043), women (Log-Rank p  = 0.004), patients over 65 years of age (Log-Rank p  = 0.007), and hypertensive patients (Log-Rank p  = 0.003). Kaplan-Meier survival estimation plots significantly showed poorest survival for distal aortic arch entry tear site group.  The location of the primary entry tear in patients with Stanford A AAD significantly influences early outcomes, short- and long-term survival of patients, whereas survival of patients free from major cerebrovascular events showed similar results among the three groups. Distal aortic entry tear site showed poorest outcomes and survival. Georg Thieme Verlag KG Stuttgart · New York.

Numerical analysis of wall shear stress in ascending aorta before tearing in type A aortic dissection.

PubMed

Chi, Qingzhuo; He, Ying; Luan, Yong; Qin, Kairong; Mu, Lizhong

2017-10-01

Although the incidence of many cardiovascular diseases has declined as medical treatments have improved, the prevalence of aortic dissection (AD) has increased. Compared to type B dissections, type A dissections are more severe, and most patients with type A dissections require surgical treatment. The objective of this study was to investigate the relationships between the wall shear stress (WSS) on the aortic endothelium and the frequent tearing positions using computational fluid dynamics. Five type A dissection cases and two normal aortas were included in the study. First, the structures of the aortas before the type A dissection were reconstructed on the basis of the original imaging data. Analyses of flow in the reconstructed premorbid structures reveals that the rupture positions in three of the five cases corresponded to the area of maximum elevated WSS. Moreover, the WSS at the junction of the aortic arch and descending aorta was found to be elevated, which is considered to be related to the locally disturbed helical flow. Meanwhile, the highest WSS in the patients with premorbid AD was found to be almost double that of the control group. Due to the noticeable morphological differences between the AD cases and the control group, the WSSs in the premorbid structures without vasodilation in the ascending part were estimated. The computational results revealed that the WSS was lower in the aorta without vasodilation, but the pressure drop in this situation was higher than that with vasodilation in the ascending aorta. Significant differences were seen between the AD cases and the control group in the angles of the side branches of the aortic arch and its bending degree. Dilation of the ascending aorta and alterations in the branching angles may be the key determinants of a high WSS that leads to type A dissection. Greater tortuosity of the aortic arch leads to stronger helical flow through the distal aortic arch, which may be related to tears in this region. Copyright © 2017 Elsevier Ltd. All rights reserved.

[Single coronary artery and right aortic arch].

PubMed

Martínez-Quintana, Efrén; Rodríguez-González, Fayna

2015-01-01

Coronary anomalies are mostly asymptomatic and diagnosed incidentally during coronary angiography or echocardiography. However, they must be taken into account in the differential diagnosis of angina, dyspnea, syncope, acute myocardial infarction or sudden death in young patients. The case is presented of two rare anomalies, single coronary artery originating from right sinus of Valsalva and right aortic arch, in a 65 year-old patient with atherosclerotic coronary artery disease treated percutaneously. Copyright © 2014 Sociedad Española de Arteriosclerosis. Published by Elsevier España. All rights reserved.

Current surgical results of acute type A aortic dissection in Japan.

PubMed

Okita, Yutaka

2016-07-01

Current surgical results of acute type A aortic dissection in Japan are presented. According to the annual survey by the Japanese Association of Thoracic Surgery, 4,444 patients with acute type A aortic dissection underwent surgical procedures and the overall hospital mortality was 9.1% in 2013. The prevalence of aortic root replacement with a valve sparing technique, total arch replacement (TAR), and frozen stent graft are presented and strategies for thrombosed dissection or organ malperfusion syndrome secondary to acute aortic dissection are discussed.

Comparison and usefulness of cardiac magnetic resonance versus computed tomography in infants six months of age or younger with aortic arch anomalies without deep sedation or anesthesia.

PubMed

Fogel, Mark A; Pawlowski, Thomas W; Harris, Matthew A; Whitehead, Kevin K; Keller, Marc S; Wilson, Justine; Tipton, Deanna; Harris, Christine

2011-07-01

The present project investigated whether cardiac magnetic resonance (CMR) of aortic arch anomalies can be performed successfully in infants <6 months of age without the use of cardiac anesthesia or deep sedation. We performed a retrospective review of infants ≤6 months old from 2005 to 2009 who underwent either CMR or computed tomography angiography to investigate aortic arch abnormalities. The CMR procedure used a "feed and swaddle" protocol without deep sedation or cardiac anesthesia. Of the 52 infants referred for CMR, 24 underwent the feed and swaddle protocol (aged 2.6 ± 1.4 months). One patient awoke during the study, and examination of the remaining 23 yielded a definitive diagnosis (success rate 96%). The scanning time was 6.2 ± 3.1 minutes, with the large airways evaluation accounting for 1/2 the time. Single-shot axial steady-state free precession, in which the definitive diagnosis was made, accounted for 0.59 ± 0.3 minutes. Fifteen infants were diagnosed with a vascular ring. Of the 8 infants who underwent surgery, the diagnostic accuracy was 100%. During the same period, 19 patients, who had undergone computed tomography angiography (aged 1.67 ± 1.20 months), were referred for aortic arch evaluation. Of these 19 patients, 6 (32%) underwent sedation or anesthesia. The imaging time was 0.08 ± 0.06 minutes, significantly different from the CMR times (p <0.01). However, the overall room times (31.3 ± 22.3 and 35.8 ± 3.86 minutes, respectively) were not different between the CMR and angiographic groups. The radiation dose was 1.41 ± 1.03 mSv. In conclusion, CMR evaluation of aortic arch anomalies in children <6 months old can be successfully completed quickly using a feed and swaddle approach with high diagnostic accuracy. This protocol avoids the risks of sedation, as well as the radiation associated with computed tomography angiography. Copyright © 2011 Elsevier Inc. All rights reserved.

A computational analysis of different endograft designs for Zone 0 aortic arch repair.

PubMed

van Bakel, Theodorus M; Arthurs, Christopher J; van Herwaarden, Joost A; Moll, Frans L; Eagle, Kim A; Patel, Himanshu J; Trimarchi, Santi; Figueroa, C Alberto

2018-03-15

Aortic arch repair remains a major surgical challenge. Multiple manufacturers are developing branched endografts for Zone 0 endovascular repair, extending the armamentarium for minimally invasive treatment of aortic arch pathologies. We hypothesize that the design of the Zone 0 endograft has a significant impact on the postoperative haemodynamic performance, particularly in the cervical arteries. The goal of our study was to compare the postoperative haemodynamic performance of different Zone 0 endograft designs. Patient-specific, clinically validated, computational fluid dynamics simulations were performed in a 71-year-old woman with a 6.5-cm saccular aortic arch aneurysm. Additionally, 4 endovascular repair scenarios using different endograft designs were created. Haemodynamic performance was evaluated by calculation of postoperative changes in blood flow and platelet activation potential (PLAP) in the cervical arteries. Preoperative cervical blood flow and mean PLAP were 1080 ml/min and 151.75, respectively. Cervical blood flow decreased and PLAP increased following endovascular repair in all scenarios. Endografts with 2 antegrade inner branches performed better compared to single-branch endografts. Scenario 3 performed the worst with a decrease in the total cervical blood flow of 4.8%, a decrease in the left hemisphere flow of 6.7% and an increase in the mean PLAP of 74.3%. Endograft design has a significant impact on haemodynamic performance following Zone 0 endovascular repair, potentially affecting cerebral blood flow during follow-up. Our results demonstrate the use of computational modelling for virtual testing of therapeutic interventions and underline the need to monitor the long-term outcomes in this cohort of patients.

Association between arterial calcifications and nonlacunar and lacunar ischemic strokes.

PubMed

van Dijk, Anouk C; Fonville, Susanne; Zadi, Taihra; van Hattem, Antonius M G; Saiedie, Ghesrouw; Koudstaal, Peter J; van der Lugt, Aad

2014-03-01

Nonlacunar cerebral infarcts are presumed to be caused by thromboembolism from the heart or extracranial arteries, whereas lacunar infarcts are thought to be caused by small vessel disease. We investigated to what extent arterial calcifications differ between nonlacunar and lacunar ischemic strokes. We studied 820 consecutive patients with transient ischemic attack or ischemic stroke in the anterior circulation who underwent multidetector computed tomography angiography and had no rare cause of stroke. The presence of likely cardioembolic pathogenesis was determined according to the Trial of Org 10172 in Acute Stroke Treatment criteria. The remaining 708 patients were categorized as nonlacunar or lacunar strokes, either transient ischemic attacks or strokes, based on clinical symptoms corrected by brain imaging results. We measured volume of calcifications in the aortic arch, symptomatic extracranial and intracranial carotid artery using multidetector computed tomography angiography. The difference in calcifications between nonlacunar and lacunar strokes was assessed with a multivariable logistic regression analysis. We adjusted for degree of symptomatic carotid artery stenosis and cardiovascular risk factors. We found an independent association between volume of aortic arch calcifications and nonlacunar ischemic strokes (adjusted odds ratio [95% confidence interval], 1.11 [1.02-1.21]). No independent associations between extracranial and intracranial carotid artery calcifications and nonlacunar strokes were present. The only difference we found between nonlacunar and lacunar strokes was a higher calcification volume in the aortic arch in nonlacunar strokes. Our findings only partially confirm the notion of distinct etiologies and suggest that the potential role of other plaque components, plaque morphology, and aortic arch calcifications in ischemic stroke subtypes awaits further evaluation.

Qureshi-5 Catheter for Complex Supra- and Abdominal-Aortic Catheterization

PubMed Central

Qureshi, Adnan I.; Xiao, WeiGang; Liu, HongLiang

2015-01-01

Background The use of previously described catheter technique was expanded to complex supra- and abdominal- aortic catheterizations. Methods A new (Qureshi 5) catheter with curved shape at the distal end that has two lumens was used. One of lumens can accommodate a 0.035-inch guide wire and the second lumen can accommodate a 0.018-inch guide wire and terminates at the beginning of the distal curve of the first lumen. The manipulation and engagement of the curved distal end catheter was facilitated by rotation and movement of the J-shaped 0.018-inch guide wire extended coaxial and beyond the distal end of catheter. Subsequently, either contrast was injected or a 0.035-inch guide wire advanced into the target artery. Results The catheters were used in one patient to perform diagnostic cerebral and abdominal angiography through a 6F introducer sheath placed in the right common femoral artery. The catheterization was complex because of severe tortuosity of arch and descending aorta secondary to kyphosis. The left and right internal carotid arteries and left and right vertebral arteries, left renal artery, and superior mesenteric artery were catheterized in patient (fluoroscopy time 19:46 min). No complications were observed in the patient. Conclusions The Qureshi-5 catheter was successful in complex supra- and abdominal-aortic catheterizations. PMID:26600925

Qureshi-5 Catheter for Complex Supra- and Abdominal-Aortic Catheterization.

PubMed

Qureshi, Adnan I; Xiao, WeiGang; Liu, HongLiang

2015-10-01

The use of previously described catheter technique was expanded to complex supra- and abdominal- aortic catheterizations. A new (Qureshi 5) catheter with curved shape at the distal end that has two lumens was used. One of lumens can accommodate a 0.035-inch guide wire and the second lumen can accommodate a 0.018-inch guide wire and terminates at the beginning of the distal curve of the first lumen. The manipulation and engagement of the curved distal end catheter was facilitated by rotation and movement of the J-shaped 0.018-inch guide wire extended coaxial and beyond the distal end of catheter. Subsequently, either contrast was injected or a 0.035-inch guide wire advanced into the target artery. The catheters were used in one patient to perform diagnostic cerebral and abdominal angiography through a 6F introducer sheath placed in the right common femoral artery. The catheterization was complex because of severe tortuosity of arch and descending aorta secondary to kyphosis. The left and right internal carotid arteries and left and right vertebral arteries, left renal artery, and superior mesenteric artery were catheterized in patient (fluoroscopy time 19:46 min). No complications were observed in the patient. The Qureshi-5 catheter was successful in complex supra- and abdominal-aortic catheterizations.

Full dimensional computer simulations to study pulsatile blood flow in vessels, aortic arch and bifurcated veins: Investigation of blood viscosity and turbulent effects.

PubMed

Sultanov, Renat A; Guster, Dennis

2009-01-01

We report computational results of blood flow through a model of the human aortic arch and a vessel of actual diameter and length. A realistic pulsatile flow is used in all simulations. Calculations for bifurcation type vessels are also carried out and presented. Different mathematical methods for numerical solution of the fluid dynamics equations have been considered. The non-Newtonian behaviour of the human blood is investigated together with turbulence effects. A detailed time-dependent mathematical convergence test has been carried out. The results of computer simulations of the blood flow in vessels of three different geometries are presented: for pressure, strain rate and velocity component distributions we found significant disagreements between our results obtained with realistic non-Newtonian treatment of human blood and the widely used method in the literature: a simple Newtonian approximation. A significant increase of the strain rate and, as a result, the wall shear stress distribution, is found in the region of the aortic arch. Turbulent effects are found to be important, particularly in the case of bifurcation vessels.

Utility of fetal cardiac magnetic resonance imaging to assess fetuses with right aortic arch and right ductus arteriosus.

PubMed

Dong, Su-Zhen; Zhu, Ming

2018-06-01

To evaluate the utility of fetal cardiac magnetic resonance imaging (MRI) to diagnose right aortic arch (RAA) with right ductus arteriosus. This retrospective study included six fetuses with right aortic arch and right ductus arteriosus. The six fetal cases were examined using a 1.5-T magnetic resonance unit. The steady-state free precession (SSFP) and single-shot turbo spin echo (SSTSE) sequences were used to evaluate the fetal heart and airway. The gestational age of the six fetuses ranged from 22 to 35 weeks (mean, 26.5 weeks). The age of the pregnant women ranged from 23 to 40 years (mean 31 years). Fetal cardiac MRI diagnosed the six fetal cases with RAA with right ductus arteriosus correctly. Among the six fetuses, four were associated with other congenital heart defects. In three of six cases, the diagnoses established using prenatal echocardiography (echo) was correct when compared with postnatal diagnosis. Fetal cardiac MRI is a useful complementary tool to assess fetuses with RAA and right ductus arteriosus.

Early Results of the PETTICOAT Technique for the Management of Acute Type A Aortic Dissection.

PubMed

Kotha, Vamshi Krishna; Pozeg, Zlatko I; Herget, Eric J; Moon, Michael C; Appoo, Jehangir J

2017-08-01

Conventional surgical techniques for acute Type A aortic dissection (ATAAD) generally fail to address residual dissection in the descending aorta. The persistence of a false lumen is associated with visceral malperfusion in the acute setting and adverse aortic remodeling in the chronic setting. Hybrid aortic arch repair techniques may improve perioperative and long-term mortality by expanding the true lumen and obliterating the false lumen. However, there is a limit to the extent of aortic coverage due to the concomitant risk of spinal cord ischemia. In Type B dissection, the PETTICOAT (Provisional Extension To Induce Complete Attachment) technique, which entails stent graft coverage of the primary intimal tear followed by bare metal stent placement distally, may improve true lumen caliber and promote false lumen thrombosis without increasing the risk of spinal cord ischemia, as intercostal branches remain perfused through the bare metal stents. The technique of hybrid arch with surgical creation of a Dacron landing zone covering a stent graft in the proximal descending aorta and bare metal stents in the thoraco-abdominal aorta is a promising concept in the treatment of ATAAD.

Segmental and age differences in the elastin network, collagen, and smooth muscle phenotype in the tunica media of the porcine aorta.

PubMed

Tonar, Zbyněk; Kubíková, Tereza; Prior, Claudia; Demjén, Erna; Liška, Václav; Králíčková, Milena; Witter, Kirsti

2015-09-01

The porcine aorta is often used in studies on morphology, pathology, transplantation surgery, vascular and endovascular surgery, and biomechanics of the large arteries. Using quantitative histology and stereology, we estimated the area fraction of elastin, collagen, alpha-smooth muscle actin, vimentin, and desmin within the tunica media in 123 tissue samples collected from five segments (thoracic ascending aorta; aortic arch; thoracic descending aorta; suprarenal abdominal aorta; and infrarenal abdominal aorta) of porcine aortae from growing domestic pigs (n=25), ranging in age from 0 to 230 days. The descending thoracic aorta had the greatest elastin fraction, which decreased proximally toward the aortic arch as well as distally toward the abdominal aorta. Abdominal aortic segments had the highest fraction of actin, desmin, and vimentin positivity and all of these vascular smooth muscle markers were lower in the thoracic aortic segments. No quantitative differences were found when comparing the suprarenal abdominal segments with the infrarenal abdominal segments. The area fraction of actin within the media was comparable in all age groups and it was proportional to the postnatal growth. Thicker aortic segments had more elastin and collagen with fewer contractile cells. The collagen fraction decreased from ascending aorta and aortic arch toward the descending aorta. By revealing the variability of the quantitative composition of the porcine aorta, the results are suitable for planning experiments with the porcine aorta as a model, i.e. power test analyses and estimating the number of samples necessary to achieving a desirable level of precision. The complete primary morphometric data, in the form of continuous variables, are made publicly available for biomechanical modeling of site-dependent distensibility and compliance of the porcine aorta. Copyright © 2015 Elsevier GmbH. All rights reserved.

Anatomy of the ventricular septal defect in outflow tract defects: similarities and differences.

PubMed

Mostefa-Kara, Meriem; Bonnet, Damien; Belli, Emre; Fadel, Elie; Houyel, Lucile

2015-03-01

The study objective was to analyze the anatomy of the ventricular septal defect found in various phenotypes of outflow tract defects. We reviewed 277 heart specimens with isolated outlet ventricular septal defect without subpulmonary stenosis (isolated outlet ventricular septal defect, 19); tetralogy of Fallot (71); tetralogy of Fallot with pulmonary atresia (51); common arterial trunk (54); double outlet right ventricle (65) with subaortic, doubly committed, or subpulmonary ventricular septal defect; and interrupted aortic arch type B (17). Special attention was paid to the rims of the ventricular septal defect viewed from the right ventricular side and the relationships between the tricuspid and aortic valves. The ventricular septal defect was always located in the outlet of the right ventricle, between the 2 limbs of the septal band. There was a fibrous continuity between the tricuspid and aortic valves in 74% of specimens with isolated outlet ventricular septal defect, 66% of specimens with tetralogy of Fallot, 39% of specimens with tetralogy of Fallot with pulmonary atresia, 4.6% of specimens with double outlet right ventricle, 1.8% of specimens with common arterial trunk, and zero of specimens with interrupted aortic arch type B (P < .005). When present, this continuity always involved the anterior tricuspid leaflet. The ventricular septal defect in outflow tract defects is always an outlet ventricular septal defect, cradled between the 2 limbs of the septal band. However, there are some differences regarding the posteroinferior and superior rims of the ventricular septal defect. These differences suggest an anatomic continuum from the isolated outlet ventricular septal defect to the interrupted aortic arch type B rather than distinct physiologic phenotypes, related to various degrees of abnormal rotation of the outflow tract during heart development: minimal in isolated outlet ventricular septal defect; incomplete in tetralogy of Fallot, tetralogy of Fallot with pulmonary atresia, and double outlet right ventricle; absent in common arterial trunk; and excessive in interrupted aortic arch type B. Copyright © 2015 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

Intracardiac echocardiographic guidance for hemodynamic assessment in a patient with congenital abnormalities and a prosthetic aortic valve.

PubMed

Papafaklis, M I; Ligthart, J M R; Vaina, S; Witsenburg, M; Bogers, A J J C; Serruys, P W

2005-01-01

In this case report, we present the use of intracardiac echocardiography (ICE) for guiding the cardiac catheterization and subsequent hemodynamic investigation in an unusual patient case with multiple congenital abnormalities (bicuspid aortic valve, left cervical aortic arch, two aortic coarctations) and two aortic valve replacement operations in the past. The ICE catheter (AcuNav) permitted us to accurately and safely puncture the interatrial septum and place the Swan-Ganz catheter in the left ventricle; additionally, visualization of the aortic coarctation in the ascending aorta was also achieved.

Ascending aortic aneurysm causing hoarse voice: a variant of Ortner's syndrome

PubMed Central

Eccles, Sinan Robert; Banks, John; Kumar, Pankaj

2012-01-01

A 68-year-old man with a persistent hoarse voice was found to have a left vocal cord paralysis. Clinical examination revealed signs consistent with aortic regurgitation. Subsequent investigation revealed an ascending aortic aneurysm. He underwent aortic root and ascending aorta replacement and his hoarseness improved. Ortner's syndrome refers to hoarseness due to recurrent laryngeal nerve palsy secondary to a cardiovascular abnormality. Recurrent laryngeal nerve palsy due to aneurysmal dilation of the ascending aorta is extremely rare, with aneurysms of the aortic arch being a more common cause. PMID:23060380

Finite element analysis of helical flows in human aortic arch: A novel index

PubMed Central

Lee, Cheng-Hung; Liu, Kuo-Sheng; Jhong, Guan-Heng; Liu, Shih-Jung; Hsu, Ming-Yi; Wang, Chao-Jan; Hung, Kuo-Chun

2014-01-01

This study investigates the helical secondary flows in the aortic arch using finite element analysis. The relationship between helical flow and the configuration of the aorta in patients of whose three-dimensional images constructed from computed tomography scans was examined. A finite element model of the pressurized root, arch, and supra-aortic vessels was developed to simulate the pattern of helical secondary flows. Calculations indicate that most of the helical secondary flow was formed in the ascending aorta. Angle α between the zero reference point and the aortic ostium (correlation coefficient (r) = −0.851, P = 0.001), the dispersion index of the cross section of the ascending (r = 0.683, P = 0.021) and descending aorta (r = 0.732, P = 0.010), all correlated closely with the presence of helical flow (P < 0.05). Stepwise multiple linear regression analysis confirmed angel α to be independently associated with the helical flow pattern in therein (standardized coefficients = −0.721, P = 0.023). The presence of helical fluid motion based on the atherosclerotic risks of patients, including those associated with diabetes, hypertension, hyperlipidemia, or renal insufficiency, was also evaluated. Numerical simulation of the flow patterns in aortas incorporating the atherosclerotic risks may better explain the mechanism of formation of helical flows and provide insight into causative factors that underlie them. PMID:24803960

Effects of Restoration of Blood Flow on the Development of Aortic Atherosclerosis in ApoE-/- Mice With Unilateral Renal Artery Stenosis.

PubMed

Pathak, Alokkumar S; Huang, Jianhua; Rojas, Mauricio; Bazemore, Taylor C; Zhou, Ruihai; Stouffer, George A

2016-04-03

Chronic unilateral renal artery stenosis (RAS) causes accelerated atherosclerosis in apolipoprotein E-deficient (ApoE(-/-)) mice, but effects of restoration of renal blood flow on aortic atherosclerosis are unknown. Male ApoE(-/-) mice underwent sham surgery (n=16) or had partial ligation of the right renal artery (n=41) with the ligature being removed 4 days later (D4LR; n=6), 8 days later (D8LR; n=11), or left in place for 90 days (chronic RAS; n=24). Ligature removal at 4 or 8 days resulted in improved renal blood flow, decreased plasma angiotensin II levels, a return of systolic blood pressure to baseline, and increased plasma levels of neutrophil gelatinase associated lipocalin. Chronic RAS resulted in increased lipid staining in the aortic arch (33.2% [24.4, 47.5] vs 11.6% [6.1, 14.2]; P<0.05) and descending thoracic aorta (10.2% [6.4, 25.9] vs 4.9% [2.8, 7.8]; P<0.05), compared to sham surgery. There was an increased amount of aortic arch lipid staining in the D8LR group (22.7% [22.1, 32.7]), compared to sham-surgery, but less than observed with chronic RAS. Lipid staining in the aortic arch was not increased in the D4LR group, and lipid staining in the descending aorta was not increased in either the D8LR or D4LR groups. There was less macrophage expression in infrarenal aortic atheroma in the D4LR and D8LR groups compared to the chronic RAS group. Restoration of renal blood flow at either 4 or 8 days after unilateral RAS had a beneficial effect on systolic blood pressure, aortic lipid deposition, and atheroma inflammation. © 2016 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.

Comparison of hybrid endovascular and open surgical repair for proximal aortic arch diseases.

PubMed

Kang, Woong Chol; Ko, Young-Guk; Shin, Eak Kyun; Park, Chul-Hyun; Choi, Donghoon; Youn, Young Nam; Lee, Do Yun

2016-01-15

To compare the outcomes of hybrid endovascular and open surgical repair for proximal aortic arch diseases. A total of 55 consecutive patients with aortic arch aneurysm or aortic dissection involving any of zone 0 to 1 (39 male, age 63.4 ± 14.3 years) underwent a hybrid endovascular repair (n=35) or open surgical repair (n=20) from 2006 to 2014 were analyzed retrospectively. Perioperative and late outcomes were compared. Baseline characteristics were similar between the two groups, except age and EuroSCORE II, which were higher in the hybrid group. Perioperative mortality or stroke was not significantly different between the two groups, however, tended to be lower in the hybrid repair group than in the open repair group (11.4% vs. 30.0%, p=0.144). Incidences of other morbidities did not differ. During follow-up, over-all survival was similar between the hybrid and the open repair was similar (87.3% vs. 79.7% at 1 year and 83.8% vs. 72.4% at 3 years; p=0.319). However, reintervention-free survival was significantly lower for hybrid repair compared with open repair (83.8% vs. 100% at 1 year and 65.7% vs. 100% at 3 years; p=0.022). Hybrid repair of proximal aortic disease showed comparable perioperative and late outcomes compared with open surgical repair despite a higher reintervention rate during follow-up. Therefore, hybrid repair may be considered as an acceptable treatment alternative to surgery especially in patients at high surgical risk. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.

CANNULATION STRATEGY FOR AORTIC ARCH RECONSTRUCTION USING DEEP HYPOTHERMIC CIRCULATORY ARREST

PubMed Central

de Zéicourt, Diane; Jung, Philsub; Horner, Marc; Pekkan, Kerem; Kanter, Kirk R.; Yoganathan, Ajit P.

2013-01-01

Background Aortic arch reconstruction in neonates is commonly performed using deep hypothermic circulatory arrest. However, concerns have arisen regarding potential adverse neurologic outcomes from this complex procedure, raising questions as to best arterial cannulation approach for cerebral perfusion and effective systemic hypothermia. In this study, we use computational fluid dynamics to investigate the impact of different cannulation strategies in neonates. Methods Using a realistic hypoplastic neonatal aorta template as the base geometry, four different cannulation options were investigated: 1) right innominate artery, 2) innominate root, 3) patent ductus arteriosus (PDA), or 4) both innominate root and PDA. Performance was evaluated based on the numerically predicted cerebral and systemic flow distributions compared with physiological perfusion under neonatal conditions. Results The four cannulation strategies were associated with different local hemodynamics, but this did not translate into any significant effect on the measured flow distributions. The largest difference only represented 0.8% of the cardiac output and was measured in the innominate artery, which received 23.2% of the cardiac output in Option 3 vs. 24% in Option 4. PA snaring benefited all systemic vessels uniformly. Conclusion Due to the very high vascular resistances in neonates, flow distribution to the different vascular beds was dictated by the downstream vascular resistances rather than the cannulation strategy, allowing the surgical team to choose their method of preference. However, patients with aortic coarctation warrant further investigation and will most likely benefit from a two cannulae approach (Option 4). PMID:22608717

Effect of coarctation of the aorta and bicuspid aortic valve on flow dynamics and turbulence in the aorta using particle image velocimetry

NASA Astrophysics Data System (ADS)

Keshavarz-Motamed, Zahra; Garcia, Julio; Gaillard, Emmanuel; Maftoon, Nima; Di Labbio, Giuseppe; Cloutier, Guy; Kadem, Lyes

2014-03-01

Blood flow in the aorta has been of particular interest from both fluid dynamics and physiology perspectives. Coarctation of the aorta (COA) is a congenital heart disease corresponding to a severe narrowing in the aortic arch. Up to 85 % of patients with COA have a pathological aortic valve, leading to a narrowing at the valve level. The aim of the present work was to advance the state of understanding of flow through a COA to investigate how narrowing in the aorta (COA) affects the characteristics of the velocity field and, in particular, turbulence development. For this purpose, particle image velocimetry measurements were conducted at physiological flow and pressure conditions, with three different aorta configurations: (1) normal case: normal aorta + normal aortic valve; (2) isolated COA: COA (with 75 % reduction in aortic cross-sectional area) + normal aortic valve and (3) complex COA: COA (with 75 % reduction in aortic cross-sectional area) + pathological aortic valve. Viscous shear stress (VSS), representing the physical shear stress, Reynolds shear stress (RSS), representing the turbulent shear stress, and turbulent kinetic energy (TKE), representing the intensity of fluctuations in the fluid flow environment, were calculated for all cases. Results show that, compared with a healthy aorta, the instantaneous velocity streamlines and vortices were deeply changed in the presence of the COA. The normal aorta did not display any regions of elevated VSS, RSS and TKE at any moment of the cardiac cycle. The magnitudes of these parameters were elevated for both isolated COA and complex COA, with their maximum values mainly being located inside the eccentric jet downstream of the COA. However, the presence of a pathologic aortic valve, in complex COA, amplifies VSS (e.g., average absolute peak value in the entire aorta for a total flow of 5 L/min: complex COA: = 36 N/m2; isolated COA = 19 N/m2), RSS (e.g., average peak value in the entire aorta for a total flow of 5 L/min: complex COA: = 84.6 N/m2; isolated COA = 44 N/m2) and TKE (e.g., average peak value in the entire aorta for a total flow of 5 L/min: complex COA: = 215 N/m2; isolated COA = 100 N/m2). This demonstrates that the pathological aortic valve strongly interacts with the COA. Findings of this study indicate that the presence of both a COA and a pathological aortic valve significantly alters hemodynamics in the aorta and thus might contribute to the progression of the disease in this region. This study can partially explain the complications associated in patients with COA, in the presence of a pathological aortic valve and the consequent adverse outcome post-surgery.

Contemporary management of aberrant right subclavian arteries.

PubMed

Stone, William M; Ricotta, Joseph J; Fowl, Richard J; Garg, Nitin; Bower, Thomas C; Money, Samuel R

2011-05-01

Aberrant origin of right subclavian arteries represents the most common of the aortic arch anomalies. This variant has few published series to guide management. Our goal was to review treatment options and results for these potentially complex reconstructions. A retrospective review was performed on all patients with a diagnosis of aberrant right subclavian artery at our institution between January 2003 and July 2009. A total of 24 patients, which comprises one of the largest series reported, including 10 males and 14 females (mean age: 46.6 years, range: 7-77), were diagnosed with an aberrant right subclavian artery. Sixteen (66%) were diagnosed incidentally, but eight (33%) had symptoms of either dysphagia, upper extremity ischemia, or both. Computed tomography was most commonly used to establish the diagnosis (19 patients, 79%). Magnetic resonance imaging established the diagnosis in three patients (12%), upper gastrointestinal barium study in one (4%), and standard angiography in one (4%). A Kommerell's diverticulum (KD) was the most common associated anomaly (seven patients, 29%). All seven patients (100%) with a KD required intervention for either symptoms or aneurysmal degeneration. Intervention was performed in 10 patients (42%), including carotid subclavian bypass in five (50%), carotid subclavian transposition in three (30%), and ascending aorta to subclavian bypass in two (20%). Four patients (40%) had additional intervention for management of aneurysmal disease of the aorta or KD, with open aortic replacement in two (20%) and aortic endografting in two (20%). There was one perioperative death (10%) in a patient undergoing aortic arch debranching with placement of an aortic endograft. In all, 18 patients survived without symptoms after a mean follow-up of 38 months. Aberrant right subclavian arteries are most commonly found incidentally with computed tomography. The presence of a KD seemed to correlate with the need for intervention. Patients with no symptoms with the absence of a KD can safely be followed. Copyright © 2011 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved.

[Late reoperations after repaired Stanford type A aortic dissection].

PubMed

Huang, F H; Li, L P; Su, C H; Qin, W; Xu, M; Wang, L M; Jiang, Y S; Qiu, Z B; Xiao, L Q; Zhang, C; Shi, H W; Chen, X

2017-04-01

Objective: To summarize the experience of reoperations on patients who had late complications related to previous aortic surgery for Stanford type A dissection. Methods: From August 2008 to October 2016, 14 patients (10 male and 4 female patients) who underwent previous cardiac surgery for Stanford type A aortic dissection accepted reoperations on the late complications at Department of Thoracic and Cardiovascular Surgery, Nanjing Hospital Affiliated to Nanjing Medical University. The range of age was from 41 to 76 years, the mean age was (57±12) years. In these patients, first time operations were ascending aorta replacement procedure in 3 patients, ascending aorta combined with partial aortic arch replacement in 4 patients, aortic root replacement (Bentall) associated with Marfan syndrome in 3 patients, aortic valve combined with ascending aorta replacement (Wheat) in 1 patient, ascending aorta combined with Sun's procedure in 1 patient, Wheat combined with Sun's procedure in 1 patient, Bentall combined with Sun's procedure in 1 patient. The interval between two operations averaged 0.3 to 10.0 years with a mean of (4.8±3.1) years. The reasons for reoperations included part anastomotic split, aortic valve insufficiency, false aneurysm formation, enlargement of remant aortal and false cavity. The selection of reoperation included anastomotic repair, aortic valve replacement, total arch replacement and Sun's procedure. Results: Of the 14 patients, the cardiopulmonary bypass times were 107 to 409 minutes with a mean of (204±51) minutes, cross clamp times were 60 to 212 minutes with a mean of (108±35) minutes, selective cerebral perfusion times were 16 to 38 minutes with a mean of (21±11) minutes. All patients survived from the operation, one patient died from severe pulmonary infection 50 days after operation. Three patients had postoperative complications, including acute renal failure of 2 patients and pulmonary infection of 1 patient, and these patients were recovered after treatment. Thirteen patients were finally recovered from hospital. The patients were followed up for 16 to 45 months, and no aortic rupture, paraplegia and death were observed in the follow-up. Conclusions: Patients for residual aortic dissection after initial operations on Stanford type A aortic dissection should be attached great importance and always need emergency surgery, but the technique is demanding and risk is great for surgeons and patients, which need enough specification and accurate on aortic operation. More importantly, the Sun's procedure also should be performed on the treatment of residual aortic dissection or distal arch expansion, and obtains the short- and long-term results in the future.

Computed tomography angiography reveals stenosis and aneurysmal dilation of an aberrant right subclavian artery causing systemic blood pressure misreading in an old Pekinese dog

PubMed Central

KIM, Jaehwan; EOM, Kidong; YOON, Hakyoung

2017-01-01

A 14-year-old dog weighing 4 kg presented with hypotension only in the right forelimb. Thoracic radiography revealed a round soft tissue opacity near the aortic arch and below the second thoracic vertebra on a lateral view. Three-dimensional computed tomography angiography clearly revealed stenosis and aneurysmal dilation of an aberrant right subclavian artery. Stenosis and aneurysm of an aberrant subclavian artery should be included as a differential diagnosis in dogs showing a round soft tissue opacity near the aortic arch and below the thoracic vertebra on the lateral thoracic radiograph. PMID:28496026

Computed tomography angiography reveals stenosis and aneurysmal dilation of an aberrant right subclavian artery causing systemic blood pressure misreading in an old Pekinese dog.

PubMed

Kim, Jaehwan; Eom, Kidong; Yoon, Hakyoung

2017-06-16

A 14-year-old dog weighing 4 kg presented with hypotension only in the right forelimb. Thoracic radiography revealed a round soft tissue opacity near the aortic arch and below the second thoracic vertebra on a lateral view. Three-dimensional computed tomography angiography clearly revealed stenosis and aneurysmal dilation of an aberrant right subclavian artery. Stenosis and aneurysm of an aberrant subclavian artery should be included as a differential diagnosis in dogs showing a round soft tissue opacity near the aortic arch and below the thoracic vertebra on the lateral thoracic radiograph.

A new variant of aberrant left brachiocephalic trunk in mam: case report and literature review.

PubMed

Szpinda, Michał

2005-02-01

Importance is placed on aberrant arteries in the radiological and surgical literature. A normal left brachiocephalic trunk is characteristic for the right aortic arch. However, an aberrant left brachiocephalic trunk arising as the last branch of the aortic arch on the left side has not yet been described in the literature. Described here is a new variant of the retro-oesophageal aberrant left brachiocephalic trunk, occasionally observed in a patient during diagnostic investigation or surgical treatment for steno-obstructive involvement of the carotid district. The triple anomaly of the left aortic arch consisted of: 1. the presence of a hypoplastic left brachiocephalic trunk behind the oesophagus, 2. the absence of a brachiocephalic trunk on the right side and 3. separate origins of the arteries on the right side, with the right common artery preceding the right subclavian artery. In front of the trachea an 8-mm prosthetic PTFE was implanted from the proximal segment of the right subclavian artery to the junction of the left common carotid and left subclavian arteries. The author demonstrates the inadequacy of auxiliary investigations to detect aberrant arteries, which may only be identified precisely intra-operatively.

An alternative method for neonatal cerebro-myocardial perfusion.

PubMed

Luciani, Giovanni Battista; De Rita, Fabrizio; Faggian, Giuseppe; Mazzucco, Alessandro

2012-05-01

Several techniques have already been described for selective cerebral perfusion during repair of aortic arch pathology in children. One method combining cerebral with myocardial perfusion has also been proposed. A novel technique is reported here for selective and independent cerebro-myocardial perfusion for neonatal and infant arch surgery. Technical aspects and potential advantages are discussed.

Predictive risk models for proximal aortic surgery

PubMed Central

Díaz, Rocío; Pascual, Isaac; Álvarez, Rubén; Alperi, Alberto; Rozado, Jose; Morales, Carlos; Silva, Jacobo; Morís, César

2017-01-01

Predictive risk models help improve decision making, information to our patients and quality control comparing results between surgeons and between institutions. The use of these models promotes competitiveness and led to increasingly better results. All these virtues are of utmost importance when the surgical operation entails high-risk. Although proximal aortic surgery is less frequent than other cardiac surgery operations, this procedure itself is more challenging and technically demanding than other common cardiac surgery techniques. The aim of this study is to review the current status of predictive risk models for patients who undergo proximal aortic surgery, which means aortic root replacement, supracoronary ascending aortic replacement or aortic arch surgery. PMID:28616348

Aortic Replacement with Sutureless Intraluminal Grafts

PubMed Central

Lemole, Gerald M.

1990-01-01

To avoid the anastomotic complications and long cross-clamp times associated with standard suture repair of aortic lesions, we have implanted sutureless intraluminal grafts in 122 patients since 1976. Forty-nine patients had disorders of the ascending aorta, aortic arch, or both: their operative mortality was 14% (7 patients), and the group's 5-year actuarial survival rate has been 64%. There have been no instances of graft dislodgment, graft infection, aortic bleeding, or pseudoaneurysm formation. Forty-two patients had disorders of the descending aorta and thoracoabdominal aorta: their early mortality was 10% (4 patients), and the group's 5-year actuarial survival rate has been 56%. There was 1 early instance of graft dislodgment, but no pseudoaneurysm formation, graft erosion, aortic bleeding, intravascular hemolysis, or permanent deficits in neurologic, renal, or vascular function. Thirty-one patients had the sutureless intraluminal graft implanted in the abdominal aortic position: their early mortality was 6% (2 patients), and the 5-year actuarial survival rate for this group has been 79%. There were no instances of renal failure, ischemic complication, postoperative paraplegia, pseudoaneurysm, or anastomotic true aneurysm. Our recent efforts have been directed toward developing an adjustable spool that can adapt to the widest aorta or the narrowest aortic arch vessel; but in the meanwhile, the present sutureless graft yields shorter cross-clamp times, fewer intraoperative complications, and both early and late results as satisfactory as those afforded by traditional methods of aortic repair. (Texas Heart Institute Journal 1990; 17:302-9) Images PMID:15227522

Early Results of the PETTICOAT Technique for the Management of Acute Type A Aortic Dissection

PubMed Central

Kotha, Vamshi Krishna; Pozeg, Zlatko I.; Herget, Eric J.; Moon, Michael C.; Appoo, Jehangir J.

2017-01-01

Conventional surgical techniques for acute Type A aortic dissection (ATAAD) generally fail to address residual dissection in the descending aorta. The persistence of a false lumen is associated with visceral malperfusion in the acute setting and adverse aortic remodeling in the chronic setting. Hybrid aortic arch repair techniques may improve perioperative and long-term mortality by expanding the true lumen and obliterating the false lumen. However, there is a limit to the extent of aortic coverage due to the concomitant risk of spinal cord ischemia. In Type B dissection, the PETTICOAT (Provisional Extension To Induce Complete Attachment) technique, which entails stent graft coverage of the primary intimal tear followed by bare metal stent placement distally, may improve true lumen caliber and promote false lumen thrombosis without increasing the risk of spinal cord ischemia, as intercostal branches remain perfused through the bare metal stents. The technique of hybrid arch with surgical creation of a Dacron landing zone covering a stent graft in the proximal descending aorta and bare metal stents in the thoraco-abdominal aorta is a promising concept in the treatment of ATAAD. PMID:29657948

Haemodynamical stress in mouse aortic arch with atherosclerotic plaques: Preliminary study of plaque progression

PubMed Central

Assemat, P.; Siu, K.K.; Armitage, J.A.; Hokke, S.N.; Dart, A.; Chin-Dusting, J.; Hourigan, K.

2014-01-01

Atherosclerotic plaques develop at particular sites in the arterial tree, and this regional localisation depends largely on haemodynamic parameters (such as wall shear stress; WSS) as described in the literature. Plaque rupture can result in heart attack or stroke and hence understanding the development and vulnerability of atherosclerotic plaques is critically important. The purpose of this study is to characterise the haemodynamics of blood flow in the mouse aortic arch using numerical modelling. The geometries are digitalised from synchrotron imaging and realistic pulsatile blood flow is considered under rigid wall assumptions. Two cases are considered; arteries with and without plaque. Mice that are fed under fat diet present plaques in the aortic arch whose size is dependent on the number of weeks under the diet. The plaque distribution in the region is however relatively constant through the different samples. This result underlines the influence of the geometry and consequently of the wall shear stresses for plaque formation with plaques growing in region of relative low shear stresses. A discussion of the flow field in real geometry in the presence and absence of plaques is conducted. The presence of plaques was shown to alter the blood flow and hence WSS distribution, with regions of localised high WSS, mainly on the wall of the brachiocephalic artery where luminal narrowing is most pronounced. In addition, arch plaques are shown to induce recirculation in the blood flow, a phenomenon with potential influence on the progression of the plaques. The oscillatory shear index and the relative residence time have been calculated on the geometry with plaques to show the presence of this recirculation in the arch, an approach that may be useful for future studies on plaque progression. PMID:25349678

Retrograde and antegrade cerebral perfusion: results in short elective arch reconstructive times.

PubMed

Milewski, Rita Karianna; Pacini, Davide; Moser, G William; Moeller, Patrick; Cowie, Doreen; Szeto, Wilson Y; Woo, Y Joseph; Desai, Nimesh; Di Marco, Luca; Pochettino, Alberto; Di Bartolomeo, Roberto; Bavaria, Joseph E

2010-05-01

Debate remains regarding optimal cerebral circulatory management during relatively noncomplex, short arch reconstructive times. Both retrograde cerebral perfusion with deep hypothermic circulatory arrest (RCP/DHCA) and antegrade cerebral perfusion with moderate hypothermic circulatory arrest (ACP/MHCA) have emerged as established techniques. The aim of the study was to evaluate perioperative outcomes between antegrade and retrograde cerebral perfusion techniques for elective arch reconstruction times less than 45 minutes. Between 1997 and September 2008, 776 cases from two institutions were reviewed to compare RCP/DHCA and ACP/MHCA perfusion techniques. At the University of Pennsylvania, 682 were treated utilizing RCP/DHCA cerebral protection. At the University of Bologna, 94 were treated with ACP/MHCA and bilateral cerebral perfusion. Mean cerebral ischemic time and visceral ischemic time differed between RCP/DHCA and ACP/MHCA (p < 0.001). Multivariate analysis showed age more than 65 years, atherosclerotic aneurysm, and cross-clamp time as predictors of the composite endpoint of mortality, neurologic event, and acute myocardial infarction. There was no significant difference in permanent neurologic deficit, temporary neurologic dysfunction, or renal failure, between RCP/DHCA and ACP/MHCA. Mortality was comparable across both techniques. Both RCP/DHCA and ACP/MHCA have emerged as effective techniques for selected aortic arch operations with low morbidity and mortality. Univariate analysis revealed no statistically significant differences in primary or secondary outcomes between techniques for aortic reconstruction times less than 45 minutes. Data from this study demonstrate that selective use of either RCP/DHCA or ACP/MHCA provides excellent cerebral and visceral outcomes for elective open aortic surgery with short arch reconstructive times. Copyright (c) 2010 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Dynamics of the aortic arch submitted to a shock loading: Parametric study with fluid-structure models.

PubMed

El Baroudi, A; Razafimahery, F; Rakotomanana, L

2012-01-01

This work aims to present some fluid-structure models for analyzing the dynamics of the aorta during a brusque loading. Indeed, various lesions may appear at the aortic arch during car crash or other accident such as brusque falling. Aortic stresses evolution are simulated during the shock at the cross section and along the aorta. One hot question was that if a brusque deceleration can generate tissue tearing, or a shock is necessary to provoke such a damage. Different constitutive laws of blood are then tested whereas the aorta is assumed linear and elastic. The overall shock model is inspired from an experimental jig. We show that the viscosity has strong influence on the stress and parietal moments and forces. The nonlinear viscosity has no significant additional effects for healthy aorta, but modifies the stress and parietal loadings for the stenotic aorta.

Use of 3D printer technology to facilitate surgical correction of a complex vascular anomaly with esophageal entrapment in a dog.

PubMed

Dundie, A; Hayes, G; Scrivani, P; Campoy, L; Fletcher, D; Ash, K; Oxford, E; Moïse, N S

2017-04-01

A 10 week old female intact Staffordshire terrier was presented with a total of five congenital cardio-thoracic vascular anomalies consisting of a patent ductus arteriosus (PDA) with an aneurysmic dilation, pulmonic stenosis, persistent right aortic arch, aberrant left subclavian artery and persistent left cranial vena cava. These abnormalities were identified with a combination of echocardiogram and computed tomography angiography (CTA). The abnormalities were associated with esophageal entrapment, regurgitation, and volume overload of the left heart with left atrial and ventricular enlargement. A 2 cm diameter aneurysmic dilation at the junction of the PDA, right aortic arch and aberrant left subclavian artery presented an unusual surgical challenge and precluded simple circumferential ligation and transection of the structure. A full scale three dimensional model of the heart and vasculature was constructed from the CTA and plasma sterilized. The model was used preoperatively to facilitate surgical planning and enhance intraoperative communication and coordination between the surgical and anesthesia teams. Intraoperatively the model facilitated spatial orientation, atraumatic vascular dissection, instrument sizing and positioning. A thoracoabdominal stapler was used to close the PDA aneurysm prior to transection. At the four-month postoperative follow-up the patient was doing well. This is the first reported application of new imaging and modeling technology to enhance surgical planning when approaching correction of complex cardiovascular anomalies in a dog. Copyright © 2016 Elsevier B.V. All rights reserved.

DOE Office of Scientific and Technical Information (OSTI.GOV)

Patel, Rakesh P., E-mail: rpatel9@nhs.net; Katsargyris, Athanasios, E-mail: kthanassos@yahoo.com; Verhoeven, Eric L. G., E-mail: Eric.Verhoeven@klinikum-nuernberg.de

The chimney technique in endovascular aortic aneurysm repair (Ch-EVAR) involves placement of a stent or stent-graft parallel to the main aortic stent-graft to extend the proximal or distal sealing zone while maintaining side branch patency. Ch-EVAR can facilitate endovascular repair of juxtarenal and aortic arch pathology using available standard aortic stent-grafts, therefore, eliminating the manufacturing delays required for customised fenestrated and branched stent-grafts. Several case series have demonstrated the feasibility of Ch-EVAR both in acute and elective cases with good early results. This review discusses indications, technique, and the current available clinical data on Ch-EVAR.

A Salmon Protein Hydrolysate Exerts Lipid-Independent Anti-Atherosclerotic Activity in ApoE-Deficient Mice

PubMed Central

Busnelli, Marco; Bjørndal, Bodil; Holm, Sverre; Brattelid, Trond; Manzini, Stefano; Ganzetti, Giulia S.; Dellera, Federica; Halvorsen, Bente; Aukrust, Pål; Sirtori, Cesare R.; Nordrehaug, Jan E.; Skorve, Jon; Berge, Rolf K.; Chiesa, Giulia

2014-01-01

Fish consumption is considered health beneficial as it decreases cardiovascular disease (CVD)-risk through effects on plasma lipids and inflammation. We investigated a salmon protein hydrolysate (SPH) that is hypothesized to influence lipid metabolism and to have anti-atherosclerotic and anti-inflammatory properties. 24 female apolipoprotein (apo) E−/− mice were divided into two groups and fed a high-fat diet with or without 5% (w/w) SPH for 12 weeks. The atherosclerotic plaque area in aortic sinus and arch, plasma lipid profile, fatty acid composition, hepatic enzyme activities and gene expression were determined. A significantly reduced atherosclerotic plaque area in the aortic arch and aortic sinus was found in the 12 apoE−/− mice fed 5% SPH for 12 weeks compared to the 12 casein-fed control mice. Immunohistochemical characterization of atherosclerotic lesions in aortic sinus displayed no differences in plaque composition between mice fed SPH compared to controls. However, reduced mRNA level of Icam1 in the aortic arch was found. The plasma content of arachidonic acid (C20∶4n-6) and oleic acid (C18∶1n-9) were increased and decreased, respectively. SPH-feeding decreased the plasma concentration of IL-1β, IL-6, TNF-α and GM-CSF, whereas plasma cholesterol and triacylglycerols (TAG) were unchanged, accompanied by unchanged mitochondrial fatty acid oxidation and acyl-CoA:cholesterol acyltransferase (ACAT)-activity. These data show that a 5% (w/w) SPH diet reduces atherosclerosis in apoE−/− mice and attenuate risk factors related to atherosclerotic disorders by acting both at vascular and systemic levels, and not directly related to changes in plasma lipids or fatty acids. PMID:24840793

Effect of Outflow Graft Size on Flow in the Aortic Arch and Cerebral Blood Flow in Continuous Flow Pumps: Possible Relevance to Strokes.

PubMed

Bhat, Sindhoor; Mathew, Jayakala; Balakrishnan, Komrakshi R; Krishna Kumar, Ramarathnam

One of the most devastating complications of continuous flow left ventricular devices (CFLVADS) is stroke, with a higher incidence in HeartWare Ventricular Assist Device (HVAD) as compared with HEARTMATE II. The reason for the observed difference in stroke rates is unclear. Because outflow graft diameters are different, we hypothesized that this could contribute to the difference in stroke rates. A computational fluid-structure interaction model was created from the computed tomography (CT) scan of a patient. Pressures were used as the boundary condition and the flow through the cerebral vessels was derived as outputs. Flow into the innominate artery was very sensitive to the anastomosis angle for a 10 mm as compared with a 14 mm graft, with the net innominate flow severely compromised with a 10 mm graft at 45° angle. Aortic insufficiency seems to affect cerebral blood flow nonlinearly with an 80% decrease at certain angles of outflow graft anastomosis. Arterial return in to the arch through a narrow graft has important jet effects and results in significant flow perturbations in the aortic arch and cerebral vessels and stasis. A 10 mm graft is more sensitive to angle of insertion than a 14 mm graft. Under some conditions, serious hypoperfusion of the innominate artery is possible. Aortic incompetence results in significant decrease of cerebral blood flow. No stasis was found in the pulsatile flow compared with LVAD flow.

An alternative method for neonatal cerebro-myocardial perfusion

PubMed Central

Luciani, Giovanni Battista; De Rita, Fabrizio; Faggian, Giuseppe; Mazzucco, Alessandro

2012-01-01

Several techniques have already been described for selective cerebral perfusion during repair of aortic arch pathology in children. One method combining cerebral with myocardial perfusion has also been proposed. A novel technique is reported here for selective and independent cerebro-myocardial perfusion for neonatal and infant arch surgery. Technical aspects and potential advantages are discussed. PMID:22307393

Incidence and Risk Factors for Right Ventricular Outflow Tract Obstruction after the Arterial Switch Operation.

PubMed

Cleuziou, Julie; Vitanova, Keti; Pabst von Ohain, Jelena; Ono, Masamichi; Tanase, Daniel; Burri, Melchior; Lange, Rüdiger

2018-05-01

 The aim of this study was to evaluate the incidence and risk factors for the development of right ventricular outflow tract obstruction (RVOTO) after the arterial switch operation (ASO).  Between 1983 and 2014, a total of 688 patients underwent ASO. RVOTO was defined as any obstruction of the right ventricular outflow tract (RVOT) requiring reintervention.  RVOTO developed in 79 patients (11%) at a median time of 3.8 years (range, 1 day-23.6 years) after ASO. Freedom from RVOT reintervention was 96 ± 1, 89 ± 1, and 83 ± 2% at 1, 10, and 25 years, respectively. Independent risk factors for the development of RVOTO in a Cox's regression model were side-by-side great arteries ( p  < 0.001), aortic arch anomalies ( p  < 0.001), use of a pericardial patch for augmentation of the coronary buttons ( p  < 0.001), and a peak gradient more than 20 mm Hg over the RVOT at discharge ( p  < 0.001).  The incidence of RVOTO after ASO is not negligible. Complex morphology, such as side-by-side great arteries and aortic arch anomalies influences the development of RVOTO. Georg Thieme Verlag KG Stuttgart · New York.

Endovascular aortic aneurysm repair with chimney and snorkel grafts: indications, techniques and results.

PubMed

Patel, Rakesh P; Katsargyris, Athanasios; Verhoeven, Eric L G; Adam, Donald J; Hardman, John A

2013-12-01

The chimney technique in endovascular aortic aneurysm repair (Ch-EVAR) involves placement of a stent or stent-graft parallel to the main aortic stent-graft to extend the proximal or distal sealing zone while maintaining side branch patency. Ch-EVAR can facilitate endovascular repair of juxtarenal and aortic arch pathology using available standard aortic stent-grafts, therefore, eliminating the manufacturing delays required for customised fenestrated and branched stent-grafts. Several case series have demonstrated the feasibility of Ch-EVAR both in acute and elective cases with good early results. This review discusses indications, technique, and the current available clinical data on Ch-EVAR.

Computational models of aortic coarctation in hypoplastic left heart syndrome: considerations on validation of a detailed 3D model.

PubMed

Biglino, Giovanni; Corsini, Chiara; Schievano, Silvia; Dubini, Gabriele; Giardini, Alessandro; Hsia, Tain-Yen; Pennati, Giancarlo; Taylor, Andrew M

2014-05-01

Reliability of computational models for cardiovascular investigations strongly depends on their validation against physical data. This study aims to experimentally validate a computational model of complex congenital heart disease (i.e., surgically palliated hypoplastic left heart syndrome with aortic coarctation) thus demonstrating that hemodynamic information can be reliably extrapolated from the model for clinically meaningful investigations. A patient-specific aortic arch model was tested in a mock circulatory system and the same flow conditions were re-created in silico, by setting an appropriate lumped parameter network (LPN) attached to the same three-dimensional (3D) aortic model (i.e., multi-scale approach). The model included a modified Blalock-Taussig shunt and coarctation of the aorta. Different flow regimes were tested as well as the impact of uncertainty in viscosity. Computational flow and pressure results were in good agreement with the experimental signals, both qualitatively, in terms of the shape of the waveforms, and quantitatively (mean aortic pressure 62.3 vs. 65.1 mmHg, 4.8% difference; mean aortic flow 28.0 vs. 28.4% inlet flow, 1.4% difference; coarctation pressure drop 30.0 vs. 33.5 mmHg, 10.4% difference), proving the reliability of the numerical approach. It was observed that substantial changes in fluid viscosity or using a turbulent model in the numerical simulations did not significantly affect flows and pressures of the investigated physiology. Results highlighted how the non-linear fluid dynamic phenomena occurring in vitro must be properly described to ensure satisfactory agreement. This study presents methodological considerations for using experimental data to preliminarily set up a computational model, and then simulate a complex congenital physiology using a multi-scale approach.

Biomechanical properties of the Marfan's aortic root and ascending aorta before and after personalised external aortic root support surgery.

PubMed

Singh, S D; Xu, X Y; Pepper, J R; Treasure, T; Mohiaddin, R H

2015-08-01

Marfan syndrome is an inherited systemic connective tissue disease which may lead to aortic root disease causing dilatation, dissection and rupture of the aorta. The standard treatment is a major operation involving either an artificial valve and aorta or a complex valve repair. More recently, a personalised external aortic root support (PEARS) has been used to strengthen the aorta at an earlier stage of the disease avoiding risk of both rupture and major surgery. The aim of this study was to compare the stress and strain fields of the Marfan aortic root and ascending aorta before and after insertion of PEARS in order to understand its biomechanical implications. Finite element (FE) models were developed using patient-specific aortic geometries reconstructed from pre and post-PEARS magnetic resonance images in three Marfan patients. For the post-PEARS model, two scenarios were investigated-a bilayer model where PEARS and the aortic wall were treated as separate layers, and a single-layer model where PEARS was incorporated into the aortic wall. The wall and PEARS materials were assumed to be isotropic, incompressible and linearly elastic. A static load on the inner wall corresponding to the patients' pulse pressure was applied. Results from our FE models with patient-specific geometries show that peak aortic stresses and displacements before PEARS were located at the sinuses of Valsalva but following PEARS surgery, these peak values were shifted to the aortic arch, particularly at the interface between the supported and unsupported aorta. Further studies are required to assess the statistical significance of these findings and how PEARS compares with the standard treatment. Copyright © 2015 IPEM. Published by Elsevier Ltd. All rights reserved.

Ischemic stroke risk reduction following cardiac surgery by carotid compression

NASA Astrophysics Data System (ADS)

Isingoma, Paul

Every year over 500,000 cardiovascular procedures requiring cardiopulmonary bypass (CPB) are performed in the United States. CPB is a technique that temporarily takes over the function of the heart and lungs during surgery, maintaining the circulation of blood and the oxygen content of the body. During CPB, an aortic cross-clamp is used to clamp the aorta and separate the systemic circulation from the outflow of the heart. Unfortunately, these procedures have been found to cause most cerebral emboli, which produce clinical, subclinical and silent neurologic injuries. Many clinical neurologic injuries occur in the postoperative period, with over 20% of the clinical strokes occurring during this period. In this study, we focus on visualizing the flow distribution in the aortic arch, the effect of carotid compression and the influence of compression time and MAP during CPB on reducing cerebral emboli. Experiments are performed with an aortic arch model in a mock cardiovascular system. Fluorescent particles are used to simulate emboli that are released into circulation immediately after carotid compression. The LVAD is used as the pump to produce flow in the system by gradually adjusting the speed to maintain desired clinical conditions. Aortic and proximal branches MAP of 65.0 +/- 5.0 mmHg (normal MAP) or 95.0 +/- 5.0 mmHg (high MAP), aortic flow of 4.0 +/- 0.5 L/min, and all branches flow (left and right carotids, and subclavian arteries) of 10% of the aortic flow. Flow distribution of particles is visualized using LaVision's DaVis imaging software and analyzed using imagej's particle analysis tool to track, count, and record particle properties from the aortic arch. Carotid compression for 10-20 seconds reduces the number of particles entering the carotid arteries by over 73% at normal MAP, and by over 85% at high MAP. A higher MAP resulted in fewer particles entering the branching vessels both at baseline and during occlusion conditions. A compression duration of 20s does not result in greater particle reduction than one of 10s. Our results demonstrate that brief compression of the common carotid arteries during an embolic shower can reduce the number of dangerous emboli by over 85%.

Stenting of the ascending aorta revisited.

PubMed

Moiduddin, Nasser J; Rios, Rodrigo; El-Said, Howaida; Moore, John W

2017-10-01

Despite few institutions stenting the ascending aorta, it has been discouraged because of the proximity of the aortic valve, the coronary artery orifices, and the aortic arch branches. We describe a small case series of patients having acquired stenosis of the ascending that was relieved successfully by stenting. © 2017 Wiley Periodicals, Inc. © 2017 Wiley Periodicals, Inc.

Similar cerebral protective effectiveness of antegrade and retrograde cerebral perfusion combined with deep hypothermia circulatory arrest in aortic arch surgery: a meta-analysis and systematic review of 5060 patients.

PubMed

Hu, Zhipeng; Wang, Zhiwei; Ren, Zongli; Wu, Hongbing; Zhang, Min; Zhang, Hao; Hu, Xiaoping

2014-08-01

Our objective was to determine if antegrade cerebral perfusion (ACP) and retrograde cerebral perfusion (RCP) combined with deep hypothermia circulatory arrest in aortic arch surgery results in different mortality and neurologic outcomes. The Cochrane Library, Medline, EMBASE, CINAHL, Web of Science, and the Chinese Biomedical Database were searched for studies reporting on postoperative strokes, permanent neurologic dysfunction, temporary neurologic dysfunction, and all causes mortality within 30 days postoperation in aortic arch surgery. Meta-analysis for effect size, t test, and I(2) for detecting heterogeneity and sensitivity analysis for assessing the relative influence of each study was performed. Fifteen included studies encompassed a total of 5060 patients of whom 2855 were treated with deep hypothermic circulatory arrest plus ACP and 1897 were treated with deep hypothermic circulatory arrest plus RCP. Pooled analysis showed no significant statistical difference (P > .01) of 30-day mortality, permanent neurologic dysfunction, and transient neurologic dysfunction in the 2 groups. Before sensitivity analysis, postoperative stroke incidence in the ACP group was higher than in the RCP group (7.2% vs 4.7%; P < .01). After a study that included a different percentage of patients with a history of central neurologic events in the 2 groups was ruled out, postoperative stroke incidence in the 2 groups also showed no significant statistical difference (P > .01). ACP and RCP provide similar cerebral protective effectiveness combined with deep hypothermia circulatory arrest and could be selected according to the actual condition in aortic arch surgery. A high-quality randomized controlled trial is urgently needed to confirm this conclusion, especially for stroke morbidity following ACP or RCP. Copyright © 2014 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.

Prenatal diagnosis of prevalence of the right heart: associated anomalies and outcome predictors.

PubMed

Peng, Ruan; Xie, Hong-Ning; Zhu, Yun-Xiao; Li, Li-Juan; Du, Liu; Zheng, Ju

2014-07-01

To analyze the characteristics, associations, and outcomes of prevalence of the right heart and to evaluate the use of sonography to predict the risk of a poor prognosis in fetuses with this condition. We conducted a retrospective cohort study of 182 fetuses with prevalence of the right heart. At the initial evaluation, the left ventricle (LV) and right ventricle (RV) sizes, left atrium and right atrium sizes, great artery diameters, appearance of the aortic arch and ductus arteriosus arch, and flow direction across the foramen ovale and aortic arch were documented. Malformations were documented in fetuses with intracardiac anomalies, who were divided into groups with and without coexisting extracardiac defects. The RV-LV diameter ratio and main pulmonary artery-to-aortic root diameter ratio were calculated and compared. The following variables were analyzed: coexisting intracardiac anomalies, associated extracardiac anomalies, diagnosis before 24 gestational weeks, fetal growth restriction, reversed flow across the foramen ovale, reversed flow in the aortic arch, and RV-LV ratio greater than 2.0. Relationships between these sonographic findings and the prognosis were evaluated by multivariable logistic regression. Of the 182 fetuses, 1 (0.5%) had intrauterine death, and 25 (13.7%) had neonatal death; 1 (0.5%) had selective reduction, and 106 (58.2%) underwent termination of pregnancy; 49 (26.9%) survived at this writing. The mean RV-LV ratio was 1.67. Multivariable logistic regression revealed that only 2 sonographic parameters, coexisting intracardiac anomalies (odds ratio, 17.75; 95% confidence interval, 4.18-75.26) and diagnosis before 24 weeks (odds ratio, 17.26; 95% confidence interval, 1.80-165.39) were significantly associated with a poor prognosis. The sonographic parameters of coexisting intracardiac anomalies and diagnosis before 24 gestational weeks are significant independent predictors of a poor prognosis in fetuses with prevalence of the right heart. Combinations of these risk factors may be useful in prenatal consultation. © 2014 by the American Institute of Ultrasound in Medicine.

[Clinical application of retrograde cerebral perfusion for brain protection during the surgery of ascending aortic aneurysm: 50 cases report].

PubMed

Dong, Pei-qing; Guan, Yu-long; He, Mei-ling; Yang, Jing; Wan, Cai-hong; Du, Shun-ping

2003-02-01

To assess retrospectively the effects of different protective methods on brain in ascending aortic aneurysm surgery. In 65 patients, aneurysm was dissected to the aortic arch or right arch. To protect brain, deep hypothermic circulatory arrest (DHCA) combined with retrograde cerebral perfusion (RCP) through the superior vena cava (n = 50) and simple DHCA (n = 15) were used during the procedure. Blood samples for lactic acid level from the jugular vein were compared in both groups at different phase, and perfusion blood distribution and oxygen content difference between the perfused and returned blood were measured in some RCP patients. The DHCA time was 35.9 +/- 18.8 min (10.0 - 63.0 min) and DHCA + RCP time was 45.5 +/- 17.2 min (16.0 - 81.0 min). The resuscitation time was 7.1 +/- 1.6 h (4.4 - 9.4 h) in DHCA patients and 5.4 +/- 2.2 h (2.0 - 9.0 h) in RCP patients. Operation death was 3/15 in the DHCA group and 1/50 in the RCP patients. Central nervous complication existed in 3/12 of DHCA patients and 1/49 of RCP patients (P < 0.01). The overall survival rate was 96% (RCP) vs 67% (DHCA), central nervous system dysfunction was 20% in DHCA vs 2% in RCP (P < 0.01). The blood lactic acid level increased significantly after reperfusion in DHCA than in RCP. The blood distribution measurement approximated to 20% of the perfused blood returned from arch vessels. Oxygen content between perfused and returned blood showed that oxygen uptake was adequate in the RCP group. The application of RCP could prolong the safety duration of circulation arrest. Cerebral perfusion may reep the brain cool and flush out particulate and air embolism. Open anastomosis of the aortic arch to the prosthesis can be safely performed. RCP is acceptable for brain protection in clinical practice.

Whole body perfusion strategy for aortic arch repair under moderate hypothermia.

PubMed

Tarola, Christopher L; Losenno, Katie L; Gelinas, Jill J; Jones, Philip M; Fernandes, Philip; Fox, Stephanie A; Kiaii, Bob; Chu, Michael W A

2018-05-01

Aortic arch reconstruction under moderate hypothermia is commonly performed with antegrade cerebral perfusion (ACP) for brain protection; however, hypothermia alone is often solely relied upon for visceral and lower body protection. We investigated whether the addition of simultaneous lower body perfusion to ACP (whole body perfusion - WBP) may ameliorate the metabolic derangements of moderate hypothermic circulatory arrest (MHCA). Between 2008 and 2014, 106 consecutive patients underwent elective or emergent aortic arch surgery with MHCA, with either ACP only (44 patients, 66±12 years, 30% female) or WBP (62 patients, 61±15 years, 31% female). Primary outcomes included 30-day/in-hospital mortality, intensive care unit (ICU) and hospital lengths of stay (LOS) and specific parameters of metabolic recovery. There were no significant differences between the groups in 30-day/in-hospital mortality (ACP: 3 (6.8%), WBP: 2 (3.2%); p=0.65), stroke (ACP: 1 (2.3%), WBP: 1 (1.6%); p=1.0) or renal failure (ACP: 2 (4.5%), WBP: 1 (1.5%); p=0.57). In the WBP group, we identified a significant reduction in lactate level at ICU admission (ACP 5.5 vs. WBP 3.5 mmol/L; p=0.002), time to lactate normalization (p=0.014) and median ICU length-of-stay (ACP 3 vs. WBP 1 days; p=0.049). There was no difference in post-operative creatinine (ACP: 104, WBP: 107 μmol/L; p=0.66). After multivariable regression adjustment, perfusion strategy no longer remained an independent predictor of ICU discharge time (p=0.09), however, cardiopulmonary bypass time (p=0.02), age (p=0.012) and emergent surgery (p=0.02) were. A WBP strategy during aortic arch reconstruction with MHCA may be associated with more rapid normalization of metabolic parameters and reduced ICU length of stay compared to using ACP alone. Further evaluation with a randomized trial is warranted.

Incidence and implication of vocal fold paresis following neonatal cardiac surgery.

PubMed

Dewan, Karuna; Cephus, Constance; Owczarzak, Vicki; Ocampo, Elena

2012-12-01

To study the incidence and implications of vocal fold paresis (VFP) following congenital neonatal cardiac surgery. Retrospective chart review. All neonates who underwent median sternotomy for cardiac surgery from May 2007 to May 2008 were evaluated. Flexible laryngoscopy was performed to evaluate vocal fold function after extubation. Swallow evaluation and a modified barium swallow study were performed prior to initiating oral feeding if the initial screening was abnormal. A total of 101 neonates underwent cardiac surgery during the study period. Ninety-four patients underwent a median sternotomy, and 76 of these were included in the study. Fifteen (19.7%) had vocal fold paresis (VFP) postoperatively. Almost 27% of the patients with aortic arch surgery had VFP while only 4.1% of the patients with nonaortic arch surgery developed VFP (P=0.02) Those patients who underwent aortic arch surgery weighed significantly less (P<0.01). All the patients with VFP had significant morbidity related to swallowing and nutrition (P=0.01) and required longer postsurgical hospitalization (P=0.02). The reported incidence of VFP following cardiac surgery via median sternotomy ranges between 1.7% and 67% depending on the type of surgery and the weight of the infant at the time of surgery. In our cohort, 19.7% had VFP. Surgery requiring aortic arch manipulation had a higher incidence of complications and required longer hospitalizations. These results may be used to improve informed consent and to manage postoperative expectations by identifying patients who are at higher risk for complications. Copyright © 2012 The American Laryngological, Rhinological, and Otological Society, Inc.

[Anesthesia for total and descending aorta replacement and aortic valve replacement for post-repair aneurysm of coarctation of aorta and aortic stenosis].

PubMed

Furuichi, Yuko; Shimizu, Jun; Sakamoto, Atsuhiro

2012-04-01

We experienced anesthesia for total arch and descending aorta replacement and aortic valve replacement for post-repair aneurysm of coarctation of aorta and aortic stenosis. Because there was possibility that post coarctectomy syndrome would occur after repair of coarctation of aorta, administration of depressor that acts on renin-angiotensin-aldosterone and careful observation were needed postoperatively. In consideration of the development of collateral vessels, preoperative imaging evaluation was added and operative method in cardiopulmonary bypass was adjusted. Careful preoperative evaluation is very important in cardiac anesthesia.

Early Results of Chimney Technique for Type B Aortic Dissections Extending to the Aortic Arch

DOE Office of Scientific and Technical Information (OSTI.GOV)

Huang, Chen; Tang, Hanfei; Qiao, Tong

ObjectiveTo summarize our early experience gained from the chimney technique for type B aortic dissection (TBAD) extending to the aortic arch and to evaluate the aortic remodeling in the follow-up period.MethodsFrom September 2011 to July 2014, 27 consecutive TBAD patients without adequate proximal landing zones were retrograde analyzed. Chimney stent-grafts were deployed parallel to the main endografts to reserve flow to branch vessels while extending the landing zones. In the follow-up period, aortic remodeling was observed with computed tomography angiography.ResultsThe technical success rate was 100 %, and endografts were deployed in zone 0 (n = 3, 11.1 %), zone 1 (n = 18, 66.7 %), and zonemore » 2 (n = 6, 22.2 %). Immediately, proximal endoleaks were detected in 5 patients (18.5 %). During a mean follow-up period of 17.6 months, computed tomography angiography showed all the aortic stent-grafts and chimney grafts to be patent. Favorable remodeling was observed at the level of maximum descending aorta and left subclavian artery with expansion of true lumen (from 18.4 ± 4.8 to 25 ± 0.86 mm, p < 0.001 and 27.1 ± 0.62 to 28.5 ± 0.37 mm, p < 0.001) and depressurization of false lumen (from 23.7 ± 2.7 to 8.7 ± 3.8 mm, p < 0.001, from 5.3 ± 1.2 to 2.1 ± 2.1 mm, p < 0.001). While at the level of maximum abdominal aorta, suboptimal remodeling of the total aorta (from 24.1 ± 0.4 to 23.6 ± 1.5 mm, p = 0.06) and true lumen (from 13.8 ± 0.6 to 14.5 ± 0.4 mm, p = 0.08) was observed.ConclusionBased on our limited experience, the chimney technique with thoracic endovascular repair is demonstrated to be promising for TBAD extending to the arch with favorable aortic remodeling.« less

A reappraisal of retrograde cerebral perfusion.

PubMed

Ueda, Yuichi

2013-05-01

Brain protection during aortic arch surgery by perfusing cold oxygenated blood into the superior vena cava was first reported by Lemole et al. In 1990 Ueda and associates first described the routine use of continuous retrograde cerebral perfusion (RCP) in thoracic aortic surgery for the purpose of cerebral protection during the interval of obligatory interruption of anterograde cerebral flow. The beneficial effects of RCP may be its ability to sustain brain hypothermia during hypothermic circulatory arrest (HCA) and removal of embolic material from the arterial circulation of the brain. RCP can offer effective brain protection during HCA for about 40 to 60 minutes. Animal experiments revealed that RCP provided inadequate cerebral perfusion and that neurological recovery was improved with selective antegrade cerebral perfusion (ACP), however, both RCP and ACP provide comparable clinical outcomes regarding both the mortality and stroke rates by risk-adjusted and case-matched comparative study. RCP still remains a valuable adjunct for brain protection during aortic arch repair in particular pathologies and patients.

A reappraisal of retrograde cerebral perfusion

PubMed Central

2013-01-01

Brain protection during aortic arch surgery by perfusing cold oxygenated blood into the superior vena cava was first reported by Lemole et al. In 1990 Ueda and associates first described the routine use of continuous retrograde cerebral perfusion (RCP) in thoracic aortic surgery for the purpose of cerebral protection during the interval of obligatory interruption of anterograde cerebral flow. The beneficial effects of RCP may be its ability to sustain brain hypothermia during hypothermic circulatory arrest (HCA) and removal of embolic material from the arterial circulation of the brain. RCP can offer effective brain protection during HCA for about 40 to 60 minutes. Animal experiments revealed that RCP provided inadequate cerebral perfusion and that neurological recovery was improved with selective antegrade cerebral perfusion (ACP), however, both RCP and ACP provide comparable clinical outcomes regarding both the mortality and stroke rates by risk-adjusted and case-matched comparative study. RCP still remains a valuable adjunct for brain protection during aortic arch repair in particular pathologies and patients. PMID:23977600

Non-Invasive Methods of Cardiovascular Exploration in Aerospace Medicine.

DTIC Science & Technology

1983-12-01

inferior vena cava Aorta right atrium filling chamber of right ventricle. Trunk of pulmonary art cry Posterior border: almost vertical AP lower arch left ... left ventricle. Inferior Vena cava infundihbulum L Upper border aortic arch Lower border superimposed borders of the RV LV right and left ventricles...iliac aneurisms is possible. isotopic phlebography is useful in the investigation of the permeability of the inferior vena cava

Elephant trunk in a small-calibre true lumen for chronic aortic dissection: cause of haemolytic anaemia?

PubMed

Araki, Haruna; Kitamura, Tadashi; Horai, Tetsuya; Shibata, Ko; Miyaji, Kagami

2014-12-01

The elephant trunk technique for aortic dissection is useful for reducing false lumen pressure; however, a folded vascular prosthesis inside the aorta can cause haemolysis. The purpose of this study was to investigate whether an elephant trunk in a small-calibre lumen can cause haemolysis. Inpatient and outpatient records were retrospectively reviewed. Two cases of haemolytic anaemia after aortic surgery using the elephant trunk technique were identified from 2011 to 2013. A 64-year-old man, who underwent graft replacement of the ascending aorta for acute Stanford type A aortic dissection, presented with enlargement of the chronic dissection of the descending aorta and moderate aortic regurgitation. A two-stage surgery was scheduled. Total arch replacement with an elephant trunk in the true lumen and concomitant aortic valve replacement were performed. Postoperatively, he developed severe haemolytic anaemia because of the folded elephant trunk. The anaemia improved after the second surgery, including graft replacement of the descending aorta. Similarly, a 61-year-old man, who underwent total arch replacement for acute Stanford type A aortic dissection, presented with enlargement of the chronic dissection of the descending aorta. Graft replacement of the descending aorta with an elephant trunk inserted into the true lumen was performed. The patient postoperatively developed haemolytic anaemia because of the folded elephant trunk, which improved after additional stent grafting into the elephant trunk. A folded elephant trunk in a small-calibre lumen can cause haemolysis. Therefore, inserting an elephant trunk in a small-calibre true lumen during surgery for chronic aortic dissection should be avoided. © The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Regional and directional compliance of the healthy aorta: an ex vivo study in a porcine model.

PubMed

Krüger, Tobias; Veseli, Kujtim; Lausberg, Henning; Vöhringer, Luise; Schneider, Wilke; Schlensak, Christian

2016-07-01

To gain differential knowledge about the physiological compliance and wall strength of the different regions of the aorta, including the ascending aorta, arch and descending aorta in both the circumferential and longitudinal directions, and to generate a hypothesis on the pathophysiological mechanisms that lead to Type A aortic dissection. Fresh tissue specimens from 22 ex vivo porcine aortas were analysed on a tensile tester. Regional and directional compliance, failure stress and failure strain were recorded. Aortic compliance appeared as a linear function of the natural logarithm (ln) of wall stress. Compliance significantly decreased along the length of the aorta. In the ascending aorta, longitudinal compliance significantly (P = 0.003) exceeded circumferential compliance, and the outer curvature was more compliant than the inner curvature (P = 0.03). In the descending aorta, this relationship is reversed: the circumferential compliance exceeded the longitudinal compliance, and the outer aspect was more compliant (P = 0.003). The median circumferential failure stress of all aortic segments was in the range of 2000-2750 kPa, whereas the longitudinal failure stress in the ascending aorta and the arch had values of 750-1000 kPa, which were significantly lower (P < 0.05). Surprisingly, the longitudinal failure stress of the inner aspect of the descending aorta was extraordinarily high (2000 kPa). Failure strain, similar to compliance, was highest in the ascending aorta and decreased along the aorta. The aorta appears to be a complex organ with distinct regional and directional differences in compliance and wall strength that is designed to effectively absorb the kinetic energy of cardiac systole and to cushion the momentum of systolic impact. Under normotensive conditions and a preconditioned physiological morphology, the aortic wall works in the steep part of the logarithmic strain-stress function; under hypertensive conditions and pathological morphology, the wall reacts in an non-compliant manner. The high longitudinal compliance and low failure stress of the ascending aorta and subsequent pathological changes may be the main determinants of the recurrent patho-anatomy of Type A aortic dissection. © The Author 2016. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Regional and directional compliance of the healthy aorta: an ex vivo study in a porcine model†

PubMed Central

Krüger, Tobias; Veseli, Kujtim; Lausberg, Henning; Vöhringer, Luise; Schneider, Wilke; Schlensak, Christian

2016-01-01

OBJECTIVES To gain differential knowledge about the physiological compliance and wall strength of the different regions of the aorta, including the ascending aorta, arch and descending aorta in both the circumferential and longitudinal directions, and to generate a hypothesis on the pathophysiological mechanisms that lead to Type A aortic dissection. METHODS Fresh tissue specimens from 22 ex vivo porcine aortas were analysed on a tensile tester. Regional and directional compliance, failure stress and failure strain were recorded. RESULTS Aortic compliance appeared as a linear function of the natural logarithm (ln) of wall stress. Compliance significantly decreased along the length of the aorta. In the ascending aorta, longitudinal compliance significantly (P = 0.003) exceeded circumferential compliance, and the outer curvature was more compliant than the inner curvature (P = 0.03). In the descending aorta, this relationship is reversed: the circumferential compliance exceeded the longitudinal compliance, and the outer aspect was more compliant (P = 0.003). The median circumferential failure stress of all aortic segments was in the range of 2000–2750 kPa, whereas the longitudinal failure stress in the ascending aorta and the arch had values of 750–1000 kPa, which were significantly lower (P < 0.05). Surprisingly, the longitudinal failure stress of the inner aspect of the descending aorta was extraordinarily high (2000 kPa). Failure strain, similar to compliance, was highest in the ascending aorta and decreased along the aorta. CONCLUSION The aorta appears to be a complex organ with distinct regional and directional differences in compliance and wall strength that is designed to effectively absorb the kinetic energy of cardiac systole and to cushion the momentum of systolic impact. Under normotensive conditions and a preconditioned physiological morphology, the aortic wall works in the steep part of the logarithmic strain–stress function; under hypertensive conditions and pathological morphology, the wall reacts in an non-compliant manner. The high longitudinal compliance and low failure stress of the ascending aorta and subsequent pathological changes may be the main determinants of the recurrent patho-anatomy of Type A aortic dissection. PMID:26993474

Experience with the conventional and frozen elephant trunk techniques: a single-centre study.

PubMed

Leontyev, Sergey; Borger, Michael A; Etz, Christian D; Moz, Monica; Seeburger, Joerg; Bakhtiary, Farhard; Misfeld, Martin; Mohr, Friedrich W

2013-12-01

The treatment of patients with extensive thoracic aortic disease involving the arch and descending/thoracoabdominal aorta is often performed using an elephant trunk procedure. We retrospectively analysed our results comparing two different techniques: the conventional elephant trunk (cET) and the frozen elephant trunk (FET) operation. Between January 2003 and December 2011, 171 consecutive patients underwent total aortic arch replacement with either a cET (n = 125) or FET (n = 46) technique. The mean age was 64 ± 13 years and was significantly higher in the FET group (P < 0.01). Acute Type A aortic dissection was the indication for surgery in 53.6% of cET and 17.4% of FET patients, and degenerative or atherosclerotic aneurysm accounted for 33.6% of cET and 58.7% of FET patients. The remaining patients were operated on for chronic Type A or acute or chronic Type B dissections with arch involvement. In-hospital mortality was 21.6 vs 8.7% for cET and FET patients, respectively (P = 0.1). Logistic regression analysis revealed Type A aortic dissection (odds ratio (OR) 3.1, P = 0.01) as the only independent predictor of hospital mortality. Stroke occurred in 16 vs 13% of cET vs FET patients (P = 0.4). Type A aortic dissection was an independent predictor of stroke by multivariable analysis (OR 2.6, P = 0.03), and axillary arterial cannulation was protective against stroke (OR 0.4, P = 0.04). The occurrence of new-onset paraplegia was significantly higher in the FET group (21.7 vs 4.0%, P < 0.001), and aortic repair with the FET technique was an independent predictor for paraplegia (OR 6.6, P = 0.001). Among patients receiving FET, a body core temperature during circulatory arrest of ≥ 28 °C in combination with a prolonged circulatory arrest time of >40 min was an independent predictor for permanent spinal cord injury (OR 5.0, 95% CI 1.1-20, P = 0.038). The estimated 1-, 3- and 5-year survival were 70 ± 4, 70 ± 4 and 68 ± 4% (cET) and 4 ± 7 and 60 ± 9, 40 ± 1% (FET), with mean survival time 5.2 ± 0.3 vs 3.8 ± 0.5 years (cET vs FET, log-rank P = 0.9). The FET procedure for extensive thoracic aortic disease is associated with an acceptable mortality rate, but with a higher incidence of perioperative spinal cord injury than cET. Arch replacement with a cET technique should be strongly considered in patients with expected prolonged circulatory arrest times, particularly if operated on under mild or moderate hypothermia. Axillary cannulation is associated with superior neurological outcomes and Type A acute aortic dissection is a risk factor for mortality and poor neurological outcomes in this patient population.

Baroreflex dysfunction induced by microgravity: potential relevance to postflight orthostatic intolerance

NASA Technical Reports Server (NTRS)

Ertl, A. C.; Diedrich, A.; Biaggioni, I.; Robertson, D. (Principal Investigator)

2000-01-01

Microgravity imposes adaptive changes in the human body. This review focuses on the changes in baroreflex function produced by actual spaceflight, or by experimental models that simulate microgravity, e.g., bed rest. We will analyze separately studies involving baroreflexes arising from carotid sinus and aortic arch afferents ("high-pressure baroreceptors"), and cardiopulmonary afferents ("low-pressure receptors"). Studies from unrelated laboratories using different techniques have concluded that actual or simulated exposure to microgravity reduces baroreflex function arising from carotid sinus afferents ("carotic-cardiac baroreflex"). The techniques used to study the carotid-cardiac baroreflex, using neck suction and compression to simulate changes in blood pressure, have been extensively validated. In contrast, it is more difficult to selectively study aortic arch or cardiopulmonary baroreceptors. Nonetheless, studies that have examined these baroreceptors suggest that microgravity produces the opposite effect, ie, an increase in the gain of aortic arch and cardiopulmonary baroreflexes. Furthermore, most studies have focus on instantaneous changes in heart rate, which almost exclusively examines the vagal limb of the baroreflex. In comparison, there is limited information about the effect of microgravity on sympathetic function. A substantial proportion of subjects exposed to microgravity develop transient orthostatic intolerance. It has been proposed that alterations in baroreflex function play a role in the orthostatic intolerance induced by microgravity. The evidence in favor and against this hypothesis is reviewed.

Pressure waves in the aorta during isolated abdominal belt loading: the magnitude, phasing, and attenuation.

PubMed

Arregui-Dalmases, C; Del Pozo, E; Stacey, S; Kindig, M; Lessley, D; Lopez-Valdes, F; Forman, J; Kent, R

2011-07-01

While rupture of the aorta is a leading cause of sudden death following motor vehicle crashes, the specific mechanism that causes this injury is not currently well understood. Aortic ruptures occurring in the field are likely due to a complex combination of contributing factors such as acceleration, compression of the chest, and increased pressure within the aorta. The objective of the current study was to investigate one of these factors in more detail than has been done previously; specifically, to investigate the in situ intra-aortic pressure generated during isolated belt loading to the abdomen. Ten juvenile swine were subjected to dynamic belt loads applied to the abdomen. Intraaortic pressure was measured at multiple locations to assess the magnitude and propagation of the resulting blood pressure wave. The greatest average peak pressure (113.6 +/- 43.5 kPa) was measured in the abdominal aorta. Pressures measured in the thoracic aorta and aortic arch were 70 per cent and 50 per cent, respectively, that measured in the abdominal aorta. No macroscopic aortic trauma was observed. To the authors' knowledge the present study is the first one to document the presence, propagation, and attenuation of a transient pressure wave in the aorta generated by abdominal belt loading. The superiorly moving wave is sufficient to generate hydrostatic and intimal shear stress in the aorta, possibly contributing to the hypothesized mechanisms of traumatic aortic rupture.

Detection of atherosclerotic plaques in ApoE-deficient mice using (99m)Tc-duramycin.

PubMed

Liu, Zhonglin; Larsen, Brandon T; Lerman, Lilach O; Gray, Brian D; Barber, Christy; Hedayat, Ahmad F; Zhao, Ming; Furenlid, Lars R; Pak, Koon Y; Woolfenden, James M

2016-08-01

Apoptosis of macrophages and smooth muscle cells is linked to atherosclerotic plaque destabilization. The apoptotic cascade leads to exposure of phosphatidylethanolamine (PE) on the outer leaflet of the cell membrane, thereby making apoptosis detectable using probes targeting PE. The objective of this study was to exploit capabilities of a PE-specific imaging probe, (99m)Tc-duramycin, in localizing atherosclerotic plaque and assessing plaque evolution in apolipoprotein-E knockout (ApoE(-/-)) mice. Atherosclerosis was induced in ApoE(-/-) mice by feeding an atherogenic diet. (99m)Tc-duramycin images were acquired using a small-animal SPECT imager. Six ApoE(-/-) mice at 20weeks of age (Group I) were imaged and then sacrificed for ex vivo analyses. Six additional ApoE(-/-) mice (Group II) were imaged at 20 and 40weeks of age before sacrifice. Six ApoE wild-type (ApoE(+/+)) mice (Group III) were imaged at 40weeks as controls. Five additional ApoE(-/-) mice (40weeks of age) (Group IV) were imaged with a (99m)Tc-labeled inactive peptide, (99m)Tc-LinDUR, to assess (99m)Tc-duramycin targeting specificity. Focal (99m)Tc-duramycin uptake in the ascending aorta and aortic arch was detected at 20 and 40weeks in the ApoE(-/-) mice but not in ApoE(+/+) mice. (99m)Tc-duramycin uptake in the aortic lesions increased 2.2-fold on quantitative imaging in the ApoE(-/-) mice between 20 and 40weeks. Autoradiographic and histological data indicated significantly increased (99m)Tc-duramycin uptake in the ascending aorta and aortic arch associated with advanced plaques. Quantitative autoradiography showed that the ratio of activity in the aortic arch to descending thoracic aorta, which had no plaques or radioactive uptake, was 2.1 times higher at 40weeks than at 20weeks (6.62±0.89 vs. 3.18±0.29, P<0.01). There was barely detectable focal uptake of (99m)Tc-duramycin in the aortic arch of ApoE(+/+) mice. No detectable (99m)Tc-LinDUR uptake was observed in the aortas of ApoE(-/-) mice. PE-targeting properties of (99m)Tc-duramycin in the atherosclerotic mouse aortas were noninvasively characterized. (99m)Tc-duramycin is promising in localizing advanced atherosclerotic plaques. Copyright © 2016 Elsevier Inc. All rights reserved.

A model for predicting aortic dynamic response to -G sub z impact acceleration.

NASA Technical Reports Server (NTRS)

Advani, S. H.; Tarnay, T. J.; Byars, E. F.; Love, J. S.

1972-01-01

A steady state dynamic response model for the radial motion of the aorta is developed from in vivo pressure-displacement and nerve stimulation experiments on canines. The model represented by a modified Van der Pol wave motion oscillator closely predicts steady state and perturbed response results. The applicability of the steady state canine aortic model to tailward acting impact forces is studied by means of the perturbed phase plane of the oscillator. The backflow through the aortic arch resulting from a specified acceleration-time profile is computed and an analysis for predicting the forced motion aortic response is presented.

A Meta-Analysis of Total Arch Replacement With Frozen Elephant Trunk in Acute Type A Aortic Dissection.

PubMed

Takagi, Hisato; Umemoto, Takuya

2016-01-01

To assess the safety and efficacy, we performed a meta-analysis of total arch replacement with frozen elephant trunk in exclusive acute type A (neither chronic nor type B) aortic dissection. Databases including MEDLINE and EMBASE were searched through March 2015 using Web-based search engines (PubMed and OVID). Eligible studies were case series of frozen elephant trunk enrolling patients with acute type A (neither chronic nor type B) aortic dissection reporting at least early (in-hospital or 30-day) all-cause mortality. Study-specific estimates were combined in both fixed- and random-effect models. Fifteen studies enrolling 1279 patients were identified and included. Pooled analyses demonstrated the cardiopulmonary bypass time of 207.1 (95% confidence interval [CI], 186.1-228.1) minutes, aortic cross-clamp time of 123.3 (95% CI, 113.1-133.5) minutes, selective antegrade cerebral perfusion time of 49.3 (95% CI, 37.6-61.0) minutes, hypothermic circulatory arrest time of 39.0 (95% CI, 30.7-47.2) minutes, early mortality of 9.2% (95% CI, 7.7-11.0%), stroke of 4.8% (95% CI, 2.5-9.0%), spinal cord injury of 3.5% (95% CI, 1.9-6.6%), mid- to long-term (≥1-year) overall mortality of 13.0% (95% CI, 10.4-16.0%), reintervention of 9.6% (95% CI, 5.6-15.8%), and false lumen thrombosis of 96.8% (95% CI, 90.7-98.9%). Total arch replacement with frozen elephant trunk provides a safe alternative to that with conventional elephant trunk in patients with acute type A aortic dissection, with acceptable early mortality and morbidity. The rates of mid- to long-term reintervention and false lumen non-thrombosis may be lower in patients undergoing the frozen than conventional elephant trunk procedure. © The Author(s) 2016.

The cis-9,trans-11 isomer of conjugated linoleic acid (CLA) lowers plasma triglyceride and raises HDL cholesterol concentrations but does not suppress aortic atherosclerosis in diabetic apoE-deficient mice.

PubMed

Nestel, Paul; Fujii, Akihiko; Allen, Terri

2006-12-01

Reduction in atherosclerosis has been reported in experimental animals fed mixtures of conjugated linoleic acid (CLA). In this study, the major naturally occurring CLA isomer (cis-9,trans-11) was tested in an atherosclerosis-prone mouse model. In a model of insulin deficient apoE deficient mice, 16 animals were fed for 20 weeks with supplemental CLA (09.%, w/w) and compared with a similar number of mice of this phenotype. A control comparison was made of metabolic changes in non-diabetic apoE deficient mice that develop little atherosclerosis over 20 weeks. At 20 weeks, plasma lipids were measured and aortic atherosclerosis quantified by Sudan staining in the arch, thoracic and abdominal segments. The diabetic apoE deficient mice developed marked dyslipidemia, primarily as cholesterol-enriched chylomicron and VLDL-sized lipoproteins and atherosclerosis in the aortic arch. However, there were no significant differences between CLA fed and non-CLA fed mice in either phenotype in plasma cholesterol concentration (in diabetic: 29.4+/-7.7 and 29.5+/-5.9 mmol/L, respectively) or in the area of aortic arch atherosclerosis (in diabetic: 24.8+/-10.3 and 27.6+/-7.7%, respectively). However, among diabetic mice the triglyceride concentration in triglyceride-rich lipoproteins was significantly lower in those fed CLA (for plasma 2.2+/-0.8 to 1.1+/-0.3 mmol/L; P<0.001), a significant difference that was seen also in the non-diabetic mice in which HDL cholesterol increased significantly with CLA (0.35+/-0.12-0.56+/-0.15 mmol/L). In this atherosclerosis-prone model, the diabetic apoE deficient mouse, supplemental 0.9% CLA (cis-9,trans-11) failed to reduce the severity of aortic atherosclerosis, although plasma triglyceride concentration was substantially lowered and HDL cholesterol raised.

Outflow tract septation and the aortic arch system in reptiles: lessons for understanding the mammalian heart.

PubMed

Poelmann, Robert E; Gittenberger-de Groot, Adriana C; Biermans, Marcel W M; Dolfing, Anne I; Jagessar, Armand; van Hattum, Sam; Hoogenboom, Amanda; Wisse, Lambertus J; Vicente-Steijn, Rebecca; de Bakker, Merijn A G; Vonk, Freek J; Hirasawa, Tatsuya; Kuratani, Shigeru; Richardson, Michael K

2017-01-01

Cardiac outflow tract patterning and cell contribution are studied using an evo-devo approach to reveal insight into the development of aorto-pulmonary septation. We studied embryonic stages of reptile hearts (lizard, turtle and crocodile) and compared these to avian and mammalian development. Immunohistochemistry allowed us to indicate where the essential cell components in the outflow tract and aortic sac were deployed, more specifically endocardial, neural crest and second heart field cells. The neural crest-derived aorto-pulmonary septum separates the pulmonary trunk from both aortae in reptiles, presenting with a left visceral and a right systemic aorta arising from the unseptated ventricle. Second heart field-derived cells function as flow dividers between both aortae and between the two pulmonary arteries. In birds, the left visceral aorta disappears early in development, while the right systemic aorta persists. This leads to a fusion of the aorto-pulmonary septum and the aortic flow divider (second heart field population) forming an avian aorto-pulmonary septal complex. In mammals, there is also a second heart field-derived aortic flow divider, albeit at a more distal site, while the aorto-pulmonary septum separates the aortic trunk from the pulmonary trunk. As in birds there is fusion with second heart field-derived cells albeit from the pulmonary flow divider as the right 6th pharyngeal arch artery disappears, resulting in a mammalian aorto-pulmonary septal complex. In crocodiles, birds and mammals, the main septal and parietal endocardial cushions receive neural crest cells that are functional in fusion and myocardialization of the outflow tract septum. Longer-lasting septation in crocodiles demonstrates a heterochrony in development. In other reptiles with no indication of incursion of neural crest cells, there is either no myocardialized outflow tract septum (lizard) or it is vestigial (turtle). Crocodiles are unique in bearing a central shunt, the foramen of Panizza, between the roots of both aortae. Finally, the soft-shell turtle investigated here exhibits a spongy histology of the developing carotid arteries supposedly related to regulation of blood flow during pharyngeal excretion in this species. This is the first time that is shown that an interplay of second heart field-derived flow dividers with a neural crest-derived cell population is a variable but common, denominator across all species studied for vascular patterning and outflow tract septation. The observed differences in normal development of reptiles may have impact on the understanding of development of human congenital outflow tract malformations.

[Bacteremia associated with mycotic aneurysm of the transversal aortic arch and myocarditis caused by Salmonella enteritidis].

PubMed

Martínez-Martínez, L; Mesa, E; Rodríguez, J E; Sánchez, M P; Ugarte, J; Algora Weber, A; Dámaso, D; Daza, R M; Mendaza, P

1989-02-01

A 60-year-old male with diabetes mellitus had Salmonella enteritidis bacteremia associated with mycotic aneurysm of the transverse aortic arc and myocarditis. Antibiotic therapy with ampicillin and chloramphenicol was ineffective despite the fact that the microorganism was sensitive in vitro to those antimicrobials, and the patient had a progressive clinical deterioration which culminated in death.

Outcomes after aortic graft-to-graft anastomosis with an automated circular stapler: A novel approach.

PubMed

Idrees, Jay J; Yazdchi, Farhang; Soltesz, Edward G; Vekstein, Andrew M; Rodriguez, Christopher; Roselli, Eric E

2016-10-01

Patients with complex aortic disease often require multistaged repairs with numerous anastomoses. Manual suturing can be time consuming. To reduce ischemic time, a circular stapling device has been used to facilitate prosthetic graft-to-graft anastomoses. Objectives are to describe this technique and assess outcomes. From February 2009 to May 2014, 44 patients underwent complex aortic repair with a circular end-to-end anastomosis (EEA) stapler at Cleveland Clinic. All patients had extensive aneurysms: 17 after ascending dissection repair, 10 chronic type B dissections, and 17 degenerative aneurysms. Stapler was used during total arch repair as an end-to-side anastomosis (n = 36; including first stage elephant trunk [ET] in 32, frozen ET in 3) and an end-to-end anastomosis during redo thoracoabdominal repair (n = 11). Three patients had the stapler used during both stages of repair. Patients underwent early and annual follow-ups with computed tomography analysis. There were no bleeds, ruptures, or leaks at the stapled site, but 2 patients died. Complications included 7 reoperations not related to the site of stapled anastomosis and 6 tracheostomies, but there was no paralysis or renal failure. Mean circulatory arrest time was 16 ± 5 minutes. Mean follow-up was 26 ± 17 months and consisted of imaging before discharge, at 3 to 6 months, and at 1 year. Planned reinterventions included 21 second-stage ET completion: Endovascular (n = 18) and open (n = 3). There were 4 late deaths. Use of an end-to-end anastomotic automated circular stapler is safe, effective, and durable in performing graft-to-graft anastomoses during complex thoracic aortic surgery. Further evaluation and refinement of this technique are warranted. Copyright © 2016 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

Patent ductus arteriosus associated with aberrant right subclavian artery: two cases, one successful interventional closure of PDA.

PubMed

Gomez, Jorge E; Gentile, Jorge I

2011-01-01

Two children were sent to the catheterization laboratory for transcatheter closure of patent ductus arteriosus (PDA). During the intervention, cineangiogram revealed associated aberrant right subclavian artery (ARSA). Both patients had left-sided aortic arch. The first patient was sent to surgery after one unsuccessful attempt to close the PDA due to the proximity of the ARSA and also because of other concomitant cardiac lesions. We successfully treated the second patient by closing the PDA with a Nit-Occlud® PDA occlusion device (Pfm Medical, Carlsbad, California). Similar mirror cases of PDA closure with aberrant left subclavian artery and right aortic arch have been reported. Anatomic features, as well as the technique and management of the procedure, are discussed here.

Vocal cord paralysis after aortic surgery.

PubMed

DiLisio, Ralph P; Mazzeffi, Michael A; Bodian, Carol A; Fischer, Gregory W

2013-06-01

The purpose of this study was to investigate variables associated with vocal cord paralysis during complex aortic procedures. A retrospective review. A tertiary care center. Four hundred ninety-eight patients who underwent aortic surgery between 2002 and 2007. Two groups were studied. Group A patients had procedures only involving their aortic root and/or ascending aorta. Group B patients had procedures only involving their aortic arch and/or descending aorta. The incidence of vocal cord paralysis was higher (7.26% v 0.8%) in group B patients (p < 0.0001). Increasing the duration of cardiopulmonary bypass time was associated with an increased risk of vocal cord paralysis and death in both groups A and B (p = 0.0002 and 0.002, respectively). Additionally, within group B, descending aneurysms emerged as an independent risk factor associated with vocal cord paralysis (p = 0.03). Length of stay was statistically significantly longer among group A patients who suffered vocal cord paralysis (p = 0.017) and trended toward significance in group B patients who suffered vocal cord paralysis (p = 0.059). The association between tracheostomy and vocal cord paralysis among group A patients reached statistical significance (p = 0.007) and trended toward significance in group B patients (p = 0.057). Increasing duration of cardiopulmonary bypass time was associated with a higher risk of vocal cord paralysis in patients undergoing aortic surgery. Additionally, within group B patients, descending aortic aneurysm was an independent risk factor associated with vocal cord paralysis. Most importantly, vocal cord paralysis appeared to have an association between an increased length of stay and tracheostomy among a select group of patients undergoing aortic surgery. Copyright © 2013 Elsevier Inc. All rights reserved.

EDUCATIONAL SERIES IN CONGENITAL HEART DISEASE: Congenital left-sided heart obstruction

PubMed Central

Carr, Michelle; Curtis, Stephanie; Marek, Jan

2018-01-01

Congenital obstruction of the left ventricular outflow tract remains a significant problem and multilevel obstruction can often coexist. Obstruction can take several morphological forms and may involve the subvalvar, valvar or supravalvar portion of the aortic valve complex. Congenital valvar stenosis presenting in the neonatal period represents a spectrum of disorders ranging from the hypoplastic left heart syndrome to almost normal hearts. Treatment options vary dependent on the severity of the left ventricular outflow tract obstruction (LVOTO) and the variable degree of left ventricular hypoplasia as well as the associated lesions such as arch hypoplasia and coarctation. PMID:29681546

Airflow obstruction, atherosclerosis and cardiovascular risk factors in the AGES Reykjavik study.

PubMed

Gudmundsson, Gunnar; Margretardottir, Olof Birna; Sigurdsson, Martin Ingi; Harris, Tamara B; Launer, Lenore J; Sigurdsson, Sigurdur; Olafsson, Orn; Aspelund, Thor; Gudnason, Vilmundur

2016-09-01

Airflow limitation, i.e. reduced forced expiratory volume in 1-s (FEV1), is associated with increased prevalence of atherosclerosis, however, causal mechanisms remain elusive. The objective of the study was to determine if the association between airflow obstruction and markers of atherosclerosis is mediated by systemic inflammation. 1154 subjects from the longitudinal AGES Reykjavik study were included. Population characteristics, systemic inflammation markers from blood (white blood cell counts (WBC) and level of C-reactive protein (CRP)) were compared between patients with and without airflow limitation defined by reduced FEV1 on spirometry. Atherosclerosis burden was quantified by measurements of coronary artery calcium, aortic arch and distal aortic calcification in addition to carotid intimal media thickness (CIMT). Subjects were split into four groups according to smoking status and whether airflow limitation was present. There was a higher overall burden of atherosclerosis in ever-smokers compared to never-smokers, and in individuals with airflow obstruction compared to individuals without airflow obstruction. After adjusting for population characteristics, Framingham cardiovascular risk factors and markers of systemic inflammation (WBC and CRP), there was a significantly increased aortic arch and distal aorta calcification and higher CIMT measurement in individuals with airflow obstruction compared to individuals without airflow obstruction. After adjusting for population characteristics, Framingham cardiovascular risk factors and markers of systemic inflammation (WBC and CRP), there was a significantly increased aortic arch and distal aorta calcification and higher CIMT measurement in individuals with airflow obstruction compared to individuals without airflow obstruction. Systemic inflammation (WBC and CRP) does not appear to mediate the association between airflow limitation and atherosclerosis. Only airflow limitation and not systemic inflammation (WBC and CRP) appears to be an independent predictor of atherosclerosis. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

Neural crest contribution to the cardiovascular system.

PubMed

Brown, Christopher B; Baldwin, H Scott

2006-01-01

Normal cardiovascular development requires complex remodeling of the outflow tract and pharyngeal arch arteries to create the separate pulmonic and systemic circulations. During remodeling, the outflow tract is septated to form the ascending aorta and the pulmonary trunk. The initially symmetrical pharyngeal arch arteries are remodeled to form the aortic arch, subclavian and carotid arteries. Remodeling is mediated by a population of neural crest cells arising between the mid-otic placode and somite four called the cardiac neural crest. Cardiac neural crest cells form smooth muscle and pericytes in the great arteries, and the neurons of cardiac innervation. In addition to the physical contribution of smooth muscle to the cardiovascular system, cardiac neural crest cells also provide signals required for the maintenance and differentiation of the other cell layers in the pharyngeal apparatus. Reciprocal signaling between the cardiac neural crest cells and cardiogenic mesoderm of the secondary heart field is required for elaboration of the conotruncus and disruption in this signaling results in primary myocardial dysfunction. Cardiovascular defects attributed to the cardiac neural crest cells may reflect either cell autonomous defects in the neural crest or defects in signaling between the neural crest and adjacent cell layers.

Mid-term results of zone 0 thoracic endovascular aneurysm repair after ascending aorta wrapping and supra-aortic debranching in high-risk patients.

PubMed

Pecoraro, Felice; Lachat, Mario; Hofmann, Michael; Cayne, Neal S; Chaykovska, Lyubov; Rancic, Zoran; Puippe, Gilbert; Pfammatter, Thomas; Mangialardi, Nicola; Veith, Frank J; Bettex, Dominique; Maisano, Francesco; Neff, Thomas A

2017-06-01

Surgical repair of aneurysmal disease involving the ascending aorta, aortic arch and eventually the descending aorta is generally associated with significant morbidity and mortality. A less invasive approach with the ascending wrapping technique (WT), supra-aortic vessel debranching (SADB) and thoracic endovascular aneurysm repair (TEVAR) in zone 0 was developed to reduce the associated risk in these patients. During a 10-year period, consecutive patients treated by the ascending WT, SADB and TEVAR in zone 0 were included. All patients were considered at high risk for conventional surgery. Measured outcomes included perioperative deaths and morbidity, maximal aortic transverse diameter (TD) and its postoperative evolution, endoleak, survival, freedom from cardiovascular reinterventions, SADB freedom from occlusion and aortic valve function during follow-up. Median follow-up was 37.4 [mean = 34; range, 0-65; standard deviation (SD) = 20] months. Twenty-six cases were included with a mean age of 71.88 ( r  = 56-87; SD = 8) years. A mean of 2.9 supra-aortic vessels (75) per patient was debranched from the ascending aorta. The mean time interval from WT/SADB and TEVAR was 29 ( r  = 0-204; SD = 48) days. TEVAR was associated with chimney and/or periscope grafts in 6 (23%) patients, and extra-anatomical supra-aortic bypasses were performed in 6 (23%) patients. Perioperative mortality was 7.7% (2/26). Neurological events were registered in 3 (11.5%) cases, and a reintervention was required in 3 (11.5%) cases. After the WT, the ascending diameter remained stable during the follow-up period in all cases. At mean follow-up, significant shrinkage of the arch/descending aorta diameter was observed. A type I/III endoleak occurred in 3 cases. At 5 years, the rates of survival, freedom from cardiovascular reinterventions and SADB freedom from occlusion were 71.7, 82.3 and 96%, respectively. The use of the ascending WT, SADB and TEVAR in selected patients with complex thoracic aorta disease is safe and shows promising mid-term results at 3 years. The combination of these techniques could represent an alternative to the standard open surgical repair, especially in older patients or in patients unfit for cardiopulmonary bypass. © The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Vocal Cord Paralysis After Thoracic Aortic Surgery: Incidence and Impact on Clinical Outcomes.

PubMed

Lodewyks, Carly L; White, Christopher W; Bay, Graham; Hiebert, Brett; Wu, Bella; Barker, Mark; Kirkpatrick, Iain; Arora, Rakesh C; Moon, Michael; Pascoe, Edward

2015-07-01

Vocal cord paralysis (VCP) is a serious complication associated with thoracic aortic surgery; however, there is a paucity of literature regarding the incidence and impact of VCP on postoperative outcomes. We sought to determine the incidence of VCP and its impact on clinical outcomes in patients who underwent thoracic aortic repair at our center. A retrospective chart review was conducted on all patients who underwent thoracic aortic surgery between January 2009 and September 2012. A total of 259 patients underwent a thoracic aortic procedure during the study period. Vocal cord paralysis was diagnosed in 12 (5%) patients, a median of 6 [3 to 21] days after extubation. The incidence was 1%, 0%, 20%, and 25% in those undergoing an open ascending, hemiarch, total arch, or descending aortic procedure, respectively. Patients with VCP had an increased incidence of pneumonia (58% vs 17%, p = 0.003), readmission to the intensive care unit for respiratory failure (17% vs 2%, p = 0.047), and longer hospital length of stay (18 [11 to 43] days versus 9 [6 to 15] days, p = 0.002). A propensity-matched analysis confirmed a higher incidence of pneumonia (58% vs 17%, p = 0.020) and longer hospital length of stay (18 [11 to 43] vs 10 [7 to 14] days, p = 0.015) in patients suffering VCP. Vocal cord paralysis is a common complication in patients undergoing open surgery of the aortic arch and descending aorta, and is associated with significant morbidity. Further research may be warranted to determine if early fiberoptic examination and consideration of a vocal cord medialization procedure may mitigate the morbidity associated with VCP. Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Exact monitoring of aortic diameters in Marfan patients without gadolinium contrast: intraindividual comparison of 2D SSFP imaging with 3D CE-MRA and echocardiography.

PubMed

Veldhoen, Simon; Behzadi, Cyrus; Derlin, Thorsten; Rybczinsky, Meike; von Kodolitsch, Yskert; Sheikhzadeh, Sara; Henes, Frank Oliver; Bley, Thorsten Alexander; Adam, Gerhard; Bannas, Peter

2015-03-01

To assess whether ECG-gated non-contrast 2D steady-state free precession (SSFP) imaging allows for exact monitoring of aortic diameters in Marfan syndrome (MFS) patients using non-ECG-gated contrast-enhanced 3D magnetic resonance angiography (CE-MRA) and echocardiography for intraindividual comparison. Non-ECG-gated CE-MRA and ECG-gated non-contrast SSFP at 1.5 T were prospectively performed in 50 patients. Two readers measured aortic diameters on para-sagittal images identically aligned with the aortic arch at the sinuses of Valsalva, sinotubular junction, ascending/descending aorta and aortic arch. Image quality was assessed on a three-point scale. Aortic root diameters acquired by echocardiography were used as reference. Intra- and interobserver variances were smaller for SSFP at the sinuses of Valsalva (p = 0.002; p = 0.002) and sinotubular junction (p = 0.014; p = 0.043). Image quality was better in SSFP than in CE-MRA at the sinuses of Valsalva (p < 0.0001), sinotubular junction (p < 0.0001) and ascending aorta (p = 0.02). CE-MRA yielded higher diameters than SSFP at the sinuses of Valsalva (mean bias, 2.5 mm; p < 0.0001), and comparison with echocardiography confirmed a higher bias for CE-MRA (7.2 ± 3.4 mm vs. SSFP, 4.7 ± 2.6 mm). ECG-gated non-contrast 2D SSFP imaging provides superior image quality with higher validity compared to non-ECG-gated contrast-enhanced 3D imaging. Since CE-MRA requires contrast agents with potential adverse effects, non-contrast SSFP imaging is an appropriate alternative for exact and riskless aortic monitoring of MFS patients.

[Simultaneous interventions on the ascending portion, arch of the aorta and cardiac valves in patients with Marfan's syndrome].

PubMed

Belov, Iu V; Stepanenko, A B; Gens, A P; Charchian, E R; Savichev, D D

2007-01-01

Simultaneous surgical interventions on the aorta and valvular system of the heart were performed in four patients presenting with aortic dissections and aneurysms conditioned by Marfan's syndrome. The following reconstructive operations were carried out: 1) prosthetic repair of the aortic valve and the ascending portion of the aorta by means of a valve-containing conduit with replantation of the openings of the coronary arteries into the side of the prosthesis according to the Benthall - De Bono technique, annuloplasty of the tricuspid valve according to the De Vega technique, valvuloplasty of the mitral valve by the Alferi technique; 2) grafting of the aortic valve and the ascending portion of the aorta by means of a valve-containing conduit with replantation of the openings of the coronary arteries according to the Kabrol's technique, plasty of the tricuspid valve by the De Vega technique; 3) prosthetic repair of the aortic arch with distal wedge-like excision of the membrane of the dissection and directing the blood flow along the both channels, plasty of the mitral valve, plasty of the aortic valve and the ascending portion of the aorta with a valve-containing conduit, accompanied by replantation of the openings of the coronary arteries into the side of the graft according to the Benthall - De Bono technique; (4) plasty of the mitral valve with a disk graft through the fibrous ring of the aortic valve, prosthetic repair of the aortic valve and the ascending portion of the aorta with a valve-containing conduit, accompanied by replantation of the openings of the coronary arteries into the side according to the Benthall-De Bono technique.

Risk model of thoracic aortic surgery in 4707 cases from a nationwide single-race population through a web-based data entry system: the first report of 30-day and 30-day operative outcome risk models for thoracic aortic surgery.

PubMed

Motomura, Noboru; Miyata, Hiroaki; Tsukihara, Hiroyuki; Takamoto, Shinichi

2008-09-30

The objective of this study was to collect integrated data from nationwide hospitals using a web-based national database system to build up our own risk model for the outcome from thoracic aortic surgery. The Japan Adult Cardiovascular Surgery Database was used; this involved approximately 180 hospitals throughout Japan through a web-based data entry system. Variables and definitions are almost identical to the STS National Database. After data cleanup, 4707 records were analyzed from 97 hospitals (between January 1, 2000, and December 31, 2005). Mean age was 66.5 years. Preoperatively, the incidence of chronic lung disease was 11%, renal failure was 9%, and rupture or malperfusion was 10%. The incidence of the location along the aorta requiring replacement surgery (including overlapping areas) was: aortic root, 10%; ascending aorta, 47%; aortic arch, 44%; distal arch, 21%; descending aorta, 27%; and thoracoabdominal aorta, 8%. Raw 30-day and 30-day operative mortality rates were 6.7% and 8.6%, respectively. Postoperative incidence of permanent stroke was 6.1%, and renal failure requiring dialysis was 6.7%. OR for 30-day operative mortality was as follows: emergency or salvage, 3.7; creatinine >3.0 mg/dL, 3.0; and unexpected coronary artery bypass graft, 2.6. As a performance metric of the risk model, C-index of 30-day and 30-day operative mortality was 0.79 and 0.78, respectively. This is the first report of risk stratification on thoracic aortic surgery using a nationwide surgical database. Although condition of these patients undergoing thoracic aortic surgery was much more serious than other procedures, the result of this series was excellent.

Mismatch between stiffness in elastic and muscular arteries as a predictor of vascular calcification in dialysis patients.

PubMed

Laucyte-Cibulskiene, Agne; Petraviciute, Modesta; Gudynaite, Migle; Gumbys, Liutauras; Valanciene, Dileta; Galiauskiene, Kristina; Ryliskyte, Ligita; Rimsevicius, Laurynas; Miglinas, Marius; Strupas, Kestutis

2018-04-01

Vascular calcification is one of the risk factors for arterial stiffness in patients with chronic kidney disease. We hypothesized that a mismatch between elastic and muscular arteries, represented as pulse wave velocity (PWV) ratio, could depict the extent of vascular calcification in end-stage renal disease. We also aimed to compare the predictive PWV ratio value to other factors possibly related to vascular calcification in dialysis population. In this cross-sectional study, in 60 chronic dialysis patients without previous cerebrovascular events, cardiovascular disease and events or clinically evident peripheral artery disease (ankle-brachial index >0.9), carotid-femoral and carotid-radial PWV as well as central hemodynamic parameters were measured by applanation tonometry (SphygmoCor). The PWV ratio using carotid-femoral PWV divided by carotid-radial PWV was calculated. Each patient underwent blood tests and chest X-ray for aortic arch calcification scoring. Two experienced radiologists blinded to patient's medical data evaluated chest X-rays (Cohen's kappa coefficient 0.76) and calculated how many sectors were calcified (Ogawa et al. in Hemodial Int 13:301-306, 2009). Differently scored chest X-rays were repeatedly reviewed and a consensus was reached. The study population consisted of 31 (51.7%) males and 29 (48.3%) females, mean age 52.73 ± 13.76 years. Increased risk for aortic arch calcification was associated with higher PWV ratio even after adjustment for age, height, heart rate, ferritin level and C-reactive protein level (OR 2.59E+04, 95% CI 2.43E+01, 2.65E+09, p = 0.021). PWV ratio together with above-mentioned variables could predict the presence of aortic arch calcification with specificity of 93% (95% CI 78, 99%) and sensitivity of 53% (95% CI 34, 72%). The elastic and muscular arteries' stiffness mismatch was strongly associated with the extent of aortic arch calcification in this dialysis population and had better calcification predictive value compared to other demographic, hemodynamic and biochemical markers.

Aortic Root Replacement for Children With Loeys-Dietz Syndrome.

PubMed

Patel, Nishant D; Alejo, Diane; Crawford, Todd; Hibino, Narutoshi; Dietz, Harry C; Cameron, Duke E; Vricella, Luca A

2017-05-01

Loeys-Dietz syndrome (LDS) is an aggressive aortopathy with a proclivity for aortic aneurysm rupture and dissection at smaller diameters than other connective tissue disorders. We reviewed our surgical experience of children with LDS to validate our guidelines for prophylactic aortic root replacement (ARR). We reviewed all children (younger than 18 years) with a diagnosis of LDS who underwent ARR at our institution. The primary endpoint was mortality, and secondary endpoints included complications and the need for further interventions. Thirty-four children with LDS underwent ARR. Mean age at operation was 10 years, and 15 (44%) were female. Mean preoperative root diameter was 4 cm. Three children (9%) had composite ARR with a mechanical prosthesis, and 31 (91%) underwent valve-sparing ARR. Concomitant procedures included arch replacement in 2 (6%), aortic valve repair in 1 (3%), and patent foramen ovale closure in 16 (47%). There was no operative mortality. Two children (6%) required late replacement of the ascending aorta, 5 (15%) required arch replacement, 1 (3%) required mitral valve replacement, and 2 (6%) had coronary button aneurysms/pseudoaneurysms requiring repair. Three children required redo valve-sparing ARR after a Florida sleeve procedure, and 2 had progressive aortic insufficiency requiring aortic valve replacement after a valve-sparing procedure. There were 2 late deaths (6%). These data confirm the aggressive aortopathy of LDS. Valve-sparing ARR should be performed when feasible to avoid the risks of prostheses. Serial imaging of the arterial tree is critical, given the rate of subsequent intervention. Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

[Progress and challenge of Stanford type A aortic dissection in China].

PubMed

Sun, L Z; Li, J R

2017-04-01

In recent 20 years, the rapid development of acute Stanford type A aortic dissection in China has been mainly due to three aspects: (1) the refined classification of aortic dissection based on Stanford classification, (2) right axillary artery canal and selective cerebral perfusion technology become basic cardiopulmonary bypass strategy for Stanford type A aortic dissection, and (3) total aortic arch replacement and descending aortic stent graft surgery (Sun's surgery) become the standard treatment of Stanford type A aortic dissection. However, there are still many problems in the diagnosis and treatment of aortic dissection in China, such as: (1) unstandardized, lack of comprehensive guidelines of aortic dissection, (2) immature, perioperative organ protection and intraoperative blood protection technology remains a big flaw, and (3) it takes a long time to get patient prepared for surgery. In conclusion, as to the issue of the management of acute Stanford type A aortic dissection, there will be a long way for Chinese doctors to go. Peers should pay more attention to this problem and take more efforts, so that the outcome of acute Stanford type A aortic dissection surgical patients can be improved.

Stenting for Acute Aortic Dissection with Malperfusion as “Bridge Therapy”

PubMed Central

Fujita, Wakako; Taniguchi, Satoshi; Daitoku, Kazuyuki; Fukuda, Ikuo

2010-01-01

The most common treatment of acute type A aortic dissection is immediate surgical repair. However, early surgery for acute dissections with peripheral vascular compromise carries a high mortality rate. Herein, we report a case in which we placed percutaneous endovascular stents in a type A dissection patient before proceeding with proximal aortic repair. Bare-metal stents were placed into the obliterated true channel of the abdominal aorta and the left external iliac artery. Endovascular stenting immediately relieved the lower-left-extremity ischemic symptoms, and the patient underwent hemi-arch replacement 7 days after the procedure. Stent placement for patients who have acute aortic dissection with malperfusion can be used as “bridge therapy.” PMID:21224949

A Case of an Upper Gastrointestinal Bleeding Due to a Ruptured Dissection of a Right Aortic Arch

DOE Office of Scientific and Technical Information (OSTI.GOV)

Born, Christine; Forster, Andreas; Rock, Clemens

2003-09-15

We report a case of severe upper gastrointestinal hemorrhage with a rare underlying cause. The patient was unconscious when he was admitted to the hospital. No chest radiogram was performed. Routine diagnostic measures, including endoscopy, failed to reveal the origin of the bleeding, which was believed to originate from the esophagus secondary to a peptic ulcer or varices. Exploratory laparotomy added no further information, but contrast-enhanced multislice computed tomography (MSCT) of the chest showed dextroposition of the widened aortic arch with a ruptured type-B dissection and a consecutive aorto-esophageal fistula (AEF). The patient died on the day of admission. Noninvasivemore » MSCT angiography gives rapid diagnostic information on patients with occult upper gastrointestinal bleeding and should be considered before more invasive conventional angiography or surgery.« less

Ureter Regeneration–The Proper Scaffold Has to Be Defined

PubMed Central

Kowalczyk, Tomasz; Nowacki, Maciej; Bodnar, Magdalena; Marszałek, Andrzej; Pokrywczyńska, Marta; Frontczak-Baniewicz, Małgorzata; Kowalewski, Tomasz A.; Chłosta, Piotr; Drewa, Tomasz

2014-01-01

The aim of this study was to compare two different acellular scaffolds: natural and synthetic, for urinary conduit construction and ureter segment reconstruction. Acellular aortic arch (AAM) and poly(L-lactide-co-caprolactone) (PLCL) were used in 24 rats for ureter reconstruction in both tested groups. Follow-up period was 4 weeks. Intravenous pyelography, histological and immunohistochemical analysis were performed. All animals survived surgical procedures. Patent uretero-conduit junction was observed only in one case using PLCL. In case of ureter segment reconstruction ureters were patent in one case using AAM and in four cases using PLCL scaffolds. Regeneration of urothelium layer and focal regeneration of smooth muscle layer was observed on both tested scaffolds. Obtained results indicates that synthetic acellular PLCL scaffolds showed better properties for ureter reconstruction than naturally derived acellular aortic arch. PMID:25162415

DOE Office of Scientific and Technical Information (OSTI.GOV)

Zou, Junjie; Jiao, Yuanyong, E-mail: wishlucky@163.com, E-mail: johemail@163.com; Zhang, Xiwei

PurposeTo examine the safety, feasibility, and mid-term efficacy of the chimney technique for aortic arch pathologies.MethodsFrom February 2011 to December 2014, a total of 35 patients (30 men; mean age 54.3 ± 14.1 years) with aortic arch pathologies underwent thoracic endovascular aortic repair combined with chimney stents. The indication was a proximal landing zone <1.5 cm. Follow-up was performed at 3, 6, and 12 months and then yearly thereafter.ResultsA total of 36 chimney stents were deployed (innominate artery, n = 1; left common carotid artery, n = 9; right subclavian artery, n = 1; left subclavian artery, n = 25). The technical success rate was 94.3 % (33/35). Immediate type Ia endoleaks (ELIa) weremore » observed in two patients (8.6 %, 2/35). Twenty-five patients were successfully followed-up for a median period of 29.3 months (range, 6–48 months). One patient died due to aortic dissection aneurysm rupture at 36 months (mortality rate of 4 %, 1/25). Three late ELIa were observed and no reinterventions were performed. The overall incidence of ELIa was 20 % (5/25). During follow-up, the patency rate for chimney stents was 92 % (23/25).ConclusionOur limited experience demonstrates that the chimney technique is a viable and relatively safe treatment for patients with challenging thoracic aortic pathologies at least in the mid-term follow-up period.« less

Evolution of surgical therapy for Stanford acute type A aortic dissection

PubMed Central

Chiu, Peter

2016-01-01

Acute type A aortic dissection (AcA-AoD) is a surgical emergency associated with very high morbidity and mortality. Unfortunately, the early outcome of emergency surgical repair has not improved substantially over the last 20 years. Many of the same debates occur repeatedly regarding operative extent and optimal conduct of the operation. The question remains: are patients suffering from too large an operation or too small? The pendulum favoring routine aortic valve resuspension, when feasible, has swung towards frequent aortic root replacement. This already aggressive approach is now being challenged with the even more extensive valve-sparing aortic root replacement (V-SARR) in selected patients. Distally, open replacement of most of the transverse arch is best in most patients. The need for late aortic re-intervention has not been shown to be affected by more extensive distal operative procedures, but the contemporary enthusiasm for a distal frozen elephant trunk (FET) only seems to build. It must be remembered that the first and foremost goal of the operation is to have an operative survivor; additional measures to reduce late morbidity are secondary aspirations. With increasing experience, true contraindications to emergency surgical operation have dwindled, but patients with advanced age, multiple comorbidities, and major neurological deficits do not fare well. The endovascular revolution, moreover, has spawned innovative options for modern practice, including ascending stent graft and adaptations of the old flap fenestration technique. Despite the increasingly complex operations and ever expanding therapies, this life-threatening disease remains a stubborn challenge for all cardiovascular surgeons. Development of specialized thoracic aortic teams and regionalization of care for patients with AcA-AoD offers the most promise to improve overall results. PMID:27563541

Aortic elongation and the risk for dissection: the Tübingen Aortic Pathoanatomy (TAIPAN) project†.

PubMed

Krüger, Tobias; Oikonomou, Alexandre; Schibilsky, David; Lescan, Mario; Bregel, Katharina; Vöhringer, Luise; Schneider, Wilke; Lausberg, Henning; Blumenstock, Gunnar; Bamberg, Fabian; Schlensak, Christian

2017-06-01

We measured aortic dimensions, particularly length parameters, using 3D imaging with the aim of refining the risk-morphology for Stanford type A aortic dissection (TAD). Computer tomography angiography studies were analysed using the curved multiplanar reformats. At defined landmarks, the diameters and lengths of aortic segments were recorded. Three groups were compared retrospectively: patients actually suffering from a TAD (TAD-group; n  = 150), patients before suffering a TAD (preTAD-group n  = 15) and a healthy control group ( n  = 215). Receiver operating characteristic curves (ROCs) were analysed (control versus preTAD) to study the diagnostic value of the individual variables. Median diameters of preTAD (43 mm) and TAD (50 mm) aortas were significantly ( P  < 0.001) larger than those of the control group (35 mm). Ninety-three percent of preTAD and 68% of TAD aortas were less than 55 mm in the mid-ascending aorta. The ascending aorta and the aortic arch were significantly longer in both preTAD and TAD aortas compared to control aortas ( P  < 0.001); in the control aortas the central line distance from the aortic valve to the brachiocephalic trunk was 93 mm. In preTAD aortas, it was 111 mm, and it was 117 mm in TAD aortas ( P  < 0.001). In ROC analysis, the area under the curve was 0.912 for the ascending diameter and 0.787 for the ascending and arch lengths. TAD-prediction based on the aortic diameter is ineffective. Besides circumferential dilatation, ascending aorta elongation precedes TAD and appears to be a useful additional parameter for prognostication. We propose a diagnostic score involving ascending aorta diameter and length. © The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Aortic arch syndrome

MedlinePlus

... including: Congenital absence of a branch of the aorta Isolation of the subclavian arteries Vascular rings An ... Braverman AC. Diseases of the aorta. In: Bonow RO, Mann DL, Zipes DP, ... Heart Disease: A Textbook of Cardiovascular Medicine . 10th ...

Elective frozen elephant trunk procedure using the E-Vita Open Plus prosthesis in 94 patients: a multicentre French registry.

PubMed

Verhoye, Jean-Philippe; Belhaj Soulami, Reda; Fouquet, Olivier; Ruggieri, Vito Giovanni; Kaladji, Adrien; Tomasi, Jacques; Sellin, Michel; Farhat, Fadi; Anselmi, Amedeo

2017-10-01

Our goal was to evaluate the operative outcomes of the frozen elephant trunk technique using the E-Vita Open Plus® hybrid prosthesis in chronic aortic arch diseases and report clinical and radiological outcomes at the 1-year follow-up. As determined from a prospective multicentre registry, 94 patients underwent frozen elephant trunk procedures using the E-Vita Open Plus hybrid device for the treatment of chronic aortic conditions, including 50% chronic aortic dissections, 40% degenerative aneurysms and 10% miscellaneous indications. Fifty percent of the cases were reoperations. The perioperative mortality rate was 11.7%. Spinal cord ischaemia and stroke rates were 4% and 9.6%, respectively. The mean cardiopulmonary bypass time was 252 ± 97 min, cardiac ischaemia time was 152 ± 53 min and cerebral perfusion time was 82 ± 22 min. Concomitant procedures were observed in 15% of patients. Among the 83 surviving patients, the survival rate after the 1-year follow-up was 98%. Eleven percent of patients underwent endovascular completion, whereas 4% of patients required aortic reintervention at 1 year. The E-Vita Open Plus hybrid device confirms the favourable short- and mid-term outcomes offered by its predecessor in frozen elephant trunk procedures in patients with chronic aortic arch disease. Implantation of the E-Vita Open Plus is associated with good 1-year survival rates, good rates of favourable aortic remodelling in both chronic dissection and degenerative aneurysms and a reproducible technique in a multicentre registry. Continued follow-up is required due to the risk of evolution at the downstream aorta. © The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

2D image classification for 3D anatomy localization: employing deep convolutional neural networks

NASA Astrophysics Data System (ADS)

de Vos, Bob D.; Wolterink, Jelmer M.; de Jong, Pim A.; Viergever, Max A.; Išgum, Ivana

2016-03-01

Localization of anatomical regions of interest (ROIs) is a preprocessing step in many medical image analysis tasks. While trivial for humans, it is complex for automatic methods. Classic machine learning approaches require the challenge of hand crafting features to describe differences between ROIs and background. Deep convolutional neural networks (CNNs) alleviate this by automatically finding hierarchical feature representations from raw images. We employ this trait to detect anatomical ROIs in 2D image slices in order to localize them in 3D. In 100 low-dose non-contrast enhanced non-ECG synchronized screening chest CT scans, a reference standard was defined by manually delineating rectangular bounding boxes around three anatomical ROIs -- heart, aortic arch, and descending aorta. Every anatomical ROI was automatically identified using a combination of three CNNs, each analyzing one orthogonal image plane. While single CNNs predicted presence or absence of a specific ROI in the given plane, the combination of their results provided a 3D bounding box around it. Classification performance of each CNN, expressed in area under the receiver operating characteristic curve, was >=0.988. Additionally, the performance of ROI localization was evaluated. Median Dice scores for automatically determined bounding boxes around the heart, aortic arch, and descending aorta were 0.89, 0.70, and 0.85 respectively. The results demonstrate that accurate automatic 3D localization of anatomical structures by CNN-based 2D image classification is feasible.

[Aneurism of the subclavian artery associated with Turner's syndrome].

PubMed

Lacombe, M; Esteva, B; Tillous-Borde, I; Lesèche, G

2004-04-01

Arterial aneurysms associated with Turner's syndrome are rare. We report a case of aneurysm of the left subclavian artery in a 16-year-old girl with Turner's syndrome. This patient was operated on: resection of the aneurysm, suture of the aortic arch and reimplantation of the subclavian artery in the left common carotid were performed. At 3-year follow-up, the evolution is favourable. Cardiovascular anomalies are observed in 50% of subjects with Turner's syndrome. This justifies complementary cardiac investigations in these patients. Congenital malformations (bicuspid aortic valve, aortic coarctation, intracardiac communications, valvular lesions) or acquired anomalies (arterial hypertension, aortic dissection) are frequent. Only one similar case of subclavian artery aneurysm has been reported until now. The risk of rupture justifies the surgical treatment.

Impact of hypertension on early outcomes and long-term survival of patients undergoing aortic repair with Stanford A dissection.

PubMed

Merkle, Julia; Sabashnikov, Anton; Deppe, Antje-Christin; Zeriouh, Mohamed; Eghbalzadeh, Kaveh; Weber, Carolyn; Rahmanian, Parwis; Kuhn, Elmar; Madershahian, Navid; Kroener, Axel; Choi, Yeong-Hoon; Kuhn-Régnier, Ferdinand; Liakopoulos, Oliver; Wahlers, Thorsten

2018-04-01

Stanford A acute aortic dissection (AAD) is a life-threatening emergency, typically occurring in hypertensive patients, requiring immediate surgical repair. The aim of this study was to evaluate early outcomes and long-term survival of hypertensive patients in comparison to normotensive patients suffering from Stanford A AAD. In our center, 240 patients with Stanford A AAD underwent aortic surgical repair from January 2006 to April 2015. After statistical and logistic regression analysis, Kaplan-Meier survival estimation was performed, with up to 9-year follow-up. The proportion of hypertensive patients suffering from Stanford A AAD was 75.4% (n=181). There were only few statistically significant differences in terms of basic demographics, comorbidities, preoperative baseline and clinical characteristics of hypertensive patients in comparison to normotensive patients. Hypertensive patients were significantly older (p=0.008), more frequently received hemi-arch repair (p=0.028) and selective brain perfusion (p=0.001). Our study showed similar statistical results in terms of 30-day mortality (p=0.196), long-term overall cumulative survival of patients (Log-Rank p=0.506) and survival of patients free from cerebrovascular events (Log-Rank p=0.186). Furthermore, subgroup analysis for long-term survival in terms of men (Log-Rank p=0.853), women (Log-Rank p=0.227), patients under and above 65 years of age (Log-Rank p=0.188 and Log-Rank p=0.602, respectively) and patients undergoing one of the three types of aortic repair surgery showed similar results for normotensive and hypertensive patient groups. Subgroup analysis for long-term survival of patients free from cerebrovascular events for women, patients under 65 years of age and patients undergoing aortic arch repair showed significant differences between the two groups in favor of hypertensive patients. Hypertensive patients suffering from Stanford A AAD were older, more frequently received hemi-arch replacement and were not associated with increased risk of 30-day mortality and poorer long-term survival compared to normotensive patients.

Case report and review of the literature total endovascular repair of acute ascending aortic rupture: a case report and review of the literature.

PubMed

McCallum, John C; Limmer, Karl K; Perricone, Anthony; Bandyk, Dennis; Kansal, Nikhil

2013-07-01

Thoracic aortic endografting has been successfully implemented to treat aneurysmal disease of the distal aortic arch and descending thoracic aorta. Although there are reports of ascending aortic endovascular interventions, the total endovascular repair of a ruptured ascending aorta secondary to a Type A dissection has not been described. We report the case of a 77-year-old patient who presented with a ruptured ascending aortic aneurysm secondary to degeneration of a Stanford type A aortic dissection. His surgical history was significant for orthotropic heart transplant 19 years prior. The dissection, aneurysm, and rupture occurred in the native aorta distal to the ascending aortic suture line. At presentation, he was hemodynamically unstable with a right hemothorax. We placed 3 Medtronic Talent Thoracic Stent Graft devices (Medtronic Inc, Minneapolis, MN) across the suture line in the ascending aorta, excluding the rupture. The patient survived and has been followed to 25 months.

Three-Channeled Aortic Dissection in a Patient without Marfan Syndrome

PubMed Central

Arita, Yoshie Inoue; Yamamoto, Takeshi; Hosokawa, Yusuke; Fujii, Masahiro; Nitta, Takashi; Shimizu, Wataru

2017-01-01

A 64-year-old man was admitted for evaluation of back pain. He did not have a Marfan syndrome (MFS)-like appearance, and had a history of a type B aortic dissection and total arch replacement. A connective tissue disorder had been suspected because of the histologic findings of the resected aortic wall. On admission, a computed tomography (CT) scan demonstrated a three-channeled aortic dissection (3ch-AD) measuring 63 mm in diameter. We planned to perform elective surgery during his hospitalization. On the fourth hospital day, he complained of severe back pain, and enhanced CT scan revealed an aortic rupture. The patients with 3ch-AD often have MFS. However, even if they do not have an MFS-like appearance, clinicians should consider fragility of the aortic wall in patients with 3ch-AD. If the aortic diameter is enlarged, early surgery is recommended. In particular, if a connective tissue disorder is obvious or suspected, emergent surgery is warranted. PMID:29187676

[Intra-operative Acute Aortic Dissection during Aortic Root Reimplantation and Mitral Valve Reconstruction Surgery in a Patient with Marfan Syndrome;Report of a Case].

PubMed

Teramoto, Chikao; Kawaguchi, Osamu; Araki, Yoshimori; Yoshikawa, Masaharu; Uchida, Wataru; Takemura, Gennta; Makino, Naoki

2016-08-01

In patients with Marfan syndrome, cardiovascular complication due to aortic dissection represents the primary cause of death. Iatrogenic acute aortic dissection during cardiac surgery is a rare, but serious adverse event. A 51-year-old woman with Marfan syndrome underwent elective aortic surgery and mitral valve reconstruction surgery for the enlarged aortic root and severe mitral regurgitation. We replaced the aortic root and ascending aorta based on reimplantation technique. During subsequent mitral valve reconstruction, we found the heart pushed up from behind. Trans-esophageal echocardiography revealed a dissecting flap in the thoracic descending aorta. There was just weak signal of blood flow in the pseudolumen. We did not add any additional procedures such as an arch replacement. Cardio-pulmonary bypass was successfully discontinued. After protamine sulfate administration and blood transfusion, blood flow in the pseudolumen disappeared. The patient was successfully discharged from the hospital on 33th postoperative day without significant morbidities.

[Study of the supra-aortic trunks using the humeral Seldinger technique and digitalized angiography of the aortic arch. Apropos of 175 cases].

PubMed

Boyer, L; Badère, J M; Dupont le Priol, P; Viallet, J F; Ribal, J P; Glanddier, G

1991-10-01

Screening of cerebrovascular disease by transbranchial arch injection. One hundred and seventy five patients underwent non selective intra arterial digital subtraction angiography using a transbranchial approach. Unilateral failure occurred in eight patients, but contralateral approach was then possible. Transient cerebral ischaemia affected one patient. Seven locoregional complications occurred, five of them underwent among the seventy three first procedures. Experience of the examining radiologist, duration of procedure and diameter of the catheter (4 or 5 F) are essential safety factors. Three false-negative and one false-positive in carotid bifurcations appears with surgical results reviews. This safe and efficient technique is often sufficient for a therapeutic decision, especially for surgery, but, in a few cases, additional selective injections can be necessary. Possible in out patients, this approach is chosen when femoral artery catheterization is impossible, or before reconstructive aorto-ilio-femoral surgery, to decrease septic risk.

An L-Shaped Incision for an Extensive Thoracic Aortic Aneurysm and Coronary Artery Bypass Using the Left Internal Thoracic Artery.

PubMed

Abe, Tomonobu; Suenaga, Hiroto; Oshima, Hideki; Araki, Yoshimori; Mutsuga, Masato; Fujimoto, Kazuro; Usui, Akihiko

2015-04-01

An L-shaped incision combining an upper half mid-sternotomy and a left antero-lateral thoracotomy at the fourth intercostal space has been proposed by several authors for extensive aneurysms involving the aortic arch and the proximal thoracic descending aorta. This approach usually requires the division of the left internal thoracic artery at its mid position, thus making it unusable for coronary artery bypass. We herein report a modified surgical approach for simultaneous extensive arch and proximal thoracic descending aorta replacement and coronary artery bypass using the left internal thoracic artery combining a left antero-lateral thoracotomy at the sixth intercostal space and upper mid-sternotomy. The visualization of the whole diseased aorta down to the level below the hilum of the left lung was good, and the integrity of the left internal thoracic artery graft was preserved by early heparin administration before sternotomy.

Effects of Aortic Irregularities on the Blood Flow

NASA Astrophysics Data System (ADS)

Gutmark-Little, Iris; Prahl-Wittberg, Lisa; van Wyk, Stevin; Mihaescu, Mihai; Fuchs, Laszlo; Backeljauw, Philippe; Gutmark, Ephraim

2013-11-01

Cardiovascular defects characterized by geometrical anomalies of the aorta and its effect on the blood flow are investigated. The flow characteristics change with the aorta geometry and the rheological properties of the blood. Flow characteristics such as wall shear stress often play an important role in the development of vascular disease. In the present study, blood is considered to be non-Newtonian and is modeled using the Quemada model, an empirical model that is valid for different red blood cell loading. Three patient-specific aortic geometries are studied using Large Eddy Simulations (LES). The three geometries represent malformations that are typical in patients populations having a genetic disorder called Turner syndrome. The results show a highly complex flow with regions of recirculation that are enhanced in two of the three aortas. Moreover, blood flow is diverted, due to the malformations, from the descending aorta to the three side branches of the arch. The geometry having an elongated transverse aorta has larger areas of strong oscillatory wall shear stress.

Neuroprotective effect of pressure-oriented flow regulation and pH-stat management in selective antegrade brain perfusion during total aortic arch repair.

PubMed

Ito, Hisato; Mizumoto, Toru; Sawada, Yasuhiro; Fujinaga, Kazuya; Tempaku, Hironori; Yamamoto, Yasunori; Tsutsui, Katsuhiro; Shimpo, Hideto

2017-10-01

The aim of this study was to assess the safety and effectiveness of our selective antegrade brain perfusion (SABP) strategy, which is characterized by moderate hypothermic and low-pressure management under pH-stat using a completely closed cardiopulmonary bypass circuit with a single centrifugal pump. Forty-nine consecutive patients (median age, 74) underwent total aortic arch replacement using a 4-branched graft. SABP was conducted with individual cannulation in all arch vessels. The SABP flow rate was monitored, and the flow rates of each arch vessel were also measured in patients with available data. One patient died of cerebral infarction, and 7 had transient neurological deficits without apparent findings on postoperative imaging studies and without residual sequels at hospital discharge. The operation, cardiopulmonary bypass, cardiac arrest, circulatory arrest and SABP times were 327 min (interquartile range, 292-381), 211 (184-247), 107 (84.8-138.3), 54.0 (48-68) and 137 (114-158), respectively. The total flow of the SABP was 18.1 ml/kg/min (15.7-20.9). The flow rates of the brachiocephalic, the left carotid and the left subclavian arteries were 9.5 ml/kg/min (7.7-11.5), 4.2 (2.8-5.7) and 4.5 (3.7-5.5), respectively. Only the flow rate of the brachiocephalic artery was significantly correlated with the total SABP flow rate (Spearman rank correlation coefficient, r = 0.58, P < 0.01). The moderate hypothermic, high-flow, low-pressure SABP strategy with pH-stat management can be applied in adult aortic surgery; however, the feasibility and effectiveness of this concept need further evaluation in a prospective controlled study. © The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Oxygenation impairment after total arch replacement with a stented elephant trunk for type-A dissection.

PubMed

Shen, Yuwen; Liu, Chuanzhen; Fang, Changcun; Xi, Jie; Wu, Shuming; Pang, Xinyan; Song, Guangmin

2018-06-01

To study the risk factors of oxygenation impairment in patients with type-A acute aortic dissection who underwent total arch replacement with a stented elephant trunk. In this study, 169 consecutive patients were enrolled who were diagnosed with type-A acute aortic dissection and underwent a total arch replacement procedure at the Qilu Hospital of Shandong University between January 2015 and February 2017. Postoperative oxygenation impairment was defined as arterial oxygen partial pressure/inspired oxygen fraction ≤ 200 with positive end expiratory pressure ≥ 5 cm H 2 O that occurred within 72 hours of surgery. Perioperative clinical characteristics of all patients were collected and univariable analyses were performed. Risk factors associated with oxygenation impairment identified by univariable analyses were included in the multivariable regression analysis. The incidence of postoperative oxygenation impairment was 48.5%. Postoperative oxygenation impairment was associated with prolonged mechanical ventilation time, intensive care unit stay, and hospital stay. Multivariable regression analysis demonstrated that body mass index (odds ratio [OR], 1.204; 95% confidence interval [CI], 1.065-1.361; P = .003), preoperative oxygenation impairment (OR, 9.768; 95% CI, 4.159-22.941; P < .001), preoperative homocysteine (OR, 1.080; 95% CI, 1.006-1.158; P = .032), circulatory arrest time (OR, 1.123; 95% CI, 1.044-1.207; P = .002), and plasma transfusion (OR, 1.002; 95% CI, 1.001-1.003; P = .002) were significantly associated with postoperative oxygenation impairment. Postoperative oxygenation impairment is a common complication of surgery for type-A acute aortic dissection. Body mass index, preoperative oxygenation impairment, preoperative homocysteine, circulatory arrest time, and plasma transfusion were independent risk factors for oxygenation impairment after a total arch replacement procedure. Copyright © 2018 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

Variation in Perfusion Strategies for Neonatal and Infant Aortic Arch Repair: Contemporary Practice in the STS Congenital Heart Surgery Database.

PubMed

Meyer, David B; Jacobs, Jeffrey P; Hill, Kevin; Wallace, Amelia S; Bateson, Brian; Jacobs, Marshall L

2016-09-01

Regional cerebral perfusion (RCP) is used as an adjunct or alternative to deep hypothermic circulatory arrest (DHCA) for neonates and infants undergoing aortic arch repair. Clinical studies have not demonstrated clear superiority of either strategy, and multicenter data regarding current use of these strategies are lacking. We sought to describe the variability in contemporary practice patterns for use of these techniques. The Society of Thoracic Surgeons Congenital Heart Surgery Database (2010-2013) was queried to identify neonates and infants whose index operation involved aortic arch repair with cardiopulmonary bypass. Perfusion strategy was classified as isolated DHCA, RCP (with less than or equal to ten minutes of DHCA), or mixed (RCP with more than ten minutes of DHCA). Data were analyzed for the entire cohort and stratified by operation subgroups. Overall, 4,523 patients (105 centers) were identified; median age seven days (interquartile range: 5.0-13.0). The most prevalent perfusion strategy was RCP (43%). Deep hypothermic circulatory arrest and mixed perfusion accounted for 32% and 16% of cases, respectively. In all, 59% of operations involved some period of RCP. Regional cerebral perfusion was the most prevalent perfusion strategy for each operation subgroup. Neither age nor weight was associated with perfusion strategy, but reoperations were less likely to use RCP (31% vs 45%, P < .001). The combined duration of RCP and DHCA in the RCP group was longer than the DHCA time in the DHCA group (45 vs 36 minutes, P < .001). There is considerable variability in practice regarding perfusion strategies for arch repair in neonates and infants. In contemporary practice, RCP is the most prevalent perfusion strategy for these procedures. Use of DHCA is also common. Further investigation is warranted to ascertain possible relative merits of the various perfusion techniques. © The Author(s) 2016.

Elastic properties of the young aorta: ex vivo perfusion experiments in a porcine model.

PubMed

Krüger, Tobias; Grigoraviciute, Akvile; Veseli, Kujtim; Schibilsky, David; Wendel, Hans P; Schneider, Wilke; Schlensak, Christian

2015-08-01

To investigate the regional and directional compliance/distensibility of the healthy aorta. Complete fresh porcine aortas (n = 11) were perfused ex vivo under defined haemodynamic parameters using a custom-made pulse duplicator. Both circumferential and longitudinal compliance were measured optically. The pulse duplicator was able to perfuse the entire aorta with arbitrary haemodynamic parameters, generating a physiological pulse curve. Aortic compliance is pressure dependent, as we observed a linear relationship between pressure and distension in the range of 5-200 mmHg; however, above 200 mmHg, the porcine aorta behaved in an inelastic manner. Circumferential compliance was highest in the ascending aorta (24%/100 mmHg) but significantly (P < 0.05) decreased in both the arch (18%/100 mmHg) and the descending aorta (15%/100 mmHg). Longitudinal compliance was highest in the ascending aorta and clearly exceeded circumferential compliance. Compliance was significantly (P < 0.05) higher in the outer curvatures of the ascending aorta and the aortic arch compared with the compliance of the inner curvature at these locations (30%/100 vs 23%/100 mmHg in the ascending aorta and 20%/100 vs 9%/100 mmHg in the arch, respectively). Longitudinal compliance of the ascending aorta, particularly the outer curvature, is predominantly responsible for the 'Windkessel effect'. Pathological changes such as elongation and pronounced angulation of the ascending aorta increase stress on the outer curvature and may be important factors in the development of aortic dissection. © The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Early and mid-term outcomes of endovascular and open surgical repair of non-dissected aortic arch aneurysm†.

PubMed

Hori, Daijiro; Okamura, Homare; Yamamoto, Takahiro; Nishi, Satoshi; Yuri, Koichi; Kimura, Naoyuki; Yamaguchi, Atsushi; Adachi, Hideo

2017-06-01

With the introduction of endovascular stent graft technology, a variety of surgical options are available for patients with aortic aneurysms. We sought to evaluate early-term and mid-term outcomes of patients undergoing endovascular and open surgical repair for non-dissected aortic arch aneurysm. Overall, 200 patients underwent treatment for isolated non-dissected aortic arch aneurysm between January 2008 and February 2016: 133 patients had open surgery and 67, endovascular repair. Early-term and mid-term outcomes were compared. Seventy percent ( n  = 47) needing endovascular repair underwent fenestrated stent graft and 30% ( n  = 20) underwent the debranched technique. Patients in the open surgery group were younger (71 vs 75 years, P  < 0.001) and had a lower prevalence of ischaemic heart disease (11% vs 35%, P  < 0.001). Intensive care unit stay (1 vs 3 days, P  < 0.001), hospital stay (11 vs 17 days, P  < 0.001) and surgical time (208 vs 390 min, P  < 0.001) were lower in the endovascular repair group than in the open surgery group. There were 3 in-hospital deaths each in the open surgery and endovascular groups (2% vs 5%, respectively, P  = 0.40). Mid-term survival ( P  < 0.001) and freedom from reintervention ( P  = 0.009) were better in the open surgery than in the endovascular repair group. No aneurysm-related deaths were observed. The propensity-matched comparison ( n  = 58) demonstrated that survival was better in the open surgery group ( P  = 0.011); no significant difference was seen in the reintervention rate ( P  = 0.28). Close follow-up for re-intervention may reduce the risk for aneurysm-related deaths and provide acceptable outcomes in patients undergoing endovascular repair. © The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Multidetector-row computed tomography of thoracic aortic anomalies in dogs and cats: Patent ductus arteriosus and vascular rings

PubMed Central

2011-01-01

Background Diagnosis of extracardiac intrathoracic vascular anomalies is of clinical importance, but remains challenging. Traditional imaging modalities, such as radiography, echocardiography, and angiography, are inherently limited by the difficulties of a 2-dimensional approach to a 3-dimensional object. We postulated that accurate characterization of malformations of the aorta would benefit from 3-dimensional assessment. Therefore, multidetector-row computed tomography (MDCT) was chosen as a 3-dimensional, new, and noninvasive imaging technique. The purpose of this study was to evaluate patients with 2 common diseases of the intrathoracic aorta, either patent ductus arteriosus or vascular ring anomaly, by contrast-enhanced 64-row computed tomography. Results Electrocardiography (ECG)-gated and thoracic nongated MDCT images were reviewed in identified cases of either a patent ductus arteriosus or vascular ring anomaly. Ductal size and morphology were determined in 6 dogs that underwent ECG-gated MDCT. Vascular ring anomalies were characterized in 7 dogs and 3 cats by ECG-gated MDCT or by a nongated thoracic standard protocol. Cardiac ECG-gated MDCT clearly displayed the morphology, length, and caliber of the patent ductus arteriosus in 6 affected dogs. Persistent right aortic arch was identified in 10 animals, 8 of which showed a coexisting aberrant left subclavian artery. A mild dilation of the proximal portion of the aberrant subclavian artery near its origin of the aorta was present in 4 dogs, and a diverticulum analogous to the human Kommerell's diverticulum was present in 2 cats. Conclusions Contrast-enhanced MDCT imaging of thoracic anomalies gives valuable information about the exact aortic arch configuration. Furthermore, MDCT was able to characterize the vascular branching patterns in dogs and cats with a persistent right aortic arch and the morphology and size of the patent ductus arteriosus in affected dogs. This additional information can be of help with regard to improved diagnoses of thoracic anomalies and the planning of surgical interventions. PMID:21943366

Does the arterial cannulation site for circulatory arrest influence stroke risk?

PubMed

Svensson, Lars G; Blackstone, Eugene H; Rajeswaran, Jeevanantham; Sabik, Joseph F; Lytle, Bruce W; Gonzalez-Stawinski, Gonzalo; Varvitsiotis, Poseidon; Banbury, Michael K; McCarthy, Patrick M; Pettersson, Gösta B; Cosgrove, Delos M

2004-10-01

We investigated whether axillary/subclavian artery inflow with a side graft decreases the risk of stroke versus cannulation at other sites during hypothermic circulatory arrest. Between January 1993 and May 2003, 1,352 operations with circulatory arrest were performed for complex adult cardiac problems. A single arterial inflow cannulation site was used in 1,336 operations, and these formed the basis for comparative analyses. Cannulation sites were axillary plus graft in 299 operations, direct cannulation of the aorta in 471, femoral in 375, innominate in 24, and axillary or subclavian without a side graft in 167. Retrograde brain perfusion was used in 933 (69%). A total of 272 (20%) were for emergencies, 432 (32%) were reoperations, and 439 (32%) were for dissections. A total of 617 (46%) had aortic valve replacement and 1,160 (87%) ascending, 415 arch (31%), and 248 descending (18%) aortic replacements. Indications also included arteriosclerosis (n = 301) and calcified aorta (n = 278). Primary comparisons were made by using propensity matching, and, secondarily, risk factors for stroke or hospital mortality were identified by multivariable logistic regression. Stroke occurred in 6.1% of patients (81/1,336): 4.0% (12/299) of those had axillary plus graft and 6.7% who had direct cannulation (69/1,037; p = 0.09; p = 0.05 among propensity-matched pairs). Operative variables associated with stroke included direct aortic cannulation, aortic arteriosclerosis, descending aorta repair, and mitral valve replacement. The risk of hospital mortality was higher (11%; 42/375) for patients who had femoral cannulation than axillary plus graft (7.0%; 21/299; p = 0.06; p = 0.02 among propensity-matched pairs). Axillary inflow plus graft reduces stroke and is our method of choice for complex cardiac and cardioaortic operations that necessitate circulatory arrest. Retrograde or antegrade perfusion is used selectively.

Prenatal Diagnosis of Fetal Interrupted Aortic Arch Type A by Two-Dimensional Echocardiography and Four-Dimensional Echocardiography with B-Flow Imaging and Spatiotemporal Image Correlation.

PubMed

Zhang, Dongyu; Zhang, Ying; Ren, Weidong; Sun, Feifei; Guo, Yajun; Sun, Wei; Wang, Yu; Huang, Liping; Cai, Ailu

2016-01-01

Fetal interrupted aortic arch (IAA) is a rare cardiac anomaly and its prenatal diagnosis is challenging. The purpose of our report is to evaluate the use of two-dimensional echocardiography (2DE) and 4D echocardiography with B-flow imaging and spatiotemporal image correlation (4D BF-STIC) in detecting IAA type A (IAA-A). Twenty-three cases of confirmed IAA-A identified by fetal echocardiography were involved in the study. The fetal echocardiography image data were reviewed to analyze the ratio of right ventricle to left ventricle (RV/LV) diameter, the ratio of main pulmonary artery to ascending aorta (MPA/AAO) diameter, and the correlation of RV/LV diameter ratio and size of ventricular septal defect (VSD). 4D BF-STIC was performed in 21 fetuses using the sagittal view (4D BF-STIC-sagittal) and the four-chamber view (4D BF-STIC-4CV) as initial planes of view. An additional 183 normal fetuses were also included in our study. RV/LV and MPA/AAO ratios were calculated and compared with that of IAA-A fetuses. Fetal 2DE, 4D BF-STIC-sagittal, and 4D BF-STIC-4CV were used to visualize the aortic arch and its associated neck vessels. Six subgroups were evaluated according to gestational age. Fetal 2DE, 4D BF-STIC-sagittal, and 4D BF-STIC-4CV made the correct prenatal diagnosis of IAA-A in 19/23 (82.6%), 14/21 (66.7%), and 19/21 (90.5%) of patients, respectively. A significantly enlarged MPA combined with symmetric ventricles was found in the IAA-A fetuses, while the size of the VSD was negatively correlated with RV/LV ratio. 4D BF-STIC-sagittal and 4D BF-STIC-4CV were better than traditional 2D ultrasound in detecting the aortic arch and neck vessels between 17 and 28 gestational weeks and 29 to 40 gestational weeks in normal fetuses. It is demonstrated that IAA-A could be diagnosed by traditional fetal echocardiography, while 4D technique could better display the anatomic structure and the spatial relationships of the great arteries. Use of volume reconstruction may promote its clinical usage and help prenatal diagnosis. © 2015, Wiley Periodicals, Inc.

New Paradigms and Improved Results for the Surgical Treatment of Acute Type A Dissection

PubMed Central

Bavaria, Joseph E.; Pochettino, Alberto; Brinster, Derek R.; Gorman, Robert C.; McGarvey, Michael L.; Gorman, Joseph H.; Escherich, Alison; Gardner, Timothy J.

2001-01-01

Objective To examine the effect of an integrated surgical approach to the treatment of acute type A dissections. Summary Background Data Acute type A dissection requires surgery to prevent death from proximal aortic rupture or malperfusion. Most series of the past decade have reported a death rate in the range of 15% to 30%. Methods From January 1994 to March 2001, 104 consecutive patients underwent repair of acute type A dissection. All had an integrated operative management as follows: intraoperative transesophageal echocardiography; hypothermic circulatory arrest (HCA) with retrograde cerebral perfusion (RCP) to replace the aortic arch; HCA established after 5 minutes of electroencephalographic (EEG) silence in neuromonitored patients (66%) or after 45 minutes of cooling in patients who were not neuromonitored (34%); reinforcement of the residual arch tissue with a Teflon felt “neo-media”; cannulation of the arch graft to reestablish cardiopulmonary bypass at the completion of HCA (antegrade graft perfusion); and remodeling of the sinus of Valsalva segments with Teflon felt “neo-media” and aortic valve resuspension (78%) or replacement with a biologic or mechanical valved conduit (22%). Results Mean age was 59 ± 15 (range 22–86) years, with 71% men and 13% redo sternotomy after a previous cardiac procedure. Mean cardiopulmonary bypass time was 196 ± 50 minutes. Mean HCA with RCP time was 42 ± 12 minutes (range 19–84). Mean cardiac ischemic time was 140 ± 45 minutes. Eleven percent of patients presented with a preoperative neurologic deficit, and 5% developed a new cerebrovascular accident after dissection repair. The in-hospital death rate was 9%. Excluding the patients who presented neurologically unresponsive or with ongoing cardiopulmonary resuscitation (n = 5), the death rate was 4%. In six patients adverse cerebral outcomes were potentially avoided when immediate surgical fenestration was prompted by a sudden change in the EEG during cooling. Forty-five percent of neuromonitored patients required greater than 30 minutes to achieve EEG silence. Conclusion The authors have shown that the surgical integration of sinus segment repair or aortic root replacement, the use of EEG monitoring, partial or total arch replacement using RCP, routine antegrade graft perfusion, and the uniform use of transesophageal echocardiography substantially decrease the death and complication rates of acute type A dissection repair. PMID:11524586

Aortic valve repair using a differentiated surgical strategy.

PubMed

Langer, Frank; Aicher, Diana; Kissinger, Anke; Wendler, Olaf; Lausberg, Henning; Fries, Roland; Schäfers, Hans-Joachim

2004-09-14

Reconstruction of the aortic valve for aortic regurgitation (AR) remains challenging, in part because of not only cusp or root pathology but also a combination of both can be responsible for this valve dysfunction. We have systematically tailored the repair to the individual pathology of cusps and root. Between October 1995 and August 2003, aortic valve repair was performed in 282 of 493 patients undergoing surgery for AR and concomitant disease. Root dilatation was corrected by subcommissural plication (n=59), supracommissural aortic replacement (n=27), root remodeling (n=175), or valve reimplantation within a graft (n=24). Cusp prolapse was corrected by plication of the free margin (n=157) or triangular resection (n =36), cusp defects were closed with a pericardial patch (n=16). Additional procedures were arch replacement (n=114), coronary artery bypass graft (n=60) or mitral repair (n=24). All patients were followed-up (follow-up 99.6% complete), and cumulative follow-up was 8425 patient-months (mean, 33+/-27 months).Results- Eleven patients died in hospital (3.9%). Nine patients underwent reoperation for recurrent AR (3.3%). Actuarial freedom from AR grade > or =II at 5 years was 81% for isolated valve repair, 84% for isolated root replacement, and 94% for combination of both; actuarial freedom from reoperation at 5 years was 93%, 95%, and 98%, respectively. No thromboembolic events occurred, and there was 1 episode of endocarditis 4.5 years postoperatively. Aortic valve repair is feasible even for complex mechanisms of AR with a systematic and individually tailored approach. Operative mortality is low and mid-term durability is encouraging. The incidence of valve-related morbidity is low compared with valve replacement.

Cardiovascular operations for Loeys-Dietz syndrome: Intermediate-term results.

PubMed

Patel, Nishant D; Crawford, Todd; Magruder, J Trent; Alejo, Diane E; Hibino, Narutoshi; Black, James; Dietz, Harry C; Vricella, Luca A; Cameron, Duke E

2017-02-01

Early experience with Loeys-Dietz syndrome (LDS) suggested an aggressive aortopathy with high risk of aneurysm dissection and rupture at young ages and at smaller aortic diameters than in other connective tissue disorders. We reviewed our experience with LDS to re-examine our indications and outcomes of surgical management. We reviewed all patients with a diagnosis of LDS who underwent cardiovascular surgery at our institution. The primary endpoint was mortality, and secondary endpoints included postoperative complications and need for reintervention. Seventy-nine operated patients with LDS were identified. Mean age at first operation was 25 years, 39 (49%) were female, and 38 (48%) were children (age <18 years). Six (8%) patients presented with acute dissection. Five (6%) patients had a bicuspid aortic valve, and all presented with an ascending aortic aneurysm with a mean root diameter of 3.5cm. Twenty (25%) patients had a previous sternotomy. Sixty-five (82%) patients underwent aortic root replacement, of whom 52 underwent a valve-sparing operation and 4 had concomitant arch replacement. Mean aortic root diameter in this group was 4.2 cm. Nine (11%) patients underwent aortic arch replacement, 2 (3%) had isolated ascending aorta replacement, and 3 (4%) underwent open thoracoabdominal repair. There were 2 (3%) operative and 8 late deaths. Nineteen patients underwent subsequent operations for late aneurysm and/or dissection. Mean follow-up was 6 years (range 0-24 years). Kaplan-Meier survival was 88% at 10 years. Growing experience with LDS has confirmed early impressions of its aggressive nature and proclivity toward aortic catastrophe. Surgical outcomes are favorable, but reintervention rates are high. Meticulous follow-up with cardiovascular surveillance imaging remain important for management, particularly as clinical LDS subtypes are characterized and more tailored treatment is developed. Copyright © 2016 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

Cardiovascular hoarseness: an unusual presentation to otolaryngologists.

PubMed

Fennessy, B G; Sheahan, P; McShane, D

2008-03-01

We discuss the case of a 73-year-old woman with a six-month history of hoarseness secondary to an aortic arch pseudoaneurysm. We present the findings of an extensive review of the literature relating to cardiovascular disorders involving the recurrent laryngeal nerve (i.e. Ortner's syndrome). Ortner's syndrome, also known as cardiovocal syndrome, is a rare condition, with few reports in the literature. This is only the second documented case of Ortner's syndrome in Great Britain and Ireland, and the first demonstrating an aortic pseudoaneurysm.

Efficacy and durability of the chimney graft technique in urgent and complex thoracic endovascular aortic repair.

PubMed

Bin Jabr, Adel; Lindblad, Bengt; Dias, Nuno; Resch, Timothy; Malina, Martin

2015-04-01

This study reports the early and midterm to long-term experience of chimney grafts (CGs) in urgent endovascular repair of complex lesions in the thoracic aorta. Twenty-nine high-risk patients (20 men) who were unfit for open repair were treated using CG technique for ruptured (n = 14) or symptomatic (n = 15) aortic lesions engaging the aortic arch itself (n = 9), the descending aorta (n = 10), or the thoracoabdominal aorta (n = 10). Twenty-two patients (76%) were treated urgently (≤24 hours) and seven were semiurgent (≤3 days). Of 41 chimneys used, 24 were placed in supra-aortic branches and 17 in visceral branches. Median follow-up (interquartile range) for the entire cohort was 2 years (0.6-3.8 years), 2.5 years (1-4 years) for 30-day survivors, and 3.5 years (1.9-6.4 years) for those who were still alive. Four patients (14%) died ≤30 days of cerebral infarction (n = 1), visceral ischemia secondary to the initial rupture (n = 1), multiple organ failure (n = 1), or heart failure (n = 1). There were 11 late deaths (38%); however, only two deaths were related to the CG technique. The primary and secondary technical success rates were 86% (25 of 29) and 97% (28 of 29), respectively. The secondary patency rate of CGs was 98%. Seventeen (68%) of the aortic lesions shrank significantly. Three patients (10%) had primary type I endoleak and another three (10%) had secondary type I endoleak. The endoleaks were managed with Onyx (ev3 Endovascular, Inc, Plymouth, Minn) or coil embolization (n = 2), restenting (n = 1), and conversion to open repair (n = 2). One secondary endoleak is still under observation after >20 months. All primary endoleaks and one secondary endoleak originated from CGs in the brachiocephalic trunk (4 of 6 [67%]). The midterm to long-term results of the CG technique for urgent and complex lesions of the thoracic aorta in high-risk patients are promising, with low early mortality and long durability of the CGs. More patients with longer follow-up are still needed. Copyright © 2015 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.

Kabuki syndrome in a girl with mosaic 45,X/47,XXX and aortic coarctation.

PubMed

Chen, Chih-Ping; Lin, Shuan-Pei; Tsai, Fuu-Jen; Chern, Schu-Rern; Wang, Wayseen

2008-06-01

To describe the clinical findings of a patient with mosaic 45,X/47,XXX and aortic coarctation. Descriptive case study. Tertiary medical center. A 6-year-old girl with stigmata of Turner syndrome, aortic coarctation, patent ductus arteriosus, and a peculiar facial appearance. None. Cytogenetic analysis. The patient manifested a characteristic Kabuki syndrome facial appearance with long palpebral fissures, everted lateral third of lower eyelids, arched eyebrows, a depressed nasal tip, large dysplastic ears and epicanthic folds. She had undergone cardiac surgery for treatment of aortic coarctation and patent ductus arteriosus. Cytogenetic analysis of the blood lymphocytes revealed a karyotype of mos 45,X,9ph [35 cells]/47,XXX,9ph [5 cells]. This is the first report of mosaic 45,X/47,XXX associated with Kabuki syndrome. We emphasize that Kabuki syndrome, a peculiar facial appearance and aortic coarctation, should be considered in girls with sex chromosome abnormalities.

Preoperative Evaluation and Endovascular Procedure of Intraoperative Aneurysm Rupture During Thoracic Endovascular Aortic Repair

DOE Office of Scientific and Technical Information (OSTI.GOV)

Zha, Bin-Shan, E-mail: binszha2013@163.com; Zhu, Hua-Gang, E-mail: huagzhu@yeah.net; Ye, Yu-Sheng, E-mail: yeyusheng@aliyun.com

Thoracic aortic aneurysms are now routinely repaired with endovascular repair if anatomically feasible because of advantages in safety and recovery. However, intraoperative aneurysm rupture is a severe complication which may have an adverse effect on the outcome of treatment. Comprehensive preoperative assessment and considerate treatment are keys to success of endovascular aneurysm repair, especially during unexpected circumstances. Few cases have reported on intraoperative aortic rupture, which were successfully managed by endovascular treatment. Here, we present a rare case of an intraoperative aneurysm rupture during endovascular repair of thoracic aortic aneurysm with narrow neck and angulated aorta arch (coarctation-associated aneurysm), whichmore » was successfully treated using double access route approach and iliac limbs of infrarenal devices.Level of EvidenceLevel 5.« less

True-lumen and false-lumen diameter changes in the downstream aorta after frozen elephant trunk implantation.

PubMed

Berger, Tim; Kreibich, Maximilian; Morlock, Julia; Kondov, Stoyan; Scheumann, Johannes; Kari, Fabian A; Rylski, Bartosz; Siepe, Matthias; Beyersdorf, Friedhelm; Czerny, Martin

2018-02-19

To evaluate early and mid-term clinical outcomes and to assess the potential of the frozen elephant trunk technique to induce remodelling of downstream aortic segments in acute and chronic thoracic aortic dissections. Over a 4-year period, 65 patients (48 men, aged 61 ± 12 years) underwent total aortic arch replacement using the frozen elephant trunk technique for acute (n = 31) and chronic (n = 34) thoracic aortic dissections at our institution. We assessed diameter changes at 3 levels: the L1 segment at the stent graft level; the L2 segment at the thoraco-abdominal transition level and the L3 segment at the coeliac trunk level. True-lumen (TL) and false-lumen (FL) diameter changes were assessed at each level. Fifty-six percent of patients had already undergone previous aortic or cardiac surgery. In-hospital mortality was 6%. Symptomatic spinal cord injury was not observed in this series. During a mean follow-up of 12 ± 12 months, late death was observed in 6% of patients. Aortic reinterventions in downstream aortic segments were performed in 28% at a mean of 394 ± 385 days. TL expansion and FL shrinkage were measured in all segments and were observed at each level. This effect was the most pronounced at the level of the stent graft in patients with chronic aortic dissection, TL diameter increased from 15 ± 17 mm before surgery to 28 ± 2 mm (P = 0.001) after 2 years, and the FL diameter decreased from 40 ± 11 mm before surgery to 32 ± 17 mm (P = 0.026). The frozen elephant trunk technique is associated with an excellent clinical outcome in a complex cohort of patients, and also effectively induces remodelling in downstream aortic segments in acute and chronic thoracic aortic dissections. The need for secondary interventions in downstream segments, which mainly depends on the extent of the underlying disease process, remains substantial. Further studies are required to assess the long-term outcome of this approach.

The utility of chest X-ray as a screening tool for blunt thoracic aortic injury.

PubMed

Gutierrez, Adam; Inaba, Kenji; Siboni, Stefano; Effron, Zachary; Haltmeier, Tobias; Jaffray, Paul; Reddy, Sravanthi; Lofthus, Alexander; Benjamin, Elizabeth; Dubose, Joseph; Demetriades, Demetrios

2016-01-01

The early and accurate identification of patients with blunt thoracic aortic injury (BTAI) remains a challenge. Traditionally, a portable AP chest X-ray (CXR) is utilized as the initial screening modality for BTAI, however, there is controversy surrounding its sensitivity. The purpose of this study was to assess the sensitivity of CXR as a screening modality for BTAI. After IRB approval, all adult (≥18 yo) blunt trauma patients admitted to LAC+USC (01/2011-12/2013) who underwent CXR and chest CT were retrospectively reviewed. Final radiology attending CXR readings were reviewed for mediastinal abnormalities (widened mediastinum, mediastinal to chest width ratio greater than 0.25, irregular aortic arch, blurred aortic contour, opacification of the aortopulmonary window, and apical pleural haematoma) suggestive of aortic injury. Chest CT final attending radiologist readings were utilized as the gold standard for diagnosis of BTAI. The primary outcome analyzed was CXR sensitivity. A total of 3728 patients were included in the study. The majority of patients were male (72.6%); mean age was 43 (SD 20). Median ISS was 9 (IQR 4-17) and median GCS was 15 (IQR 14-15). The most common mechanism of injury was MVC (48.0%), followed by fall (20.6%), and AVP (16.9%). The total number of CXRs demonstrating a mediastinal abnormality was 200 (5.4%). Widened mediastinum was present on 191 (5.1%) of CXRs, blurred aortic contour on 10 (0.3%), and irregular aortic arch on 4 (0.1%). An acute aortic injury confirmed by chest CT was present in 17 (0.5%) patients. Only 7 of these with CT-confirmed BTAI had a mediastinal abnormality identified on CXR, for a sensitivity of 41% (95% CI: 19-67%). The results from this study suggest that CXR alone is not a reliable screening modality for BTAI. A combination of screening CXR and careful consideration of other factors, such as mechanism of injury, will be required to effectively discriminate between those who should and should not undergo chest CT. Copyright © 2015 Elsevier Ltd. All rights reserved.

DOE Office of Scientific and Technical Information (OSTI.GOV)

Chan, Gabriel, E-mail: dr.changabriel@gmail.com; Quek, Lawrence Hwee Han, E-mail: lawrence-quek@ttsh.com.sg; Tan, Glenn Leong Wei, E-mail: glenn-tan@ttsh.com.sg

BackgroundInsertion of a carotid chimney graft during thoracic endovascular aortic repair (Ch-TEVAR) is a recognized technique to extend the proximal landing zone into the aortic arch in the treatment of thoracic aortic disease. Conventional technique requires surgical exposure of the carotid artery for insertion of the carotid chimney graft.MethodologyWe describe our experience in the use of a suture-mediated closure device in percutaneous Ch-TEVAR in four patients.ResultsSuccessful hemostasis was achieved in all four patients. No complications related to the carotid puncture were recorded.ConclusionWe conclude that using suture-mediated closure device for carotid closure appears feasible and deserves further studies as a potentialmore » alternative to conventional surgical approach.« less

PAR2 (Protease-Activated Receptor 2) Deficiency Attenuates Atherosclerosis in Mice.

PubMed

Jones, Shannon M; Mann, Adrien; Conrad, Kelsey; Saum, Keith; Hall, David E; McKinney, Lisa M; Robbins, Nathan; Thompson, Joel; Peairs, Abigail D; Camerer, Eric; Rayner, Katey J; Tranter, Michael; Mackman, Nigel; Owens, A Phillip

2018-06-01

PAR2 (protease-activated receptor 2)-dependent signaling results in augmented inflammation and has been implicated in the pathogenesis of several autoimmune conditions. The objective of this study was to determine the effect of PAR2 deficiency on the development of atherosclerosis. PAR2 mRNA and protein expression is increased in human carotid artery and mouse aortic arch atheroma versus control carotid and aortic arch arteries, respectively. To determine the effect of PAR2 deficiency on atherosclerosis, male and female low-density lipoprotein receptor-deficient ( Ldlr -/- ) mice (8-12 weeks old) that were Par2 +/+ or Par2 -/- were fed a fat- and cholesterol-enriched diet for 12 or 24 weeks. PAR2 deficiency attenuated atherosclerosis in the aortic sinus and aortic root after 12 and 24 weeks. PAR2 deficiency did not alter total plasma cholesterol concentrations or lipoprotein distributions. Bone marrow transplantation showed that PAR2 on nonhematopoietic cells contributed to atherosclerosis. PAR2 deficiency significantly attenuated levels of the chemokines Ccl2 and Cxcl1 in the circulation and macrophage content in atherosclerotic lesions. Mechanistic studies using isolated primary vascular smooth muscle cells showed that PAR2 deficiency is associated with reduced Ccl2 and Cxcl1 mRNA expression and protein release into the supernatant resulting in less monocyte migration. Our results indicate that PAR2 deficiency is associated with attenuation of atherosclerosis and may reduce lesion progression by blunting Ccl2 - and Cxcl1 -induced monocyte infiltration. © 2018 American Heart Association, Inc.

Does altered aortic flow in marfan syndrome relate to aortic root dilatation?

PubMed

Wang, Hung-Hsuan; Chiu, Hsin-Hui; Tseng, Wen-Yih Isaac; Peng, Hsu-Hsia

2016-08-01

To examine possible hemodynamic alterations in adolescent to adult Marfan syndrome (MFS) patients with aortic root dilatation. Four-dimensional flow MRI was performed in 20 MFS patients and 12 age-matched normal subjects with a 3T system. The cross-sectional areas of 10 planes along the aorta were segmented for calculating the axial and circumferential wall shear stress (WSSaxial , WSScirc ), oscillatory shear index (OSIaxial , OSIcirc ), and the nonroundness (NR), presenting the asymmetry of segmental WSS. Pearson's correlation analysis was performed to present the correlations between the quantified indices and the body surface area (BSA), aortic root diameter (ARD), and Z score of the ARD. P < 0.05 indicated statistical significance. Patients exhibited lower WSSaxial in the aortic root and the WSScirc in the arch (P < 0.05-0.001). MFS patients exhibited higher OSIaxial and OSIcirc in the sinotubular junction and arch, but lower OSIcirc in the descending aorta (all P < 0.05). The NR values were lower in patients (P < 0.05). The WSSaxial or WSScirc exhibited moderate to strong correlations with BSA, ARD, or Z score (R(2)  = 0.50-0.72) in MFS patients. The significant differences in the quantified indices, which were associated with BSA, ARD, or Z score, in MFS were opposite to previous reports for younger MFS patients, indicating that altered flows in MFS patients may depend on the disease progress. The possible time dependency of hemodynamic alterations in MFS patients strongly suggests that longitudinal follow-up of 4D Flow is needed to comprehend disease progress. J. Magn. Reson. Imaging 2016;44:500-508. © 2016 Wiley Periodicals, Inc.

The DeBakey classification exactly reflects late outcome and re-intervention probability in acute aortic dissection with a slightly modified type II definition.

PubMed

Tsagakis, Konstantinos; Tossios, Paschalis; Kamler, Markus; Benedik, Jaroslav; Natour, Dorgam; Eggebrecht, Holger; Piotrowski, Jarowit; Jakob, Heinz

2011-11-01

The DeBakey classification was used to discriminate the extent of acute aortic dissection (AD) and was correlated to long-term outcome and re-intervention rate. A slight modification of type II subgroup definition was applied by incorporating the aortic arch, when full resectability of the dissection process was given. Between January 2001 and March 2010, 118 patients (64% male, mean age 59 years) underwent surgery for acute AD. As many as 74 were operated on for type I and 44 for type II AD. Complete resection of all entry sites was performed, including antegrade stent grafting for proximal descending lesions. Patients were comparable with respect to demographics and preoperative hemodynamic status. They underwent isolated ascending replacement, hemiarch, or total arch replacement in 7%, 26%, and 67% in type I, versus 27%, 37%, and 36% in type II, respectively. Additional descending stent grafting was performed in 33/74 (45%) type I patients. In-hospital mortality was 14%, 16% (12/74) in type I versus 9% (4/44, type II), p=0.405. After 5 years, the estimated survival rate was 63% in type I versus 80% in type II, p=0.135. In type II, no distal aortic re-intervention was required. In type I, the freedom of distal re-interventions was 82% in patients with additional stent grafting versus 53% in patients without, p=0.022. The slightly modified DeBakey classification exactly reflects late outcome and aortic re-intervention probability. Thus, in type II patients, the aorta seems to be healed without any probability of later re-operation or re-intervention. Copyright © 2011 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

Does altered aortic flow in marfan syndrome relate to aortic root dilatation?

PubMed Central

Wang, Hung‐Hsuan; Chiu, Hsin‐Hui; Tseng, Wen‐Yih Isaac

2016-01-01

Purpose To examine possible hemodynamic alterations in adolescent to adult Marfan syndrome (MFS) patients with aortic root dilatation. Materials and Methods Four‐dimensional flow MRI was performed in 20 MFS patients and 12 age‐matched normal subjects with a 3T system. The cross‐sectional areas of 10 planes along the aorta were segmented for calculating the axial and circumferential wall shear stress (WSSaxial, WSScirc), oscillatory shear index (OSIaxial, OSIcirc), and the nonroundness (NR), presenting the asymmetry of segmental WSS. Pearson's correlation analysis was performed to present the correlations between the quantified indices and the body surface area (BSA), aortic root diameter (ARD), and Z score of the ARD. P < 0.05 indicated statistical significance. Results Patients exhibited lower WSSaxial in the aortic root and the WSScirc in the arch (P < 0.05–0.001). MFS patients exhibited higher OSIaxial and OSIcirc in the sinotubular junction and arch, but lower OSIcirc in the descending aorta (all P < 0.05). The NR values were lower in patients (P < 0.05). The WSSaxial or WSScirc exhibited moderate to strong correlations with BSA, ARD, or Z score (R2 = 0.50–0.72) in MFS patients. Conclusion The significant differences in the quantified indices, which were associated with BSA, ARD, or Z score, in MFS were opposite to previous reports for younger MFS patients, indicating that altered flows in MFS patients may depend on the disease progress. The possible time dependency of hemodynamic alterations in MFS patients strongly suggests that longitudinal follow‐up of 4D Flow is needed to comprehend disease progress. J. Magn. Reson. Imaging 2016;44:500–508. PMID:26854646

Micro-computed Tomography Provides High Accuracy Congenital Heart Disease Diagnosis in Neonatal and Fetal Mice

PubMed Central

Kim, Andrew J.; Francis, Richard; Liu, Xiaoqin; Devine, William A.; Ramirez, Ricardo; Anderton, Shane J.; Wong, Li Yin; Faruque, Fahim; Gabriel, George C.; Leatherbury, Linda; Tobita, Kimimasa; Lo, Cecilia W.

2013-01-01

Background Mice are well suited for modeling human congenital heart defects (CHD), given their four-chamber cardiac anatomy. However, mice with CHD invariably die prenatally/neonatally, causing CHD phenotypes to be missed. Therefore, we investigated the efficacy of noninvasive micro-computed tomography (micro-CT) to screen for CHD in stillborn/fetal mice. These studies were carried out using chemically mutagenized mice expected to be enriched for birth defects including CHD. Methods and Results Stillborn/fetal mice obtained from the breeding of N-ethyl-N-nitrosourea (ENU) mutagenized mice were formalin-fixed and stained with iodine, then micro-CT scanned. Those diagnosed with CHD and some CHD-negative pups were necropsied. A subset of these were further analyzed by histopathology to confirm the CHD/no-CHD diagnosis. Micro-CT scanning of 2105 fetal/newborn mice revealed an abundance of ventricular septal defects (VSD) (n=307). Overall, we observed an accuracy of 89.8% for VSD diagnosis. Outflow tract anomalies identified by micro-CT included double outlet right ventricle (n=36), transposition of the great arteries (n=14), and persistent truncus arteriosus (n=3). These were diagnosed with a 97.4% accuracy. Aortic arch anomalies also were readily detected with an overall 99.6% accuracy. This included right aortic arch (n=28) and coarctation/interrupted aortic arch (n=12). Also detected by micro-CT were atrioventricular septal defects (n=22), tricuspid hypoplasia/atresia (n=13), and coronary artery fistulas (n=16). They yielded accuracies of 98.9%, 100%, and 97.8% respectively. Conclusions Contrast enhanced micro-CT imaging in neonatal/fetal mice can reliably detect a wide spectrum of CHD. We conclude micro-CT imaging can be used for routine rapid assessments of structural heart defects in fetal/newborn mice. PMID:23759365

Massive hemorrhage after Kasai portoenterostomy in a patient with a congenital extrahepatic portosystemic shunt, malrotation and a double aortic arch: report of a case.

PubMed

Takazawa, Shinya; Uchida, Hiroo; Kawashima, Hiroshi; Tanaka, Yujiro; Sato, Kaori; Jimbo, Takahiro; Deie, Kyoichi; Koiwai, Kazuki; Nomura, Koji; Iwanaka, Tadashi

2014-08-01

A newborn female was transferred to our hospital presenting with severe respiratory distress. She underwent tracheal intubation and nasogastric tubing. Investigations revealed a congenital extrahepatic portosystemic shunt (CEPS) type 1, biliary atresia, heterotaxia, polysplenia, malrotation and a double aortic arch (DAA). She underwent the Kasai portoenterostomy and the Ladd procedure when she was 29 days old. On postoperative day 20, she developed sudden hematemesis with bright red blood. Endoscopy showed massive bleeding from an esophageal ulcer, and endoscopic therapy was performed successfully. During left thoracotomy, an aortoesophageal fistula (AEF) was detected and repaired by direct suturing. The postoperative course was uneventful. CEPS type 1 is commonly associated with other congenital malformations; however, there have been no previous reports of an association between CEPS and DAA. Nasogastric tube insertion in a patient with DAA can result in catastrophic AEF. The treatment strategy should be carefully considered in patients with CEPS type 1 and multiple congenital fetal anomalies.

Goal-directed-perfusion in neonatal aortic arch surgery.

PubMed

Cesnjevar, Robert Anton; Purbojo, Ariawan; Muench, Frank; Juengert, Joerg; Rueffer, André

2016-07-01

Reduction of mortality and morbidity in congenital cardiac surgery has always been and remains a major target for the complete team involved. As operative techniques are more and more standardized and refined, surgical risk and associated complication rates have constantly been reduced to an acceptable level but are both still present. Aortic arch surgery in neonates seems to be of particular interest, because perfusion techniques differ widely among institutions and an ideal form of a so called "total body perfusion (TBP)" is somewhat difficult to achieve. Thus concepts of deep hypothermic circulatory arrest (DHCA), regional cerebral perfusion (RCP/with cardioplegic cardiac arrest or on the perfused beating heart) and TBP exist in parallel and all carry an individual risk for organ damage related to perfusion management, chosen core temperature and time on bypass. Patient safety relies more and more on adequate end organ perfusion on cardiopulmonary bypass, especially sensitive organs like the brain, heart, kidney, liver and the gut, whereby on adequate tissue protection, temperature management and oxygen delivery should be visualized and monitored.

A comparative study of quantitative assessment with fluorine-18-fluorodeoxyglucose positron-emission tomography and endoscopic ultrasound in oesophageal cancer.

PubMed

Borakati, Aditya; Razack, Abdul; Cawthorne, Chris; Roy, Rajarshi; Usmani, Sharjeel; Ahmed, Najeeb

2018-07-01

This study aims to assess the correlation between PET/CT and endoscopic ultrasound (EUS) parameters in patients with oesophageal cancer. All patients who had complete PET/CT and EUS staging performed for oesophageal cancer at our centre between 2010 and 2016 were included. Images were retrieved and analysed for a range of parameters including tumour length, volume and position relative to the aortic arch. Seventy patients were included in the main analysis. A strong correlation was found between EUS and PET/CT in the tumour length, the volume and the position of the tumour relative to the aortic arch. Regression modelling showed a reasonable predictive value for PET/CT in calculating EUS parameters, with r higher than 0.585 in some cases. Given the strong correlation between EUS and PET parameters, fluorine-18 fluorodeoxyglucose (F-FDG) PET can provide accurate information on the length and the volume of tumour in patients who either cannot tolerate EUS or have impassable strictures.

H+/K+-ATPase-Inhibition Causes Left-Right Aortic Arch Inversion in Mouse Development.

PubMed

Miyachi, Yukihisa

2017-09-01

An organ known as a "node" forms during embryogenesis and plays a vital role in determining laterality in vertebrates. However, according to some reports in vertebrates, left-right patterning may be determined long before the node has developed. In this study, we analyzed left-right asymmetry formation in mammals based on ion-signaling factors, which has never been attempted before. First, a proton pump inhibitor was injected into pregnant mice to investigate whether H + /K + -ATPase is involved in the differentiation of pharyngeal arch arteries during embryonic development. Injection of 30 mg/kg of lansoprazole early in the organogenesis period increased the penetrance of right aortic arch formation by 34% compared to a saline injection. Furthermore, administration of a proton pump inhibitor resulted in strong expression of PI3K/phosphor-AKT, which led to potent inhibition of apoptosis induction factors such as BAD. This could relate to why the right pharyngeal arch arteries, which should have disappeared during differentiation, remained intact. The other important point is that proton pump inhibitors suppressed calcineurin signaling, and Wnt5a expression was significantly higher than in the controls. This research is particularly notable for demonstrating that administration of an H + /K + -ATPase inhibitor could cause dextroposition of the fetal vasculature. Moreover, since previous publications have reported that H + /K + -ATPase plays a role in asymmetry in other species, this article adds important information for developmental biology in that the role of H + /K + -ATPase in asymmetry is conserved in the mouse model, suggesting that rodents are not unique and that a common mechanism may function across vertebrates.

[Intravascular Hemolysis Caused by Stenosis of an Elephant Trunk;Report of a Case].

PubMed

Takamaru, Rikako; Kawahito, Koji; Aizawa, Kei; Misawa, Yoshio

2017-07-01

Symptomatic intravascular hemolysis after prosthetic aortic graft replacement is rare. It is primarily attributed to mechanical injury of red blood cells caused by stenosis of the vascular graft. A 50-year-old man presented with hemolytic anemia, 5 years after total arch replacement with an elephant trunk for type A aortic dissection. The hemolysis was caused by graft stenosis of the elephant trunk. Endovascular treatment for the stenotic elephant trunk was successfully performed. The postoperative course was uneventful, and the hemolysis was resolved immediately after operation.

Anterior spinal artery aneurysm in aortic stenosis of different etiology: Report of three cases.

PubMed

Singh, Vivek; Naik, Suprava; Bhoi, Sanjeev K; Phadke, R V

2017-04-01

Isolated aneurysms of spinal arteries are rare. Spinal artery aneurysms are commonly found in association with spinal cord arteriovenous malformation and coarctation of aorta and rarely with aortic arch interruption and Klippel-Trenaunay syndrome. Spinal angiograms are the gold standard for diagnosing these spinal artery aneurysms but with the advances in computed tomography technology these aneurysms can also be very well demonstrated in computed tomography angiograms. We describe three cases of anterior spinal artery aneurysm, those are flow related aneurysms, associated with coarctation of aorta and with Takayasu arteritis.

Advantages of the L-incision approach comprising a combination of left anterior thoracotomy and upper half-median sternotomy for aortic arch aneurysms.

PubMed

Oishi, Yasuhisa; Sonoda, Hiromichi; Tanoue, Yoshihisa; Nishida, Takahiro; Tokunaga, Shigehiko; Nakashima, Atsuhiro; Shiokawa, Yuichi; Tominaga, Ryuji

2011-09-01

Although surgical outcomes of total arch replacement have improved, the strategy for extended arch aneurysms remains controversial. We have applied the L-incision approach (combination of left anterior thoracotomy and upper half-median sternotomy) for total arch replacement for single-stage repair of extensive arch aneurysms. We retrospectively reviewed the operative outcomes of patients who underwent total arch or extended total arch replacement for degenerative aneurysms from 1999 to 2010. Operations were performed via median sternotomy in 47 patients (M group) and the L-incision approach was used in 38 patients (L group). Through the L-incision approach, we were able to complete distal anastomosis below the pulmonary hilus. The L-incision approach has advantages of reducing selective antegrade cerebral perfusion and lower body circulatory arrest times compared with the M group. Recurrent laryngeal nerve palsy and renal dysfunction were less frequent in the L group than those in the M group. Respiratory dysfunction and wound infection were similar between the groups. Hospital mortalities were 5.3% in the L group and 6.4% in the M group. The L-incision approach has similar or better postoperative outcomes compared with the median sternotomy approach. This approach could be useful for single-stage extended total arch replacement with relatively low risk.

Inactivation of Bmp4 from the Tbx1 Expression Domain Causes Abnormal Pharyngeal Arch Artery and Cardiac Outflow Tract Remodeling

PubMed Central

Nie, Xuguang; Brown, Christopher B.; Wang, Qin; Jiao, Kai

2011-01-01

Maldevelopment of outflow tract and aortic arch arteries is among the most common forms of human congenital heart diseases. Both Bmp4 and Tbx1 are known to play critical roles during cardiovascular development. Expression of these two genes partially overlaps in pharyngeal arch areas in mouse embryos. In this study, we applied a conditional gene inactivation approach to test the hypothesis that Bmp4 expressed from the Tbx1 expression domain plays a critical role for normal development of outflow tract and pharyngeal arch arteries. We showed that inactivation of Bmp4 from Tbx1-expressing cells leads to the spectrum of deformities resembling the cardiovascular defects observed in human DiGeorge syndrome patients. Inactivation of Bmp4 from the Tbx1 expression domain did not cause patterning defects, but affected remodeling of outflow tract and pharyngeal arch arteries. Our further examination revealed that Bmp4 is required for normal recruitment/differentiation of smooth muscle cells surrounding the PAA4 and survival of outflow tract cushion mesenchymal cells. PMID:21123999

Coronary reconnection in emergency "conduit operation" for acute type-a aortic dissection with aortic insufficiency: experience with 24 cases.

PubMed

Massimo, C G; Presenti, L F; Favi, P P; Duranti, A; Poma, A G; Marranci, P; Modiano, C

1987-12-01

Twenty-four cases of acute type-A aortic dissection with aortic valvular insufficiency were treated in our institution by means of an emergency operation in which the aortic valve, ascending aorta, and aortic arch were resected and replaced with a valved conduit that had been lengthened with a tubular Dacron graft. The procedure included the use of deep hypothermia for cerebral protection, as well as extracorporeal circulation. Aortic resection was performed from the aortic valve to the origin of the descending thoracic aorta; the aortic graft was anastomosed proximally to the valve annulus and distally to the descending aorta. The carotid orifices were connected to the side of the graft in a single tissue button. The coronary arteries were then reconnected by means of double venous bypass grafts to the innominate artery, to allow for inclusion of the graft. Within 1 month after operation, four patients died of the consequences of dissection. Six months postoperatively, one patient succumbed to an infarction. Six months to 5 years after operation, the remaining 19 patients are still alive. On the basis of this experience, we believe that acute type-A aortic dissection with aortic valvular insufficiency should be treated during the first hours after the onset of symptoms. The above-described procedure proved effective in the control of bleeding, which is the major risk in emergency operations of this type.

Genetic architecture of atherosclerosis dissected by QTL analyses in three F2 intercrosses of apolipoprotein E-null mice on C57BL6/J, DBA/2J and 129S6/SvEvTac backgrounds

PubMed Central

Makhanova, Natalia; Morgan, Andrew P.; Kayashima, Yukako; Makhanov, Andrei; Hiller, Sylvia; Zhilicheva, Svetlana; Xu, Longquan; Pardo-Manuel de Villena, Fernando; Maeda, Nobuyo

2017-01-01

Quantitative trait locus (QTL) analyses of intercross populations between widely used mouse inbred strains provide a powerful approach for uncovering genetic factors that influence susceptibility to atherosclerosis. Epistatic interactions are common in complex phenotypes and depend on genetic backgrounds. To dissect genetic architecture of atherosclerosis, we analyzed F2 progeny from a cross between apolipoprotein E-null mice on DBA/2J (DBA-apoE) and C57BL/6J (B6-apoE) genetic backgrounds and compared the results with those from two previous F2 crosses of apolipoprotein E-null mice on 129S6/SvEvTac (129-apoE) and DBA-apoE backgrounds, and B6-apoE and 129-apoE backgrounds. In these round-robin crosses, in which each parental strain was crossed with two others, large-effect QTLs are expected to be detectable at least in two crosses. On the other hand, observation of QTLs in one cross only may indicate epistasis and/or absence of statistical power. For atherosclerosis at the aortic arch, Aath4 on chromosome (Chr)2:66 cM follows the first pattern, with significant QTL peaks in (DBAx129)F2 and (B6xDBA)F2 mice but not in (B6x129)F2 mice. We conclude that genetic variants unique to DBA/2J at Aath4 confer susceptibility to atherosclerosis at the aortic arch. A similar pattern was observed for Aath5 on chr10:35 cM, verifying that the variants unique to DBA/2J at this locus protect against arch plaque development. However, multiple loci, including Aath1 (Chr1:49 cM), and Aath2 (Chr1:70 cM) follow the second type of pattern, showing significant peaks in only one of the three crosses (B6-apoE x 129-apoE). As for atherosclerosis at aortic root, the majority of QTLs, including Ath29 (Chr9:33 cM), Ath44 (Chr1:68 cM) and Ath45 (Chr2:83 cM), was also inconsistent, being significant in only one of the three crosses. Only the QTL on Chr7:37 cM was consistently suggestive in two of the three crosses. Thus QTL analysis of round-robin crosses revealed the genetic architecture of atherosclerosis. PMID:28837567

Deep Hypothermic Circulatory Arrest vs. Antegrade Cerebral Perfusion in Cerebral Protection during the Surgical Treatment of Chronic Dissection of the Ascending and Arch Aorta

PubMed Central

Kamenskaya, Oksana Vasilyevna; Klinkova, Asya Stanislavovna; Chernyavsky, Alexander Mikhailovich; Lomivorotov, Vladimir Vladimirovich; Meshkov, Ivan Olegovich; Karaskov, Alexander Mikhailovich

2017-01-01

Abstract: Circulatory arrest during aortic surgery presents a risk of neurological complications. The present study aimed to investigate the effectiveness of deep hypothermic circulatory arrest (DHCA) vs. antegrade cerebral perfusion (ACP) in cerebral protection during the surgical treatment of chronic dissection of the ascending and arch aorta and to assess the quality-of-life (QoL) in the long-term postoperative period with respect to the used cerebral protection method. In a prospective, randomized study, 58 patients with chronic type I aortic dissection who underwent ascending aorta and aortic arch replacement surgery were included. Patients were allocated in two groups: 29 patients who underwent surgery under moderate hypothermia (24°C) combined with ACP and 29 patients who underwent surgery under DHCA (18°C) with craniocerebral hypothermia. The regional hemoglobin oxygen saturation (rSO2, %) were compared during surgery, neurological complications were analyzed during the early postoperative period, QoL was compared in the long-term postoperative period (1-year follow-up). During the early postoperative period, 37.9% of patients in the DHCA group exhibited neurological complications, compared with 13.8% of those in the ACP group (p < .05). The risk of neurological complications in the early postoperative period was dependent on the extent of rSO2 decrease during circulatory arrest. In the ACP group, rSO2 decreased by ≤17% from baseline during circulatory arrest. In the DHCA group, a more profound decrease in rSO2 (>30%) was recorded (p < .05). QoL in the long-term period after surgery improved, but it was not dependent on the cerebral protection method used during surgery. ACP during aortic replacement demonstrated the most advanced properties of cerebral protection that can be evidenced by a lesser degree of neurological complications, compared with patients who underwent surgery under conditions of DHCA. QoL after surgery was not dependent on the cerebral protection method used during surgery. PMID:28298661

DOE Office of Scientific and Technical Information (OSTI.GOV)

Lotfi, S., E-mail: shamim.lotfi@kcl.ac.uk; Clough, R. E.; Ali, T.

Hybrid repair constitutes supra-aortic debranching before thoracic endovascular aortic repair (TEVAR). It offers improved short-term outcome compared with open surgery; however, longer-term studies are required to assess patient outcomes and patency of the extra-anatomic bypass grafts. A prospectively maintained database of 380 elective and urgent patients who had undergone TEVAR (1997-2011) was analyzed retrospectively. Fifty-one patients (34 males; 17 females) underwent hybrid repair. Median age was 71 (range, 18-90) years with mean follow-up of 15 (range, 0-61) months. Perioperative complications included death: 10 % (5/51), stroke: 12 % (6/51), paraplegia: 6 % (3/51), endoleak: 16 % (8/51), rupture: 4 %more » (2/51), upper-limb ischemia: 2 % (1/51), bypass graft occlusion: 4 % (2/51), and cardiopulmonary complications in 14 % (7/51). Three patients (6 %) required emergency intervention for retrograde dissection: (2 aortic root repairs; 2 innominate stents). Early reintervention was performed for type 1 endoleak in two patients (2 proximal cuff extensions). One patient underwent innominate stenting and revision of their bypass for symptomatic restenosis. At 48 months, survival was 73 %. Endoleak was detected in three (6 %) patients (type 1 = 2; type 2 = 1) requiring debranching with proximal stent graft (n = 2) and proximal extension cuff (n = 1). One patient had a fatal rupture of a mycotic aneurysm and two arch aneurysms expanded. No bypass graft occluded after the perioperative period. Hybrid operations to treat aortic arch disease can be performed with results comparable to open surgery. The longer-term outcomes demonstrate low rates of reintervention and high rates of graft patency.« less

The Transcranial Doppler Sonography for Optimal Monitoring and Optimization of Cerebral Perfusion in Aortic Arch Surgery: A Case Series.

PubMed

Ghazy, Tamer; Darwisch, Ayham; Schmidt, Torsten; Nguyen, Phong; Elmihy, Sohaila; Fajfrova, Zuzana; Zickmüller, Claudia; Matschke, Klaus; Kappert, Utz

2017-06-16

To analyze the feasibility and advantages of transcranial doppler sonography (TCD) for monitoring and optimization of selective cerebral perfusion (SCP) in aortic arch surgery. From April 2013 to April 2014, nine patients with extensive aortic pathology underwent surgery under moderate hypothermic cardiac arrest with unilateral antegrade SCP under TCD monitoring in our institution. Adequate sonographic window and visualization of circle of Willis were to be confirmed. Intraoperatively, a cerebral cross-filling of the contralateral cerebral arteries on the unilateral SCP was to be confirmed with TCD. If no cross-filling was confirmed, an optimization of the SCP was performed via increasing cerebral flow and increasing PCO2. If not successful, the SCP was to be switched to bilateral perfusion. Air bubble hits were recorded at the termination of SCP. A sonographic window was confirmed in all patients. Procedural success was 100%. The mean operative time was 298 ± 89 minutes. Adequate cross-filling was confirmed in 8 patients. In 1 patient, inadequate cross-filling was detected by TCD and an optimization of cerebral flow was necessary, which was successfully confirmed by TCD. There was no conversion to bilateral perfusion. Extensive air bubble hits were confirmed in 1 patient, who suffered a postoperative stroke. The 30-day mortality rate was 0. Conclusion: The TCD is feasible for cerebral perfusion monitoring in aortic surgery. It enables a confirmation of adequacy of cerebral perfusion strategy or the need for its optimization. Documentation of calcific or air-bubble hits might add insight into patients suffering postoperative neurological deficits.

Fetal Diagnosis of Abnormal Origin of the Left Pulmonary Artery.

PubMed

Tretter, Justin T; Tretter, Eric M; Rafii, Daniela Y; Anderson, Robert H; Bhatla, Puneet

2016-08-01

Isolated anomalies of the branch pulmonary arteries are rare, more often occurring in the setting of complex congenital heart disease. These isolated anomalies are often not identified in the prenatal period. We describe two cases of isolated anomalies of the left pulmonary artery which were identified on fetal echocardiography and confirmed postnatally, an anomalous left pulmonary artery arising from the base of the left-sided brachiocephalic artery in the setting of a right-sided aortic arch, and a left pulmonary artery sling. These two cases support our current understanding of normal and abnormal development of the extrapericardial arterial vessels and highlight the importance of meticulous attention when sweeping from the three-vessel tracheal view. © 2016, Wiley Periodicals, Inc.

A systematic review and meta-analysis of variations in branching patterns of the adult aortic arch.

PubMed

Popieluszko, Patrick; Henry, Brandon Michael; Sanna, Beatrice; Hsieh, Wan Chin; Saganiak, Karolina; Pękala, Przemysław A; Walocha, Jerzy A; Tomaszewski, Krzysztof A

2018-07-01

The aortic arch (AA) is the main conduit of the left side of the heart, providing a blood supply to the head, neck, and upper limbs. As it travels through the thorax, the pattern in which it gives off the branches to supply these structures can vary. Variations of these branching patterns have been studied; however, a study providing a comprehensive incidence of these variations has not yet been conducted. The objective of this study was to perform a meta-analysis of all the studies that report prevalence data on AA variants and to provide incidence data on the most common variants. A systematic search of online databases including PubMed, Embase, Scopus, ScienceDirect, Web of Science, SciELO, BIOSIS, and CNKI was performed for literature describing incidence of AA variations in adults. Studies including prevalence data on adult patients or cadavers were collected and their data analyzed. A total of 51 articles were included (N = 23,882 arches). Seven of the most common variants were analyzed. The most common variants found included the classic branching pattern, defined as a brachiocephalic trunk, a left common carotid, and a left subclavian artery (80.9%); the bovine arch variant (13.6%); and the left vertebral artery variant (2.8%). Compared by geographic data, bovine arch variants were noted to have a prevalence as high as 26.8% in African populations. Although patients who have an AA variant are often asymptomatic, they compose a significant portion of the population of patients and pose a greater risk of hemorrhage and ischemia during surgery in the thorax. Because of the possibility of encountering such variants, it is prudent for surgeons to consider potential variations in planning procedures, especially of an endovascular nature, in the thorax. Copyright © 2017 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.

Ventriculoarterial coupling in palliated hypoplastic left heart syndrome: Noninvasive assessment of the effects of surgical arch reconstruction and shunt type.

PubMed

Biglino, Giovanni; Giardini, Alessandro; Ntsinjana, Hopewell N; Schievano, Silvia; Hsia, Tain-Yen; Taylor, Andrew M

2014-10-01

To assess the coupling efficiency in hypoplastic left heart syndrome, considering the effect of surgical arch reconstruction and the shunt type received during the Norwood procedure. Ventriculoarterial coupling was assessed before Fontan completion in 32 patients with hypoplastic left heart syndrome (19 modified Blalock-Taussig and 13 Sano shunts at stage 1). Cardiovascular magnetic resonance data were analyzed, deriving functional parameters and 3-dimensional volumes. Dimensional indexes were computed from 3-dimensional data sets as the area ratio of the isthmus to the descending aorta (Risthmus) and the isthmus to surgically enlarged transverse arch (Rarch). Wave intensity was calculated from cardiac magnetic resonance, using the peaks of the forward compression and expansion waves in early and late systole as surrogate indicators of ventriculoarterial coupling. Aortic distensibility (3.6±2.7×10(-3) 1/mm Hg) was not associated with the time elapsed from stage 1 palliation (P=.94), suggesting an early loss of elasticity that did not progress thereafter. Risthmus was 1.0±0.4, and Rarch was 0.3±0.1, indicating the dilated reconstructed arch was the main anatomic feature. The forward compression wave correlated significantly with Rarch (R2=0.23, P=.006) but not with Risthmus (R2<0.01, P=.63). Patients with a reduced ejection fraction exhibited a larger ventricular mass (R2=0.28, P=.003). The Sano shunt patients had a lower ejection fraction (51%±6% vs 57%±6%, P=.02); however, neither the forward compression nor expansion wave varied significantly between shunt type or the other functional parameters. Ventriculoarterial coupling in operated hypoplastic left heart syndrome was affected by aortic arch size mismatch but not by the type of shunt placed at the Norwood operation. Copyright © 2014 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

Aortic Dissection in Turner Syndrome

PubMed Central

Bondy, Carolyn A.

2009-01-01

Purpose of review Turner syndrome (TS) is a relatively common disorder of female development with cardinal features of short stature and congenital cardiovascular defects (CHD). TS is the most common established cause of aortic dissection in young women, but has received little attention outside of pediatric literature. This review focuses on emerging knowledge of the characteristics of aortic disease in TS in comparison with Marfan-like syndromes and isolated aortic valve disease. Recent findings The incidence of aortic dissection is significantly increased in individuals with TS at all ages, highest during young adult years and in pregnancy. Pediatric patients with dissection have known CHD, but adults often have aortic valve and arch abnormalities detected only by screening cardiac MR (CMR). Thoracic aortic dilation in TS must be evaluated in relation to body surface area (BSA). Dilation is most prominent at the ascending aorta similar to the pattern seen in non-syndromic bicuspid aortic valve (BAV), is equally prevalent (20-30%) in children and adults, and does not seem to be rapidly progressive. Cardiovascular anomalies and risk for aortic dissection in TS are strongly linked to a history of fetal lymphedema, evidenced by the presence of neck webbing and shield chest. Summary Risk for acute aortic dissection is increased by more than 100-fold in young and middle-aged women with TS. Monitoring frequency and treatment modalities are decided on an individual basis until more information on outcomes becomes available. PMID:18839441

Late outcomes for aortic valve replacement with the Carpentier-Edwards pericardial bioprosthesis: up to 17-year follow-up in 1,000 patients.

PubMed

McClure, R Scott; Narayanasamy, Narendren; Wiegerinck, Esther; Lipsitz, Stuart; Maloney, Ann; Byrne, John G; Aranki, Sary F; Couper, Gregory S; Cohn, Lawrence H

2010-05-01

This study reviews a single institution experience with the Carpentier-Edwards pericardial aortic valve bioprosthesis, concentrating on late outcomes. From December 1991 to June 2002, 1,000 patients underwent aortic valve replacement with the Carpentier-Edwards pericardial valve (mean follow-up 6.01 +/- 3.56 years). The institutional database was reviewed. Follow-up data were acquired through telephone interviews and mail-in questionnaires. Time-to-event analyses were performed by the Kaplan-Meier method. Mean age was 74.1 years; 545 patients (54.5%) were male. Mean preoperative ejection fraction was 52.5%. Isolated aortic valve replacement occurred in 372 cases (37.2%). Combined aortic valve replacement with coronary artery bypass grafting occurred in 443 cases (44.3%). The remaining 185 patients (18.5%) underwent complex procedures with concomitant mitral, tricuspid, or arch repair. One hundred forty patients (14.0%) had prior aortic valve surgery. Follow-up was 99.4% complete. Overall operative mortality was 7.2% (72 of 1,000). There were 503 late deaths (50.3%). Age-stratified survival at 15 years was 43.7% for patients less than 65 years of age; 18.2% for patients aged 65 to 75; and 9.4% for patients aged more than 75 years. There were 26 failed bioprostheses (2.6%) requiring reoperation. Structural valve deterioration was the cause in 13 of 26 cases (50%), endocarditis in 11 of 26 (42%), and perivalvular leak in 2 of 26 (7.6%). Age-stratified freedom from reoperation due to structural valve deterioration at 15 years was 34.7% for patients less than 65 years of age; 89.4% for patients aged 65 to 75; and 99.5% for patients aged more than 75 years. The Carpentier-Edwards pericardial bioprosthesis shows long-term durability with low rates of structural failure. Copyright (c) 2010 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Outcomes After Operations for Unicuspid Aortic Valve With or Without Ascending Repair in Adults

PubMed Central

Zhu, Yuanjia; Roselli, Eric E.; Idrees, Jay J.; Wojnarski, Charles M.; Griffin, Brian; Kalahasti, Vidyasagar; Pettersson, Gosta; Svensson, Lars G.

2016-01-01

Background Unicuspid aortic valve is an important subset of bicuspid aortic valve, and knowledge regarding its aortopathy pattern and surgical outcomes is limited. Our objectives were to characterize unicuspid aortic valve patients, associated aortopathy, and surgical outcomes. Methods From January 1990 to May 2013, 149 adult unicuspid aortic valve patients underwent aortic valve replacement or repair for aortic stenosis (n = 13), regurgitation (n = 13), or both (n = 123), and in 91 (61%) the aortic valve operation was combined with aortic repair. Data were obtained from the Cardiovascular Information Registry and medical record review. Three-dimensional imaging analysis was performed from preoperative computed tomography and magnetic resonance imaging scans. The Kaplan-Meier method was used for survival analysis. Results Patients had a mean maximum aortic diameter of 44 ± 8 mm and variably involved the aortic root, ascending, or arch, or both. Patients with valve operations alone were more likely to be hypertensive (p = 0.01) and to have severe aortic stenosis (p = 0.07) than those who underwent concurrent aortic operations. There were no operative deaths, strokes, or myocardial infarctions. Patients undergoing aortic repair had better long-term survival. Estimated survival at 1, 5, and 10 years was 100%, 100%, and 100% after combined operations and was 100%, 88%, and 88% after valve operations alone (p = 0.01). Conclusions Patients with a dysfunctional unicuspid aortic valve frequently present with an ascending aneurysm that requires repair. Combined aortic valve operations and aortic repair was associated with significantly better long-term survival than a valve operation alone. Further study of this association may direct decisions about timing of surgical intervention. PMID:26453423

Stanford-A acute aortic dissection, inflammation, and metalloproteinases: a review.

PubMed

Cifani, Noemi; Proietta, Maria; Tritapepe, Luigi; Di Gioia, Cira; Ferri, Livia; Taurino, Maurizio; Del Porto, Flavia

2015-01-01

Acute aortic dissection (AAD) is a life-threatening disease with an incidence of about 2.6-3.6 cases per 100,000/year. Depending on the site of rupture, AAD is classified as Stanford-A when the ascending aortic thoracic tract and/or the arch are involved, and Stanford-B when the descending thoracic aorta and/or aortic abdominal tract are targeted. It was recently shown that inflammatory pathways underlie aortic rupture in both type A and type B Stanford AAD. An immune infiltrate has been found within the middle and outer tunics of dissected aortic specimens. It has also been observed that the recall and activation of macrophages inside the middle tunic are key events in the early phases of AAD. Macrophages are able to release metalloproteinases (MMPs) and pro-inflammatory cytokines which, in turn, give rise to matrix degradation and neoangiogenesis. An imbalance between the production of MMPs and MMP tissue inhibitors is pivotal in the extracellular matrix degradation underlying aortic wall remodelling in dissections occurring both in inherited conditions and in atherosclerosis. Among MMPs, MMP-12 is considered a specific marker of aortic wall disease, whatever the genetic predisposition may be. The aim of this review is, therefore, to take a close look at the immune-inflammatory mechanisms underlying Stanford-A AAD.

Familial Thoracic Aortic Aneurysm with Dissection Presenting as Flash Pulmonary Edema in a 26-Year-Old Man

PubMed Central

Omar, Sabry; Moore, Tyler; Payne, Drew; Momeni, Parastoo; Mulkey, Zachary; Nugent, Kenneth

2014-01-01

We are reporting a case of familial thoracic aortic aneurysm and dissection in a 26-year-old man with no significant past medical history and a family history of dissecting aortic aneurysm in his mother at the age of 40. The patient presented with cough, shortness of breath, and chest pain. Chest X-ray showed bilateral pulmonary infiltrates. CT scan of the chest showed a dissection of the ascending aorta. The patient underwent aortic dissection repair and three months later he returned to our hospital with new complaints of back pain. CT angiography showed a new aortic dissection extending from the left carotid artery through the bifurcation and into the iliac arteries. The patient underwent replacement of the aortic root, ascending aorta, total aortic arch, and aortic valve. The patient recovered well postoperatively. Genetic studies of the patient and his children revealed no mutations in ACTA2, TGFBR1, TGFBR2, TGFB2, MYH11, MYLK, SMAD3, or FBN1. This case report focuses on a patient with familial TAAD and discusses the associated genetic loci and available screening methods. It is important to recognize potential cases of familial TAAD and understand the available screening methods since early diagnosis allows appropriate management of risk factors and treatment when necessary. PMID:25104961

Complications at the Proximal Landing Zone of Endovascular Stent Grafts Deployed in Surgically Replaced Ascending Aorta.

PubMed

Kotha, Vamshi K; Herget, Eric J; Appoo, Jehangir J

2016-11-01

The ascending aorta, with its hostile angulations and forces, is the next frontier in the evolution of endovascular surgery. Type II hybrid arch repair, involving surgical replacement of the ascending aorta, arch debranching, and stent graft deployment in the ascending aortic graft, offers an opportunity to study the behavior of an endovascular prosthesis in the ascending aorta. We report complications seen at the proximal landing zone after type II hybrid arch repair. A dedicated imaging protocol was used to monitor 20 consecutive patients who underwent type II hybrid arch repair at a single center from June 2009 to July 2014. Mean age was 66 years (range, 47 to 82 years). Mean imaging follow-up was 34 months (range, 12 to 64 months). There was 1 operative death (5%). Bird beaking (>5 mm of nonapposition) of the stent graft at the proximal landing zone occurred in 12 patients, and >20 mm of bird beaking occurred in 7 patients. Proximal landing zone complications occurred in 4 patients (20%), comprising 2 type Ia endoleaks, 1 graft migration, and 1 graft infolding detected on postoperative days 4, 11, 5, and 755, respectively. Three patients underwent endovascular reintervention for proximal landing zone complications. There were no late deaths. Thoracic aortic stent grafts may be prone to proximal landing zone complications when deployed in the ascending aorta. Bird beaking is common when endografts are deployed in the Dacron (DuPont, Wilmington, DE) ascending aorta. Angulation issues will likely need to be overcome by stent graft refinement to enable future closed chest approaches to the ascending aorta. Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Marked Acceleration of Atherosclerosis following Lactobacillus casei induced Coronary Arteritis in a Mouse Model of Kawasaki Disease

PubMed Central

Chen, Shuang; Lee, Young Ho; Crother, Timothy R.; Fishbein, Michael; Zhang, Wenxuan; Yilmaz, Atilla; Shimada, Kenichi; Schulte, Danica J; Lehman, Thomas J.A.; Shah, Prediman K.; Arditi, Moshe

2012-01-01

Objective To investigate if Lactobacillus casei cell wall extract (LCWE)-induced Kawasaki Disease (KD) accelerates atherosclerosis in hypercholesterolemic mice. Method and Resuslts Apoe−/− or Ldlr−/− mice were injected with LCWE (KD mice) or PBS, fed high fat diet for 8 weeks, and atherosclerotic lesions in aortic sinuses (AS), arch (AC) and whole aorta were assessed. KD mice had larger, more complex aortic lesions with abundant collagen, and both extracellular and intracellular lipid and foam cells, compared to lesions in control mice despite similar cholesterol levels. Both Apoe−/− KD and Ldlr−/− KD mice showed dramatic acceleration in atherosclerosis vs. controls, with increases in en face aortic atherosclerosis and plaque size in both the AS and AC plaques. Accelerated atherosclerosis was associated with increased circulating IL-12p40, IFN-γ, TNF-α, and increased macrophage, DC, and T cell recruitment in lesions. Furthermore, daily injections of the IL-1Ra, which inhibits LCWE induced KD vasculitis, prevented the acceleration of atherosclerosis. Conclusions Our results suggest an important pathophysiologic link between coronary arteritis/vasculitis in the KD mouse model and subsequent atherosclerotic acceleration, supporting the concept that a similar relation may also be present in KD patients. These results also suggest that KD in childhood may predispose to accelerated and early atherosclerosis as adults. PMID:22628430

A Case of Traumatic Retrograde Type A Aortic Dissection Accompanied by Multiorgan Injuries.

PubMed

Tsukioka, Katsuaki; Kono, Tetsuya; Takahashi, Kohei; Kehara, Hiromu; Urashita, Shuichi; Komatsu, Kazunori

2018-03-25

A 75-year-old woman was involved in a traffic accident and suffered retrograde type A aortic dissection, multiple rib fractures, and grade II hepatic injury accompanied by intraperitoneal bleeding. We performed total arch replacement using an open stent graft with cardiopulmonary bypass and circulatory arrest. This procedure requires anticoagulation and hypothermia, which are principally contraindicated in severe trauma patients. However, this situation was resolved by managing the patient non-operatively for 7 days, confirming the stabilization of other injured organs, and then performing the surgery. She required prolonged postoperative rehabilitation; however, she recovered steadily.

Impact of Age-Dependent Adventitia Inflammation on Structural Alteration of Abdominal Aorta in Hyperlipidemic Mice

PubMed Central

Sakamoto, Sumiharu; Tsuruda, Toshihiro; Hatakeyama, Kinta; Imamura, Takuroh; Asada, Yujiro; Kitamura, Kazuo

2014-01-01

Background The adventitia is suggested to contribute to vascular remodeling; however, the site-selective inflammatory responses in association with the development of atherosclerosis remain to be elucidated. Methods and Results Wild-type or apolipoprotein E knockout male C57BL/6J background mice were fed standard chow for 16, 32, and 52 weeks, and the morphology of the aortic arch, descending aorta, and abdominal aorta was compared. Atheromatous plaque formation progressed with age, particularly in the aortic arch and abdominal aorta but not in the descending aorta. In addition, we found that the numbers of macrophages, T-lymphocytes, and microvessels, assessed by anti-F4/80, CD3, and CD31 antibodies, were higher in the adventitia of the abdominal aorta at 52 weeks. These numbers were positively correlated with plaque formation, but negatively correlated with elastin content, resulting in the enlargement of the total vessel area. In aortic tissues, interleukin-6 levels increased in the atheromatous plaque with age, whereas the level of regulated on activation, normal T cell expressed and secreted (RANTES) increased with age, and compared with other sites, it was particularly distributed in inflammatory cells in the adventitia of the abdominal aorta. Conclusion This study suggests that adventitial inflammation contributes to the age-dependent structural alterations, and that the activation/inactivation of cytokines/chemokines is involved in the process. PMID:25153991

A Case of an Aortic Abscess around the Elephant Trunk.

PubMed

Fujii, Takeshiro; Kawasaki, Muneyasu; Katayanagi, Tomoyuki; Okuma, Shinnosuke; Masuhara, Hiroshi; Shiono, Noritsugu; Watanabe, Yoshinori

2015-01-01

A 52-year-old male patient with a history of total arch replacement using the elephant trunk technique for acute aortic dissection 4 years before visited our hospital with the chief complaint of persistent fever. Chest computed tomography (CT) suggested prosthetic vascular graft infection, which was treated surgically after chemotherapy. The first surgery consisted of debridement of an abscess around the vascular graft and in the aorta around the elephant trunk, and thoracic descending aorta replacement and vacuum-assisted closure (VAC) in view of the risk of bleeding from the peripheral region of the elephant trunk. One week later, omental filling was performed as the second step. This is a very rare case of aortic abscess around the elephant trunk that could successfully be managed by graft-conserving treatment.

Ascending Aortic Stenting for Acute Supraaortic Stenosis From Graft Collapse.

PubMed

Lader, Joshua M; Smith, Deane E; Staniloae, Cezar; Fallahi, Arzhang; Iqbal, Sohah N; Galloway, Aubrey C; Williams, Mathew R

2018-06-01

A 78-year-old man with remote type-A dissection presented with acute-onset dyspnea. Twenty-two years prior, treatment for his aortic disease required replacement of ascending and arch aneurysms with a polyester graft (Dacron) using the graft inclusion technique. He presented currently in cardiogenic shock. Echocardiography demonstrated new severe hypokinesis of all apical segments. Left-heart catheterization revealed a 120 mm Hg intragraft gradient. Computed tomography arteriography was unrevealing, but intraaortic ultrasound demonstrated critical intragraft stenosis. A balloon expandable stent (Palmaz stent, Cordis, Milpitas, CA) was deployed in the stenotic region with gradient resolution. The patient later underwent aortic root replacement and ascending aneurysm repair (Bio-Bentall technique) and is doing well at 24 months. Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Results of celiac trunk stenting during fenestrated or branched aortic endografting.

PubMed

Wattez, Hélène; Martin-Gonzalez, Teresa; Lopez, Benjamin; Spear, Rafaëlle; Clough, Rachel E; Hertault, Adrien; Sobocinski, Jonathan; Haulon, Stéphan

2016-12-01

Endovascular repair of aortic aneurysms involving the visceral segment of the aorta often requires placement of a covered bridging stent in the celiac axis (CA). The median arcuate ligament (MAL) is a fibrous arch that unites the diaphragmatic crura on either side of the aortic hiatus. The ligament may compress and distort the celiac artery and result in difficult cannulation, or stenosis and occlusion of the vessel. This study evaluated the influence of the MAL compression on the technical success and the patency of the celiac artery after branched and fenestrated endovascular aortic repair. We retrospectively analyzed a cohort of consecutive patients treated electively for complex aneurysms with branched and fenestrated endovascular aortic repair between January 2007 and April 2014. All data were collected prospectively. Analysis of preoperative computed tomography angiography on a three-dimensional workstation determined the presence of MAL compression. Patency of the CA bridging stent was assessed during follow-up by computed tomography angiography and duplex ultrasound evaluation. Statistical analysis was performed to compare the outcomes of patients with MAL (MAL+) and without MAL (MAL-) compression. Of 315 patients treated for aortic disease involving the visceral segment during the study period, 113 had endografts designed with a branch (n = 57) or fenestration (n = 56) for the CA. In 45 patients (39.8%), asymptomatic compression of the CA by the MAL was depicted (MAL+). Complex endovascular techniques were required in this group to access the CA in 16 (14.2%) patients (vs none in the MAL- group; P = .003), which lead to a failed bridging stent implantation in seven patients (6.2%). Increased operative time and dose area product were observed in the MAL+ group, but this did not reach statistical significance. In the MAL+ group, no thrombosis of the CA bridging stents were observed during follow-up; an external compression of the CA bridging stent was depicted in six patients but without hemodynamic effect on duplex ultrasound imaging. In the MAL- group, one CA bridging stent occlusion occurred owing to an embolus from a cardiac source. MAL compression is associated with good celiac trunk bridging stent patency during follow-up, but with a higher rate of technical difficulties and failed bridging stent implantation during the procedure. Copyright © 2016 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.

Secondary hypertension due to isolated interrupted aortic arch in a 45-year-old person: A case report.

PubMed

Zhou, Jian Mei; Liu, Xin Wen; Yang, Yi; Wang, Bo Zhong; Wang, Jian An

2017-12-01

Though it is rare, isolated interrupted aortic arch (IAA) could lead to hypertension. Surgical repair is the only effective curative method to treat IAA conditions and patients with IAA can hardly survive to adulthood with medication alone. We report an IAA case that of a 45-year-old male patient who survived for 45 years without surgical treatment. A 45-year-old man was referred to the hospital presenting with abnormal blood pressure level. Both computed tomography angiogram (CTA) and angiography revealed IAA. The patient was diagnosed as IAA based on computed tomography angiogram (CTA) and angiography. The patient's blood pressure was severely high and refractory. He refused surgical treatment and accepted antihypertensive medication for 10 days. The patient's office blood pressure level was abnormal, fluctuating between 140/90 and 160/100 mm Hg, but 24-hour ambulatory blood pressure monitoring showed normal level. Hypertension due to IAA could be controlled with medications, even surgery is not performed. The discrepancy between ambulatory and office blood pressure levels may be due to the white coat effect.

Aortic stiffness and calcification in men in a population-based international study.

PubMed

Sekikawa, Akira; Shin, Chol; Curb, J David; Barinas-Mitchell, Emma; Masaki, Kamal; El-Saed, Aiman; Seto, Todd B; Mackey, Rachel H; Choo, Jina; Fujiyoshi, Akira; Miura, Katsuyuki; Edmundowicz, Daniel; Kuller, Lewis H; Ueshima, Hirotsugu; Sutton-Tyrrell, Kim

2012-06-01

Aortic stiffness, a hallmark of vascular aging, is an independent risk factor of cardiovascular disease and all-cause mortality. The association of aortic stiffness with aortic calcification in middle-aged general population remains unknown although studies in patients with end-stage renal disease or elderly subjects suggest that aortic calcification is an important determinant of aortic stiffness. The goal of this study was to examine the association of aortic calcification and stiffness in multi-ethnic population-based samples of relatively young men. We examined the association in 906 men aged 40-49 (81 Black Americans, 276 Japanese Americans, 258 White Americans and 291 Koreans). Aortic stiffness was measured as carotid-femoral pulse wave velocity (cfPWV) using an automated waveform analyzer. Aortic calcification from aortic arch to iliac bifurcation was evaluated using electron-beam computed tomography. Aortic calcium score was calculated and was categorized into four groups: zero (n=303), 1-100 (n=411), 101-300 (n=110), and 401+ (n=82). Aortic calcification category had a significant positive association with cfPWV after adjusting for age, race, and mean arterial pressure (mean (standard error) of cfPWV (cm/s) from the lowest to highest categories: 836 (10), 850 (9), 877 (17) and 941 (19), P for trend <0.001). The significant positive association remained after further adjusting for other cardiovascular risk factors. The significant positive association was also observed in each race group. The results suggest that aortic calcification can be one mechanism for aortic stiffness and that the association of aortic calcification with stiffness starts as early as the 40s. Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.

Aortic stiffness and calcification in men in a population-based international study

PubMed Central

Sekikawa, Akira; Shin, Chol; Curb, J. David; Barinas-Mitchell, Emma; Masaki, Kamal; El-Saed, Aiman; Seto, Todd B.; Mackey, Rachel H.; Choo, Jina; Fujiyoshi, Akira; Miura, Katsuyuki; Edmundowicz, Daniel; Kuller, Lewis H.; Ueshima, Hirotsugu; Sutton-Tyrrell, Kim

2012-01-01

Objectives Aortic stiffness, a hallmark of vascular aging, is an independent risk factor of cardiovascular disease and all-cause mortality. The association of aortic stiffness with aortic calcification in middle-aged general population remains unknown although studies in patients with end-stage renal disease or elderly subjects suggest that aortic calcification is an important determinant of aortic stiffness. The goal of this study was to examine the association of aortic calcification and stiffness in multi-ethnic population-based samples of relatively young men. Methods We examined the association in 906 men aged 40–49 (81 Black Americans, 276 Japanese Americans, 258 White Americans and 291 Koreans). Aortic stiffness was measured as carotid-femoral pulse wave velocity (cfPWV) using an automated waveform analyzer. Aortic calcification from aortic arch to iliac bifurcation was evaluated using electron-beam computed tomography. Results Aortic calcium score was calculated and was categorized into four groups: zero (n=303), 1–100 (n=411), 101–300 (n=110), and 401+ (n=82). Aortic calcification category had a significant positive association with cfPWV after adjusting for age, race, and mean arterial pressure (mean (standard error) of cfPWV (cm/second) from the lowest to highest categories: 836 (10), 850 (9), 877 (17) and 941 (19), p for trend <0.001). The significant positive association remained after further adjusting for other cardiovascular risk factors. The significant positive association was also observed in each race group. Conclusions The results suggest that aortic calcification can be one mechanism for aortic stiffness and that the association of aortic calcification with stiffness starts as early as the 40’s. PMID:22537531

Aortic Blood Flow Reversal Determines Renal Function: Potential Explanation for Renal Dysfunction Caused by Aortic Stiffening in Hypertension.

PubMed

Hashimoto, Junichiro; Ito, Sadayoshi

2015-07-01

Aortic stiffness determines the glomerular filtration rate (GFR) and predicts the progressive decline of the GFR. However, the underlying pathophysiological mechanism remains obscure. Recent evidence has shown a close link between aortic stiffness and the bidirectional (systolic forward and early diastolic reverse) flow characteristics. We hypothesized that the aortic stiffening-induced renal dysfunction is attributable to altered central flow dynamics. In 222 patients with hypertension, Doppler velocity waveforms were recorded at the proximal descending aorta to calculate the reverse/forward flow ratio. Tonometric waveforms were recorded to measure the carotid-femoral (aortic) and carotid-radial (peripheral) pulse wave velocities, to estimate the aortic pressure from the radial waveforms, and to compute the aortic characteristic impedance. In addition, renal hemodynamics was evaluated by duplex ultrasound. The estimated GFR was inversely correlated with the aortic pulse wave velocity, reverse/forward flow ratio, pulse pressure, and characteristic impedance, whereas it was not correlated with the peripheral pulse wave velocity or mean arterial pressure. The association between aortic pulse wave velocity and estimated GFR was independent of age, diabetes mellitus, hypercholesterolemia, and antihypertensive medication. However, further adjustment for the aortic reverse/forward flow ratio and pulse pressure substantially weakened this association, and instead, the reverse/forward flow ratio emerged as the strongest determinant of estimated GFR (P=0.001). A higher aortic reverse/forward flow ratio was also associated with lower intrarenal forward flow velocities. These results suggest that an increase in aortic flow reversal (ie, retrograde flow from the descending thoracic aorta toward the aortic arch), caused by aortic stiffening and impedance mismatch, reduces antegrade flow into the kidney and thereby deteriorates renal function. © 2015 American Heart Association, Inc.

A new classification scheme for treating blunt aortic injury.

PubMed

Starnes, Benjamin W; Lundgren, Rachel S; Gunn, Martin; Quade, Samantha; Hatsukami, Thomas S; Tran, Nam T; Mokadam, Nahush; Aldea, Gabriel

2012-01-01

There are numerous questions about the treatment of blunt aortic injury (BAI), including the management of small intimal tears, what injury characteristics are predictive of death from rupture, and which patients actually need intervention. We used our experience in treating BAI during the past decade to create a classification scheme based on radiographic and clinical data and to provide clear treatment guidelines. The records of patients admitted with BAI from 1999 to 2008 were retrospectively reviewed. Patients with a radiographically or operatively confirmed diagnosis (echocardiogram, computed tomography, or angiography) of BAI were included. We created a classification system based on the presence or absence of an aortic external contour abnormality, defined as an alteration in the symmetric, round shape of the aorta: (1) intimal tear (IT)-absence of aortic external contour abnormality and intimal defect and/or thrombus of <10 mm in length or width; (2) large intimal flap (LIF)-absence of aortic external contour abnormality and intimal defect and/or thrombus of ≥10 mm in length or width; (3) pseudoaneurysm-presence of aortic external contour abnormality and contained rupture; (4) rupture-presence of aortic external contour abnormality and free contrast extravasation or hemothorax at thoracotomy. We identified 140 patients with BAI. Most injuries were pseudoaneurysm (71%) at the isthmus (70%), 16.4% had an IT, 5.7% had a LIF, and 6.4% had a rupture. Survival rates by classification were IT, 87%; LIF, 100%; pseudoaneurysm, 76%; and rupture, 11% (one patient). Of the ITs, LIFs, and pseudoaneurysms treated nonoperatively, none worsened, and 65% completely healed. No patient with an IT or LIF died. Most patients with ruptures lost vital signs before presentation or in the emergency department and did not survive. Hypotension before or at hospital presentation and size of the periaortic hematoma at the level of the aortic arch predicted likelihood of death from BAI. As a result of this new classification scheme, no patient without an external aortic contour abnormality died of their BAI. ITs can be managed nonoperatively. BAI patients with rupture will die, and resources could be prioritized elsewhere. Those with LIFs do well, and currently, most at our institution are treated with a stent graft. If a pseudoaneurysm is going to rupture, it does so early. Hematoma at the arch on computed tomography scan and hypotension before or at arrival help to predict which pseudoaneurysms need urgent repair. Copyright © 2012 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.

Arsenic exacerbates atherosclerotic lesion formation and inflammation in ApoE-/- mice

DOE Office of Scientific and Technical Information (OSTI.GOV)

Srivastava, Sanjay, E-mail: sanjay@louisville.ed; Center for Environmental Genomics and Integrative Biology, University of Louisville, Louisville, KY 40202; Vladykovskaya, Elena N.

2009-11-15

Exposure to arsenic-contaminated water has been shown to be associated with cardiovascular disease, especially atherosclerosis. We examined the effect of arsenic exposure on atherosclerotic lesion formation, lesion composition and nature in ApoE-/- mice. Early post-natal exposure (3-week-old mice exposed to 49 ppm arsenic as NaAsO{sub 2} in drinking water for 7 weeks) increased the atherosclerotic lesion formation by 3- to 5-fold in the aortic valve and the aortic arch, without affecting plasma cholesterol. Exposure to arsenic for 13 weeks (3-week-old mice exposed to 1, 4.9 and 49 ppm arsenic as NaAsO{sub 2} in drinking water) increased the lesion formation andmore » macrophage accumulation in a dose-dependent manner. Temporal studies showed that continuous arsenic exposure significantly exacerbated the lesion formation throughout the aortic tree at 16 and 36 weeks of age. Withdrawal of arsenic for 12 weeks after an initial exposure for 21 weeks (to 3-week-old mice) significantly decreased lesion formation as compared with mice continuously exposed to arsenic. Similarly, adult exposure to 49 ppm arsenic for 24 weeks, starting at 12 weeks of age increased lesion formation by 2- to 3.6-fold in the aortic valve, the aortic arch and the abdominal aorta. Lesions of arsenic-exposed mice displayed a 1.8-fold increase in macrophage accumulation whereas smooth muscle cell and T-lymphocyte contents were not changed. Expression of pro-inflammatory chemokine MCP-1 and cytokine IL-6 and markers of oxidative stress, protein-HNE and protein-MDA adducts were markedly increased in lesions of arsenic-exposed mice. Plasma concentrations of MCP-1, IL-6 and MDA were also significantly elevated in arsenic-exposed mice. These data suggest that arsenic exposure increases oxidative stress, inflammation and atherosclerotic lesion formation.« less

Tissue Doppler Imaging in the evaluation of abdominal aortic pulsatility: a useful tool for the neonatologist.

PubMed

Valerio, Enrico; Grison, Alessandra; Capretta, Anna; Golin, Rosanna; Ferrarese, Paola; Bellettato, Massimo

2017-03-01

Sonographic cardiac evaluation of newborns with suspected aortic coarctation (AoC) should tend to demonstrate a good phasic and pulsatile flow and the absence of pressure gradient along a normally conformed aortic arch from the modified left parasternal and suprasternal echocardiographic views; these findings, however, may not necessarily rule out a more distal coarctation in the descending aorta. For this reason, the sonographic exam of newborns with suspected AoC should always include a Doppler evaluation of abdominal aortic blood flow from the subcostal view. Occasionally, however, a clearly pulsatile Doppler flow trace in abdominal aorta may be difficult to obtain due to the bad insonation angle existing between the probe and the vessel. In such suboptimal ultrasonic alignment situation, the use of Tissue Doppler Imaging instead of classic Doppler flow imaging may reveal a preserved aortic pulsatility by sampling the aortic wall motion induced by normal flow. We propose to take advantage of the TDI pattern as a surrogate of a normal pulsatile Doppler flow trace in abdominal aorta when the latter is difficult to obtain due to malalignment with the insonated vessel.

Effect of atherothrombotic aorta on outcomes of total aortic arch replacement.

PubMed

Okada, Kenji; Omura, Atsushi; Kano, Hiroya; Inoue, Takeshi; Oka, Takanori; Minami, Hitoshi; Okita, Yutaka

2013-04-01

The effect of an atherothrombotic aorta on the short- and long-term outcomes of total aortic arch replacement, including postoperative neurologic deficits, remains unknown. We evaluated this relationship and also elucidated the synergistic effect of multiple other risk factors, in addition to an atherothrombotic aorta, on the neurologic outcome. A group of 179 consecutive patients undergoing total aortic arch replacement were studied. An atherothrombotic aorta was present in 34 patients (19%), more than moderate leukoaraiosis in 71 (39.7%), and significant extracranial carotid artery stenosis in 27 (15.1%). In-hospital deaths occurred in 2 patients, 1 (2.9%) of 34 patients with and 1 (0.7%) of 145 patients without an atherothrombotic aorta (P = .26). Permanent neurologic deficits occurred in 4 (2.2%) and transient neurologic deficits in 17 (9.5%) patients. Multivariate analysis demonstrated that the risk factors for transient neurologic deficits were an atherothrombotic aorta (odds ratio, 4.4), extracranial carotid artery stenosis (odds ratio, 5.5), moderate/severe leukoaraiosis (odds ratio, 3.6), and cardiopulmonary bypass time (odds ratio, 1.02). To calculate the probability of transient neurologic deficits, the following equation was derived: probability of transient neurologic deficits = {1 + exp [7.276 - 1.489 (atherothrombotic aorta) - 1.285 (leukoaraiosis) - 1.701 (extracranial carotid artery stenosis) - 0.017 (cardiopulmonary bypass time)]}(-1). An exponential increase occurred in the probability of transient neurologic deficits with presence of an atherothrombotic aorta and other risk factors in relation to the cardiopulmonary bypass time. Survival at 3 years after surgery was significantly reduced in patients with vs without an atherothrombotic aorta (75.0% ± 8.8% vs 89.2% ± 3.1%, P = .01). Patients with an atherothrombotic aorta and associated preoperative comorbidities might be predisposed to adverse short- and long-term outcomes, including transient neurologic deficits. Copyright © 2013 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.

Comparison of endovascular repair with branched stent graft and open repair for aortic arch aneurysm.

PubMed

Kawatou, Masahide; Minakata, Kenji; Sakamoto, Kazuhisa; Nakatsu, Taro; Tazaki, Junichi; Higami, Hirooki; Uehara, Kyokun; Yamazaki, Kazuhiro; Inoue, Kanji; Kimura, Takeshi; Sakata, Ryuzo

2017-08-01

Although conventional open repair is our preference for patients with aortic arch aneurysms, we have often chosen thoracic endovascular aneurysm repair (TEVAR) with a handmade branched stent graft (bTEVAR) in high-risk patients. The aim of this study was to compare the midterm clinical outcomes of our bTEVAR technique to those of the open repair. Between January 2007 and December 2014, we treated 129 patients with aortic arch aneurysm by means of either conventional open repair (OPEN, n = 61) or bTEVAR (n = 68) at our institution. The mean ages were 70.5 ± 12.7 years in the OPEN group and 72.7 ± 12.5 years in the bTEVAR group (P = 0.32). The aetiologies included true aneurysm in 101 patients (78.3%) and chronic dissection in 26 (20.1%). There were 2 (3.3%) in-hospital deaths in the OPEN group and 3 (4.4%) in the bTEVAR group. The mean follow-up duration was 3.0 ± 2.1 years (2.4 ± 1.9 years in the OPEN group and 3.6 ± 2.3 years in the bTEVAR group). There was no difference in 5-year aneurysm-related mortality between groups (10.7% in OPEN vs 12.8% in bTEVAR, P = 0.50). In terms of late additional procedures, however, none were required in the OPEN group, whereas 10 (15.4%) additional endovascular repairs and 4 (6.2%) open repairs were required in the bTEVAR group. Our bTEVAR could be performed with low early mortality, and it yielded similar midterm aneurysm-related mortality to that of conventional open repair. However, these patients undergoing this technique required more late additional procedures than those undergoing conventional open repair. © The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Effect of the Antioxidant Lipoic Acid in Aortic Phenotype in a Marfan Syndrome Mouse Model.

PubMed

Guido, Maria C; Debbas, Victor; Salemi, Vera M; Tavares, Elaine R; Meirelles, Thayna; Araujo, Thaís L S; Nolasco, Patricia; Ferreira-Filho, Julio C A; Takimura, Celso K; Pereira, Lygia V; Laurindo, Francisco R

2018-01-01

Marfan syndrome (MFS) cardiovascular manifestations such as aortic aneurysms and cardiomyopathy carry substantial morbidity/mortality. We investigated the effects of lipoic acid, an antioxidant, on ROS production and aortic remodeling in a MFS mgΔ loxPneo mouse model. MFS and WT (wild-type) 1-month-old mice were allocated to 3 groups: untreated, treated with losartan, and treated with lipoic acid. At 6 months old, echocardiography, ROS production, and morphological analysis of aortas were performed. Aortic ROS generation in 6-month-old MFS animals was higher at advanced stages of disease in MFS. An unprecedented finding in MFS mice analyzed by OCT was the occurrence of focal inhomogeneous regions in the aortic arch, either collagen-rich extremely thickened or collagen-poor hypotrophic regions. MFS animals treated with lipoic acid showed markedly reduced ROS production and lower ERK1/2 phosphorylation; meanwhile, aortic dilation and elastic fiber breakdown were unaltered. Of note, lipoic acid treatment associated with the absence of focal inhomogeneous regions in MFS animals. Losartan reduced aortic dilation and elastic fiber breakdown despite no change in ROS generation. In conclusion, oxidant generation by itself seems neutral with respect to aneurysm progression in MFS; however, lipoic acid-mediated reduction of inhomogeneous regions may potentially associate with less anisotropy and reduced chance of dissection/rupture.

Vascular geometry of the extracranial carotid arteries: an analysis of length, diameter, and tortuosity.

PubMed

Choudhry, Farooq A; Grantham, John T; Rai, Ansaar T; Hogg, Jeffery P

2016-05-01

Stable access is essential for successful intracranial interventions. Quantifying variations in extracranial carotid arteries may help in the selection and development of access catheters. This study describes the vascular dimensions from the aortic arch to the skull base. CT angiography analysis was performed on 100 patients. The lengths, diameters, and tortuosity of the common carotid artery (CCA) and internal carotid artery (ICA) were measured from the aortic arch to the skull base. The mean±SD length of the carotid artery from the aortic arch to the skull base was 22.2±2.2 cm for the right side and 20.8±1.9 cm for the left side (p<0.0001). The length of the right CCA was 13.6±1.2 cm and the length of the left CCA was 12.4±1.4 cm (p<0.0001). The length of the right ICA was 8.6±1.4 cm compared with 8.4±1.4 cm for the left ICA (p=0.3). The ICA length in men and women was 8.9±1.3 cm and 8.2±1.3 cm, respectively (p=0.0001), and the CCA length in men and women was 13.6±1.5 cm and 12.3±1.6 cm, respectively (p<0.0001). The lengths of the CCA and ICA in patients aged ≥60 years were 13.3±1.7 cm and 8.9±1.5 cm, respectively compared with 12.8±1.7 cm and 8.2±1.1 cm, respectively, for patients aged <60 years (p=0.04 for CCA, p=0.0002 for ICA). Tortuosity of the CCA and ICA was 1.2±0.2 and 1.3±0.1, respectively, in patients aged ≥60 years compared with 1.1±0.1 for both the ICA and CCA in patients aged <60 years (p<0.0001 for both). There was a consistent ratio of CCA/ICA length of 1.6±0.3 on the right and 1.5±0.3 on the left (p<0.0001). The arterial diameters did not show any significant difference. The distance from the aortic arch to the skull base is longer on the right than on the left side. Both the CCA and ICA are longer in men and in patients aged ≥60 years. The tortuosity of both segments significantly increases with age. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

Embolic capture with updated intra-aortic filter during coronary artery bypass grafting and transaortic transcatheter aortic valve implantation: first-in-human experience.

PubMed

Ye, Jian; Webb, John G

2014-12-01

We report our first-in-human clinical experience in the use of the new version of the EMBOL-X intra-aortic filter (Edwards Lifesciences Corporation, Irvine, Calif) to capture embolic material during transaortic transcatheter aortic valve implantation and cardiac surgery. Five patients were enrolled into the first-in-human clinical assessment of the new version of the EMBOL-X intra-aortic filter. Three patients underwent coronary artery bypass grafting, and 2 patients underwent transaortic transcatheter aortic valve implantation. During coronary artery bypass grafting, the filter was deployed before clamping of the aorta and removal of the aortic clamp. In contrast, the filter was deployed before aortic puncture for transaortic transcatheter aortic valve implantation and kept in the aorta throughout the entire procedure. The filter introducer sheath and filter were easily placed and removed without difficulty. There were no complications related to the use of the filter. Postoperative examination of the retrieved filters revealed the presence of multiple microemboli in the filters from all 5 cases. Histologic study revealed various kinds of tissue and thrombus. This first-in-human clinical experience has demonstrated the safety and feasibility of using the new version of the EMBOL-X intra-aortic filter during either cardiac surgery or transaortic transcatheter aortic valve implantation. We believe that the combination of the transaortic approach without aortic arch manipulation and the use of the EMBOL-X filter with a high capture rate is a promising strategy to reduce the incidence of embolic complications during transcatheter aortic valve implantation. Copyright © 2014 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

Anomalous vertebral artery origins: the first and second reports of two variants.

PubMed

Hsu, Daniel P; Alexander, Ashley D; Gilkeson, Robert C

2010-06-01

We present two cases of aberrant origins of vertebral arteries. Case 1 is of a patient undergoing evaluation of an infrarenal aortic aneurysm stent graft. Computed tomography (CT) angiogram revealed an aberrant right vertebral artery that subsequently joined a second right vertebral artery that had the typical origin off the right subclavian artery. This represents an unusual anatomic variation not previously reported in the literature. Case 2 is of a patient being evaluated for thoracic aorta injury. CT angiogram of the chest revealed a five-vessel aortic arch with aberrant origin of the bilateral vertebral arteries distal to the left subclavian artery.

Occlusive Disease of the Vessels of the Aortic Arch—Diagnosis and Management

PubMed Central

Johnson, C. Delmar; Zirkle, Thomas J.; Smith, Louis L.

1968-01-01

Physicians should be alert to the possibility of occlusion of one or more of the branches of the aortic arch in any patient having neurologic symptoms or complaint of claudication in the upper extremities. The finding of a pulse deficit in the neck or arm and a blood pressure difference of more than 30 mm of mercury between the two arms is pathognomic of this disease. The presence of the occlusive process can be confirmed and its extent determined by angiography. Vascular reconstruction can be expected to restore normal hemodynamics with gratifying relief of symptoms in the majority of cases. PMID:18730091

Influence of surgical implantation angle of left ventricular assist device outflow graft and management of aortic valve opening on the risk of stroke in heart failure patients

NASA Astrophysics Data System (ADS)

Chivukula, V. Keshav; McGah, Patrick; Prisco, Anthony; Beckman, Jennifer; Mokadam, Nanush; Mahr, Claudius; Aliseda, Alberto

2016-11-01

Flow in the aortic vasculature may impact stroke risk in patients with left ventricular assist devices (LVAD) due to severely altered hemodynamics. Patient-specific 3D models of the aortic arch and great vessels were created with an LVAD outflow graft at 45, 60 and 90° from centerline of the ascending aorta, in order to understand the effect of surgical placement on hemodynamics and thrombotic risk. Intermittent aortic valve opening (once every five cardiac cycles) was simulated and the impact of this residual native output investigated for the potential to wash out stagnant flow in the aortic root region. Unsteady CFD simulations with patient-specific boundary conditions were performed. Particle tracking for 10 cardiac cycles was used to determine platelet residence times and shear stress histories. Thrombosis risk was assessed by a combination of Eulerian and Lagrangian metrics and a newly developed thrombogenic potential metric. Results show a strong influence of LVAD outflow graft angle on hemodynamics in the ascending aorta and consequently on stroke risk, with a highly positive impact of aortic valve opening, even at low frequencies. Optimization of LVAD implantation and management strategies based on patient-specific simulations to minimize stroke risk will be presented

INCLUDING AORTIC VALVE MORPHOLOGY IN COMPUTATIONAL FLUID DYNAMICS SIMULATIONS: INITIAL FINDINGS AND APPLICATION TO AORTIC COARCTATION

PubMed Central

Wendell, David C.; Samyn, Margaret M.; Cava, Joseph R.; Ellwein, Laura M.; Krolikowski, Mary M.; Gandy, Kimberly L.; Pelech, Andrew N.; Shadden, Shawn C.; LaDisa, John F.

2012-01-01

Computational fluid dynamics (CFD) simulations quantifying thoracic aortic flow patterns have not included disturbances from the aortic valve (AoV). 80% of patients with aortic coarctation (CoA) have a bicuspid aortic valve (BAV) which may cause adverse flow patterns contributing to morbidity. Our objectives were to develop a method to account for the AoV in CFD simulations, and quantify its impact on local hemodynamics. The method developed facilitates segmentation of the AoV, spatiotemporal interpolation of segments, and anatomic positioning of segments at the CFD model inlet. The AoV was included in CFD model examples of a normal (tricuspid AoV) and a post-surgical CoA patient (BAV). Velocity, turbulent kinetic energy (TKE), time-averaged wall shear stress (TAWSS), and oscillatory shear index (OSI) results were compared to equivalent simulations using a plug inlet profile. The plug inlet greatly underestimated TKE for both examples. TAWSS differences extended throughout the thoracic aorta for the CoA BAV, but were limited to the arch for the normal example. OSI differences existed mainly in the ascending aorta for both cases. The impact of AoV can now be included with CFD simulations to identify regions of deleterious hemodynamics thereby advancing simulations of the thoracic aorta one step closer to reality. PMID:22917990

Extent of Aortic Replacement in Type A Dissection: Current Answers for an Endless Debate.

PubMed

Waterford, Stephen D; Gardner, Rita L; Moon, Marc R

2018-05-17

The proximal and distal extent of surgery for type A dissection is the subject of this review article. In this report, we summarize select series that illumine the issue at hand and provide insight into the surgical approach at our institution to DeBakey type I aortic dissections. For proximal extent, we discuss preservation of the aortic valve in the presence of aortic insufficiency, as well as management of the aortic root in the setting of root dilation. Distal extent of surgery for type A dissection has been a much more controversial topic. At our institution, we subscribe to the philosophy of ascending or hemiarch replacement alone for dissection under most circumstances. We describe when we believe a more aggressive arch replacement for type A dissection may be considered and detail the reports of other groups that have performed this operation more routinely. We also touch upon the frozen elephant trunk operation and its role in type A dissection, although we believe it should be reserved for high-volume dedicated aortic centers. Finally, we conclude by discussing the role of experience in choosing aortic operations for type A dissection. In our opinion, there is no single correct operation for a patient with type A dissection, but there is a correct operation for each surgeon and clinical scenario. Copyright © 2018. Published by Elsevier Inc.

Effect of the Antioxidant Lipoic Acid in Aortic Phenotype in a Marfan Syndrome Mouse Model

PubMed Central

Debbas, Victor; Salemi, Vera M.; Tavares, Elaine R.; Meirelles, Thayna; Ferreira-Filho, Julio C. A.; Takimura, Celso K.; Pereira, Lygia V.; Laurindo, Francisco R.

2018-01-01

Marfan syndrome (MFS) cardiovascular manifestations such as aortic aneurysms and cardiomyopathy carry substantial morbidity/mortality. We investigated the effects of lipoic acid, an antioxidant, on ROS production and aortic remodeling in a MFS mgΔloxPneo mouse model. MFS and WT (wild-type) 1-month-old mice were allocated to 3 groups: untreated, treated with losartan, and treated with lipoic acid. At 6 months old, echocardiography, ROS production, and morphological analysis of aortas were performed. Aortic ROS generation in 6-month-old MFS animals was higher at advanced stages of disease in MFS. An unprecedented finding in MFS mice analyzed by OCT was the occurrence of focal inhomogeneous regions in the aortic arch, either collagen-rich extremely thickened or collagen-poor hypotrophic regions. MFS animals treated with lipoic acid showed markedly reduced ROS production and lower ERK1/2 phosphorylation; meanwhile, aortic dilation and elastic fiber breakdown were unaltered. Of note, lipoic acid treatment associated with the absence of focal inhomogeneous regions in MFS animals. Losartan reduced aortic dilation and elastic fiber breakdown despite no change in ROS generation. In conclusion, oxidant generation by itself seems neutral with respect to aneurysm progression in MFS; however, lipoic acid-mediated reduction of inhomogeneous regions may potentially associate with less anisotropy and reduced chance of dissection/rupture. PMID:29765495

Tight Left Upper Lobe Collapse from Lung Cancer

DTIC Science & Technology

2010-07-01

misinterpreted or overlooked on chest radiographs. In reviewing lobar collapse, a typical cause is from proximal occlusion or stenosis of a lobar...common causes include fibrotic stenosis from granulomatous disease, post- radiation bronchial stenosis , and inflammatory conditions (eg. polychondritis...pleural space. On frontal radiograph, a cresentic hyperlucency may be noted adjacent to the thoracic aortic arch in about half of cases

Fibulin-1 is required for morphogenesis of neural crest-derived structures

PubMed Central

Cooley, Marion A.; Kern, Christine B.; Fresco, Victor M.; Wessels, Andy; Thompson, Robert P.; McQuinn, Tim C.; Twal, Waleed O.; Mjaatvedt, Corey H.; Drake, Christopher J.; Argraves, W. Scott

2008-01-01

Here we report that mouse embryos homozygous for a gene trap insertion in the fibulin-1 (Fbln1) gene are deficient in Fbln1 and exhibit cardiac ventricular wall thinning and ventricular septal defects with double outlet right ventricle or overriding aorta. Fbln1 nulls also display anomalies of aortic arch arteries, hypoplasia of the thymus and thyroid, underdeveloped skull bones, malformations of cranial nerves and hemorrhagic blood vessels in the head and neck. The spectrum of malformations is consistent with Fbln1 influencing neural crest cell (NCC)-dependent development of these tissues. This is supported by evidence that Fbln1 expression is associated with streams of cranial NCCs migrating adjacent to rhombomeres 2–7 and that Fbln1-deficient embryos display patterning anomalies of NCCs forming cranial nerves IX and X, which derive from rhombomeres 6 and 7. Additionally, Fbln1-deficient embryos show increased apoptosis in areas populated by NCCs derived from rhombomeres 4, 6 and 7. Based on these findings, it is concluded that Fbln1 is required for the directed migration and survival of cranial NCCs contributing to the development of pharyngeal glands, craniofacial skeleton, cranial nerves, aortic arch arteries, cardiac outflow tract and cephalic blood vessels. PMID:18538758

Complete trisomy 9 with unusual phenotypic associations: Dandy-Walker malformation, cleft lip and cleft palate, cardiovascular abnormalities.

PubMed

Tonni, Gabriele; Lituania, Mario; Chitayat, David; Bonasoni, Maria Paola; Keating, Sarah; Thompson, Megan; Shannon, Patrick

2014-12-01

Trisomy 9 is a rare chromosomal abnormality usually associated with first-trimester miscarriage; few fetuses survive until the second trimester. We report two new cases of complete trisomy 9 that both present unusual phenotypic associations, and we analyze the genetic pathway involved in this chromosomal abnormality. The first fetus investigated showed Dandy-Walker malformation, cleft lip, and cleft palate) at the second trimester scan. Cardiovascular abnormalities were characterized by a right-sided, U-shaped aortic arch associated with a ventricular septal defect (VSD). Symmetrical intrauterine growth restriction and multicystic dysplastic kidney disease were associated findings. The second fetus showed a dysmorphic face, bilateral cleft lip, hypoplastic corpus callosum, and a Dandy-Walker malformation. Postmortem examination revealed cardiovascular abnormalities such as persistent left superior vena cava draining into the coronary sinus, membranous ventricular septal defect, overriding aorta, pulmonary valve with two cusps and three sinuses, and the origin of the left subclavian artery distal to the junction of ductus arteriosus and aortic arch. Complete trisomy 9 may result in a wide spectrum of congenital abnormalities, and the presented case series contributes further details on the phenotype of this rare aneuploidy. Copyright © 2014. Published by Elsevier B.V.

Creating vascular models by postprocessing computed tomography angiography images: a guide for anatomical education.

PubMed

Govsa, Figen; Ozer, Mehmet Asim; Sirinturk, Suzan; Eraslan, Cenk; Alagoz, Ahmet Kemal

2017-08-01

A new application of teaching anatomy includes the use of computed tomography angiography (CTA) images to create clinically relevant three-dimensional (3D) printed models. The purpose of this article is to review recent innovations on the process and the application of 3D printed models as a tool for using under and post-graduate medical education. Images of aortic arch pattern received by CTA were converted into 3D images using the Google SketchUp free software and were saved in stereolithography format. Using a 3D printer (Makerbot), a model mode polylactic acid material was printed. A two-vessel left aortic arch was identified consisting of the brachiocephalic trunk and left subclavian artery. The life-like 3D models were rotated 360° in all axes in hand. The early adopters in education and clinical practices have embraced the medical imaging-guided 3D printed anatomical models for their ability to provide tactile feedback and a superior appreciation of visuospatial relationship between the anatomical structures. Printed vascular models are used to assist in preoperative planning, develop intraoperative guidance tools, and to teach patients surgical trainees in surgical practice.

Persistent right aortic arch and aberrant left subclavian artery in a white Bengal tiger (Panthera tigris).

PubMed

Ketz, C J; Radlinsky, M; Armbrust, L; Carpenter, J W; Isaza, R

2001-06-01

A 3-mo-old male white Bengal tiger (Panthera tigris) presented with the chief complaint of regurgitation of solid food since weaning at 2 mo of age. Compared with its littermates, the tiger was in poor body condition and weighed only 10.3 kg when its littermates were estimated at 20-25 kg. Thoracic radiographs showed a megaesophagus cranial to the heart base. A contrast esophagram more clearly outlined the megaesophagus, and fluoroscopy demonstrated normal motility of the caudal esophagus. Endoscopic examination revealed a structure coursing dorsally from right to left over the esophagus and a constrictive band on the left of the esophagus at the heart base. Nonselective angiography confirmed the presence of a persistent right aortic arch, as well as an aberrant left subclavian artery. A left fourth intercostal thoracotomy was performed, and the ligamentum arteriosum was double ligated and divided. The left subclavian artery did not cause significant compromise of the esophagus and was not manipulated at surgery. The tiger recovered well from anesthesia and surgery. Solid food was slowly introduced over a 2-mo period without any regurgitation. The cub gained weight rapidly after surgery.

[Modern aortic surgery in Marfan syndrome--2011].

PubMed

Kallenbach, K; Schwill, S; Karck, M

2011-09-01

Marfan syndrome is a hereditary disease with a prevalence of 2-3 in 10,000 births, leading to a fibrillin connective tissue disorder with manifestations in the skeleton, eye, skin, dura mater and in particular the cardiovascular system. Since other syndromes demonstrate similar vascular manifestations, but therapy may differ significantly, diagnosis should be established using the revised Ghent nosology in combination with genotypic analysis in specialized Marfan centres. The formation of aortic root aneurysms with the subsequent risk of acute aortic dissection type A (AADA) or aortic rupture limits life expectancy in patients with Marfan syndrome. Therefore, prophylactic replacement of the aortic root needs to be performed before the catastrophic event of AADA can occur. The goal of surgery is the complete resection of pathological aortic tissue. This can be achieved with excellent results by using a (mechanically) valved conduit that replaces both the aortic valve and the aortic root (Bentall operation). However, the need for lifelong anticoagulation with Coumadin can be avoided using the aortic valve sparing reimplantation technique according to David. The long-term durability of the reconstructed valve is favourable, and further technical improvements may improve longevity. Although results of prospective randomised long-term studies comparing surgical techniques are lacking, the David operation has become the surgical method of choice for aortic root aneurysms, not only at the Heidelberg Marfan Centre. Replacement of the aneurysmal dilated aortic arch is performed under moderate hypothermic circulatory arrest combined with antegrade cerebral perfusion using a heart-lung machine, which we also use in thoracic or thoracoabdominal aneurysms. Close post-operative follow-up in a Marfan centre is pivotal for the early detection of pathological changes on the diseased aorta.

Open Versus Endovascular or Hybrid Thoracic Aortic Aneurysm Repair.

PubMed

Clare, Ryan; Jorgensen, Julianne; Brar, Somjot S

2016-10-01

Thoracic aortic aneurysms are associated with significant morbidity and mortality. There are multiple underlying etiologies, including genetic abnormalities, that have important implications in their natural history. The variable histologic, anatomic, and clinical presentations necessitate careful consideration of available treatment options. Surgical repair of these aneurysms has been the mainstay of treatment; however, these approaches can carry a relatively high risk of morbidity and mortality. Endovascular approaches have now become first-line therapy for descending thoracic aneurysms, and with advancements in graft technology, endovascular approaches are being increasingly employed for hybrid repairs of the aortic arch and even the ascending aorta. However, to date, clinical outcomes from randomized trials and long-term follow-up are limited. As technology continues to advance, there is the potential for further integration of surgical and endovascular treatments so that patients have the best opportunity for a favorable outcome.

Tension pneumothorax accompanied by type A aortic dissection.

PubMed

Hifumi, Toru; Kiriu, Nobuaki; Inoue, Junichi; Koido, Yuichi

2012-11-09

A 51-year-old man was brought to the emergency room because of a sudden onset of severe dysponea. On presentation, his blood pressure was 94/55 mm Hg. Oxygen saturation was 86% while he was receiving 10 l/min oxygen through a non-rebreather mask. On physical examination, no jugular venous distention was noted, but breath sounds over the left lung were diminished. A bedside chest radiograph showed left tension pneumothorax, for which urgent needle decompression followed by chest thoracostomy was performed. Ventricular tachycardia developed, but a biphasic shock at 120 J immediately restored normal sinus rhythm. His vital signs, however, did not improve. A CT scan of the chest showed type A aortic dissection with bullae in the upper lobe of the left lung. He had an emergency operation for distal aortic arch displacement and was discharged on the 37th day of hospitalisation.

In elective arch surgery with circulatory arrest, does the arterial cannulation site really matter? A propensity score analysis of right axillary and innominate artery cannulation.

PubMed

Preventza, Ourania; Price, Matt D; Spiliotopoulos, Konstantinos; Amarasekara, Hiruni S; Cornwell, Lorraine D; Omer, Shuab; de la Cruz, Kim I; Zhang, Qianzi; Green, Susan Y; LeMaire, Scott A; Rosengart, Todd K; Coselli, Joseph S

2018-05-01

The preferred arterial cannulation site for elective proximal aortic procedures requiring circulatory arrest varies, and different sites have been tried. We evaluated the relationships between arterial cannulation site and adverse outcomes, including stroke, in patients undergoing elective aortic arch surgery. We reviewed the records of 938 patients who underwent elective hemiarch or total arch surgery with circulatory arrest between 2006 and 2016. Five cannulation sites were used: the right axillary (n = 515; 54.9%), innominate (n = 376; 40.1%), and right common carotid arteries (n = 15; 1.6%), each with a side graft; the ascending aorta (n = 19; 2.0%); and the femoral artery (n = 13; 1.4%). Multivariable logistic regression analysis was used to model the effects of cannulation site on adverse outcomes for the entire cohort and for a subcohort of 891 patients who underwent innominate or axillary artery cannulation. Propensity-matching yielded 564 patients (282 pairs) from the right axillary and innominate artery groups. For the entire cohort, mortality, stroke, and composite adverse outcome (operative death or persistent stroke or renal failure at hospital discharge) rates were 7.0%, 4.1%, and 9.8%. In the multivariable analysis of the axillary/innominate subcohort, cannulation site did not independently predict operative mortality, persistent stroke, or composite adverse event. These results were confirmed with the propensity-matched analysis, where both axillary and innominate artery cannulation provided equivalent composite adverse event rates, operative death rates, and overall stroke rates. During elective arch surgery, right axillary artery cannulation and innominate artery cannulation (both via a side graft) produce excellent results and can be used interchangeably. Copyright © 2017 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

Degree of fusiform dilatation of the proximal descending aorta in type B acute aortic dissection can predict late aortic events.

PubMed

Marui, Akira; Mochizuki, Takaaki; Koyama, Tadaaki; Mitsui, Norimasa

2007-11-01

Predicting the risk factors for late aortic events in patients with type B acute aortic dissection without complications may help to determine a therapeutic strategy for this disorder. We investigated whether late aortic events in type B acute aortic dissection can be predicted accurately by an index that expresses the degree of fusiform dilatation of the proximal descending aorta during the acute phase; this index can be calculated as follows: (maximum diameter of the proximal descending aorta)/(diameter of the distal aortic arch + diameter of the descending aorta at the pulmonary artery level). Patients with type B acute aortic dissection without complications (n = 141) were retrospectively analyzed to determine the predictors of late aortic events; these include aortic dilatation, rupture, refractory pain, organ ischemia, rapid aortic enlargement, and rapid enlargement of ulcer-like projections. The fusiform index in patients with late aortic events (0.59) was higher than that in patients without late aortic events (0.53, P < .01). Patients with a higher fusiform index exhibited aortic dilatation earlier than those with a lower fusiform index. By multivariate analysis, we conclude that the predominant independent predictors of late aortic events were a maximum aortic diameter of 40 mm or more, a patent false lumen, and a fusiform index of 0.64 or more (hazard ratios, 3.18, 2.64, and 2.73, respectively). The values of actuarial freedom from aortic events for patients with all 3 predictors at 1, 5, and 10 years were 22%, 17%, and 8%, respectively, whereas the values in those without these predictors were 97%, 94%, and 90%, respectively. The degree of fusiform dilatation of the proximal descending aorta, a patent false lumen, and a large aortic diameter can be predominant predictors of late aortic events in patients with type B acute aortic dissection. Patients with these predictors should be recommended to undergo early interventions (surgery or stent-graft implantation) or at least be closely followed up during the chronic phase before such events develop.

Long-term results of aortic valve replacement with Edwards Prima Plus stentless bioprosthesis: eleven years' follow up.

PubMed

Auriemma, Stefano; D'Onofrio, Augusto; Brunelli, Massimo; Magagna, Paolo; Paccanaro, Mariemma; Rulfo, Fanny; Fabbri, Alessandro

2006-09-01

The Edwards Lifesciences Prima Plus stentless valve (ELSV) is a bioprosthesis manufactured from a porcine aortic root. The study aim was to evaluate late clinical outcomes after aortic valve replacement (AVR) with ELSV implanted as a miniroot in patients with aortic valve disease. Between 1993 and 2004, 318 patients (232 males, 86 females; mean age 69 +/- 9 years; range: 37-83 years) underwent AVR with the ELSV. Preoperatively, 102 patients (32%), 162 (51%) and 54 (17%) were in NYHA classes I/II, III and IV, respectively. Aortic stenosis, aortic regurgitation and combined lesions were present in 124 patients (39%), 114 (36%) and 41 (13%), respectively. Twenty patients (6%) were referred for an acute aortic dissection, 20 (6%) for an aortic root aneurysm, and 139 (44%) had an associated aneurysmal dilatation of the ascending aorta. The ascending aorta was replaced in 159 patients (50%); aortic arch replacement was required in 10 (3%). Coronary artery bypass graft was performed in 86 patients (27%). The follow up was based on clinical data. Operative mortality was 5% (n = 17). There were 49 late deaths (5.2%/pt-yr). Valve-related mortality occurred in 10 patients (1%/pt-yr). Actuarial survival at five and 10 years was 78% and 33%, respectively. Actuarial freedom from valve reoperation and structural valve deterioration at 10 years were 100% and 64%. Actuarial freedom from embolic events and endocarditis at 10 years were 84% and 81%, respectively. The ELSV, when implanted as a miniroot, provided good early and long-term results in terms of survival and freedom from major complications.

Unusual vertebral artery origins: examples and related pathology.

PubMed

Koenigsberg, Robert A; Pereira, Lorianne; Nair, Bronwyn; McCormick, Daniel; Schwartzman, Robert

2003-06-01

Anomalies of the vertebral arteries are uncommon, but important to recognize in the diagnosis and catheter based evaluation and treatment of patients suffering cerebrovascular disease. This article illustrates our experience with such anomalies. These include the vertebral artery arising as the fourth and most distal branch of the aortic arch, as a right subclavian artery branch arising distal to the right thyrocervical trunk, as a right common carotid artery branch in a patient with an aberrant right subclavian artery, and a case of left vertebral artery proximal duplication, with both aortic and left subclavian vertebral arteries present in the same patient; the latter join to form a single distal cervical vertebral artery. Copyright 2003 Wiley-Liss, Inc.

Natural history of aneurysmal aortic arch branch vessels in a single tertiary referral center.

PubMed

Brownstein, Adam J; Rajaee, Sareh; Erben, Young; Li, Yupeng; Rizzo, John A; Lyall, Vikram; Mojibian, Hamid; Ziganshin, Bulat A; Elefteriades, John A

2018-05-23

Little is known about the natural history and management of aneurysmal aortic arch branch vessels (AABVs). The objectives of this study were to assess the natural history of aneurysmal AABVs and to examine the outcomes of operative intervention. A retrospective review of the Yale radiologic database from 1999 to 2016 was performed. Only those patients with an aneurysmal AABV and a computed tomography scan were selected for review. Patients' demographics, aneurysm characteristics, management, and follow-up information were collected. There were 105 patients with 147 aneurysmal AABVs; 76 were male (72%), with a mean age of 70 years (range, 17-93 years). We identified 63 innominate, 50 left subclavian, 30 right subclavian, and 4 common carotid artery aneurysms. On computed tomography, 65 (62%) had aortic aneurysms and six (6%) had suffered an aortic dissection. Most were asymptomatic (104 [99%]); one had chest pain and an enlarging swollen mass. Twelve (11%) patients underwent operative repair (OR) for 12 aneurysmal AABVs because of symptoms, growth, or concomitant aortic operations; 93 (89%) were observed in the no operative repair (NOR) group with cross-sectional imaging. The overall mean vessel diameter was 2.08 ± 0.68 cm. The mean diameters in the OR and NOR groups were 3.32 ± 1.24 cm and 1.97 ± 0.46 cm, respectively (P = .002). OR included nine bypasses with resection, two stent grafts, and one resection without reconstruction. Two patients developed postoperative hemorrhage requiring re-exploration, one patient developed stent thrombosis, and one patient required pseudoaneurysm repair 20 years after index operation. Mean follow-up was 52 ± 51 months for the NOR group, with no ruptures or emboli. The growth rate was 0.04 ± 0.10 cm/y. On multivariable regression analysis, a descending aortic aneurysm (P = .041) and a left subclavian artery aneurysm (P = .016) were associated with higher growth rates, whereas height was associated with a lower growth rate (P = .001). Aneurysmal AABVs tend to have a benign natural history with slow growth rates and low rates of complications, including rupture and embolization. We recommend expectant observational management for small, incidentally detected aneurysms. Copyright © 2018 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.

Contemporary insights into the management of type A aortic dissection.

PubMed

Tolis, George; Sundt, Thoralf M

2016-10-01

Acute Type A Dissection remains a surgical emergency with a relatively high operative mortality despite advances in cardiac surgical techniques and medical management over the past thirty years. In this presentation we will discuss the issues surrounding diagnosis, triage, surgical treatment and perioperative medical management as well as long term surveillance of patients suffering from Acute Type A Dissection and present the literature that supports our management strategies. Expert commentary: The ultimate goal of surgical intervention for patients with Type A Acute Aortic Dissection is an alive patient. A more complicated operation which addresses the root and arch and potentially reduces late complications should be approached with caution since it may increase the operative mortality of the procedure itself. With the recent evolution in endovascular techniques, there is hope that later complications can be reduced without increasing the risk of the primary operation. It remains to be seen whether the improved distal aortic remodeling afforded by a combined open/endovascular approach to Acute Type A Dissection will lead to decreased need for aortic reinterventions and overall long term complications of a residual descending thoracic chronic dissection.

Scan-rescan reproducibility of segmental aortic wall shear stress as assessed by phase-specific segmentation with 4D flow MRI in healthy volunteers.

PubMed

van der Palen, Roel L F; Roest, Arno A W; van den Boogaard, Pieter J; de Roos, Albert; Blom, Nico A; Westenberg, Jos J M

2018-05-26

The aim was to investigate scan-rescan reproducibility and observer variability of segmental aortic 3D systolic wall shear stress (WSS) by phase-specific segmentation with 4D flow MRI in healthy volunteers. Ten healthy volunteers (age 26.5 ± 2.6 years) underwent aortic 4D flow MRI twice. Maximum 3D systolic WSS (WSSmax) and mean 3D systolic WSS (WSSmean) for five thoracic aortic segments over five systolic cardiac phases by phase-specific segmentations were calculated. Scan-rescan analysis and observer reproducibility analysis were performed. Scan-rescan data showed overall good reproducibility for WSSmean (coefficient of variation, COV 10-15%) with moderate-to-strong intraclass correlation coefficient (ICC 0.63-0.89). The variability in WSSmax was high (COV 16-31%) with moderate-to-good ICC (0.55-0.79) for different aortic segments. Intra- and interobserver reproducibility was good-to-excellent for regional aortic WSSmax (ICC ≥ 0.78; COV ≤ 17%) and strong-to-excellent for WSSmean (ICC ≥ 0.86; COV ≤ 11%). In general, ascending aortic segments showed more WSSmax/WSSmean variability compared to aortic arch or descending aortic segments for scan-rescan, intraobserver and interobserver comparison. Scan-rescan reproducibility was good for WSSmean and moderate for WSSmax for all thoracic aortic segments over multiple systolic phases in healthy volunteers. Intra/interobserver reproducibility for segmental WSS assessment was good-to-excellent. Variability of WSSmax is higher and should be taken into account in case of individual follow-up or in comparative rest-stress studies to avoid misinterpretation.

Effects of Leaflet Design on Transvalvular Gradients of Bioprosthetic Heart Valves.

PubMed

Dabiri, Yaghoub; Ronsky, Janet; Ali, Imtiaz; Basha, Ameen; Bhanji, Alisha; Narine, Kishan

2016-12-01

Bioprosthetic aortic valves (BAVs) are becoming the prostheses of choice in heart valve replacement. The objective of this paper is to assess the effects of leaflet geometry on the mechanics and hemodynamics of BAVs in a fluid structure interaction model. The curvature and angle of leaflets were varied in 10 case studies whereby the following design parameters were altered: a circular arch, a line, and a parabola for the radial curvature, and a circular arch, a spline, and a parabola for the circumferential curvature. Six different leaflet angles (representative of the inclination of the leaflets toward the surrounding aortic wall) were analyzed. The 3-dimensional geometry of the models were created using SolidWorks, Pointwise was used for meshing, and Comsol Multiphysics was used for implicit finite element calculations. Realistic loading was enforced by considering the time-dependent strongly-coupled interaction between blood flow and leaflets. Higher mean pressure gradients as well as von Mises stresses were obtained with a parabolic or circular curvature for radial curvature or a parabolic or spline curvature for the circumferential curvature. A smaller leaflet angle was associated with a lower pressure gradient, and, a lower von Mises stress. The leaflet curvature and angle noticeably affected the speed of valve opening, and closing. When a parabola was used for circumferential or radial curvature, leaflets displacements were asymmetric, and they opened and closed more slowly. A circular circumferential leaflet curvature, a linear leaflet radial curvature, and leaflet inclination toward the surrounding aortic wall were associated with superior BAVs mechanics.

Regression of left ventricular dilation after percutaneous closure of a large intralobar pulmonary sequestration.

PubMed

Alvarez, Alejandro; Borgia, Francesco; Guccione, Paolo

2010-02-01

We describe an infant of 8 months who presented with left ventricular dilation due to an extensive intralobar sequestration of the right lung. The pulmonary sequestration was associated with a patent arterial duct and a right aortic arch. Percutaneous closure of the anomalous aberrant artery feeding the sequestrated lung resulted in prompt regression of the left ventricular enlargement.

Technical and Clinical Success and Long-Term Durability of Endovascular Treatment for Atherosclerotic Aortic Arch Branch Origin Obstruction: Evaluation of 144 Procedures.

PubMed

van de Weijer, M A J; Vonken, E J P A; de Vries, J-P P M; Moll, F L; Vos, J A; de Borst, G J

2015-07-01

Endovascular treatment of atherosclerotic obstruction of aortic arch branch origins (AABO) has largely replaced open surgery, but long-term outcome data are lacking. This study evaluated mid-term and long-term results of these procedures. Retrospective cohort study. Patients underwent endovascular treatment for symptomatic atherosclerotic stenosis of AABO between 1995 and 2012. Technical success was defined as uncomplicated revascularization and residual stenosis ≤30%. The primary end point was freedom from restenosis ≥50% on Duplex ultrasonography or magnetic resonance angiography. Secondary end points were freedom from target lesion revascularization or recurrent symptoms. 144 lesions were treated in 114 patients (75 female; mean age 66.3 years), by percutaneous transluminal angioplasty (PTA) in 20 patients and PTA and stent in 117 patients (brachiocephalic artery [BCA] 9/54; left common carotid artery [LCCA] 0/7; left subclavian artery [LSA] 11/56). The lesion could not be passed in four patients, and in three patients the intervention was terminated before angioplasty. The 30-day technical success was 94.4%, without deaths or strokes. Mean follow-up was 52.0 months (range 2-163 months). Restenosis-free survival was 95.6%, 92.9%, 87.6%, and 83.2% at 12, 24, 48, and 60 months, respectively. Log-rank test showed no significant difference between PTA only and PTA with additional stent placement at any point (p = .375), nor between BCA (n = 51), LCCA (n = 6), or LSA (n = 57). During follow-up, 27 patients (23.7%) became symptomatic (15 BCA, 1 LCCA, and 11 LSA); 19 patients with a restenosis of the target lesion (mean 56.7 months). Symptom-free survival was 94.7%, 92.0%, 82.3%, and 77.9% at 12, 24, 48, and 60 months, respectively. Endovascular treatment of aortic arch branch origin obstruction is safe and efficacious in experienced hands and can be considered as the preferred treatment, with good mid-term durability. Recurrent symptomatic lesions can be treated safely by renewed endovascular means. Copyright © 2015 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.

Comparable Cerebral Blood Flow in Both Hemispheres During Regional Cerebral Perfusion in Infant Aortic Arch Surgery.

PubMed

Rüffer, André; Tischer, Philip; Münch, Frank; Purbojo, Ariawan; Toka, Okan; Rascher, Wolfgang; Cesnjevar, Robert Anton; Jüngert, Jörg

2017-01-01

Cerebral protection during aortic arch repair can be provided by regional cerebral perfusion (RCP) through the innominate artery. This study addresses the question of an adequate bilateral blood flow in both hemispheres during RCP. Fourteen infants (median age 11 days [range, 3 to 108]; median weight, 3.6 kg [range, 2.8 to 6.0 kg]) undergoing RCP (flow rate 54 to 60 mL · kg -1 · min -1 ) were prospectively included. Using combined transfontanellar/transtemporal two- and three-dimensional power/color Doppler sonography, cerebral blood flow intensity in the main cerebral vessels was displayed. Mean time average velocities were measured with combined pulse-wave Doppler in the basilar artery, and both sides of the internal carotid, anterior, and medial cerebral arteries. In addition, bifrontal regional cerebral oximetry (rSO 2 ) was assessed. Comparing both hemispheres, measurements were performed at target temperature (28°C) during full-flow total body perfusion (TBP) and RCP. A regular circle of Willis with near-symmetric blood flow intensity to both hemispheres was visualized in all infants during both RCP and TBP. In the left internal carotid artery, blood flow direction was mixed (retrograde, n = 5; antegrade, n = 8) during TBP and retrograde during RCP. Comparison between sides showed comparable cerebral time average velocities and rSO 2 , except for higher time average velocities in the right internal carotid artery (TBP p = 0.019, RCP p = 0.09). Unilateral comparison between perfusion methods revealed significantly higher rSO 2 in the right hemisphere during TBP (82% ± 9%) compared with RCP (74% ± 11%, p = 0.036). Bilateral assessment of cerebral rSO 2 and time average velocity in the main great cerebral vessels suggests that RCP is associated with near-symmetric blood flow intensity to both hemispheres. Further neurodevelopmental studies are necessary to verify RCP for neuroprotection during aortic arch repair. Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Diffusion-weighted MRI determined cerebral embolic infarction following transcatheter aortic valve implantation: assessment of predictive risk factors and the relationship to subsequent health status.

PubMed

Fairbairn, Timothy A; Mather, Adam N; Bijsterveld, Petra; Worthy, Gillian; Currie, Stuart; Goddard, Anthony J P; Blackman, Daniel J; Plein, Sven; Greenwood, John P

2012-01-01

'Silent' cerebral infarction and stroke are complications of transcatheter aortic valve implantation (TAVI). To assess the occurrence of cerebral infarction, identify predictive risk factors and examine the impact on patient health-related quality of life (HRQoL). Cerebral diffusion weighted MRI of 31 patients with aortic stenosis undergoing CoreValve TAVI was carried out. HRQoL was assessed at baseline and at 30 days by SF-12v2 and EQ5D questionnaires. New cerebral infarcts occurred in 24/31 patients (77%) and stroke in 2 (6%). Stroke was associated with a greater number and volume of cerebral infarcts. Age (r=0.37, p=0.042), severity of atheroma (arch and descending aorta; r=0.91, p<0.001, r=0.69, p=0.001, respectively) and catheterisation time (r=0.45, p=0.02) were predictors of the number of new cerebral infarcts. HRQoL improved overall: SF-12v2 physical component summary increased significantly (32.4±6.2 vs 36.5±7.2; p=0.03) with no significant change in mental component summary (43.5±11.7 vs. 43.1±14.3; p=0.85). The EQ5D score and Visual Analogue Scale showed no significant change (0.56±0.26 vs. 0.59±0.31; p=0.70, and 54.2±19 vs. 58.2±24; p=0.43). Multiple small cerebral infarcts occurred in 77% of patients with TAVI. The majority of infarcts were 'silent' with clinical stroke being associated with a both higher infarct number and volume. Increased age and the severity of aortic arch atheroma were independent risk factors for the development of new cerebral infarcts. Overall HRQoL improved and there was no association between the number of new cerebral infarcts and altered health status.

Antegrade or Retrograde Cerebral Perfusion in Ascending Aorta and Hemiarch Surgery? A Propensity-Matched Analysis.

PubMed

Perreas, Konstantinos; Samanidis, George; Thanopoulos, Apostolis; Georgiopoulos, Georgios; Antoniou, Theofani; Khoury, Mazen; Michalis, Alkiviadis; Bairaktaris, Andreas

2016-01-01

Over the years, numerous options have been proposed for surgical management of ascending aorta and aortic arch pathology in an attempt to minimize postoperative morbidity and probability of death. We present a propensity score-matching analysis of 259 patients from a single unit who were operated on under deep hypothermic arrest with retrograde cerebral perfusion (DHCA/RCP) or moderate hypothermic circulatory arrest with selective antegrade cerebral perfusion (via common carotid artery) (MHCA/ACP). Between 2006 and 2014 a total of 259 consecutive patients underwent ascending aorta and hemiarch correction under HCA. DHCA/RCP and MHCA/ACP were performed on 207 and 52 patients, respectively. Baseline patient characteristics accounted for in the propensity matching were age, sex, acute aortic dissection, emergency operation, re-operation, preoperative hemodynamic instability, preoperative kidney injury, and CA time. After propensity scoring 40 pairs (80 patients) were successfully matched (p = 0.732). Outcomes were defined as the incidence of postoperative neurologic complications, 30-day mortality, and all-cause midterm mortality. Surgical procedure that involved the MHCA/ACP technique was associated with 76.5% decreased risk (risk ratio, 0.235; 95% CI, 0.079 to 0.699) of postoperative neurologic complications (p = 0.009). In addition to MHCA/ACP in surgical procedure for acute aortic dissection a relevant trend was established for 30-day mortality (risk ratio, 0.333; 95% CI, 0.09 to 1.23). For midterm all-cause mortality, MHCA/ACP modestly decreased the number of deaths (p = 0.0456) in comparison with the DHCA/RCP technique. MHCA/ACP in aortic arch surgical procedure is associated with a decreased risk of all types of neurologic complications and a trend toward decreased 30-day and midterm mortality in comparison with DHCA/RCP. Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Increased aortic wave reflection contributes to higher systolic blood pressure in adolescents born preterm.

PubMed

Kowalski, Remi R; Beare, Richard; Mynard, Jonathan P; Cheong, Jeanie L Y; Doyle, Lex W; Smolich, Joseph J; Cheung, Michael M H

2018-03-29

To evaluate the wave reflection characteristics in the aortic arch and common carotid artery of ex-preterm adolescents and assess their relationship to central blood pressure in a cohort followed prospectively since birth. Central blood pressures, pulse wave velocity, augmentation index, microvascular reactive hyperemia, arterial distensibility, compliance and stiffness index, and also aortic and carotid wave intensity were measured in 18-year-olds born extremely preterm at below 28 weeks' gestation (n = 76) and term-born controls (n = 42). Compared with controls, ex-preterm adolescents had higher central systolic (111 ± 11 vs. 105 ± 10 mmHg; P < 0.001) and diastolic blood pressures (73 ± 7 vs. 67 ± 7 mmHg; P < 0.001). Although conventional measures of arterial function and biomechanics such as pulse wave velocity and augmentation index were no different between groups, wave intensity analysis revealed elevated backward compression wave area (-0.39 ± 0.21 vs. -0.29 ± 0.17 W/m/s × 10; P = 0.03), backward compression wave pressure change (9.0 ± 3.5 vs. 6.6 ± 2.5 mmHg; P = 0.001) and reflection index (0.44 ± 0.15 vs. 0.32 ± 0.08; P < 0.001) in the aorta of ex-preterm adolescents compared with controls. These changes were less pronounced in the carotid artery. On multivariable analysis, forward and backward compression wave areas were the only biomechanical variables associated with central systolic pressure. Ex-preterm adolescents demonstrate elevated wave reflection indices in the aortic arch, which correlate with central systolic pressure. Wave intensity analysis may provide a sensitive novel marker of evolving vascular dysfunction in ex-preterm survivors.

Chinese yellow wine and red wine inhibit matrix metalloproteinase-2 and improve atherosclerotic plaque in LDL receptor knockout mice.

PubMed

Guo, Hangyuan; Liu, Longbin; Shi, Yafei; Sun, Aijing; Xu, Fukang; Chi, Jufang; Huang, Dilai

2010-06-01

Our previous study found that Chinese yellow wine could inhibit the production of homocysteine (HCY) induced extracellular matrix metalloproteinase-2 (MMP-2) in the cultured rat vascular smooth muscle cells. Little is known about the relationship between Chinese yellow wine and atherosclerosis or MMP-2 in vivo. Thirty-two LDL Receptor knockout mice on a high-fat and L-methionine diet developed plasma hyperhomocysteinemia and atherosclerosis. They were randomly divided into yellow wine group (n = 8), red wine group (n = 8), ethanol group (n = 8), and control group (n = 8), they were sacrificed after 14 weeks. There were no significant differences with plasma total cholesterol (TC), triglyceride (TG), high-density lipoprotein cholesterol (HDL-C), alanine aminotransferase (ALT), and aspartate aminotransferase (AST) levels in the four groups. Plasma HCY was significantly decreased in the yellow wine group compared to the other three groups (P < 0.01). Yellow wine and red wine groups significantly reduced the atherosclerosis lesion area compared to ethanol and control groups (P < 0.001). However, there was no significant discrepancy between the yellow wine group and red wine group. Compared to the control group and ethanol group, the production of MMP-2 reduced 26.8% and 23.6% in the aortic sinus and the activation of MMP-2 reduced 32.6% and 27.3% in the aortic arch in the yellow wine group; the production of MMP-2 reduced 25.7% and 22.4% in the aortic sinus and the activation of MMP-2 reduced 30.2% and 26.6% in the aortic arch in the red wine group. These results suggest that Chinese yellow wine and red wine can inhibit MMP-2 and improve atherosclerosis, and maybe both Chinese yellow wine and red wine have beneficial effects on cardiovascular disease by inhibiting MMP-2.

Improvement in conformability of the latest generation of thoracic stent grafts.

PubMed

Canaud, Ludovic; Cathala, Philipe; Joyeux, Frédéric; Branchereau, Pascal; Marty-Ané, Charles; Alric, Pierre

2013-04-01

Poor aortic arch apposition increases the risk of technical failure after thoracic endovascular repair. The aim of this study was to assess the conformability of the latest generation of thoracic stent grafts in relation to the degree of device oversizing and aortic arch angulation. A benchtop pulsatile flow model was designed to test stent graft anchorage in a 2-cm-long proximal landing zone at varying landing zone angles (from 140° down to 70°) and stent graft oversizing (12%-28%). The experiments were performed using 10 human thoracic cadaveric aortas and four stent grafts: C-TAG, Zenith TX2 Pro-Form, Valiant Captivia, and Relay. Device-wall apposition was measured as a function of landing zone angulation and oversizing during static and dynamic (60 pulses/min, 300/150 mm Hg) tests. The Valiant stent graft remained apposed to the aortic wall at each increment of neck angulation and device oversizing. Lack of apposition of the proximal anchorage segment was observed with the C-TAG above 120° landing zone angulation (1-2 mm) and with the Relay above 110° landing zone angulation (1-4 mm). Lack of "body" apposition (1-4 mm) was first observed with the Zenith Pro-Form stent graft above 110° angulation (P = .001). When the device was not apposed to the aortic wall, an increase in stent graft oversizing significantly (P = .01) decreased device-wall apposition. The requirement for close conformability has influenced the design of next-generation devices. Manufacturers have modified devices and/or their deployment system to specifically address this problem. When compared with the results of our previous experimental test, this study demonstrates that these alterations have resulted in a marked improvement in the performance of commercially available stent graft systems. Copyright © 2013 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.

[Clinical amalysis of left subclavian artery revascularization by stented trunk fenestration for acute Stanford type A aortic dissection].

PubMed

Tang, Y F; Han, L; Lu, F L; Song, Z G; Lang, X L; Zou, L J; Xu, Z Y

2016-07-01

To summarize the results and methods of left subclavian artery revascularization by stented trunk fenestration for acute Stanford type A aortic dissection. Clinical data of 67 patients (54 male and 13 female, mean age of (50±10) years) underwent surgical treatment of left subclavian artery fenestration for acute Stanford A aortic dissection in Department of Cardiothoracic Surgery, Changhai Hospital, Second Military Medical College between September 2008 and December 2014 were analyzed retrospectively. The origin of the left subclavian artery was in the true lumen and no dissection existed near the artery's starting. There were 18 cases of Marfan's syndrome. Preoperative echocardiography showed moderate to severe aortic regurgitation in 10 cases, and mitral regurgitation in 3 cases. Electrocardiogram showed myocardial ischemia in 5 cases. Three patients had acute impaired renal function. All the patients received total arch replacement combined with stented elephant trunk implantation. Left subclavian artery revascularization was performed by stented trunk fenestration as follows: firstly, stented elephant trunk was implanted to completely cover the left subclavian artery, then part of stented trunk's polyester lining was removed which is located at the origin of left subclavian artery. Aortic root procedures included aortic valve replacement in 2 cases, Bentall procedure in 21 cases and aortic valve sparing in 44 cases. Three patients received mitral valve repair and 6 patients received coronary artery bypass grafting. The cardiopulmonary bypass time, cross-clamp time, and circulatory arrest time were (179±32) minutes, (112±25) minutes, and (26±10) minutes, respectively. The in-hospital mortality was 7.5% (5/67): 2 patients died of multiple organ failure, 1 patient died of acute renal failure and another 2 patients died of severe infection shock. Two patients required reexploration for root bleeding. Transient neurology dysfunction developed in 6 patients. Six patients received tracheotomy and prolonged ventilation due to pulmonary infection. All patients discharged from the hospital were followed up for 1 to 5 years. During long-term follow-up, the survival rate was 100% and 89.8% at 1 and 5 years, respectively. CT angiography was performed once per year after discharged. The left subclavian artery perfusion was good. No dissection or anastomosis leakage was identified in any case. Stroke and left limb ischemia did not develope. For acute Stanford type A aortic dissection whose origin of the left subclavian artery is in the true lumen and no dissection existed near the artery's starting, the left subclavian artery revascularization by stented trunk fenestration technique during total arch replacement combined with stented elephant trunk implantation is reliable and effective.

Aortic root replacement using a biovalsalva prosthesis in comparison to a "handsewn" composite bioprosthesis.

PubMed

Moorjani, Narain; Modi, Amit; Mattam, Kavita; Barlow, Clifford; Tsang, Geoffrey; Haw, Marcus; Livesey, Steven; Ohri, Sunil

2010-05-01

The Biovalsalva aortic root prosthesis incorporates an Elan porcine stentless biological aortic valve suspended within a triple-layered vascular conduit with preformed aortic sinuses of Valsalva. This study compared implantation of the Biovalsalva prosthesis with a "handsewn" composite bioprosthetic graft (CE Perimount bovine bioprosthesis anastomosed to a gelatin-impregnated gelweave Dacron graft). Between December 2004 and January 2009, 39 patients underwent elective or urgent aortic root replacement (modified Bentall procedure with coronary button reimplantation) using a Biovalsalva (n = 21) or a handsewn bioprosthesis (n = 18) for aortic root dilatation. There was no significant difference in the preoperative variables between the two study groups including age (70.7 +/- 1.7 vs. 67.6 +/- 2.9 years, p > 0.05). There was no in-hospital mortality. Three patients in each group underwent concomitant aortic hemi-arch replacement. Patients who underwent Biovalsalva implantation had a reduced need for transfusion of blood (1.25 +/- 0.32 vs. 3.17 +/- 0.71 units, p < 0.05) and fresh frozen plasma (2.78 +/- 0.39 vs. 1.85 +/- 0.31, p < 0.05), and reduced mediastinal blood loss (416 +/- 52 vs. 583 +/- 74 mL, p < 0.05) compared to those with a handsewn bioprosthesis. Cardiopulmonary bypass time (141 +/- 6 vs. 170 +/- 17 minutes, p = NS) and aortic cross-clamp time (113 +/- 6 vs. 115 +/- 7 minutes, p = NS) were similar. Postoperative echocardiography demonstrated excellent hemodynamic function of the Biovalsalva prosthesis (mean size 25.1 +/- 0.4 mm valved conduit) with a peak pressure gradient of 26.2 +/- 1.9 mmHg and no or trivial valvular regurgitation. The Biovalsalva prosthesis should be considered for patients requiring a biological aortic root replacement. It offers an "off-the-shelf" preassembled composite biological valve conduit with excellent hemostatic and hemodynamic properties.

[Endovascular and surgical treatment of a patient with traumatic rupture of the aorta and hepatic artery].

PubMed

Chernaya, N R; Muslimov, R Sh; Selina, I E; Kokov, L S; Vladimirova, E S; Navruzbekov, M S; Gulyaev, V A

2016-01-01

Traumatic rupture of the aorta is the second most common cause of death in closed chest injury. The latest findings of autopsy showed that 80% of lethal outcomes in aortic injury occur in the prehospital period. Taking into consideration the incidence and high rate of death prior to the diagnosis stage, aortic rupture in closed thoracic injury is an important problem. Due to the characteristic mechanism of the development (during sharp deceleration of the body) this type of traumatic lesion of the aorta became known as "deceleration syndrome". The most vulnerable to tension aortic portion is its neck where the mobile part of the thoracic aorta is connected to the fixed arch in the place of the arterial ligament attachment. Open surgical intervention in patients with severe closed chest injury (often concomitant injury) is associated with high mortality and complications. Currently endovascular prosthetic repair of the aorta is a method of choice at the primary stage of treatment of patients with aortic injury. In this article we present a rare case report of concomitant lesion of large vessels (the descending aortic portion and proper hepatic artery) in a patient with severe concomitant injury, as well as peculiarities of diagnosis and combined treatment (endovascular prosthetic repair of the aorta and hepatic artery with an aotovein).

Topsy-turvy heart with associated congenital tracheobronchial stenosis and airway compression requiring surgical reconstruction.

PubMed

Herrera, Patricio; Caldarone, Christopher A; Forte, Vito; Holtby, Helen; Cox, Peter; Chiu, Priscilla; Kim, Peter C W

2008-07-01

We describe a case of "topsy-turvy heart" that necessitated simultaneous left tracheobronchial repair, aortic arch reconstruction, and bronchial stenting in an 11-month-old girl. This case highlights the significant therapeutic dilemmas clinicians are faced with when dealing with conditions having an unknown natural history and unpredictable surgical outcomes, and reinforces the need for these patients to be managed by a multidisciplinary team approach.

Three-dimensional thoracic aorta principal strain analysis from routine ECG-gated computerized tomography: feasibility in patients undergoing transcatheter aortic valve replacement.

PubMed

Satriano, Alessandro; Guenther, Zachary; White, James A; Merchant, Naeem; Di Martino, Elena S; Al-Qoofi, Faisal; Lydell, Carmen P; Fine, Nowell M

2018-05-02

Functional impairment of the aorta is a recognized complication of aortic and aortic valve disease. Aortic strain measurement provides effective quantification of mechanical aortic function, and 3-dimenional (3D) approaches may be desirable for serial evaluation. Computerized tomographic angiography (CTA) is routinely performed for various clinical indications, and offers the unique potential to study 3D aortic deformation. We sought to investigate the feasibility of performing 3D aortic strain analysis in a candidate population of patients undergoing transcatheter aortic valve replacement (TAVR). Twenty-one patients with severe aortic valve stenosis (AS) referred for TAVR underwent ECG-gated CTA and echocardiography. CTA images were analyzed using a 3D feature-tracking based technique to construct a dynamic aortic mesh model to perform peak principal strain amplitude (PPSA) analysis. Segmental strain values were correlated against clinical, hemodynamic and echocardiographic variables. Reproducibility analysis was performed. The mean patient age was 81±6 years. Mean left ventricular ejection fraction was 52±14%, aortic valve area (AVA) 0.6±0.3 cm 2 and mean AS pressure gradient (MG) 44±11 mmHg. CTA-based 3D PPSA analysis was feasible in all subjects. Mean PPSA values for the global thoracic aorta, ascending aorta, aortic arch and descending aorta segments were 6.5±3.0, 10.2±6.0, 6.1±2.9 and 3.3±1.7%, respectively. 3D PSSA values demonstrated significantly more impairment with measures of worsening AS severity, including AVA and MG for the global thoracic aorta and ascending segment (p<0.001 for all). 3D PSSA was independently associated with AVA by multivariable modelling. Coefficients of variation for intra- and inter-observer variability were 5.8 and 7.2%, respectively. Three-dimensional aortic PPSA analysis is clinically feasible from routine ECG-gated CTA. Appropriate reductions in PSSA were identified with increasing AS hemodynamic severity. Expanded study of 3D aortic PSSA for patients with various forms of aortic disease is warranted.

Dysphagia lusoria: a late onset presentation.

PubMed

Bennett, Alice Louise; Cock, Charles; Heddle, Richard; Morcom, Russell Kym

2013-04-21

Dysphagia lusoria is a term used to describe dysphagia secondary to vascular compression of the oesophagus. The various embryologic anomalies of the arterial brachial arch system often remain unrecognised and asymptomatic, but in 30%-40% of cases can result in tracheo-oesophageal symptoms, which in the majority of cases manifest as dysphagia. Diagnosis of dysphagia lusoria is via barium swallow and chest Computed tomography scan. Manometric abnormalities are variable, but age-related manometric changes may contribute to clinically relevant dysphagia lusoria in patients who present later in life. Our report describes a case of late-onset dysphagia secondary to a right aortic arch with an aberrant left subclavian artery, which represents a rare variant of dysphagia lusoria. The patient had proven additional oesophageal dysmotility with solid bolus only and a clinical response to dietary modification.

Stent-assisted, balloon-induced intimal disruption and relamination of aortic dissection in patients with Marfan syndrome: Midterm outcomes and aortic remodeling.

PubMed

Faure, Elsa Madeleine; El Batti, Salma; Abou Rjeili, Marwan; Ben Abdallah, Iannis; Julia, Pierre; Alsac, Jean-Marc

2018-05-17

The study objective was to assess the midterm outcomes and aortic remodeling in patients with Marfan syndrome with complicated acute type B aortic dissection treated with stent-assisted, balloon-induced intimal disruption and relamination. We reviewed all patients treated with stent-assisted, balloon-induced intimal disruption and relamination for a complicated acute type B aortic dissection associated with Marfan syndrome according to the revised Ghent criteria. Between 2015 and November 2017, 7 patients with Marfan syndrome underwent stent-assisted, balloon-induced intimal disruption and relamination for a complicated acute type B aortic dissection. The median age of patients was 47 years (range, 23-70). Four patients had a history of aortic root replacement. Technical success was achieved in 100%. Three patients required an adjunctive procedure for renal artery stenting (n = 2) and iliac artery stenting (n = 1). There was no in-hospital death, 30-day postoperative stroke, spinal cord ischemia, ischemic colitis, or renal failure requiring dialysis. At a median follow-up of 15 months (range, 7-28), 1 patient required aortic arch replacement for aneurysmal degeneration associated with a type Ia endoleak at 2 years, giving a late reintervention rate of 14%. There was no other secondary endoleak. The primary visceral patency rate was 100%. There were no all-cause deaths reported. At last computed tomography scan, all patients had complete aortic remodeling of the treated thoracoabdominal aorta. Distally, at the nonstented infrarenal aortoiliac level, 6 patients had persistent false lumen flow with stable aorto-iliac diameter in 5. One patient had iliac diameter growth (27 mm diameter at last computed tomography scan). Stent-assisted, balloon-induced intimal disruption and relamination of aortic dissection in patients with Marfan syndrome is feasible, safe, and associated with an immediate and midterm persisting thoracoabdominal aortic remodeling. Copyright © 2018 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

Developmental sensitivity to the induction of great vessel malformations by N-(2-aminoethyl)ethanolamine.

PubMed

Moore, Nigel P; Tornesi, Belen; Yano, Barry L; Nitschke, Kenneth D; Carney, Edward W

2012-04-01

N-(2-Aminoethyl)ethanolamine (AEEA) induced malformations of the great vessels in the offspring of rats treated during gestation and early lactation (Schneider et al., 2012. Birth Defects Res B Dev Reprod Toxicol [in press]). The aim of this study was to determine if in utero exposure alone was sufficient to induce these malformations or whether a peri-postnatal exposure or physiological component was required. Three groups of five time-mated female Wistar Han rats were administered AEEA (250 mg/kg/day) by gavage from gestation day (GD) 6 to GD 19 (groups 1 and 2) or from GD 6 to postnatal day 3 (group 3). Animals were euthanized on GD 21 (group 1) or postnatal day 4 (groups 2 and 3), and the hearts of the offspring were examined for changes to the great vessels. The incidence of malformations in group 1 was 91.1%, and primarily consisted of high aortic arch and abnormal carotid course. One fetus had an aortic aneurysm. All fetuses in groups 2 and 3 were malformed, primarily exhibiting abnormal carotid course and aneurysms, which mainly affected the aorta, ductus arteriosus, and pulmonary trunk. The incidence of high aortic arch was lower relative to group 1. Aneurysms were more prevalent in group 3 compared to group 2. These findings indicate that exposure to AEEA during gestation alone was sufficient to induce malformations of the great vessels and aneurysms, which may be triggered by physiological changes that occur during or after birth, but that the critical period of susceptibility to AEEA-induced aneurysms in the rat extends beyond gestation into the early postnatal period. © 2012 Wiley Periodicals, Inc.

Impact of Surgical Stroke on the Early and Late Outcomes After Thoracic Aortic Operations.

PubMed

Okada, Noritaka; Oshima, Hideki; Narita, Yuji; Abe, Tomonobu; Araki, Yoshimori; Mutsuga, Masato; Fujimoto, Kazuro L; Tokuda, Yoshiyuki; Usui, Akihiko

2015-06-01

Thoracic aortic operations still remain associated with substantial risks of death and neurologic injury. This study investigated the impact of surgical stroke on the early and late outcomes, focusing on the physical status and quality of life (QOL). From 1986 to 2008, 500 patients (aged 63 ± 13 years) underwent open thoracic aortic repair for root and ascending (31%), arch (39%), extended arch (10%), and descending and thoracoabdominal (19%) aneurysms. Brain protection consisted of retrograde cerebral perfusion (52%), antegrade cerebral perfusion (29%), and simple deep hypothermic circulatory arrest (19%). Surgical stroke was defined as a neurologic deficit persisting more than 72 hours after the operation. QOL was assessed with the Short-Form 36 Health Survey Questionnaire 5.9 ± 4.2 years after the operation. Stroke occurred in 10.3% of patients. Hospital mortality was 21% in the stroke group and 2.7% in the nonstroke group (p < 0.001). At hospital discharge, 76% of survivors in the stroke group had permanent neurologic deficits (PNDs), with sustained tracheostomy in 39%, tube feeding in 46%, and gastrostomy in 14%, and 89% required transfer to other facilities. PND was an independent risk factor for late death (hazard ratio, 2.29; 95% confidence interval, 1.04 to 4.62; p = 0.041) in a multivariate analysis. The physical component of the QOL score was worse in the PND group (51% vs 100%; p = 0.039), whereas the mental component was similar in both groups (14% vs 14%). Surgical stroke is associated with high hospital mortality and PNDs that decrease late survival and the physical component score of the QOL survey. Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Investigation of pulsatile flowfield in healthy thoracic aorta models.

PubMed

Wen, Chih-Yung; Yang, An-Shik; Tseng, Li-Yu; Chai, Jyh-Wen

2010-02-01

Cardiovascular disease is the primary cause of morbidity and mortality in the western world. Complex hemodynamics plays a critical role in the development of aortic dissection and atherosclerosis, as well as many other diseases. Since fundamental fluid mechanics are important for the understanding of the blood flow in the cardiovascular circulatory system of the human body aspects, a joint experimental and numerical study was conducted in this study to determine the distributions of wall shear stress and pressure and oscillatory WSS index, and to examine their correlation with the aortic disorders, especially dissection. Experimentally, the Phase-Contrast Magnetic Resonance Imaging (PC-MRI) method was used to acquire the true geometry of a normal human thoracic aorta, which was readily converted into a transparent thoracic aorta model by the rapid prototyping (RP) technique. The thoracic aorta model was then used in the in vitro experiments and computations. Simulations were performed using the computational fluid dynamic (CFD) code ACE+((R)) to determine flow characteristics of the three-dimensional, pulsatile, incompressible, and Newtonian fluid in the thoracic aorta model. The unsteady boundary conditions at the inlet and the outlet of the aortic flow were specified from the measured flowrate and pressure results during in vitro experiments. For the code validation, the predicted axial velocity reasonably agrees with the PC-MRI experimental data in the oblique sagittal plane of the thoracic aorta model. The thorough analyses of the thoracic aorta flow, WSSs, WSS index (OSI), and wall pressures are presented. The predicted locations of the maxima of WSS and the wall pressure can be then correlated with that of the thoracic aorta dissection, and thereby may lead to a useful biological significance. The numerical results also suggest that the effects of low WSS and high OSI tend to cause wall thickening occurred along the inferior wall of the aortic arch and the anterior wall of the brachiocephalic artery, similar implication reported in a number of previous studies.

Utility of a super-flexible three-dimensional printed heart model in congenital heart surgery.

PubMed

Hoashi, Takaya; Ichikawa, Hajime; Nakata, Tomohiro; Shimada, Masatoshi; Ozawa, Hideto; Higashida, Akihiko; Kurosaki, Kenichi; Kanzaki, Suzu; Shiraishi, Isao

2018-05-28

The objective of this study was to assess the utility of 3D printed heart models of congenital heart disease for preoperative surgical simulation. Twenty patient-specific 3D models were created between March 2015 and August 2017. All operations were performed by a young consultant surgeon who had no prior experience with complex biventricular repair. All 15 patients with balanced ventricles had outflow tract malformations (double-outlet right ventricle in 7 patients, congenitally corrected transposition of great arteries in 5, transposition of great arteries in 1, interrupted aortic arch Type B in 1, tetralogy of Fallot with pulmonary atresia and major aortopulmonary collateral arteries in 1). One patient had hypoplastic left heart complex, and the remaining 4 patients had a functional single ventricle. The median age at operation was 1.4 (range 0.1-5.9) years. Based on a multislice computed tomography data set, the 3D models were made of polyurethane resins using stereolithography as the printing technology and vacuum casting as the manufacturing method. All but 4 patients with a functional single ventricle underwent complete biventricular repair. The median cardiopulmonary bypass time and aortic cross-clamp time were 345 (110-570) min and 114 (35-293) min, respectively. During the median follow-up period of 1.3 (0.1-2.5) years, no mortality was observed. None of the patients experienced surgical heart block or systemic ventricular outflow tract obstruction. Three-dimensional printed heart models showed potential utility, especially in understanding the relationship between intraventricular communications and great vessels, as well as in simulation for creating intracardiac pathways.

Side differences in cerebrovascular accidents after cardiac surgery: a statistical analysis of neurologic symptoms and possible implications for anatomic mechanisms of aortic particle embolization.

PubMed

Boivie, Patrik; Edström, Cecilia; Engström, Karl Gunnar

2005-03-01

Aortic manipulation and particle embolization have been identified to cause cerebrovascular accidents in cardiac surgery. Recent data suggest that left-hemispheric cerebrovascular accident (right-sided symptoms) is more common, and this has been interpreted as being caused by aortic cannula stream jets. Our aim was to evaluate symptoms of cerebrovascular accident and side differences from a retrospective statistical analysis. During a 2-year period, 2641 consecutive cardiac surgery cases were analyzed. Patients positive for cerebrovascular accident were extracted from a database designed to monitor clinical symptoms. A protocol was used to confirm symptom data with the correct diagnosis in patient records. Patients were subdivided into 3 groups: control, immediate cerebrovascular accident, and delayed cerebrovascular accident. Among pooled patients, immediate and delayed cerebrovascular accidents were 3.0% and 0.9%, respectively. The expected predisposing factors behind immediate cerebrovascular accidents were significant, although the type of operation affected this search. Aortic quality was a strong predictor ( P < .001). The rate of delayed cerebrovascular accident was unaffected by surgery group. Left-sided symptoms of immediate cerebrovascular accident were approximately twice as frequent ( P = .016) as on the contralateral side. This phenomenon was observed for pooled patients and for isolated coronary bypass procedures (n = 1882; P = .025). Immediate cerebrovascular accident and aortic calcifications are linked. The predominance of left-sided symptoms may suggest that aortic manipulation and anatomic mechanisms in the aortic arch are more likely to cause cerebrovascular accidents than effects from cannula stream jets.

Prospective comparative study of brain protection in total aortic arch replacement: deep hypothermic circulatory arrest with retrograde cerebral perfusion or selective antegrade cerebral perfusion.

PubMed

Okita, Y; Minatoya, K; Tagusari, O; Ando, M; Nagatsuka, K; Kitamura, S

2001-07-01

The purpose of this study was to compare the results of total aortic arch replacement using two different methods of brain protection, particularly with respect to neurologic outcome. From June 1997, 60 consecutive patients who underwent total arch replacement through a midsternotomy were alternately allocated to one of two methods of brain protection: deep hypothermic circulatory arrest with retrograde cerebral perfusion (RCP: 30 patients) or with selective antegrade cerebral perfusion (SCP: 30 patients). Preoperative and postoperative (3 weeks) brain CT scan, neurological examination, and cognitive function tests were performed. Serum 100b protein was assayed before and after the cardiopulmonary bypass, as well as 24 hours and 48 hours after the operation. Hospital mortality occurred in 2 patients in the RCP group (6.6%) and 2 in the SCP group (6.6%). New strokes occurred in 1 (3.3%) of the RCP group and in 2 (6.6%) of the SCP group (p = 0.6). The incidence of transient brain dysfunction was significantly higher in the RCP group than in the SCP group (10, 33.3% vs 4, 13.3%, p = 0.05). Except in patients with strokes, S-100b values showed no significant differences in the two groups (RCP: SCP, prebypass 0.01+/-0.04: 0.05+/-0.16, postbypass 2.17+/-0.94: 1.97+/-1.00, 24 hours 0.61+/-0.36: 0.60+/-0.37, 48 hours 0.36+/-0.45: 0.46+/-0.40 microg/L, p = 0.7). There were no intergroup differences in the scores of memory decline (RCP 0.74+/-0.99; SCP 0.55+/-1.19, p = 0.6), orientation (RCP 1.11+/-1.29; SCP 0.50+/-0.76, p = 0.08), or intellectual function (RCP 1.21+/-1.27; SCP 1.05+/-1.15, p = 0.7). Both methods of brain protection for patients undergoing total arch replacement resulted in acceptable levels of mortality and morbidity. However, the prevalence of transient brain dysfunction was significantly higher in patients with the RCP.

Endovascular management of axillo-subclavian arterial injury: A review of published experience.

DTIC Science & Technology

2012-01-01

follow up, 10 patients (6.3%) were noted to have stent fracture (1), stenosis or occlusion (9) requiring repeat Table 1 (Continued ) Year Study No... stenosis of at least 50% luminal narrowing that required no additional intervention. Only one patient required delayed open surgical bypass, which...structures within this confined space. Extending from its origin (innominate artery on the right and aortic arch on the left), the first portion of the

Use of a biodegradable, oversized stent in a child with tracheomalacia secondary to vascular external compression.

PubMed

Di Dedda, Giovanni; Mirabile, Cristian

2017-01-01

We describe the implantation of an absorbable, custom-made stent of polydioxanone to treat tracheomalacia in a 5-month-old patient with extrinsic compression by a double aortic arch. The use of an absorbable, oversized stent treated the tracheal collapse caused by vascular compression, avoided removal procedures, and allowed the infant's growth. The use of an oversized stent prevented stent migration and gave minimal problems of granulation.

Predictive factors for cerebrovascular accidents after thoracic endovascular aortic repair.

PubMed

Mariscalco, Giovanni; Piffaretti, Gabriele; Tozzi, Matteo; Bacuzzi, Alessandro; Carrafiello, Giampaolo; Sala, Andrea; Castelli, Patrizio

2009-12-01

Cerebrovascular accidents are devastating and worrisome complications after thoracic endovascular aortic repair. The aim of this study was to determine cerebrovascular accident predictors after thoracic endovascular aortic repair. Between January 2001 and June 2008, 76 patients treated with thoracic endovascular aortic repair were prospectively enrolled. The study cohort included 61 men; mean age was 65.4 +/- 16.8 years. All patients underwent a specific neurologic assessment on an hourly basis postoperatively to detect neurologic deficits. Cerebrovascular accidents were diagnosed on the basis of physical examination, tomography scan or magnetic resonance imaging, or autopsy. Cerebrovascular accidents occurred in 8 (10.5%) patients, including 4 transient ischemic attack and 4 major strokes. Four cases were observed within the first 24-hours. Multivariable analysis revealed that anatomic incompleteness of the Willis circle (odds ratio [OR] 17.19, 95% confidence interval [CI] 2.10 to 140.66), as well as the presence of coronary artery disease (OR 6.86, 95 CI% 1.18 to 40.05), were independently associated with postoperative cerebrovascular accident development. Overall hospital mortality was 9.2%, with no significant difference for patients hit by cerebrovascular accidents (25.0% vs 7.3%, p = 0.102). Preexisting coronary artery disease, reflecting a severe diseased aorta and anomalies of Willis circle are independent cerebrovascular accident predictors after thoracic endovascular aortic repair procedures. A careful evaluation of the arch vessels and cerebral vascularization should be mandatory for patients suitable for thoracic endovascular aortic repair.

3D Geometric Analysis of the Pediatric Aorta in 3D MRA Follow-Up Images with Application to Aortic Coarctation.

PubMed

Wörz, Stefan; Schenk, Jens-Peter; Alrajab, Abdulsattar; von Tengg-Kobligk, Hendrik; Rohr, Karl; Arnold, Raoul

2016-10-17

Coarctation of the aorta is one of the most common congenital heart diseases. Despite different treatment opportunities, long-term outcome after surgical or interventional therapy is diverse. Serial morphologic follow-up of vessel growth is necessary, because vessel growth cannot be predicted by primer morphology or a therapeutic option. For the analysis of the long-term outcome after therapy of congenital diseases such as aortic coarctation, accurate 3D geometric analysis of the aorta from follow-up 3D medical image data such as magnetic resonance angiography (MRA) is important. However, for an objective, fast, and accurate 3D geometric analysis, an automatic approach for 3D segmentation and quantification of the aorta from pediatric images is required. We introduce a new model-based approach for the segmentation of the thoracic aorta and its main branches from follow-up pediatric 3D MRA image data. For robust segmentation of vessels even in difficult cases (e.g., neighboring structures), we propose a new extended parametric cylinder model that requires only relatively few model parameters. Moreover, we include a novel adaptive background-masking scheme used for least-squares model fitting, we use a spatial normalization scheme to align the segmentation results from follow-up examinations, and we determine relevant 3D geometric parameters of the aortic arch. We have evaluated our proposed approach using different 3D synthetic images. Moreover, we have successfully applied the approach to follow-up pediatric 3D MRA image data, we have normalized the 3D segmentation results of follow-up images of individual patients, and we have combined the results of all patients. We also present a quantitative evaluation of our approach for four follow-up 3D MRA images of a patient, which confirms that our approach yields accurate 3D segmentation results. An experimental comparison with two previous approaches demonstrates that our approach yields superior results. From the results, we found that our approach is well suited for the quantification of the 3D geometry of the aortic arch from follow-up pediatric 3D MRA image data. In future work, this will enable to investigate the long-term outcome of different surgical and interventional therapies for aortic coarctation.

Intraoperative care for aortic surgery using circulatory arrest

PubMed Central

Fernández Del Valle, David; González Alvarez, Adrián; Pérez-Lozano, Blanca

2017-01-01

The total circulatory arrest (CA) is necessary to achieve optimal surgical conditions in certain aortic pathologies, especially in those affecting the ascending aorta and aortic arch. During this procedure it is necessary to protect all the organs of ischemia, especially those of the central nervous system and for this purpose several strategies have been developed. The first and most important protective method is systemic hypothermia. The degree of hypothermia and the route of application have been evolving and currently tend to use moderate hypothermia (MH) (20.1–28 °C) associated with unilateral or bilateral selective cerebral perfusion methods. In this way the neurological results are better, the interval of security is greater and the times of extracorporeal circulation are smaller. Even so, it is necessary to take into account that there is the possibility of ischemia in the lower part of the body, especially of the abdominal viscera and the spinal cord, therefore the time of circulatory stop should be limited and not to exceed 80 minutes. Evidence of possible neurological drug protection is very weak and only mannitol, magnesium, and statins can produce some benefit. Inhalational anesthetics and some intravenous seem to have advantages, but more studies would be needed to test their long-term benefit. Other important parameters to be monitored during these procedures are blood glucose, anemia and coagulation disorders and acid-base balance. The recommended monitoring is common in complex cardiovascular procedures and it is of special importance the neurological monitoring that can be performed with several techniques, although currently the most used are Bispectral Index (BIS) and Near-Infrared Spectroscopy (NIRS). It is also essential to monitor the temperature routinely at the nasopharyngeal and bladder level and it is important to control coagulation with rotational thromboelastometry (ROTEM). PMID:28616347

Retrograde cerebral perfusion as an adjunct to prolonged hypothermic circulatory arrest.

PubMed

Esmailian, F; Dox, H; Sadeghi, A; Eghbali, K; Laks, H

1999-10-01

This study was designed to evaluate the use of retrograde cerebral perfusion (RCP) combined with deep hypothermic circulatory arrest (DHCA) in the treatment of complex congenital and adult cardiac disease. Retrospective chart review of 52 cardiac surgery patients (34 male and 18 female; age range, 3 weeks to 89 years old; mean age, 60 years old) who received RCP in conjunction with DHCA from July 1991 through August 1998. Surgical procedures consisted of the following: (1) repair of ascending aortic aneurysms (n = 16); (2) repair of type A aortic dissection (n = 16); (3) repair of arch aneurysms (n = 10); (4) renal cell carcinoma with tumor extension to the inferior vena cava (IVC) and right atrium (n = 5); (6) coronary artery bypass grafting and concomitant aortic valve replacement with calcified aorta (n = 2); (7) Norwood procedure and take down of a Pott's shunt (n = 2); and (8) massive air embolism treatment (n = 1). Mean RCP time was 39 min (range, 3 to 88 min). Thirteen patients had RCP times > 60 min. Mean core temperature (rectal or bladder) was 19 degrees C (range, 15 degrees to 28 degrees C). There were six early deaths, four of which were related to persistent low-output cardiac failure, and two resulted from perioperative stroke. All remaining patients recovered fully without neurologic deficits. RCP is a reliable and technically appealing tool that does the following: (1) it improves DHCA safety and is applicable in a variety of clinical settings with relative ease; (2) it potentially provides oxygen and nutritional support to the brain during DHCA; (3) it helps remove air and other debris from the cerebral vessels; and (4) it is useful in dealing with congenital heart disease and tumor extension into the IVC.

DOE Office of Scientific and Technical Information (OSTI.GOV)

Midulla, Marco, E-mail: marco.midulla@chru-lille.fr; Moreno, Ramiro, E-mail: ramoroa@gmail.com; Negre-Salvayre, Anne, E-mail: anne.negre-salvayre@inserm.fr

PurposeAlthough the widespread acceptance of thoracic endovascular aortic repair (TEVAR) as a first-line treatment option for a multitude of thoracic aortic diseases, little is known about the consequences of the device implantation on the native aortic anatomy. We propose a comparative analysis of the pre- and postoperative geometry on a clinical series of patients and discuss the potential clinical implicationsMethodsCT pre- and postoperative acquisitions of 30 consecutive patients treated by TEVAR for different pathologies (20 thoracic aortic aneurysms, 6 false aneurysms, 3 penetrating ulcers, 1 traumatic rupture) were used to model the vascular geometry. Pre- and postoperative geometries were comparedmore » for each patient by pairing and matching the 3D models. An implantation site was identified, and focal differences were detected and described.ResultsSegmentation of the data sets was successfully performed for all 30 subjects. Geometry differences between the pre- and postoperative meshes were depicted in 23 patients (76 %). Modifications at the upper implantation site were detected in 14 patients (47 %), and among them, the implantation site involved the arch (Z0–3) in 11 (78 %).ConclusionModeling the vascular geometry on the basis of imaging data offers an effective tool to perform patient-specific analysis of the vascular geometry before and after the treatment. Future studies will evaluate the consequences of these changes on the aortic function.« less

The role of cardiovascular magnetic resonance in the assessment of severe aortic stenosis and in post-procedural evaluation following transcatheter aortic valve implantation and surgical aortic valve replacement.

PubMed

Musa, Tarique Al; Plein, Sven; Greenwood, John P

2016-06-01

Degenerative aortic stenosis (AS) is the most common valvular disease in the western world with a prevalence expected to double within the next 50 years. International guidelines advocate the use of cardiovascular magnetic resonance (CMR) as an investigative tool, both to guide diagnosis and to direct optimal treatment. CMR is the reference standard for quantifying both left and right ventricular volumes and mass, which is essential to assess the impact of AS upon global cardiac function. Given the ability to image any structure in any plane, CMR offers many other diagnostic strengths including full visualisation of valvular morphology, direct planimetry of orifice area, the quantification of stenotic jets and in particular, accurate quantification of valvular regurgitation. In addition, CMR permits reliable and accurate measurements of the aortic root and arch which can be fundamental to appropriate patient management. There is a growing evidence base to indicate tissue characterisation using CMR provides prognostic information, both in asymptomatic AS patients and those undergoing intervention. Furthermore, a number of current clinical trials will likely raise the importance of CMR in routine patient management. This article will focus on the incremental value of CMR in the assessment of severe AS and the insights it offers following valve replacement.

Is moderate hypothermic circulatory arrest with selective antegrade cerebral perfusion superior to deep hypothermic circulatory arrest in elective aortic arch surgery?

PubMed

Poon, Shi Sum; Estrera, Anthony; Oo, Aung; Field, Mark

2016-09-01

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether moderate hypothermia circulatory arrest with selective antegrade cerebral perfusion (SACP) is more beneficial than deep hypothermic circulatory arrest in elective aortic arch surgery. Altogether, 1028 papers were found using the reported search, of which 6 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. There were four retrospective observational studies, one prospective randomized controlled trial and one meta-analysis study. There were no local or neuromuscular complications related to axillary arterial cannulation reported. In the elective setting, four studies showed that the in-hospital mortality for moderate hypothermia is consistently low, ranging from 1.0 to 4.3%. In a large series of hemiarch replacement comparing 682 cases of deep hypothermia with 94 cases of moderate hypothermia with SACP, 20 cases (2.8%) of permanent neurological deficit were reported, compared to 3 cases (3.2%) in moderate hypothermia. Three observational studies and a meta-analysis study did not identify an increased risk of postoperative renal failure and dialysis following either deep or moderate hypothermia although a higher incidence of stroke was reported in the meta-analysis study with deep hypothermia (12.7 vs 7.3%). Longer cardiopulmonary bypass time and circulatory arrest time were reported in four studies for deep hypothermia, suggesting an increased time required for systemic cooling and rewarming in that group. Overall, these findings suggested that in elective aortic arch surgery, moderate hypothermia with selective antegrade cerebral perfusion adapted to the duration of circulatory arrest can be performed safely with acceptable mortality and morbidity outcomes. The risk of spinal cord and visceral organ complications is low with the use of this cerebral adjunct. Current studies did not identify an advantage in terms of postoperative bleeding when compared with deep hypothermia. The moderate hypothermia strategy reduced operative time without increasing the mortality and morbidity of surgery. © The Author 2016. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Translocation of an Aberrant Right Subclavian Artery With Resolution of Dysphagia Lusoria.

PubMed

Thompson, Jess L; Burkhart, Harold M

2016-07-01

The presence of a left aortic arch with an aberrant right subclavian artery is a well-described anatomic variant that rarely causes symptoms. When symptoms of dysphagia lusoria do occur, however, operative intervention may be necessary. The purpose of this report is to describe our preferred surgical approach to treat dysphagia lusoria secondary to an aberrant right subclavian artery. Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Automatic segmentation of thoracic aorta segments in low-dose chest CT

NASA Astrophysics Data System (ADS)

Noothout, Julia M. H.; de Vos, Bob D.; Wolterink, Jelmer M.; Išgum, Ivana

2018-03-01

Morphological analysis and identification of pathologies in the aorta are important for cardiovascular diagnosis and risk assessment in patients. Manual annotation is time-consuming and cumbersome in CT scans acquired without contrast enhancement and with low radiation dose. Hence, we propose an automatic method to segment the ascending aorta, the aortic arch and the thoracic descending aorta in low-dose chest CT without contrast enhancement. Segmentation was performed using a dilated convolutional neural network (CNN), with a receptive field of 131 × 131 voxels, that classified voxels in axial, coronal and sagittal image slices. To obtain a final segmentation, the obtained probabilities of the three planes were averaged per class, and voxels were subsequently assigned to the class with the highest class probability. Two-fold cross-validation experiments were performed where ten scans were used to train the network and another ten to evaluate the performance. Dice coefficients of 0.83 +/- 0.07, 0.86 +/- 0.06 and 0.88 +/- 0.05, and Average Symmetrical Surface Distances (ASSDs) of 2.44 +/- 1.28, 1.56 +/- 0.68 and 1.87 +/- 1.30 mm were obtained for the ascending aorta, the aortic arch and the descending aorta, respectively. The results indicate that the proposed method could be used in large-scale studies analyzing the anatomical location of pathology and morphology of the thoracic aorta.

Radial k-t SPIRiT: autocalibrated parallel imaging for generalized phase-contrast MRI.

PubMed

Santelli, Claudio; Schaeffter, Tobias; Kozerke, Sebastian

2014-11-01

To extend SPIRiT to additionally exploit temporal correlations for highly accelerated generalized phase-contrast MRI and to compare the performance of the proposed radial k-t SPIRiT method relative to frame-by-frame SPIRiT and radial k-t GRAPPA reconstruction for velocity and turbulence mapping in the aortic arch. Free-breathing navigator-gated two-dimensional radial cine imaging with three-directional multi-point velocity encoding was implemented and fully sampled data were obtained in the aortic arch of healthy volunteers. Velocities were encoded with three different first gradient moments per axis to permit quantification of mean velocity and turbulent kinetic energy. Velocity and turbulent kinetic energy maps from up to 14-fold undersampled data were compared for k-t SPIRiT, frame-by-frame SPIRiT, and k-t GRAPPA relative to the fully sampled reference. Using k-t SPIRiT, improvements in magnitude and velocity reconstruction accuracy were found. Temporally resolved magnitude profiles revealed a reduction in spatial blurring with k-t SPIRiT compared with frame-by-frame SPIRiT and k-t GRAPPA for all velocity encodings, leading to improved estimates of turbulent kinetic energy. k-t SPIRiT offers improved reconstruction accuracy at high radial undersampling factors and hence facilitates the use of generalized phase-contrast MRI for routine use. Copyright © 2013 Wiley Periodicals, Inc.

Poly-2-methoxyethylacrylate-coated cardiopulmonary bypass circuit can reduce transfusion of platelet products compared to heparin-coated circuit during aortic arch surgery.

PubMed

Hosoyama, Katsuhiro; Ito, Koki; Kawamoto, Shunsuke; Kumagai, Kiichiro; Akiyama, Masatoshi; Adachi, Osamu; Kawatsu, Satoshi; Sasaki, Konosuke; Suzuki, Marina; Sugawara, Yumi; Shimizu, Yuya; Saiki, Yoshikatsu

2016-09-01

Several coating techniques for extracorporeal circulation have been developed to reduce the systemic inflammatory response during cardiopulmonary bypass (CPB). We compared the clinical effectiveness and biocompatibility of poly-2-methoxyethylacrylate (PMEA)- and heparin-coated CPB circuits in total aortic arch replacement (TAR) with the prolonged use of the bypass technique. Twenty patients who underwent elective TAR were divided randomly into two equal groups: group P (n = 10) to use PMEA-coated circuits and group H (n = 10) to use heparin-coated circuits. Clinical outcomes, hematological variables, and acute phase inflammatory response were analyzed perioperatively. Demographic, CPB, and clinical outcome data were similar for both groups. Hemoglobin and platelet count showed similar time-course curves. However, the amount of platelet products transfused intraoperatively was significantly larger in group H (group P 26.0 ± 7.0 units; group H 33.0 ± 6.7 units, p = 0.04). Total protein, and albumin levels were significantly higher in group P during and after the operation (total protein, p = 0.04; albumin, p = 0.02). The use of PMEA-coated circuit is associated with retainment of perioperative plasma proteins levels and may help to reduce transfusion of platelet products in TAR in comparison with the heparin-coated circuit.

First report of atretic coronary sinus stenting in a 5-kg infant resulting in dramatic improvement of ventricular function in functional single ventricle.

PubMed

El-Said, Howaida; Hegde, Sanjeet; Moore, John

2014-01-01

The patient was a male infant with L-transposition of great arteries (L-TGA), Ebstein's anomaly of the tricuspid valve, subvalvar aortic stenosis, ventricular septal defect (VSD), hypoplastic right ventricle, arch hypoplasia, and congenital complete heart block. He underwent a Norwood procedure, aortic arch repair, permanent pacemaker implantation, and a 3.5-mm aortopulmonary shunt at 4 days of age. At the time of his surgery, left ventricular function was in the normal range (ejection fraction [EF] = 67%). However by 3 months of age, he was noted to have developed moderate-severe biventricular dysfunction (left ventricular ejection fraction [LVEF] = 34%). Atresia of the coronary sinus with a small left superior venacava (LSVC) and a bridging vein was discovered during cardiac catheterization at this time. The coronary sinus mean pressure was 17 mm Hg, and the common atrial mean pressure was 6 mmHg. We opened the atretic coronary sinus ostium using radiofrequency ablation and stent placement. There was dramatic improvement in ventricular function observed over a 2-month period. Follow-up cardiac catheterization 5 months later revealed the stent in the coronary sinus to be widely patent with no intimal buildup, and the ventricular function was normal (LVEF = 58%). The patient had a bidirectional Glenn procedure with an uncomplicated postoperative course and is currently awaiting Fontan completion. © 2013 Wiley Periodicals, Inc.

Right-ventricular global longitudinal strain may predict neo-aortic arch obstruction after Norwood/Sano procedure in children with hypoplastic left heart syndrome.

PubMed

Raucci, Frank J; Seckeler, Michael D; Saunders, Christine; Gangemi, James J; Peeler, Benjamin B; Jayakumar, K Anitha

2013-01-01

Neo-aortic arch obstruction (NAAO) is a common complication following the Norwood/Sano procedure (NP) for hypoplastic left heart syndrome (HLHS) and is associated with increased morbidity and mortality. However, there is currently no objective method for predicting which patients will develop NAAO. This study was designed to test the hypothesis that hemodynamic changes from development of NAAO after NP in patients with HLHS will lead to changes in myocardial dynamics that could be detected before clinical symptoms develop with strain analysis using velocity vector imaging. Patients with HLHS who had at least one cardiac catheterization after NP were identified retrospectively. Strain analysis was performed on all echocardiograms preceding the first catheterization and any subsequent catheterization performed for intervention on NAAO. Twelve patients developed NAAO and 30 patients never developed NAAO. Right ventricular strain was worse in the group that developed NAAO (-6.2 vs. -8.6 %, p = 0.040) at a median of 59 days prior to diagnosis of NAAO. Those patients that developed NAAO following NP were significantly younger at the time of first catheterization than those that did not develop NAAO (92 ± 50 vs. 140 ± 36 days, p = 0.001). This study demonstrates that right ventricular GLS is abnormal in HLHS patients following NP and worsening right ventricular strain may be predictive of the future development of NAAO.

Comparative clinical study between retrograde cerebral perfusion and selective cerebral perfusion in surgery for acute type A aortic dissection.

PubMed

Usui, A; Yasuura, K; Watanabe, T; Maseki, T

1999-05-01

Selection of a brain protection method is a primary concern for aortic arch surgery. We performed a retrospective study to compare the respective advantages and disadvantages of retrograde cerebral perfusion (RCP) and selective cerebral perfusion (SCP) in patients who underwent surgery for acute type A aortic dissection. The study reviewed 166 patients who underwent surgery at Nagoya University or its eight branch hospitals between January 1990 and August 1996. There were 91 patients who received SCP and 75 patients who underwent RCP. Results for these two groups were compared. There were no significant differences in age, gender, Marfan syndrome rate, DeBakey classification, or emergency operation rate. Rates of various preoperative complications were similar except for aortic valve regurgitation. Arch replacement was performed more often in SCP than in RCP patients (49% vs. 27%, P = 0.0028). There were no significant differences between groups in cardiac ischemic time or visceral organ ischemic time. However, RCP group showed shorter cardio-pulmonary bypass time (297+/-99 vs. 269+/-112 min, P = 0.013) and lower the lowest core temperature (21.6+/-3.1 degrees C vs. 18.7+/-2.1 degrees C, P = 0.0001). SCP duration was longer than RCP duration (103+/-56 vs. 54+/-24 min, P < 0.0001). Despite these differences, RCP patients were not significantly different from SCP patients with regard to any postoperative complication, neurological dysfunction (16 vs. 19%), or operative mortality (all deaths within the hospitalization; 24 vs. 21%). Regarding neurologic dysfunction, there were six cases of coma, six of motor paralysis, two of paraplegia and one of visual loss among SCP patients, and eight cases of coma, three of motor paralysis, and three of convulsion in the RCP group. The incidence of motor paralysis was higher in the SCP group, while the incidence of coma was higher in the RCP group. RCP can be performed without clamping or cannulation of the cervical arteries, which is an advantage in reducing the chances of arterial injury or cerebral embolization. RCP is comparable to SCP in terms of clinical outcome.

Angiotensin II modulates interleukin-1{beta}-induced inflammatory gene expression in vascular smooth muscle cells via interfering with ERK-NF-{kappa}B crosstalk

DOE Office of Scientific and Technical Information (OSTI.GOV)

Xu, Shanqin; Zhi, Hui; Hou, Xiuyun

2011-07-08

Highlights: {yields} We examine how angiotensin II modulates ERK-NF-{kappa}B crosstalk and gene expression. {yields} Angiotensin II suppresses IL-1{beta}-induced prolonged ERK and NF-{kappa}B activation. {yields} ERK-RSK1 signaling is required for IL-1{beta}-induced prolonged NF-{kappa}B activation. {yields} Angiotensin II modulates NF-{kappa}B responsive genes via regulating ERK-NF-{kappa}B crosstalk. {yields} ERK-NF-{kappa}B crosstalk is a novel mechanism regulating inflammatory gene expression. -- Abstract: Angiotensin II is implicated in cardiovascular diseases, which is associated with a role in increasing vascular inflammation. The present study investigated how angiotensin II modulates vascular inflammatory signaling and expression of inducible nitric oxide synthase (iNOS) and vascular cell adhesion molecule (VCAM)-1. Inmore » cultured rat aortic vascular smooth muscle cells (VSMCs), angiotensin II suppressed interleukin-1{beta}-induced prolonged phosphorylation of extracellular signal-regulated kinase (ERK) and ribosomal S6 kinase (RSK)-1, and nuclear translocation of nuclear factor (NF)-{kappa}B, leading to decreased iNOS but enhanced VCAM-1 expression, associated with an up-regulation of mitogen-activated protein kinase phosphatase-1 expression. Knock-down of RSK1 selectively down regulated interleukin-1{beta}-induced iNOS expression without influencing VCAM-1 expression. In vivo experiments showed that interleukin-1{beta}, iNOS, and VCAM-1 expression were detectable in the aortic arches of both wild-type and apolipoprotein E-deficient (ApoE{sup -/-}) mice. VCAM-1 and iNOS expression were higher in ApoE{sup -/-} than in wild type mouse aortic arches. Angiotensin II infusion (3.2 mg/kg/day, for 6 days, via subcutaneous osmotic pump) in ApoE{sup -/-} mice enhanced endothelial and adventitial VCAM-1 and iNOS expression, but reduced medial smooth muscle iNOS expression associated with reduced phosphorylation of ERK and RSK-1. These results indicate that angiotensin II can differentially modulate inflammatory gene expression in aortic smooth muscle cells through influencing ERK-NF-{kappa}B crosstalk, which may contribute to angiotensin II-induced inflammatory disorders related to cardiovascular diseases.« less

Endovascular treatment of symptomatic true-lumen collapse of the downstream aorta after open surgery for acute aortic dissection type A.

PubMed

Conzelmann, L O; Doemland, M; Weigang, E; Frieß, T; Schotten, S; Düber, C; Vahl, C F

2013-04-01

The aim of the present study was to evaluate the outcome of endovascular treatment of true-lumen collapse (TLC) of the downstream aorta after open surgery for acute aortic dissection type A (AADA). Retrospective, observational study with follow-up of 16 ± 7.6 months. From April 2010 to January 2012, 89 AADA-patients underwent aortic surgery. Out of these, computed tomography revealed a TLC of the downstream aorta in 13 patients (14.6%). They all received additional thoracic endovascular aortic repair (TEVAR) in consequence of malperfusion syndromes. In all 13 TLC-patients, dissection after AADA-surgery extended from the aortic arch to the abdominal aorta and malperfusion syndromes occurred. Remodeling of the true-lumen was achieved by TEVAR with complemental stent disposal in abdominal and iliac arteries in all cases. One patient died on the third postoperative day due to intracerebral hemorrhage. Another patient, who presented under severe cardiogenic shock died despite AADA-surgery and TEVAR-treatment. Thirty-day mortality was 15.4% in TLC-patients (N = 2/13). In the follow-up period, 3 patients required additional aortic stents after the emergency TEVAR procedures. After 20 weeks, a third patient died secondary to malperfusion due to false-lumen recanalization. Therefore, late mortality was 23.1%. After proximal aortic repair for AADA, early postoperative computed tomography should be demanded in all patients to exclude a TLC of the descending aorta. Mortality is still substantial in these patients despite instant TEVAR application. Thus, in case of TLC and malperfusion syndrome of the downstream aorta, TEVAR should be performed early to alleviate or even prevent ischemic injury.

Quantifying Turbulent Kinetic Energy in an Aortic Coarctation with Large Eddy Simulation and Magnetic Resonance Imaging

NASA Astrophysics Data System (ADS)

Lantz, Jonas; Ebbers, Tino; Karlsson, Matts

2012-11-01

In this study, turbulent kinetic energy (TKE) in an aortic coarctation was studied using both a numerical technique (large eddy simulation, LES) and in vivo measurements using magnetic resonance imaging (MRI). High levels of TKE are undesirable, as kinetic energy is extracted from the mean flow to feed the turbulent fluctuations. The patient underwent surgery to widen the coarctation, and the flow before and after surgery was computed and compared to MRI measurements. The resolution of the MRI was about 7 × 7 voxels in axial cross-section while 50x50 mesh cells with increased resolution near the walls was used in the LES simulation. In general, the numerical simulations and MRI measurements showed that the aortic arch had no or very low levels of TKE, while elevated values were found downstream the coarctation. It was also found that TKE levels after surgery were lowered, indicating that the diameter of the constriction was increased enough to decrease turbulence effects. In conclusion, both the numerical simulation and MRI measurements gave very similar results, thereby validating the simulations and suggesting that MRI measured TKE can be used as an initial estimation in clinical practice, while LES results can be used for detailed quantification and further research of aortic flows.

Clinical features and prognosis of patients with acute aortic dissection in China

PubMed Central

Zhao, Lujing; Chai, Yanfen

2017-01-01

Objective To evaluate the clinical features, risk factors, and prognostic significance of different Stanford types of acute aortic dissection (AAD). Methods We retrospectively analyzed the clinical data and prognostic predictors in 105 patients with AAD (37 with Stanford type A and 68 with Stanford type B) at Tianjin Medical University General Hospital and Tianjin 4th Central Hospital from January 2014 to November 2015. Results Patients with Marfan syndrome and bicuspid aortic valve constituted 24.3% and 8.1%, respectively, of patients with type A AAD; these proportions were significantly higher than those of patients with type B AAD (7.4% and 0.0%, respectively). The proportion of iatrogenic causes of type A AAD (8.1%) was significantly higher than that of type B AAD (0.0%). Computed tomography angiography showed that the proportion of involvement of the aortic arch and pericardial effusion (86.5% and 18.9%, respectively) in patients with type A AAD were higher than those in patients with type B AAD (23.5% and 5.9%, respectively). Endovascular treatment was performed in a higher proportion of patients with type B than A AAD (70.6% vs. 5.4%, respectively). Conclusion Systolic blood pressure, pericardial effusion, periaortic hematoma, conservative treatment, and open surgery were independent predictors of increased mortality in patients with AAD. PMID:28345421

Visual loss in Takayasu Arteritis - Look Beyond the Eye.

PubMed

Peter, Jayanthi; Joseph, George; Mathew, Vivek; Peter, John Victor

2014-08-01

Patients with Takayasu arteritis often present with reduced vision related either to the disease per se or due to complications of therapy. We report a patient with Takayasu arteritis who developed acute onset bilateral visual loss 6wks following percutaneous revascularization of occluded aortic arch branches. No ocular cause for the visual loss was evident. The reason for visual loss in this patient was an extraocular cause. Ocular and extraocular causes of visual loss in Takayasu arteritis are discussed.

Aortic elasticity and left ventricular function after arterial switch operation: MR imaging--initial experience.

PubMed

Grotenhuis, Heynric B; Ottenkamp, Jaap; Fontein, Duveken; Vliegen, Hubert W; Westenberg, Jos J M; Kroft, Lucia J M; de Roos, Albert

2008-12-01

To prospectively assess aortic dimensions, aortic elasticity, aortic valve competence, and left ventricular (LV) systolic function in patients after the arterial switch operation (ASO) by using magnetic resonance (MR) imaging. Informed consent was obtained from all participants for this local ethics committee-approved study. Fifteen patients (11 male patients, four female patients; mean age, 16 years +/- 4 [standard deviation]; imaging performed 16.1 years after surgery +/- 3.7) and 15 age- and sex-matched control subjects (11 male subjects, four female subjects; mean age, 16 years +/- 4) were evaluated. Velocity-encoded MR imaging was used to assess aortic pulse wave velocity (PWV), and a balanced turbo-field-echo sequence was used to assess aortic root distensibility. Standard velocity-encoded and multisection-multiphase imaging sequences were used to assess aortic valve function, systolic LV function, and LV mass. The two-tailed Mann-Whitney U test and Spearman rank correlation coefficient were used for statistical analysis. Patients treated with the ASO showed aortic root dilatation at three predefined levels (mean difference, 5.7-9.4 mm; P < or = .007) and reduced aortic elasticity (PWV of aortic arch, 5.1 m/sec +/- 1.2 vs 3.9 m/sec +/- 0.7, P = .004; aortic root distensibility, [2.2 x 10(-3)] x mm Hg(-1) +/- 1.8 vs [4.9 x 10(-3)] x mm Hg(-1) +/- 2.9, P < .01) compared with control subjects. Minor degrees of aortic regurgitation (AR) were present (AR fraction, 5% +/- 3 in patients vs 1% +/- 1 in control subjects; P < .001). Patients had impaired systolic LV function (LV ejection fraction [LVEF], 51% +/- 6 vs 58% +/- 5 in control subjects; P = .003), in addition to enlarged LV dimensions (end-diastolic volume [EDV], 112 mL/m(2) +/- 13 vs 95 mL/m(2) +/- 16, P = .007; end-systolic volume [ESV], 54 mL/m(2) +/- 11 vs 39 mL/m(2) +/- 7, P < .001). Degree of AR predicted decreased LVEF (r = 0.41, P = .026) and was correlated with increased LV dimensions (LV EDV: r = 0.48, P = .008; LV ESV: r = 0.67, P < .001). Aortic root dilatation and reduced elasticity of the proximal aorta are frequently observed in patients who have undergone the ASO, in addition to minor degrees of AR, reduced LV systolic function, and increased LV dimensions. RSNA, 2008

AORTIC INJURY DUE TO PARAGLIDING: A CASE REPORT

PubMed Central

Omori, Kazuhiko; Jitsuiki, Kei; Majima, Takashi; Takeuchi, Ikuto; Yoshizaw, Toshihiko; Ishikawa, Kouhei; Ohsaka, Hiromichi; Tambara, Keiichi

2017-01-01

A 64-year-old male fell from an altitude of 10 m while paragliding after stalling due to the wind. The purpose of this case report is to describe the outcomes after multiple injuries sustained during a paragliding accident, including a potentially life-threating injury to the thoracic aorta. The subject sustained a bite wound on his tongue, injuries to his chest (left side) and back, and a right forearm deformity. Enhanced whole body computed tomography (CT) revealed fractures of the bilateral laminae of the second and third cervical bones, right first rib, the tenth thoracic vertebral body (compression type), second lumbar vertebral body (burst type) and the right radius, Other injuries included an injury to the thoracic aortic arch and the presence of intraabdominal fluid collection without perforation of the digestive tract. Endovascular treatment was selected for the aortic injury because of multiple injuries. Immediate management included hypotensive rate control therapy using calcium and a beta blocker. On the fourth hospital day, the subject underwent deployment of a stent-graft to the aorta and subsequent surgical immobilization for the lumbar burst fracture. He also underwent surgical immobilization of the radial fracture and was discharged on the 28th hospital day. First responders or physicians should consider the possibility of aortic injury when treating patients who suffer falls while paragliding and provide appropriate management. Failure to provide appropriate management of an aortic injury could result in death. Level of Evidence 4 PMID:28593092

Complex branchial fistula: a variant arch anomaly.

PubMed

De Caluwé, D; Hayes, R; McDermott, M; Corbally, M T

2001-07-01

A 5-year-old boy presented with an infected left-sided branchial fistula. Despite antibiotic treatment and repeated excision of the fistula, purulent discharge from the wound persisted. Three-dimensional computed tomography (3D CT) reconstruction greatly facilitated the diagnosis and management of this case by showing the course of the fistulous tract. The complexity of the tract suggests that this represents a variant arch anomaly because it contains features of first, second, third, and fourth arch remnants. Copyright 2001 by W.B. Saunders Company.

Class II malocclusion with complex problems treated with a novel combination of lingual orthodontic appliances and lingual arches.

PubMed

Yanagita, Takeshi; Nakamura, Masahiro; Kawanabe, Noriaki; Yamashiro, Takashi

2014-07-01

This case report describes a novel method of combining lingual appliances and lingual arches to control horizontal problems. The patient, who was 25 years of age at her first visit to our hospital with a chief complaint of crooked anterior teeth, was diagnosed with skeletal Class II and Angle Class II malocclusion with anterior deep bite, lateral open bite, premolar crossbite, and severe crowding in both arches. She was treated with premolar extractions and temporary anchorage devices. Conventionally, it is ideal to use labial brackets simultaneously with appliances, such as a lingual arch, a quad-helix, or a rapid expansion appliance, in patients with complex problems requiring horizontal, anteroposterior, and vertical control; however, this patient strongly requested orthodontic treatment with lingual appliances. A limitation of lingual appliances is that they cannot be used with other conventional appliances. In this report, we present the successful orthodontic treatment of a complex problem using modified lingual appliances that enabled combined use of a conventional lingual arch. Copyright © 2014 American Association of Orthodontists. Published by Mosby, Inc. All rights reserved.

Automated quantitative 3D analysis of aorta size, morphology, and mural calcification distributions

DOE Office of Scientific and Technical Information (OSTI.GOV)

Kurugol, Sila, E-mail: sila.kurugol@childrens.harvard.edu; Come, Carolyn E.; Diaz, Alejandro A.

Purpose: The purpose of this work is to develop a fully automated pipeline to compute aorta morphology and calcification measures in large cohorts of CT scans that can be used to investigate the potential of these measures as imaging biomarkers of cardiovascular disease. Methods: The first step of the automated pipeline is aorta segmentation. The algorithm the authors propose first detects an initial aorta boundary by exploiting cross-sectional circularity of aorta in axial slices and aortic arch in reformatted oblique slices. This boundary is then refined by a 3D level-set segmentation that evolves the boundary to the location of nearbymore » edges. The authors then detect the aortic calcifications with thresholding and filter out the false positive regions due to nearby high intensity structures based on their anatomical location. The authors extract the centerline and oblique cross sections of the segmented aortas and compute the aorta morphology and calcification measures of the first 2500 subjects from COPDGene study. These measures include volume and number of calcified plaques and measures of vessel morphology such as average cross-sectional area, tortuosity, and arch width. Results: The authors computed the agreement between the algorithm and expert segmentations on 45 CT scans and obtained a closest point mean error of 0.62 ± 0.09 mm and a Dice coefficient of 0.92 ± 0.01. The calcification detection algorithm resulted in an improved true positive detection rate of 0.96 compared to previous work. The measurements of aorta size agreed with the measurements reported in previous work. The initial results showed associations of aorta morphology with calcification and with aging. These results may indicate aorta stiffening and unwrapping with calcification and aging. Conclusions: The authors have developed an objective tool to assess aorta morphology and aortic calcium plaques on CT scans that may be used to provide information about the presence of cardiovascular disease and its clinical impact in smokers.« less

Automated quantitative 3D analysis of aorta size, morphology, and mural calcification distributions.

PubMed

Kurugol, Sila; Come, Carolyn E; Diaz, Alejandro A; Ross, James C; Kinney, Greg L; Black-Shinn, Jennifer L; Hokanson, John E; Budoff, Matthew J; Washko, George R; San Jose Estepar, Raul

2015-09-01

The purpose of this work is to develop a fully automated pipeline to compute aorta morphology and calcification measures in large cohorts of CT scans that can be used to investigate the potential of these measures as imaging biomarkers of cardiovascular disease. The first step of the automated pipeline is aorta segmentation. The algorithm the authors propose first detects an initial aorta boundary by exploiting cross-sectional circularity of aorta in axial slices and aortic arch in reformatted oblique slices. This boundary is then refined by a 3D level-set segmentation that evolves the boundary to the location of nearby edges. The authors then detect the aortic calcifications with thresholding and filter out the false positive regions due to nearby high intensity structures based on their anatomical location. The authors extract the centerline and oblique cross sections of the segmented aortas and compute the aorta morphology and calcification measures of the first 2500 subjects from COPDGene study. These measures include volume and number of calcified plaques and measures of vessel morphology such as average cross-sectional area, tortuosity, and arch width. The authors computed the agreement between the algorithm and expert segmentations on 45 CT scans and obtained a closest point mean error of 0.62 ± 0.09 mm and a Dice coefficient of 0.92 ± 0.01. The calcification detection algorithm resulted in an improved true positive detection rate of 0.96 compared to previous work. The measurements of aorta size agreed with the measurements reported in previous work. The initial results showed associations of aorta morphology with calcification and with aging. These results may indicate aorta stiffening and unwrapping with calcification and aging. The authors have developed an objective tool to assess aorta morphology and aortic calcium plaques on CT scans that may be used to provide information about the presence of cardiovascular disease and its clinical impact in smokers.

Automated quantitative 3D analysis of aorta size, morphology, and mural calcification distributions

PubMed Central

Kurugol, Sila; Come, Carolyn E.; Diaz, Alejandro A.; Ross, James C.; Kinney, Greg L.; Black-Shinn, Jennifer L.; Hokanson, John E.; Budoff, Matthew J.; Washko, George R.; San Jose Estepar, Raul

2015-01-01

Purpose: The purpose of this work is to develop a fully automated pipeline to compute aorta morphology and calcification measures in large cohorts of CT scans that can be used to investigate the potential of these measures as imaging biomarkers of cardiovascular disease. Methods: The first step of the automated pipeline is aorta segmentation. The algorithm the authors propose first detects an initial aorta boundary by exploiting cross-sectional circularity of aorta in axial slices and aortic arch in reformatted oblique slices. This boundary is then refined by a 3D level-set segmentation that evolves the boundary to the location of nearby edges. The authors then detect the aortic calcifications with thresholding and filter out the false positive regions due to nearby high intensity structures based on their anatomical location. The authors extract the centerline and oblique cross sections of the segmented aortas and compute the aorta morphology and calcification measures of the first 2500 subjects from COPDGene study. These measures include volume and number of calcified plaques and measures of vessel morphology such as average cross-sectional area, tortuosity, and arch width. Results: The authors computed the agreement between the algorithm and expert segmentations on 45 CT scans and obtained a closest point mean error of 0.62 ± 0.09 mm and a Dice coefficient of 0.92 ± 0.01. The calcification detection algorithm resulted in an improved true positive detection rate of 0.96 compared to previous work. The measurements of aorta size agreed with the measurements reported in previous work. The initial results showed associations of aorta morphology with calcification and with aging. These results may indicate aorta stiffening and unwrapping with calcification and aging. Conclusions: The authors have developed an objective tool to assess aorta morphology and aortic calcium plaques on CT scans that may be used to provide information about the presence of cardiovascular disease and its clinical impact in smokers. PMID:26328995

Upregulation of microRNA-876 Induces Endothelial Cell Apoptosis by Suppressing Bcl-Xl in Development of Atherosclerosis.

PubMed

Xu, Kaicheng; Liu, Peng; Zhao, Yue

2017-01-01

The injury and apoptotic cell death of endothelial cells hallmark the development of atherosclerosis (AS), characterized by dysregulation of lipid homeostasis, immune responses, and formation of coronary plaques. However, the mechanisms underlying the initiation of endothelial cell apoptosis remain ill-defined. Recent evidence suggests a role of microRNAs in the processes of AS-associated endothelial cell apoptosis. Thus, we studied this question in the current study. AS was developed in ApoE (-/-) mice suppled with high-fat diet (HFD), compared to ApoE (-/-) mice suppled with normal diet (ND). Mouse endothelial cells were isolated from the aortic arch using flow cytometry based on their expression of Pecam-1. Oxidized low-density lipoprotein (ox-LDL) were used to treat human aortic endothelial cells (HAECs) as an in vitro model for AS. Gene expression was quantified by RT-qPCR and protein levels were analyzed by Western blotting. Apoptosis was evaluated by FITC Annexin V Apoptosis essay and by TUNEL staining. Prediction of the binding between miRNAs and 3'-UTR of mRNA from the target gene was performed by bioinformatics analyses and confirmed by a dual luciferase reporter assay. HFD mice, but not ND mice, developed AS in 12 weeks. Significantly reduced endothelial cell marks and significantly increased mesenchymal cell marks were detected in the aortic arch of the HFD mice, compared to the ND mice. The endothelial cell apoptosis was significantly higher in HFD mice, seemingly due to functional suppression of protein translation of anti-apoptotic Bcl-Xl protein through upregulation of miR-876. Similar results were obtained from in vitro study. Inhibition of miR-876 abolished the effects of ox-LDL-induced apoptotic cell death of HAECs. AS-associated endothelial cell apoptosis may partially result from downregulation of Bcl-Xl, through upregulation of miR-876 that binds and suppresses translation of Bcl-Xl mRNA. © 2017 The Author(s). Published by S. Karger AG, Basel.

Prosthetic vascular graft infection through a median sternotomy: a multicentre review †.

PubMed

Oda, Tatsuya; Minatoya, Kenji; Kobayashi, Junjiro; Okita, Yutaka; Akashi, Hidetoshi; Tanaka, Hiroyuki; Kawaharada, Nobuyoshi; Saiki, Yoshikatsu; Kuniyoshi, Yukio; Nishimura, Kunihiro

2015-06-01

The aim of this study is to analyse the treatment outcomes of thoracic prosthetic graft infection. A retrospective chart review was conducted at six hospitals and included the records of 68 patients treated for postoperative prosthetic vascular graft infection (mean age: 62.3 ± 15.1, male 51) from January 2000 to December 2013. The number of patients and the locations of the treated infections were as follows: 13 for aortic root, 16 for ascending aorta, 35 for aortic arch and 4 for aortic root to arch. In-hospital infection occurred in 43 patients and after discharge in 25. The mean follow-up time was 2.0 ± 2.3 years. The follow-up rate was 94.1%. The most commonly isolated micro-organism was Staphylococcus aureus (72.1%). Rereplacement of infectious graft was performed in 18 patients (Dacron graft in 12, homograft in 4 and rifampicin-bonded Dacron graft in 2). The overall hospital mortality rate was 35.3% (24/68). The mortality rate among the patients with graft rereplacement was 33.3% (6/18), with pedicled muscle flaps or pedicled omental flaps to cover the graft 25.9% (7/27), with irrigation 55.0% (11/20) and on antibiotic therapy only 0% (0/3). Our multivariate analysis demonstrated that the risk factors of hospital death increased in the absence of pedicled flaps (muscle or omentum) to cover the graft (P = 0.001), age over 55 (P = 0.003), time from onset of initial operation <1 week (P = 0.031) and period before 2008 (P = 0.001). The overall 1-year survival rate was 58.6%. The treatment outcomes of thoracic prosthetic vascular graft infection have not been satisfactory. However, the use of pedicled muscle or omental flaps to cover the graft could improve the outcomes. © The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

First trimester fetal echocardiography: which planes and defects can be displayed during the daily routine in a prenatal medicine unit?

PubMed

Krapp, M; Ludwig, A; Axt-Fliedner, R; Kreiselmaier, P

2011-08-01

The objective of this study was to evaluate which cardiac planes and malformations can be visualized by first trimester fetal echocardiography during the daily routine in a prenatal medicine unit. From October 2007 to June 2009, all fetuses with a crown rump length between 45 and 84 mm were included in the study. The fetal echocardiographies were carried out by one examiner. The entire examination including fetal echocardiography was completed within a time interval of 30 minutes. When possible, the abdominal plane, 4-chamber view (CV), pulmonary veins, left ventricular outflow tract, 3-vessel view (3-VV) and the aortic arch were visualized by color Doppler and/or power Doppler sonography. 690 fetuses were enrolled in the retrospective study. The abdominal plane, 4-CV, pulmonary veins, left ventricular outflow tract, 3-VV and the aortic arch were visualized in 99 %, 96 %, 23 %, 97 %, 98 % and 72 % of cases, respectively. During the study interval, 17 cardiac malformations were diagnosed. Outcome data were obtained in 92 % of the normal fetuses. 5 cardiac anomalies were diagnosed beyond the first trimester. The standard planes of fetal echocardiography can be displayed in the first trimester in the clinical routine. Pulmonary veins can be visualized in almost a quarter of the cases. First trimester congenital heart diseases are strongly associated with chromosomal abnormalities during the first trimester. © Georg Thieme Verlag KG Stuttgart · New York.

Esophageal dysfunction in four alpaca crias and a llama cria with vascular ring anomalies.

PubMed

McKenzie, Erica C; Seguin, Bernard; Cebra, Christopher K; Margiocco, Marco L; Anderson, David E; Löhr, Christiane V

2010-08-01

3 alpaca crias and cadavers of an alpaca cria and a llama cria were evaluated for evidence of esophageal dysfunction. All 5 crias were between 3 and 5 months of age when clinical signs developed, and all had a thin body condition when examined. Clinical signs included coughing, regurgitation, and grossly visible esophageal peristaltic waves. A barium esophagram was used to diagnose esophageal obstruction, megaesophagus, and a vascular ring anomaly (VRA). Fluoroscopy was used to evaluate deglutition, esophageal peristalsis, and the extent of esophageal dilation in 1 alpaca cria. A persistent right aortic arch was identified in 1 alpaca cria, and a left aortic arch with right ductus arteriosus or ligamentum arteriosum and an aberrant right subclavian artery were identified in the 4 remaining crias. Surgical correction of the VRA was attempted in the 3 live alpaca crias. It was complicated by the conformation and location of each VRA and inaccurate anatomic diagnosis of the VRAs before surgery. Treatment was universally unsuccessful because of intraoperative complications and the persistence of clinical signs after surgery. Megaesophagus is typically an idiopathic condition in camelids. However, these findings suggested that camelids with esophageal dysfunction during the neonatal period may have a VRA. The prognosis is grave for camelids with VRA, and accurate anatomic diagnosis of the VRA via the use of advanced imaging techniques (eg, angiography, computed tomography, or magnetic resonance imaging) may improve the success of surgical intervention.

Atresia of the Descending Aorta in a Young Woman Requiring Bypass Graft.

PubMed

Dsc, Adcasdc Sadfasdf; Mashhood, Ammarah; Ali, Taimur Asif; Fatimi, Saulat Hasnain

2016-11-01

Congenital aortic atresia is a malformation accounting for 4 - 6% of all congenital heart diseases in children. Left ventricular outflow obstruction due to atresia is common at the aortic valve but rarely has atresia been identified in the descending aorta. We report the case of a 25-year woman who was evaluated for headache and uncontrolled hypertension. CTscan chest showed a short atretic segment in the descending aorta at the isthmus, distal to the takeoff of the subclavian artery. She underwent surgery; a 22 mm Dacron graft was taken and jump graft was placed between the arch of the aorta and the descending aorta, using partial occlusion clamps. Patient tolerated the procedure well and was discharged on ACE Inhibitors and beta blockers, which were then weaned off over a period of one year. She remained stable and had no further complaints.

The paediatric cardiac centre for Africa--proceedings of the March 2012 symposium.

PubMed

Kinsley, Robin H; Edwin, Frank; Entsua-Mensah, Kow

2013-04-01

The Pediatric Cardiac Centre for Africa (PCCA) was opened by national patron Mr Nelson Mandela on November 7, 2003. In 2008, the Centre's international pediatric cardiac symposium was introduced as a learning forum for pediatric cardiac surgeons and cardiologists in the continent. The symposium has consistently grown in attendance and attracted distinguished leaders in the field. The 2012 symposium featured Dr. Thomas Spray of Children's Hospital of Philadelphia, Dr. David Barron of Birmingham Children's Hospital, and Dr. John Brown of Indiana University School of Medicine as guest speakers. Experience of the Fontan procedure, the small aortic root, hypoplastic left heart syndrome, right ventricular outflow tract reconstruction, transposition of the great arteries, and interrupted aortic arch were the highlights of the symposium. In the "African Corner," centers in South Africa, Ghana, and Angola presented work done from across the African continent.

Gadolinium-enhanced versus time-of-flight magnetic resonance angiography: what is the benefit of contrast enhancement in evaluating carotid stenosis?

PubMed

Muhs, Bart E; Gagne, Paul; Wagener, Jael; Baker, Jessica; Ortega, Marta Ramirez; Adelman, Mark A; Cayne, Neal S; Rockman, Caron B; Maldonado, Thomas

2005-11-01

Accurate patient selection based on preoperative imaging is imperative to good risk reduction in patients undergoing carotid endarterectomy (CEA). The goal of this study was to assess the accuracy of gadolinium-enhanced magnetic resonance angiography (GE MRA) versus time-of-flight (TOF) MRA in the work-up of patients undergoing CEA. Patients undergoing CEA between 1999 and 2001 were identified from a prospectively maintained institutional database. GE or TOF MRA was obtained on extracranial carotid arteries (n = 319) in patients undergoing CEA. Stenosis on MRA images was graded as moderate (n = 76) or severe (n = 243) by an attending radiologist who was blind to duplex results. Duplex imaging was performed in an Intersocietal Commission for the Accreditation of Vascular Labs (ICAVL) accredited lab, and stenosis was stratified as moderate (50-79%, n = 76) or high (80-99%, n = 243) grade using University of Washington criteria. For each patient, the degree of stenosis as determined by MRA (GE versus TOF) was compared to percent stenosis on duplex. For moderate-grade lesions, GE MRA concurred with duplex in 11.1% (4/36), underestimated in 2.8% (1/36), and overestimated in 86.1% (31/36) of carotid arteries imaged. TOF MRA concurred with duplex in 35% (14/40), underestimated in 0% (0/40), and overestimated in 65% (26/40) of carotid arteries. High-grade lesions demonstrated improved concordance between MRA and duplex. For these lesions, GE MRA concurred with duplex in 95.6% (130/136) of carotid arteries imaged, never overestimated stenosis (0/136), and underestimated in 4.4% (6/136). TOF MRA concurred with duplex 96.3% (103/107), overestimated stenosis as an occlusion in 0.9% (1/107), and underestimated in 2.8% (3/107). In addition to neck visualization, the GE technique allowed simultaneous aortic arch imaging. This was accomplished in 79.1% (136/172) of all GE MRAs. Simultaneous aortic arch imaging was not technically feasible with TOF MRA. For moderate-grade lesions, both MR techniques are inaccurate predictors of degree of carotid stenosis and result in a significant overestimation of stenosis. Each technique demonstrates improved concordance with duplex ultrasound in the setting of severe carotid artery stenoses. The ability of GE MRA to simultaneously image the aortic arch and the neck may allow for detection of occult tandem lesions and other anatomic variations, which may be particularly important in preoperative planning for carotid artery stenting.

LOFT/FET complex. Construction view of abutment footings for arches of ...

Library of Congress Historic Buildings Survey, Historic Engineering Record, Historic Landscapes Survey

LOFT/FET complex. Construction view of abutment footings for arches of hangar (TAN-629). Tunnels between basement of hangar and control building (TAN-630) had to fit between arches. (Note concrete work taking place at hole at lower edge of view. This photo may document unexpected bubble in underlying lava rock. It was dumped full of concrete and a footing made. Source: Interview with John DeClue). Date: December 19, 1957. Photographer: Jack L. Anderson. INEEL negative no. 57-6203 - Idaho National Engineering Laboratory, Test Area North, Scoville, Butte County, ID

Distant downstream steady-state flow studies of a mechanical heart valve: PIV study of secondary flow in a model aortic arch

NASA Astrophysics Data System (ADS)

Fix, Brandon R.; Popma, Christopher J.; Bulusu, Kartik V.; Plesniak, Michael W.

2013-11-01

Each year, hundreds of thousands of aortic and mitral heart valves are replaced with prosthetic valves. In efforts to develop a valve that does not require lifelong anticoagulation therapy, previous experimental research has been devoted to analyzing the hemodynamics of various heart valve designs, limited to the flow up to only 2 diameters downstream of the valve. Two-component, two-dimensional (2C-2D) particle image velocimetry (PIV) was used in this study to examine secondary flow velocity fields in a curved tube modeling an aorta at five locations (0-, 45-, 90-, 135-, 180-degrees). A bileaflet valve, opened to 30-, 45-, and 59-degrees, and one (no-valve) baseline condition were examined under three steady flow inflows (Re = 218, 429, 634). In particular, variations in the two-dimensional turbulent shear stresses at each cross sectional plane were analyzed. The results suggest that bileaflet valves in the aortic model produce significant turbulence and vorticity up to 5.5 downstream diameters, i.e. up to the 90-degrees location. Expanding this research towards aortic heart valve hemodynamics highlights a need for additional studies extending beyond the typical few diameters downstream to fully characterize valvular function. Supported by the NSF Grant No. CBET- 0828903 and GW Center for Biomimetics and Bioinspired Engineering.

Patient-specific finite element analysis of ascending aorta aneurysms

PubMed Central

Martin, Caitlin; Elefteriades, John

2015-01-01

Catastrophic ascending aorta aneurysm (AsAA) dissection and rupture can be prevented by elective surgical repair, but identifying individuals at risk remains a challenge. Typically the decision to operate is based primarily on the overall aneurysm size, which may not be a reliable indicator of risk. In this study, AsAA inflation and rupture was simulated in 27 patient-specific finite element models constructed from clinical CT imaging data and tissue mechanical testing data from matching patients. These patients included n = 8 with concomitant bicuspid aortic valve (BAV), n = 10 with bovine aortic arch (BAA), and n = 10 with neither BAV nor BAA. AsAA rupture risk was found to increase with elevated systolic wall stress and tissue stiffness. The aortic size index was sufficient for identifying the patients with the lowest risk of rupture, but unsuitable for delineating between patients at moderate and high risk. There was no correlation between BAV or BAA and AsAA rupture risk; however, the AsAA morphology was different among these patients. These results support the use of mechanical parameters such as vessel wall stress and tissue stiffness for AsAA presurgical evaluation. PMID:25770248

The TachoSil-Pledget stitch: towards eradication of suture hole bleeding.

PubMed

Shimamoto, Takeshi; Marui, Akira; Nishina, Takeshi; Saji, Yoshiaki; Komeda, Masashi

2008-12-01

We describe a novel suture consisting of a small piece of TachoSil (Nycomed, Copenhagen, Denmark) and a felt pledget-the TachoSil-pledget stitch-which was used to facilitate mechanical and biologic hemostasis in 5 patients undergoing aortic arch aneurysm repair. The TachoSil-pledget stitch achieved good or very good hemostasis at all 56 bleeding points to which it was applied, while 5 of 12 points to which a conventional felt-pledget stitch was applied required additional stitching or an additional hemostatic method.

Aortic valve bypass surgery in severe aortic valve stenosis: Insights from cardiac and brain magnetic resonance imaging.

PubMed

Mantini, Cesare; Caulo, Massimo; Marinelli, Daniele; Chiacchiaretta, Piero; Tartaro, Armando; Cotroneo, Antonio Raffaele; Di Giammarco, Gabriele

2018-04-13

To investigate and describe the distribution of aortic and cerebral blood flow (CBF) in patients with severe valvular aortic stenosis (AS) before and after aortic valve bypass (AVB) surgery. We enrolled 10 consecutive patients who underwent AVB surgery for severe AS. Cardiovascular magnetic resonance imaging (CMR) and brain magnetic resonance imaging were performed as baseline before surgery and twice after surgery. Quantitative flow measurements were obtained using 1.5-T magnetic resonance imaging (MRI) scanner phase-contrast images of the ascending aorta, descending thoracic aorta (3 cm proximally and distally from the conduit-to-aorta anastomosis), and ventricular outflow portion of the conduit. The evaluation of CBF was performed using 3.0-T MRI scanner arterial spin labeling (ASL) through sequences acquired at the gray matter, dorsal default-mode network, and sensorimotor levels. Conduit flow, expressed as the percentage of total antegrade flow through the conduit, was 63.5 ± 8% and 67.8 ± 7% on early and mid-term postoperative CMR, respectively (P < .05). Retrograde perfusion from the level of the conduit insertion in the descending thoracic aorta toward the aortic arch accounted for 6.9% of total cardiac output and 11% of total conduit flow. We did not observe any significant reduction in left ventricular stroke volume at postoperative evaluation compared with preoperative evaluation (P = .435). No differences were observed between preoperative and postoperative CBF at the gray matter, dorsal default-mode network, and sensorimotor levels (P = .394). After AVB surgery in patients with severe AS, cardiac output is split between the native left ventricular outflow tract and the apico-aortic bypass, with two-thirds of the total antegrade flow passing through the latter and one-third passing through the former. In our experience, CBF assessment confirms that the flow redistribution does not jeopardize cerebral blood supply. Copyright © 2018 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

Aortic Valve Stenosis Increases Helical Flow and Flow Complexity: A Study of Intra-Operative Cardiac Vector Flow Imaging.

PubMed

Hansen, Kristoffer Lindskov; Møller-Sørensen, Hasse; Kjaergaard, Jesper; Jensen, Maiken Brit; Jensen, Jørgen Arendt; Nielsen, Michael Bachmann

2017-08-01

Aortic valve stenosis alters blood flow in the ascending aorta. Using intra-operative vector flow imaging on the ascending aorta, secondary helical flow during peak systole and diastole, as well as flow complexity of primary flow during systole, were investigated in patients with normal, stenotic and replaced aortic valves. Peak systolic helical flow, diastolic helical flow and flow complexity during systole differed between the groups (p < 0.0001), and correlated to peak systolic velocity (R = 0.94, 0.87 and 0.88, respectively). The study indicates that aortic valve stenosis increases helical flow and flow complexity, which are measurable with vector flow imaging. For assessment of aortic stenosis and optimization of valve surgery, vector flow imaging may be useful. Copyright © 2017 World Federation for Ultrasound in Medicine & Biology. Published by Elsevier Inc. All rights reserved.

A systematic review of primary endovascular repair of the ascending aorta.

PubMed

Muetterties, Corbin E; Menon, Rohan; Wheatley, Grayson H

2018-01-01

Endovascular repair of the ascending aorta is currently limited to patients at high surgical risk with aortic diseases originating above the sinotubular junction. A number of different endovascular technologies and approaches have been used, although no consensus exists regarding a standardized technique. To better understand real-world endovascular approaches to the ascending aorta, we performed a comprehensive review of the types of endovascular aortic stents and associated vascular access used in repair of the ascending aorta. A search of the MEDLINE database was conducted from January 1, 1995, through January 31, 2017, with the search term "ascending aortic stent." Studies involving endovascular stenting in which the primary therapy was confined exclusively to the ascending aorta were included. Studies involving hybrid arch procedures and surgical replacement of the ascending aorta associated with aortic stenting were excluded. The type of aortic stent, underlying aortic disease, and surgical approach were recorded along with outcomes, need for reinterventions, and follow-up. A total of 46 publications that focused on primary endovascular repair of the ascending aorta were identified. Thirteen different aortic stent grafts of various designs were used in 118 total patients. The most commonly used device types were thoracic stents (n = 84 [71.2%]) along with abdominal cuffs (n = 13 [11%]) and custom-made grafts (n = 12 [10.2%]). The most commonly treated aortic disease was type A aortic dissection (n = 59 [50%]), followed by aortic pseudoaneurysm (n = 35 [29.7%]), aortic aneurysm (n = 6 [5.1%]), penetrating atherosclerotic ulcer (n = 5 [4.2%]), and acute aortic rupture (n = 3 [2.5%]). Femoral arterial access was used in 62.7% of patients (n = 74); transapical (n = 17 [14.4%]), carotid (n = 15 [12.7%]), and axillary (n = 8 [6.8%]) approaches were also used. The overall type I endoleak rate was 18.6% (n = 22), with 11 patients (9.3%) requiring reintervention. Other complications included all-cause mortality (n = 18 [15.2%]), conversions to open surgery (n = 4 [3.4%]), and cerebrovascular complications (n = 4 [3.4%]). Aorta-related mortality was 5% (n = 6), and average follow-up was 17.2 months. Despite the absence of a dedicated aortic stent graft for the ascending aorta, patients with a range of ascending aortic diseases are being successfully treated by endovascular technologies. For optimal outcomes, patient selection is critical to align aortic anatomy with the limited device sizing options, and it should be reserved for patients at high surgical risk. Copyright © 2017 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.

Is the frozen elephant trunk procedure superior to the conventional elephant trunk procedure for completion of the second stage?

PubMed

Rustum, Saad; Beckmann, Erik; Wilhelmi, Mathias; Krueger, Heike; Kaufeld, Tim; Umminger, Julia; Haverich, Axel; Martens, Andreas; Shrestha, Malakh

2017-10-01

Our goal was to compare the results and outcomes of second-stage completion in patients who had previously undergone the elephant trunk (ET) or the frozen elephant trunk (FET) procedure for the treatment of complex aortic arch and descending aortic disease. Between August 2001 and December 2014, 53 patients [mean age 61 ± 13 years, 64% (n = 34) male] underwent a second-stage completion procedure. Of these patients, 32% (n = 17) had a previous ET procedure and 68% (n = 36) a previous FET procedure as a first-stage procedure. The median times to the second-stage procedure were 7 (0-78) months in the ET group and 8 (0-66) months in the FET group. The second-stage procedure included thoracic endovascular aortic repair in 53% (n = 28) of patients and open surgical repair in 47% (n = 25). More endovascular interventions were performed in FET patients (61%, n = 22) than in the ET group (35%, n = 6, P = 0.117). The in-hospital mortality rate was significantly lower in the FET (8%, n = 3) group compared with the ET group (29%, n = 5, P = 0.045). The median follow-up time after the second-stage operation for the entire cohort was 4.6 (0.4-10.4) years. The 5-year survival rate was 76% in the ET patients versus 89% in the FET patients (log-rank: P = 0.11). We observed a significantly lower in-hospital mortality rate in the FET group compared to the ET group. This result might be explained by the higher rate of endovascular completion in the FET group. We assume that the FET procedure offers the benefit of a more ideal landing zone, thus facilitating endovascular completion. © The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Intra-Operative Vector Flow Imaging Using Ultrasound of the Ascending Aorta among 40 Patients with Normal, Stenotic and Replaced Aortic Valves.

PubMed

Hansen, Kristoffer Lindskov; Møller-Sørensen, Hasse; Kjaergaard, Jesper; Jensen, Maiken Brit; Lund, Jens Teglgaard; Pedersen, Mads Møller; Lange, Theis; Jensen, Jørgen Arendt; Nielsen, Michael Bachmann

2016-10-01

Stenosis of the aortic valve gives rise to more complex blood flows with increased velocities. The angle-independent vector flow ultrasound technique transverse oscillation was employed intra-operatively on the ascending aorta of (I) 20 patients with a healthy aortic valve and 20 patients with aortic stenosis before (IIa) and after (IIb) valve replacement. The results indicate that aortic stenosis increased flow complexity (p < 0.0001), induced systolic backflow (p < 0.003) and reduced systolic jet width (p < 0.0001). After valve replacement, the systolic backflow and jet width were normalized (p < 0.52 and p < 0.22), but flow complexity was not (p < 0.0001). Flow complexity (p < 0.0001), systolic jet width (p < 0.0001) and systolic backflow (p < 0.001) were associated with peak systolic velocity. The study found that aortic stenosis changes blood flow in the ascending aorta and valve replacement corrects some of these changes. Transverse oscillation may be useful for assessment of aortic stenosis and optimization of valve surgery. Copyright © 2016 World Federation for Ultrasound in Medicine & Biology. Published by Elsevier Inc. All rights reserved.

The Provisional Extension To Induce Complete Attachment (PETTICOAT) technique to promote distal aortic remodelling in repair of acute DeBakey type I aortic dissection: preliminary results.

PubMed

Hsu, Hung-Lung; Chen, Yin-Yin; Huang, Chun-Yang; Huang, Jih-Hsin; Chen, Jer-Shen

2016-07-01

To report our preliminary results of an aggressive technique, the Provisional Extension To Induce Complete Attachment (PETTICOAT), in repair of acute DeBakey type I aortic dissection. From April 2014 to November 2014, 18 patients with acute DeBakey type I aortic dissection were reviewed retrospectively. Nine patients underwent open repair combined with proximal stent grafting and distal bare stenting (PETTICOAT group). For comparison, another 9 patients underwent open repair combined with proximal stent grafting (NON-PETTICOAT group) were included. Open repair entailed ascending aorta plus total arch replacement under circulatory arrest, with variable aortic root work. Mortality and morbidity were recorded, and computed tomography was performed to evaluate the aortic remodelling at 6 months postoperatively. Preoperative parameters were similar. In the PETTICOAT group, one early mortality was noted. One complication of cardiac tamponade and sternal wound infection led to reopen surgeries. In the NON-PETTICOAT group, one case of transient ischaemic attack took place. Compared with the NON-PETTICOAT group, a significant increase in diameter of true lumen (median, 0.6 vs 0.1 mm, P < 0.01) and a decrease in diameter of false lumen (FL; median, -0.9 vs 0.0 mm, P < 0.01) at the level of lowest renal artery were noted in the PETTICOAT group. Moreover, significant FL volume regression (median, -102.0 vs -42.2 mm(3), P = 0.03) was observed in the PETTICOAT group. More cases of total thrombosis or regression of FL down to the level of renal artery were also noted in the PETTICOAT group (5/8 vs 0/9, P < 0.01). Two patients of the NON-PETTICOAT group received endovascular distal aortic reintervention at 6 months. The PETTICOAT technique in the management of acute DeBakey type I dissection is a feasible and promising method to promote distal aortic remodelling. However, outcomes are preliminary and further follow-up is required. © The Author 2016. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Periodontal Disease Associated with Aortic Arch Atheroma in Patients with Stroke or Transient Ischemic Attack.

PubMed

Sen, Souvik; Chung, Matthew; Duda, Viktoriya; Giamberardino, Lauren; Hinderliter, Alan; Offenbacher, Steven

2017-10-01

Periodontal disease (PD) is associated with recurrent vascular event in stroke or transient ischemic attack (TIA). In this study, we investigated whether PD is independently associated with aortic arch atheroma (AA). We also explored the relationship PD has with AA plaque thickness and other characteristics associated with atheroembolic risk among patients with stroke or TIA. Finally, we confirmed the association between AA and recurrent vascular event in patients with stroke or TIA. In this prospective longitudinal hospital-based cohort study, PD was assessed in patients with stroke and TIA. Patients with confirmed stroke and TIA (n = 106) were assessed by calibrated dental examiners to determine periodontal status and were followed over a median of 24 months for recurrent vascular events (stroke, myocardial infarction, and death). The extent of AA and other plaque characteristics was assessed by transesophageal echocardiography. Within our patient cohort, 27 of the 106 participants had recurrent vascular events (including 16 with stroke or TIA) over the median of 24-month follow-up. Severe PD was associated with increased AA plaque thickness and calcification. The results suggest that PD may be a risk factor for AA. In this cohort, we confirm the association of severe AA with recurrent vascular events. In patients with stroke or TIA, severe PD is associated with increased AA plaque thickness, a risk factor for recurrent events. Further studies are needed to confirm this finding and to determine whether treatment of PD can reduce the rate of AA plaque progression and recurrent vascular events. Copyright © 2017 National Stroke Association. Published by Elsevier Inc. All rights reserved.

Thoracoscopy with Concurrent Esophagoscopy for Persistent Right Aortic Arch in 9 Dogs.

PubMed

Townsend, Sarah; Oblak, Michelle L; Singh, Ameet; Steffey, Michele A; Runge, Jeffrey J

2016-11-01

To report the diagnosis, treatment, and short-term outcome in dogs with suspected persistent right aortic arch (PRAA) undergoing thoracoscopy with concurrent esophagoscopy. Multi-institutional retrospective case series. Dogs with suspected PRAA (n=9). Medical records were reviewed from 2012 to 2016. Dogs undergoing thoracoscopy for PRAA at 3 referral hospitals were included. Signalment, clinical signs, diagnostic imaging, anesthesia protocol (including the use of one-lung ventilation), surgical approach, complications, and short-term outcome were recorded. Dogs underwent a left-sided intercostal thoracoscopic approach with concurrent intraoperative esophagoscopy. The ligamentum arteriosum (LA) and constricting fibers were divided using a vessel-sealing device using a 3 or 4 port thoracoscopy technique. Visualization and dissection of the LA was aided by transesophageal illumination by esophagoscopy. Thoracoscopy confirmed PRAA in 9 dogs, with an aberrant left subclavian artery (LS) identified in 5 dogs. Major complications occurred in 2 dogs: postoperative hemorrhage from the LS and esophageal perforation, which resulted in euthanasia. Median follow-up was 250 days (range, 56-1,595). Regurgitation resolved in 4 of 8 surviving dogs. One dog had recurrence of regurgitation 1,450 days postoperatively, esophageal compression by the LS was identified, and regurgitation resolved following LS transection. Esophagoscopy aided identification and dissection of the LA in all cases. Due to the potential for the LS to cause clinical esophageal constriction postoperatively, a recommendation for LS transection may be warranted. Vascular clips can also be considered as an alternative for vessel ligation to avoid complications associated with vessel-sealing device use. © Copyright 2016 by The American College of Veterinary Surgeons.

Endovascular Embolization of Bronchial Artery Originating from the Upper Portion of Aortic Arch in Patients with Massive Hemoptysis

DOE Office of Scientific and Technical Information (OSTI.GOV)

Jiang, Sen, E-mail: jasfly77@vip.163.com; Sun, Xi-Wen, E-mail: xwsun@citiz.net; Yu, Dong, E-mail: yudong_mail@126.com

2013-05-15

PurposeOur experience with endovascular embolization (EVE) of the bronchial artery (BA) originating from the upper portion of the aortic arch (AA) in six patients is described.MethodsAltogether, 818 patients with hemoptysis underwent multidetector row computed tomography angiography (MDCTA) before EVE or AA angiography during EVE. Aberrant BAs originating from the upper portion of the AA were the source of massive hemoptysis in six patients (0.73 %). MDCT angiograms and/or Digital subtraction angiograms were retrospectively reviewed. Selective catheterization and embolization were performed.ResultsThe ostia of the BAs were located on the superior surface of the AA between the brachiocephalic trunk and left common carotidmore » artery in three patients, the junction of the aorta and medial surface of the left subclavian artery in two, and the posterior wall of the upper portion of the AA in one. The six BAs comprised two common trunks, three single right sides, and one single left side. The targeted vessels were successfully catheterized and embolized by a coaxial microcatheter system using polyvinyl alcohol particles. Other pathologic BAs and nonbronchial systemic arteries also were embolized. Bleeding was immediately controlled in all patients with no recurrence of hemoptysis. No procedure-related complications occurred.ConclusionsApplication of EVE of anomalous origin of BAs in patients with hemoptysis is important, as demonstrated in the six reported patients. MDCTA before EVE or AA angiography during EVE is critical to avoid missing a rare aberrant BA originating from the upper portion of the AA.« less

Decreased levels of embryonic retinoic acid synthesis accelerate recovery from arterial growth delay in a mouse model of DiGeorge syndrome.

PubMed

Ryckebüsch, Lucile; Bertrand, Nicolas; Mesbah, Karim; Bajolle, Fanny; Niederreither, Karen; Kelly, Robert G; Zaffran, Stéphane

2010-03-05

Loss of Tbx1 and decrease of retinoic acid (RA) synthesis result in DiGeorge/velocardiofacial syndrome (DGS/VCFS)-like phenotypes in mouse models, including defects in septation of the outflow tract of the heart and anomalies of pharyngeal arch-derived structures including arteries of the head and neck, laryngeal-tracheal cartilage, and thymus/parathyroid. Wild-type levels of T-box transcription factor (Tbx)1 and RA signaling are required for normal pharyngeal arch artery development. Recent studies have shown that reduction of RA or loss of Tbx1 alters the contribution of second heart field (SHF) progenitor cells to the elongating heart tube. Here we tested whether Tbx1 and the RA signaling pathway interact during the deployment of the SHF and formation of the mature aortic arch. Molecular markers of the SHF, neural crest and smooth muscle cells, were analyzed in Raldh2;Tbx1 compound heterozygous mutants. Our results revealed that the SHF and outflow tract develop normally in Raldh2(+/-);Tbx1(+/-) embryos. However, we found that decreased levels of RA accelerate the recovery from arterial growth delay observed in Tbx1(+/-) mutant embryos. This compensation coincides with the differentiation of smooth muscle cells in the 4th pharyngeal arch arteries, and is associated with severity of neural crest cell migration defects observed in these mutants. Our data suggest that differences in levels of embryonic RA may contribute to the variability in great artery anomalies observed in DGS/VCFS patients.

Moving into the paravisceral aorta using fenestrated and branched endografts.

PubMed

Farber, Mark A; Vallabhaneni, Raghuveer

2012-12-01

When one compares the potential advantages of endovascular aortic repair with respect to traditional open repair, it would seem logical that extension into the paravisceral aorta would be easily justified, given the complexity of open aortic repair and its associated complications. Eight years have transpired between trial initiation and Food and Drug Administration approval of the first fenestrated device in the United States for the treatment of juxtarenal aneurysms. While there are only a few centers in the United States with substantial experience performing fenestrated and branched endovascular aortic repair, there is a diverse experience outside the United States that has been gained over the past decade. It is through the experience of these centers that the technical and procedural complexities of complex endovascular aortic repair has been solved and provide the foundation that has allowed aortic specialists to move endovascular therapy into the paravisceral aorta with fenestrated and branched endovascular aortic repairs. Copyright © 2012 Elsevier Inc. All rights reserved.

In vitro flow assessment: from PC-MRI to computational fluid dynamics including fluid-structure interaction

NASA Astrophysics Data System (ADS)

Kratzke, Jonas; Rengier, Fabian; Weis, Christian; Beller, Carsten J.; Heuveline, Vincent

2016-04-01

Initiation and development of cardiovascular diseases can be highly correlated to specific biomechanical parameters. To examine and assess biomechanical parameters, numerical simulation of cardiovascular dynamics has the potential to complement and enhance medical measurement and imaging techniques. As such, computational fluid dynamics (CFD) have shown to be suitable to evaluate blood velocity and pressure in scenarios, where vessel wall deformation plays a minor role. However, there is a need for further validation studies and the inclusion of vessel wall elasticity for morphologies being subject to large displacement. In this work, we consider a fluid-structure interaction (FSI) model including the full elasticity equation to take the deformability of aortic wall soft tissue into account. We present a numerical framework, in which either a CFD study can be performed for less deformable aortic segments or an FSI simulation for regions of large displacement such as the aortic root and arch. Both of the methods are validated by means of an aortic phantom experiment. The computational results are in good agreement with 2D phase-contrast magnetic resonance imaging (PC-MRI) velocity measurements as well as catheter-based pressure measurements. The FSI simulation shows a characteristic vessel compliance effect on the flow field induced by the elasticity of the vessel wall, which the CFD model is not capable of. The in vitro validated FSI simulation framework can enable the computation of complementary biomechanical parameters such as the stress distribution within the vessel wall.

Etiology and Risk Factors for Cerebral Infarct after Surgical Aortic Valve Replacement

PubMed Central

Massaro, Allie; Messé, Steven R.; Acker, Michael A.; Kasner, Scott E.; Torres, Jose; Fanning, Molly; Giovannetti, Tania; Ratcliffe, Sarah J.; Bilello, Michel; Szeto, Wilson Y.; Bavaria, Joseph E.; Mohler, Emile R.; Floyd, Thomas F.

2016-01-01

Background and Purpose Stroke is a potentially devastating complication of cardiac surgery. Identifying predictors of radiographic infarct may lead to improved stroke prevention for surgical patients. Methods We reviewed 129 post-operative brain MRIs from a prospective study of patients undergoing surgical aortic valve replacement (AVR). Acute infarcts were classified as watershed or embolic using pre-specified criteria. Results Acute infarct on MRI was seen in 79 of 129 patients (61%), interrater reliability for stroke etiology was high (κ =0.93). Embolic infarcts only were identified in 60 (46%), watershed only in 2 (2%), and both in 17 (13%). In multivariable logistic regression, embolic infarct was associated with aortic arch atheroma (OR=3.4, 95%CI 1.0-12.0, p=0.055), old subcortical infarcts (OR= 5.5, 95%CI 1.1-26.6, p=0.04), no history of PTCA or CABG (OR=4.0, 95%CI 1.2-13.7, p=0.03), and higher aortic valve gradient (OR=1.3 per 5mmHg, 95%CI 1.09-1.6, p=0.004). Watershed infarct was associated with internal carotid artery stenosis ≥70% (OR=11.7, 95%CI 1.8-76.8, p=0.01) and increased left ventricular ejection fraction (OR=1.6 per 5% increase, 95%CI 1.08-2.4, p=0.02). Conclusions The principal mechanism of acute cerebral infarction after AVR is embolism. There are distinct factors associated with watershed and embolic infarct, some of which may be modifiable. PMID:27382005

Transition of intestinal fatty acid-binding protein on hypothermic circulatory arrest with cardiopulmonary bypass.

PubMed

Kano, Hiroya; Takahashi, Hiroaki; Inoue, Takeshi; Tanaka, Hiroshi; Okita, Yutaka

2017-04-01

Intestinal fatty acid-binding protein (I-FABP) is increasingly employed as a highly specific marker of intestinal necrosis. However, the value of this marker associated with cardiovascular surgery with hypothermic circulatory arrest is unclear. The aim of this study was to measure serum I-FABP levels and provide the transition of I-FABP levels with hypothermic circulatory arrest to help in the management of intestinal perfusion. From August 2011 to September 2013, 33 consecutive patients who had aortic arch surgery with hypothermic circulatory arrest or heart valve surgery performed were enrolled in the study. Twenty patients had aortic surgery with hypothermic (23-29°C) circulatory arrest and 13 patients had heart valve surgery with cardiopulmonary bypass (33°C). I-FABP levels increased, both in patients undergoing aortic surgery with hypothermic circulatory arrest and heart valve surgery with cardiopulmonary bypass, reaching peak levels shortly after the administration of protamine. I-FABP levels in patients with aortic surgery were significantly higher with circulatory arrest. They reached peak levels immediately after recirculation and there was a significant drop at the end of surgery (p<0.001). I-FABP levels in heart valve surgery were gradually increased, with the highest at the administration of protamine; they gradually decreased. Peak I-FABP levels were significantly higher in patients undergoing aortic surgery with hypothermic circulatory arrest than in patients with heart valve surgery. However, no postoperative reperfusion injury occurred in the intestinal tract due to the use of hypothermic organ protection. Plasma I-FABP monitoring could be a valuable method for finding an intestinal ischemia in patients with cardiovascular surgery.

Acute cardioembolic cerebral infarction: answers to clinical questions.

PubMed

Arboix, Adria; Alio, Josefina

2012-02-01

Cardioembolic cerebral infarction (CI) is the most severe subtype of ischaemic stroke but some clinical aspects of this condition are still unclear. This article provides the reader with an overview and up-date of relevant aspects related to clinical features, specific cardiac disorders and prognosis of CI. CI accounts for 14-30% of ischemic strokes; patients with CI are prone to early and long-term stroke recurrence, although recurrences may be preventable by appropriate treatment during the acute phase and strict control at follow-up. Certain clinical features are suggestive of CI, including sudden onset to maximal deficit, decreased level of consciousness at onset, Wernicke's aphasia or global aphasia without hemiparesis, a Valsalva manoeuvre at the time of stroke onset, and co-occurrence of cerebral and systemic emboli. Lacunar clinical presentations, a lacunar infarct and especially multiple lacunar infarcts, make cardioembolic origin unlikely. The most common disorders associated with a high risk of cardioembolism include atrial fibrillation, recent myocardial infarction, mechanical prosthetic valve, dilated myocardiopathy and mitral rheumatic stenosis. Patent foramen ovale and complex atheromatosis of the aortic arch are potentially emerging sources of cardioembolic infarction. Mitral annular calcification can be a marker of complex aortic atheroma in stroke patients of unkown etiology. Transthoracic and transesophageal echocardiogram can disclose structural heart diseases. Paroxysmal atrial dysrhythmia can be detected by Holter monitoring. Magnetic resonance imaging, transcranial Doppler, and electrophysiological studies are useful to document the source of cardioembolism. In-hospital mortality in cardioembolic stroke (27.3%, in our series) is the highest as compared with other subtypes of cerebral infarction. Secondary prevention with anticoagulants should be started immediately if possible in patients at high risk for recurrent cardioembolic stroke in which contraindications, such as falls, poor compliance, uncontrolled epilepsy or gastrointestinal bleeding are absent. Dabigatran has been shown to be non-inferior to warfarin in the prevention of stroke or systemic embolism. All significant structural defects, such as atrial septal defects, vegetations on valve or severe aortic disease should be treated. Aspirin is recommended in stroke patients with a patent foramen ovale and indications of closure should be individualized. CI is an important topic in the frontier between cardiology and vascular neurology, occurs frequently in daily practice, has a high impact for patients, and health care systems and merits an update review of current clinical issues, advances and controversies.

Radial force measurement of endovascular stents: Influence of stent design and diameter.

PubMed

Matsumoto, Takuya; Matsubara, Yutaka; Aoyagi, Yukihiko; Matsuda, Daisuke; Okadome, Jun; Morisaki, Koichi; Inoue, Kentarou; Tanaka, Shinichi; Ohkusa, Tomoko; Maehara, Yoshihiko

2016-04-01

Angioplasty and endovascular stent placement is used in case to rescue the coverage of main branches to supply blood to brain from aortic arch in thoracic endovascular aortic repair. This study assessed mechanical properties, especially differences in radial force, of different endovascular and thoracic stents. We analyzed the radial force of three stent models (Epic, E-Luminexx and SMART) stents using radial force-tester method in single or overlapping conditions. We also analyzed radial force in three thoracic stents using Mylar film testing method: conformable Gore-TAG, Relay, and Valiant Thoracic Stent Graft. Overlapping SMART stents had greater radial force than overlapping Epic or Luminexx stents (P < 0.01). The radial force of the thoracic stents was greater than that of all three endovascular stents (P < 0.01). Differences in radial force depend on types of stents, site of deployment, and layer characteristics. In clinical settings, an understanding of the mechanical characteristics, including radial force, is important in choosing a stent for each patient. © The Author(s) 2015.

The high opening of the right bronchial artery with a non-typical course.

PubMed

Maciejewski, R; Madej, B; Anasiewicz, A

1995-01-01

Authors describing the bronchial vessels agree to the fact that they are characterised by a great variability in regard to their number and the place where they leave aorta (1, 2, 6). The characteristic feature of the right bronchial artery is that it often forms common trunks with other vessels (mainly with the first right aortic intercostal branch or with one of the upper oesophageal arteries). It can also have a common let-out trunk with the left upper bronchial artery (4). Bearing in mind that the operations on trachea and bronchi are difficult, and that it is very important to maintain the blood supply of the walls in the operated organs we have decided to publish our observations. They refer to a case, not described before, in which the right bronchial artery left the aortic arch in a high position making the vascular supply to the front lower half of the trachea and its bifurcation. Then, it went down to the membranous part of the right bronchus.

Protection against atherogenesis with the polymer drag-reducing agent Separan AP-30.

PubMed

Faruqui, F I; Otten, M D; Polimeni, P I

1987-03-01

The inhibitory effect of Separan AP-30, an anionic polyacrylamide, on atherosclerotic plaque formation in aortas of rabbits on a high (2%) cholesterol diet was tested over a period extending from 37 to 170 days. Atherogenesis was quantified morphometrically by application of a computer-assisted image analysis of histologic cross sections of the aorta. The area of vessel wall-atheroma interface, fraction of lumen occluded, and other indexes of atherogenesis were measured in each of 26 segments of aorta excised from the animals, half of which were administered injections (intravenous) of Separan three times a week. Regression analysis of the morphometric data indicates that the polyelectrolyte exerts a powerful antiatherogenic effect in all regions of the aorta, inhibiting the formation of plaque mass to less than half in the aortic arch and about one-fifth in the descending aorta as compared with the aortic plaque masses in untreated rabbits. Results are compatible with the suggestion that a novel hemodynamic principle in vivo, polymer drag reduction, might be effectively applied against atherosclerosis.

Subglottic granuloma after aortic replacement: resection via flexible bronchoscopy after an emergency tracheostomy

PubMed Central

Nose, Naohiro; So, Tetsuya; Sekimura, Atsushi; Miyata, Takeaki; Yoshimatsu, Takashi

2014-01-01

A subglottic granuloma is one of the late-phase complications that can occur after intubation. It can cause a life-threatening airway obstruction; therefore, a rapid diagnosis and appropriate treatment plan is necessary. A 62-year-old male had undergone an emergency total arch replacement for acute aortic dissection. Postoperative ventilation support had been performed until the 15th postoperative day (POD). He was discharged from the hospital on POD 30. On POD 50, he was brought to our hospital by an ambulance with severe dyspnea. A large subglottic granuloma occupying the trachea was identified by flexible bronchoscopy. After an emergency tracheostomy, resection of the granuloma with argon plasma coagulation via flexible bronchoscopy was performed safely. Physicians should suspect a post-intubation subglottic granuloma when patients who have undergone intubation report feeling throat discomfort. Resection via flexible bronchoscopy after tracheostomy is a safe and feasible procedure that may shorten the duration of therapy and hospital stay. PMID:25180216

Direct reperfusion of the right common carotid artery prior to cardiopulmonary bypass in patients with brain malperfusion complicated with acute aortic dissection.

PubMed

Okita, Yutaka; Matsumori, Masamichi; Kano, Hiroya

2016-04-01

The cases of 3 patients with brain malperfusion secondary to acute aortic dissection who underwent preoperative perfusion of the right common carotid artery are presented. The patients were 64, 65 and 72 years old and 2 were female. All were in a comatose or semi-comatose state with left hemiplegia. The right common carotid artery was exposed and directly cannulated, using a 12-Fr paediatric arterial cannula. The right common femoral artery was chosen for arterial drainage, using a 14-Fr double-lumen cannula. The circuit contained a small roller pump and heat exchanger coil. Target flow was set at 90 ml/min and blood temperature at 30 °C. Durations of right carotid perfusion were 120, 100 and 45 min, respectively. All underwent partial arch replacement and survived. Postoperative neurological sequelae were minimal in all cases. © The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Regulation of Facial Morphogenesis by Endothelin Signaling: Insights from Mice and Fish

PubMed Central

Clouthier, David E.; Garcia, Elvin; Schilling, Thomas F.

2010-01-01

Craniofacial morphogenesis is accomplished through a complex set of developmental events, most of which are initiated in neural crest cells within the pharyngeal arches. Local patterning cues from the surrounding environment induce gene expression within neural crest cells, leading to formation of a diverse set of skeletal elements. Endothelin-1 (Edn1) is one of the primary signals that establish the identities of neural crest cells within the mandibular portion of the first pharyngeal arch. Signaling through its cognate receptor, the endothelin-A receptor, is critical for patterning the ventral/distal portion of the arch (lower jaw) and also participates with Hox genes in patterning more posterior arches. Edn1/Ednra signaling is highly conserved between mouse and zebrafish, and genetic analyses in these two species have provided complementary insights into the patterning cues responsible for establishing the craniofacial complex as well as the genetic basis of facial birth defect syndromes. PMID:20684004

Ground zero: not asthma at all.

PubMed

de Benedictis, Fernando Maria; de Benedictis, Diletta; Mirabile, Lorenzo; Pozzi, Marco; Guerrieri, Arcangela; Di Pillo, Sabrina

2015-09-01

Upper airway obstruction is commonly misdiagnosed as asthma. We report on four children with recurrent respiratory symptoms who had been erroneously diagnosed as having asthma and who received anti-asthma medication for several years. The evaluation of spirometry tracing was neglected in all cases. Subglottic stenosis, tracheomalacia secondary to tracheo-esophageal fistula, double aortic arch, and vocal cord dysfunction were suspected by direct inspection of the flow-volume curves and eventually diagnosed. The value of clinical history and careful evaluation of spirometry tracing in children with persistent respiratory symptoms is critically discussed. © 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

Ingested bony foreign body abutting thoracic aorta

PubMed Central

Leahy, Travis William; Kuthubutheen, Jafri

2011-01-01

The authors present the case of a 38-year-old female who presented with an ingested oesophageal foreign body (lamb bone) following consumption of a casserole. The bone was initially not seen on plain x-ray but CT imaging revealed a 21×20 mm pyramid shaped bone distending the proximal oesophageal mucosa and lodged only 2 mm from the aortic arch. Cardiothoracic surgery services were available on standby to perform an emergency thoracotomy in the event of any haemorrhage. However, the bone was removed successfully with rigid oesophagoscopy and the patient made a full recovery. PMID:22689831

Dual origin of the right vertebral artery from the right common carotid and aberrant right subclavian arteries.

PubMed

Moshayedi, Pouria; Walker, Gregory B; Tavakoli, Sina; Desai, Shashvat M; Jadhav, Ashutosh P

2018-07-01

This report describes a case of duplicated origin of the right vertebral artery incidentally found in a young patient. Computed tomographic angiography and digital subtraction angiography showed a dominant branch derived from the right common carotid artery and an accessory branch that derived from the right subclavian artery, which aberrantly originated from the far left aortic arch, and adjoined the dominant branch at the C5 level. We discuss angiographic findings, clinical implications and embryological basis for this rare anomaly. Copyright © 2018 Elsevier Ltd. All rights reserved.

A Potential Pitfall in the Use of the Monorail System for Carotid Stenting

PubMed Central

Pereira, E.; Birnbaum, L.

2006-01-01

Summary The use of EPDs seems to be necessary for safe CAS. Though the monorail system may offer advantages for a single operator, we caution its use with certain aortic arch anatomies. In such anatomies, using an OTW system or at least a 300 cm filter wire or devices that support wire extension will remedy some complications, such as the loss of the guiding sheath. As in our case, the added advantage of a 300 cm filter wire enabled us to avoid a poor outcome or an emergency vascular surgery. PMID:20569594

A potential pitfall in the use of the monorail system for carotid stenting. A technical case report.

PubMed

Pereira, E; Birnbaum, L

2006-12-15

The use of EPDs seems to be necessary for safe CAS. Though the monorail system may offer advantages for a single operator, we caution its use with certain aortic arch anatomies. In such anatomies, using an OTW system or at least a 300 cm filter wire or devices that support wire extension will remedy some complications, such as the loss of the guiding sheath. As in our case, the added advantage of a 300 cm filter wire enabled us to avoid a poor outcome or an emergency vascular surgery.

Interdisciplinary Management of a Perforated Aneurysmal Arteria Lusoria: A Case Report.

PubMed

Rouman, Mina; Petrovitch, Alexander; Gey, Eva-Maria; Kuntze, Thomas

2017-01-01

Background  An aberrant right subclavian artery (RSA) or arteria lusoria is the most common congenital abnormality of the aortic arch with an incidence of 0.3 to 3.0%. Case Description  We report a case of a perforated aneurysmal aberrant RSA, managed using a hybrid approach. Conclusion  In emergency cases with acute bleeding, we recommend an endovascular approach to avoid the lethal sequel of arterial leakage. Whenever possible, the pulsatile blood flow to the right arm should be restored. Management should be tailored to the nature of the aneurysmal aberrant RSA, patient's comorbidities, and concomitant lesions.

Thoracic aorta 3D hemodynamics in pediatric and young adult patients with bicuspid aortic valve.

PubMed

Allen, Bradley D; van Ooij, Pim; Barker, Alex J; Carr, Maria; Gabbour, Maya; Schnell, Susanne; Jarvis, Kelly B; Carr, James C; Markl, Michael; Rigsby, Cynthia; Robinson, Joshua D

2015-10-01

To evaluate the 3D hemodynamics in the thoracic aorta of pediatric and young adult bicuspid aortic valve (BAV) patients. 4D flow MRI was performed in 30 pediatric and young adult BAV patients (age: 13.9 ± 4.4 (range: [3.4, 20.7]) years old, M:F = 17:13) as part of this Institutional Review Board-approved study. Nomogram-based aortic root Z-scores were calculated to assess aortic dilatation and degree of aortic stenosis (AS) severity was assessed on MRI. Data analysis included calculation of time-averaged systolic 3D wall shear stress (WSSsys ) along the entire aorta wall, and regional quantification of maximum and mean WSSsys and peak systolic velocity (velsys ) in the ascending aorta (AAo), arch, and descending aorta (DAo). The 4D flow MRI AAo velsys was also compared with echocardiography peak velocity measurements. There was a positive correlation with both mean and max AAo WSSsys and peak AAo velsys (mean: r = 0.84, P < 0.001, max: r = 0.94, P < 0.001) and AS (mean: rS  = 0.43, P = 0.02, max: rS  = 0.70, P < 0.001). AAo peak velocity was significantly higher when measured with echo compared with 4D flow MRI (2.1 ± 0.98 m/s versus 1.27 ± 0.49 m/s, P < 0.001). In pediatric and young adult patients with BAV, AS and peak ascending aorta velocity are associated with increased AAo WSS, while aortic dilation, age, and body surface area do not significantly impact AAo hemodynamics. Prospective studies are required to establish the role of WSS as a risk-stratification tool in these patients. © 2015 Wiley Periodicals, Inc.

Turbulent Kinetic Energy Assessed by Multipoint 4-Dimensional Flow Magnetic Resonance Imaging Provides Additional Information Relative to Echocardiography for the Determination of Aortic Stenosis Severity.

PubMed

Binter, Christian; Gotschy, Alexander; Sündermann, Simon H; Frank, Michelle; Tanner, Felix C; Lüscher, Thomas F; Manka, Robert; Kozerke, Sebastian

2017-06-01

Turbulent kinetic energy (TKE), assessed by 4-dimensional (4D) flow magnetic resonance imaging, is a measure of energy loss in disturbed flow as it occurs, for instance, in aortic stenosis (AS). This work investigates the additional information provided by quantifying TKE for the assessment of AS severity in comparison to clinical echocardiographic measures. Fifty-one patients with AS (67±15 years, 20 female) and 10 healthy age-matched controls (69±5 years, 5 female) were prospectively enrolled to undergo multipoint 4D flow magnetic resonance imaging. Patients were split into 2 groups (severe and mild/moderate AS) according to their echocardiographic mean pressure gradient. TKE values were integrated over the aortic arch to obtain peak TKE. Integrating over systole yielded total TKE sys and by normalizing for stroke volume, normalized TKE sys was obtained. Mean pressure gradient and TKE correlated only weakly ( R 2 =0.26 for peak TKE and R 2 =0.32 for normalized TKE sys ) in the entire study population including control subjects, while no significant correlation was observed in the AS patient group. In the patient population with dilated ascending aorta, both peak TKE and total TKE sys were significantly elevated ( P <0.01), whereas mean pressure gradient was significantly lower ( P <0.05). Patients with bicuspid aortic valves also showed significantly increased TKE metrics ( P <0.01), although no significant difference was found for mean pressure gradient. Elevated TKE levels imply higher energy losses associated with bicuspid aortic valves and dilated ascending aortic geometries that are not assessable by current echocardiographic measures. These findings indicate that TKE may provide complementary information to echocardiography, helping to distinguish within the heterogeneous population of patients with moderate to severe AS. © 2017 American Heart Association, Inc.

Echocardiographic Assessment of Aortic Pulse-Wave Velocity: Validation against Invasive Pressure Measurements.

PubMed

Styczynski, Grzegorz; Rdzanek, Adam; Pietrasik, Arkadiusz; Kochman, Janusz; Huczek, Zenon; Sobieraj, Piotr; Gaciong, Zbigniew; Szmigielski, Cezary

2016-11-01

Aortic pulse-wave velocity (PWV) is a measure of aortic stiffness that has a prognostic role in various diseases and in the general population. A number of methods are used to measure PWV, including Doppler ultrasound. Although echocardiography has been used for PWV measurement, to the authors' knowledge, it has never been tested against an invasive reference method at the same time point. Therefore, the aim of this study was to compare prospectively an echocardiographic PWV measurement, called echo-PWV, with an invasive study. Forty-five patients (mean age, 66 years; 60% men) underwent simultaneous intra-arterial pressure recording and echocardiographic Doppler flow evaluation during elective cardiac catheterization. Proximal pressure and Doppler waveforms were acquired in the aortic arch. Distal pressure waveforms were registered in the right and distal Doppler waveforms in the left external iliac artery. Transit time was measured as a delay of the foot of pressure or Doppler waveform in the distal relative to the proximal location. Distance was measured on the catheter for invasive PWV and over the surface for echo-PWV. Echo-PWV was calculated as distance divided by transit time. In the whole group, mean invasive PWV was 9.38 m/sec and mean echo-PWV was 9.51 m/sec (P = .78). The Pearson' correlation coefficient between methods was 0.93 (P < .0001). A Bland-Altman plot revealed a mean difference between invasive PWV and echo-PWV of 0.13 ± 0.79 m/sec. Echo-PWV, based on Doppler echocardiography, is a reliable method of aortic PWV measurement, with a close correlation with invasive assessment. Wider implementation of the echo-PWV method for the evaluation of aortic wall stiffness can further expand the clinical and scientific utility of echocardiography. Copyright © 2016 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.

Assessment of Hemodynamic Conditions in the Aorta Following Root Replacement with Composite Valve-Conduit Graft.

PubMed

Cheng, Zhuo; Kidher, Emaddin; Jarral, Omar A; O'Regan, Declan P; Wood, Nigel B; Athanasiou, Thanos; Xu, Xiao Yun

2016-05-01

This paper presents the analysis of detailed hemodynamics in the aortas of four patients following replacement with a composite bio-prosthetic valve-conduit. Magnetic resonance image-based computational models were set up for each patient with boundary conditions comprising subject-specific three-dimensional inflow velocity profiles at the aortic root and central pressure waveform at the model outlet. Two normal subjects were also included for comparison. The purpose of the study was to investigate the effects of the valve-conduit on flow in the proximal and distal aorta. The results suggested that following the composite valve-conduit implantation, the vortical flow structure and hemodynamic parameters in the aorta were altered, with slightly reduced helical flow index, elevated wall shear stress and higher non-uniformity in wall shear compared to normal aortas. Inter-individual analysis revealed different hemodynamic conditions among the patients depending on the conduit configuration in the ascending aorta, which is a key factor in determining post-operative aortic flow. Introducing a natural curvature in the conduit to create a smooth transition between the conduit and native aorta may help prevent the occurrence of retrograde and recirculating flow in the aortic arch, which is particularly important when a large portion or the entire ascending aorta needs to be replaced.

Initial experience of a novel sheath guide for transbrachial coil embolization of cerebral aneurysms in the anterior cerebral circulation.

PubMed

Iwata, Tomonori; Mori, Takahisa; Tajiri, Hiroyuki; Miyazaki, Yuichi; Nakazaki, Masahito; Mizokami, Koji

2013-03-01

The transfemoral approach is a common technique for coil embolization of cerebral aneurysms in the anterior cerebral circulation. However, it is difficult to advance a guiding catheter into the carotid artery via the femoral route in patients with a tortuous aortic arch, an unfavorable supra-aortic takeoff, aortic diseases, or occlusion of the femoral artery. To report our initial experiences of coil embolization of cerebral aneurysms in the anterior cerebral circulation with a novel sheath guide for transbrachial carotid cannulation. A sheath guide designed specifically for transbrachial carotid cannulation was developed; transbrachial coil embolization for cerebral aneurysms began in May 2011. Included for analysis were patients who underwent transbrachial coil embolization for cerebral aneurysms in the anterior cerebral circulation from May 2011 to January 2012. Adjuvant techniques, angiographic results, procedural success, and periprocedural complications were investigated. Ten patients underwent transbrachial coil embolization of cerebral aneurysms in the anterior cerebral circulation. All procedures were successful using the brachial route. No periprocedural complications occurred. Patients were permitted to get seated immediately after coil embolization even during hemostasis. The sheath guide specifically designed for transbrachial carotid cannulation was useful for coil embolization of cerebral aneurysms in the anterior cerebral circulation.

Anatomical Study of Healthy Aortic Arches.

PubMed

Girsowicz, Elie; Georg, Yannick; Lefebvre, François; Lejay, Anne; Thaveau, Fabien; Roy, Catherine; Ohana, Mickael; Chakfe, Nabil

2017-10-01

With the steady increase of endovascular procedures involving the aortic arch (AA), an actual depiction of its anatomy has become mandatory. It has also become necessary to evaluate the natural evolution of the AA morphology as part of the evaluation of endovascular devices durability. The objective of this study was to perform a morphological and anatomical study of the AA and of the supra aortic trunks (SAT) in healthy patients, with an evaluation of their evolution with time, with a specific orientation applied to endovascular therapies of the AA. Sixty-one patients (31 men, mean age 50.8 [18-82]) with a normal anatomy were included in the study. Measurements included the diameters of the AA and SAT in 17 locations, their distance and angulation based on computed tomography angiography data. Statistical analysis focused on descriptive statistics, differences between genders, as well as correlations with age. Aortic diameters (mean ± SD) were 29.5 ± 3.9 mm at the ascending aorta, 28.6 ± 3.9 mm at the innominate artery (IA), 27.1 ± 3.2 mm at the left common carotid artery (LCCA), 25.3 ± 3.0 mm at the left subclavian artery (LSCA), 23.9 ± 3.3 mm at the descending aorta. Mean angulation of the AA was 82° (95% confidence interval [CI]: 78.95-85.19°), mean angulation between LSCA/LCCA was -5.7° (95% CI: -0.9 to 18.7°) and -1.8° (95% CI: 5.4-26.4°) between LCCA/IA. Mean distance between the LSCA and the LCCA was 14.3 mm (95% CI: 13-15.6 mm) and 21.8 mm (95% CI: 20.3-23.4 mm) between LCCA and IA. All diameters of the AA increased with age (P < 0.05). Men had diameters statistically (P < 0.05) greater than women except at the LCCA ostium level. A statistically significant increase of the distances between the LSCA and the LCCA, between the LSCA and the IA and between the IA and the LCCA was found with age, P = 0.027, <0.01 and 0.012 respectively. This study allows obtaining accurate information of the AA and the SAT anatomy. It enabled to obtain a better understanding of the three-dimensional aspects of the AA, confirmed the variability and heterogeneity of the SAT disposition, and discussed the principles of vascular aging. Copyright © 2017 Elsevier Inc. All rights reserved.

Fracture mechanics of shear crack propagation and dissection in the healthy bovine descending aortic media.

PubMed

Haslach, Henry W; Siddiqui, Ahmed; Weerasooriya, Amanda; Nguyen, Ryan; Roshgadol, Jacob; Monforte, Noel; McMahon, Eileen

2018-03-01

This experimental study adopts a fracture mechanics strategy to investigate the mechanical cause of aortic dissection. Inflation of excised healthy bovine aortic rings with a cut longitudinal notch that extends into the media from the intima suggests that an intimal tear may propagate a nearly circumferential-longitudinal rupture surface that is similar to the delamination that occurs in aortic dissection. Radial and 45°-from-radial cut notch orientations, as seen in the thickness surface, produce similar circumferential crack propagation morphologies. Partial cut notches, whose longitudinal length is half the width of the ring, measure the influence of longitudinal material on crack propagation. Such specimens also produce circumferential cracks from the notch root that are visible in the thickness circumferential-radial plane, and often propagate a secondary crack from the base of the notch, visible in the intimal circumferential-longitudinal plane. Inflation of rings with pairs of cut notches demonstrates that a second notch modifies the propagation created in a specimen with a single notch. The circumferential crack propagation is likely a consequence of the laminar medial structure. These fracture surfaces are probably due to non-uniform circumferential shear deformation in the heterogeneous media as the aortic wall expands. The qualitative deformation morphology around the root of the cut notch during inflation is evidence for such shear deformation. The shear apparently results from relative slip in the circumferential direction of collagen fibers. The slip may produce shear in the longitudinal-circumferential plane between medial layers or in the radial-circumferential plane within a medial lamina in an idealized model. Circumferential crack propagation in the media is then a shear mechanical process that might be facilitated by disease of the tissue. An intimal tear of an apparently healthy aortic wall near the aortic arch is life-threatening because it may lead to full rupture or to wall dissection in which delamination of the medial layer extends around most of the aortic circumference. The mechanical events underlying dissection are not definitively established. This experimental fracture mechanics study provides evidence that shear rupture is the main mechanical process underlying aortic dissection. The commonly performed tensile strength tests of aortic tissue are not clinically useful to predict or describe aortic dissection. One implication of the study is that shear tests might produce more fruitful simple assessments of the aortic wall strength. A clinical implication is that when presented with an intimal tear, those who guide care might recommend steps to reduce the shear load on the aorta. Copyright © 2017 Acta Materialia Inc. Published by Elsevier Ltd. All rights reserved.

Atorvastatin restores arsenic-induced vascular dysfunction in rats: Modulation of nitric oxide signaling and inflammatory mediators

DOE Office of Scientific and Technical Information (OSTI.GOV)

Kesavan, Manickam; Sarath, Thengumpallil Sasindran; Kannan, Kandasamy

We evaluated whether atorvastatin, an extensively prescribed statin for reducing the risks of cardiovascular diseases, can reduce the risk of arsenic-induced vascular dysfunction and inflammation in rats and whether the modulation could be linked to improvement in vascular NO signaling. Rats were exposed to sodium arsenite (100 ppm) through drinking water for 90 consecutive days. Atorvastatin (10 mg/kg bw, orally) was administered once daily during the last 30 days of arsenic exposure. On the 91{sup st} day, blood was collected for measuring serum C-reactive protein. Thoracic aorta was isolated for assessing reactivity to phenylephrine, sodium nitroprusside and acetylcholine; evaluating eNOSmore » and iNOS mRNA expression and measuring NO production, while abdominal aorta was used for ELISA of cytokines, chemokine and vascular cell adhesion molecules. Histopathology was done in aortic arches. Arsenic did not alter phenylephrine-elicited contraction. Atorvastatin inhibited E{sub max} of phenylephrine, but it augmented the contractile response in aortic rings from arsenic-exposed animals. Sodium nitroprusside-induced relaxation was not altered with any treatment. However, arsenic reduced acetylcholine-induced relaxation and affected aortic eNOS at the levels of mRNA expression, protein concentration, phosphorylation and NO production. Further, it increased aortic iNOS mRNA expression, iNOS-derived NO synthesis, production of pro-inflammatory mediators (IL-1β, IL-6, MCP-1, VCAM, sICAM) and serum C-reactive protein and aortic vasculopathic lesions. Atorvastatin attenuated these arsenic-mediated functional, biochemical and structural alterations. Results show that atorvastatin has the potential to ameliorate arsenic-induced vascular dysfunction and inflammation by restoring endothelial function with improvement in NO signaling and attenuating production of pro-inflammatory mediators and cell adhesion molecules. - Highlights: • We evaluated if atorvastatin reduce arsenic-induced vascular dysfunction. • Arsenic reduced ACh-induced aortic relaxation but didn’t alter response to SNP and PE. • Arsenic affected aortic NO signalling and production of inflammatory mediators. • Arsenic produced vasculopathic lesions in aorta. • Atorvastatin restored arsenic-induced functional, biochemical and structural changes.« less

Hemodynamic and Mechanical Properties of the Proximal Aorta in Young and Middle-Aged Adults With Isolated Systolic Hypertension: The Dallas Heart Study.

PubMed

Yano, Yuichiro; Neeland, Ian J; Ayers, Colby; Peshock, Ronald; Berry, Jarett D; Lloyd-Jones, Donald M; Greenland, Philip; Mitchell, Gary F; Vongpatanasin, Wanpen

2017-07-01

The aim of this study was to assess characteristic impedance (Z c ) of the proximal aorta in young and middle-aged individuals with isolated systolic hypertension (ISH). Z c is an index of aortic stiffness relative to aortic size. In the Dallas Heart Study, 2001 untreated participants 18 to 64 years of age (mean age: 42.3 years; 44% black race) were divided into the following groups based on office blood pressure (BP) measurements: (1) optimal BP (systolic BP [SBP] <120 mm Hg and diastolic BP [DBP] <80 mm Hg; n=837); (2) prehypertension (SBP 120-139 mm Hg and DBP 80-89 mm Hg; n=821); (3) ISH (SBP ≥140 mm Hg and DBP <90 mm Hg; n=121); (4) isolated diastolic hypertension (SBP <140 mm Hg and DBP ≥90 mm Hg; n=44); and (5) systolic-diastolic hypertension (SBP ≥140 mm Hg and DBP ≥90 mm Hg; n=178). Z c , aortic arch pulse wave velocity, and minimum ascending aortic size were quantified using cardiovascular magnetic resonance. In multivariable-adjusted linear models, Z c was highest in the ISH group compared with the optimal BP, isolated diastolic hypertension, or systolic-diastolic hypertension groups (103.2±4.0 versus 68.3±2.1, 75.4±6.0, and 88.9±4.8 dyne*seconds/cm 5 , respectively; all P <0.05). The Z c -ISH association did not differ by race. Aortic pulse wave velocity was highest in the ISH group compared with the optimal BP, isolated diastolic hypertension, or systolic-diastolic hypertension groups (6.3±0.3 versus 4.3±0.1, 4.4±0.4 and 5.5±0.3 m/s, respectively; all P <0.05), whereas aortic size was similar across groups (all P >0.2). Results were similar in a subgroup of 1551 participants 18 to 49 years of age. In a multiracial population-based sample, we found evidence of a mismatch between proximal aortic stiffness and diameter in young and middle-aged adults with ISH. © 2017 American Heart Association, Inc.

Branchial cleft anomaly, congenital heart disease, and biliary atresia: Goldenhar complex or Lambert syndrome?

PubMed

Cohen, J; Schanen, N C

2000-01-01

The features of Goldenhar complex have been well-described and classically include branchial arch abnormalities, epibulbar dermoid and vertebral abnormalities. We have identified an infant with these features in association with complex congenital heart disease and intrahepatic biliary atresia. Although Lambert described an autosomal recessive disorder with an association of biliary atresia and branchial arch abnormalities, none of those cases had epibulbar dermoid. Diagnostic considerations in this case include inclusion of biliary atresia as a new feature in the expanding spectrum of the Goldenhar complex, versus Lambert syndrome with epibulbar dermoid.

Antegrade versus retrograde cerebral perfusion for hemiarch replacement with deep hypothermic circulatory arrest: Does it matter? A propensity-matched analysis

PubMed Central

Ganapathi, Asvin M.; Hanna, Jennifer M.; Schechter, Matthew A.; Englum, Brian R.; Castleberry, Anthony W.; Gaca, Jeffrey G.; Hughes, G. Chad

2015-01-01

Objective The choice of cerebral perfusion strategy for aortic arch surgery has been debated, and the superiority of antegrade (ACP) or retrograde (RCP) cerebral perfusion has not been shown. We examined the early and late outcomes for ACP versus RCP in proximal (hemi-) arch replacement using deep hypothermic circulatory arrest (DHCA). Methods A retrospective analysis of a prospectively maintained database was performed for all patients undergoing elective and nonelective hemiarch replacement at a single referral institution from June 2005 to February 2013. Total arch cases were excluded to limit the analysis to shorter DHCA times and a more uniform patient population for whom clinical equipoise regarding ACP versus RCP exists. A total of 440 procedures were identified, with 360 (82%) using ACP and 80 (18%) using RCP. The endpoints included 30-day/in-hospital and late outcomes. A propensity score with 1:1 matching of 40 pre- and intraoperative variables was used to adjust for differences between the 2 groups. Results All 80 RCP patients were propensity matched to a cohort of 80 similar ACP patients. The pre- and intra-operative characteristics were not significantly different between the 2 groups after matching. No differences were found in 30-day/in-hospital mortality or morbidity outcomes. The only significant difference between the 2 groups was a shorter mean operative time in the RCP cohort (P = .01). No significant differences were noted in late survival (P = .90). Conclusions In proximal arch operations using DHCA, equivalent early and late outcomes can be achieved with RCP and ACP, although the mean operative time is significantly less with RCP, likely owing to avoidance of axillary cannulation. Questions remain regarding comparative outcomes with straight DHCA and lesser degrees of hypothermia. PMID:24908350

Relationship between fibrillin-1 genotype and severity of cardiovascular involvement in Marfan syndrome.

PubMed

Franken, Romy; Teixido-Tura, Gisela; Brion, Maria; Forteza, Alberto; Rodriguez-Palomares, Jose; Gutierrez, Laura; Garcia Dorado, David; Pals, Gerard; Mulder, Barbara Jm; Evangelista, Artur

2017-11-01

The effect of FBN1 mutation type on the severity of cardiovascular manifestations in patients with Marfan syndrome (MFS) has been reported with disparity results. This study aims to determine the impact of the FBN1 mutation type on aortic diameters, aortic dilation rates and on cardiovascular events (ie, aortic dissection and cardiovascular mortality). MFS patients with a pathogenic FBN1 mutation followed at two specialised units were included. FBN1 mutations were classified as being dominant negative (DN; incorporation of non-mutated and mutated fibrillin-1 in the extracellular matrix) or having haploinsufficiency (HI; only incorporation of non-mutated fibrillin-1, thus a decreased amount of fibrillin-1 protein). Aortic diameters and the aortic dilation rate at the level of the aortic root, ascending aorta, arch, descending thoracic aorta and abdominal aorta by echocardiography and clinical endpoints comprising dissection and death were compared between HI and DN patients. Two hundred and ninety patients with MFS were included: 113 (39%) with an HI- FBN1 mutation and 177 (61%) with a DN- FBN1 . At baseline, patients with HI- FBN1 had a larger aortic root diameter than patients with DN- FBN1 (HI: 39.3±7.2 mm vs DN: 37.3±6.8 mm, p=0.022), with no differences in age or body surface area. After a mean follow-up of 4.9±2.0 years, aortic root and ascending dilation rates were increased in patients with HI- FBN1 (HI: 0.57±0.8 vs DN: 0.28±0.5 mm/year, p=0.004 and HI: 0.59±0.9 vs DN: 0.30±0.7 mm/year, p=0.032, respectively). Furthermore, patients with HI- FBN1 tended to be at increased risk for the combined endpoint of dissection and death compared with patients with DN- FBN1 (HR: 3.3, 95% CI 1.0 to 11.4, p=0.060). Patients with an HI mutation had a more severely affected aortic phenotype, with larger aortic root diameters and a more rapid dilation rate, and tended to have an increased risk of death and dissections compared with patients with a DN mutation. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Bicuspid aortic valve syndrome: a multidisciplinary approach for a complex entity

PubMed Central

Lorca, Rebeca; Rozado, José; Alvarez-Cabo, Rubén; Calvo, Juan; Pascual, Isaac; Cigarrán, Helena; Rodríguez, Isabel; Morís, César

2017-01-01

Bicuspid aortic valve (BAV) or bicuspid aortopathy is the most common congenital heart disease. It can be clinically silent and it is often identified as an incidental finding in otherwise healthy, asymptomatic patients. However, it can be dysfunctioning at birth, even requiring neonatal intervention, or, in time, lead to aortic stenosis, aortic insufficiency, and endocarditis, and also be associated with aortic aneurysm and aortic dissection. Given its prevalence and significant complications, it is estimated that BAV is responsible for more deaths and morbidity than the combined effects of all the other congenital heart defects. Pathology of BAV is still not well known and many questions are unresolved. In this manuscript we review some aspects on bicuspid aortopathy, a heterogeneous and frequent disease in which like some authors have previously described, complex gene environment are present. Further investigations and, what is more, multidisciplinary teams are needed to improve our knowledge on this really fascinating disease. PMID:28616342

Turning crocodilian hearts into bird hearts: growth rates are similar for alligators with and without right-to-left cardiac shunt

PubMed Central

Eme, John; Gwalthney, June; Owerkowicz, Tomasz; Blank, Jason M.; Hicks, James W.

2010-01-01

The functional and possible adaptive significance of non-avian reptiles' dual aortic arch system and the ability of all non-avian reptiles to perform central vascular cardiac shunts have been of great interest to comparative physiologists. The unique cardiac anatomy of crocodilians – a four-chambered heart with the dual aortic arch system – allows for only right-to-left (R–L; pulmonary bypass) cardiac shunt and for surgical elimination of this shunt. Surgical removal of the R–L shunt, by occluding the left aorta (LAo) upstream and downstream of the foramen of Panizza, results in a crocodilian with an obligatory, avian/mammalian central circulation. In this study, R–L cardiac shunt was eliminated in age-matched, female American alligators (Alligator mississippiensis; 5–7 months of age). We tested the hypothesis that surgical elimination of R–L cardiac shunt would impair growth (a readily measured proxy for fitness) compared with sham-operated, age-matched controls, especially in animals subjected to exhaustive exercise. While regular exercise caused a decrease in size (snout-to-vent length, head length and body mass), elimination of the capacity for R–L cardiac shunt did not greatly reduce animal growth, despite a chronic ventricular enlargement in surgically altered juvenile alligators. We speculate that, despite being slightly smaller, alligators with an occluded LAo would have reached sexual maturity in the same breeding season as control alligators. This study suggests that crocodilian R–L cardiac shunt does not provide an adaptive advantage for juvenile alligator growth and supports the logic that cardiac shunts persist in crocodilians because they have not been selected against. PMID:20639429

Aortic arch calcification detectable on chest X-ray films is associated with plasma diacron-reactive oxygen metabolites in patients with type 2 diabetes but without cardiovascular disease.

PubMed

Watanabe, Kentaro; Ohara, Makoto; Suzuki, Tatsuya; Ouchi, Motoshi; Suzuki, Kazunari; Hashimoto, Masao; Saigusa, Taro; Aoyama, Junya; Nakano, Hiroshi; Oba, Kenzo

2013-01-01

This study aimed to evaluate the relationship between aortic arch calcification (AAC) detectable on chest X-ray films and plasma diacron-reactive oxygen metabolites (d-ROMs) in patients with type 2 diabetes but without cardiovascular disease. Forty-nine patients with type 2 diabetes but without cardiovascular disease were evaluated with chest X-ray examinations and divided into those with AAC (n=26) and those without AAC (n=23). Biochemical variables, including plasma levels of d-ROMS, high-sensitivity C-reactive protein (hsCRP), plasminogen activator inhibitor-1 (PAI-1), and lipoprotein(a) (Lp(a)), were evaluated after an overnight fast. The relationships of AAC with both inflammation and oxidative-stress variables were evaluated. The plasma level of d-ROMs in subjects with AAC was significantly higher than that in subjects without AAC, whereas plasma levels of hsCRP, PAI-1, and Lp(a) in subjects with AAC were higher, but not significantly so, than those in subjects without AAC. Multivariate linear regression analysis with AAC grade as the dependent variable and plasma levels of d-ROMs, hsCRP, PAI-1, or Lp(a) as independent variables demonstrated a significant association of AAC grade with plasma levels of d-ROMs but not with plasma levels of hsCRP, PAI-1, or Lp(a). The plasma level of d-ROMs is associated with AAC in patients with type 2 diabetes but without cardiovascular disease. Hence, the results of the present study suggest that AAC in these patients is strongly associated with oxidative stress. Furthermore, patients with type 2 diabetes and AAC may be at high risk for the development and progression of various diabetic complications induced by oxidative stress.

[Aortopexy for tracheomalacia in infants and children].

PubMed

Vinograd, I; Klin, B; Silbiger, A; Eshel, G

2000-06-15

During the past 12 years (1985-1998), 28 infants and children were operated on here for tracheomalacia. The diagnosis was made in all using rigid bronchoscopy. During the examination the infants breathed spontaneously, but the trachea collapsed on forced expiration. Indications for surgery were repeated cyanotic spells ("dying spells") in 22, recurrent pneumonia, and inability to extubate (in 8). In 11 there were more than 1 indications. Age at surgery was from 7 days to 3 years (average 11.7 months). All 28 children underwent bronchoscopy and guided aortopexy via a left-third intercostal approach. The ascending aorta and aortic arch (and in 6 the proximal innominate artery as well) were lifted anteriorly, using 3-5 non-absorbable sutures (5.0). The sutures were placed through the adventitia of the great vessels and then passed through the sternum. Respiratory distress was significantly improved in 21. Another 2 required external tracheal stenting with autologous rib grafts, and in 1 other an internal Palmaz stent was introduced for tracheal stability. In 4 aortopexy failed, 1 of whom had tracheobronchomalacia throughout, and another 3 had laryngomalacia which required tracheostomy to relieve the respiratory symptoms. Postoperative complications were minor: pericardial effusion in 1 and relaxation of the left diaphragm in another. 1 infant subsequently died, of unknown cause 10 days after operation, after having been extubated on the 1st postoperative day. On long-term follow-up (6 months to 12 years) 25 were found free of residual respiratory symptoms and 3 remained with a tracheostomy. Thus, infants and children with severe tracheomalacia associated with severe respiratory symptoms, can be relieved by bronchoscopic guided suspension of the aortic arch to the sternum.

Ticagrelor Versus Aspirin in Acute Embolic Stroke of Undetermined Source.

PubMed

Amarenco, Pierre; Albers, Gregory W; Denison, Hans; Easton, J Donald; Evans, Scott R; Held, Peter; Hill, Michael D; Jonasson, Jenny; Kasner, Scott E; Ladenvall, Per; Minematsu, Kazuo; Molina, Carlos A; Wang, Yongjun; Wong, K S Lawrence; Johnston, S Claiborne

2017-09-01

Ticagrelor is an effective antiplatelet therapy among patients with atherosclerotic disease and, therefore, could be more effective than aspirin in preventing recurrent stroke and cardiovascular events among patients with embolic stroke of unknown source (ESUS), which includes patients with ipsilateral stenosis <50% and aortic arch atherosclerosis. We randomized 13 199 patients with a noncardioembolic, nonsevere ischemic stroke or high-risk transient ischemic attack to ticagrelor (180 mg loading dose on day 1 followed by 90 mg twice daily for days 2-90) or aspirin (300 mg on day 1 followed by 100 mg daily for days 2-90) within 24 hours of symptom onset. In all patients, investigators informed on the presence of ipsilateral stenosis ≥50%, small deep infarct <15 mm, and on cardiac source of embolism detected after enrollment or rare causes, which allowed to construct an ESUS category in all other patients with documented brain infarction. The primary end point was the time to the occurrence of stroke, myocardial infarction, or death within 90 days. ESUS was identified in 4329 (32.8%) patients. There was no treatment-by-ESUS category interaction ( P =0.83). Hazard ratio in ESUS patients was 0.87 (95% confidence interval, 0.68-1.10; P =0.24). However, hazard ratio was 0.51 (95% confidence interval, 0.29-0.90; P =0.02) in ESUS patients with ipsilateral stenosis <50% or aortic arch atherosclerosis (n=961) and 0.98 (95% confidence interval, 0.76-1.27; P =0.89) in the remaining ESUS patients (n=3368; P for heterogeneity =0.04). In this post hoc, exploratory analysis, we found no treatment-by-ESUS category interaction. ESUS subgroups have heterogeneous response to treatment (Funded by AstraZeneca). URL: http://www.clinicaltrials.gov. Unique identifier: NCT01994720. © 2017 American Heart Association, Inc.

Role of aortic arch vascular mechanics in cardiovagal baroreflex sensitivity.

PubMed

Klassen, Stephen A; Chirico, Daniele; Dempster, Kylie S; Shoemaker, J Kevin; O'Leary, Deborah D

2016-07-01

Cardiovagal baroreflex sensitivity (cvBRS) measures the efficiency of the cardiovagal baroreflex to modulate heart rate in response to increases or decreases in systolic blood pressure (SBP). Given that baroreceptors are located in the walls of the carotid sinuses (CS) and aortic arch (AA), the arterial mechanics of these sites are important contributors to cvBRS. However, the relative contribution of CS and AA mechanics to cvBRS remains unclear. This study employed sex differences as a model to test the hypothesis that differences in cvBRS between groups would be explained by the vascular mechanics of the AA but not the CS. Thirty-six young, healthy, normotensive individuals (18 females; 24 ± 2 yr) were recruited. cvBRS was measured using transfer function analysis of the low-frequency region (0.04-0.15 Hz). Ultrasonography was performed at the CS and AA to obtain arterial diameters for the measurement of distensibility. Local pulse pressure (PP) was taken at the CS using a hand-held tonometer, whereas AA PP was estimated using a transfer function of brachial PP. Both cvBRS (25 ± 11 vs. 19 ± 7 ms/mmHg, P = 0.04) and AA distensibility (16.5 ± 6.0 vs. 10.5 ± 3.8 mmHg(-1) × 10(-3), P = 0.02) were greater in females than males. Sex differences in cvBRS were eliminated after controlling for AA distensibility (P = 0.19). There were no sex differences in CS distensibility (5.32 ± 2.3 vs. 4.63 ± 1.3 mmHg(-1) × 10(-3), P = 0.32). The present data demonstrate that AA mechanics are an important contributor to differences in cvBRS. Copyright © 2016 the American Physiological Society.

The management of newborns with esophageal atresia and right aortic arch: A systematic review or still unsolved problem.

PubMed

Parolini, Filippo; Armellini, Andrea; Boroni, Giovanni; Bagolan, Pietro; Alberti, Daniele

2016-02-01

The management of newborns with esophageal atresia (EA) and right aortic arch (RAA) is still an unsolved problem. This study provides a systematic review of epidemiology, diagnosis, management and short-term results of children with EA and RAA. The PubMed database was searched for original studies on children with EA and RAA. In each study, data were extracted for the following outcomes: number of patients, associated anomalies, type of surgical repair, morbidity and mortality rate. Eight studies were selected, including 54 patients with EA and RAA. RAA was encountered in 3.6% of infants. Preoperative detection of RAA was reported in 7 of them. In these patients, primary anastomosis was achieved through the right approach in 3 (thoracotomy in 2 and thoracoscopy in 1) while the left approach was the primary choice in 4 (thoracotomy in 2 and thoracoscopy in 2). No significant differences were found between the right and left approaches with regard to leaks (P=0.89), strictures (P=1) or mortality (P=1). In 47/54 patients (87%) RAA was noted during right thoracotomy, and primary anastomosis was achieved through the same approach in 29 (61.7%); conversion to other approaches (left thoracotomy or esophageal substitution) was performed in 15 children (38.3%). No significant differences were found between primary left thoracotomy (LT) and LT after RT with regard to leaks (P=0.89), strictures (P=1) or mortality (P=1). Skills and preferences of the surgeon still guide the choice of surgical approach even when preoperatively faced with RAA. A multicenter, prospective randomized study is strongly required. Copyright © 2016 Elsevier Inc. All rights reserved.

Characterizing saccular aortic arch aneurysms from the geometry-flow dynamics relationship.

PubMed

Natsume, Kayoko; Shiiya, Norihiko; Takehara, Yasuo; Sugiyama, Masataka; Satoh, Hiroshi; Yamashita, Katsushi; Washiyama, Naoki

2017-06-01

Low wall shear stress (WSS) has been reported to be associated with accelerated atherosclerosis, aneurysm growth, or rupture. We evaluated the geometry of aortic arch aneurysms and their relationship with WSS by using the 4-dimensional flow magnetic resonance imaging to better characterize the saccular aneurysms. We analyzed the geometry in 100 patients using multiplanar reconstruction of computed tomography. We evaluated WSS and vortex flow using 4-dimensional flow magnetic resonance imaging in 16 of them, which were compared with 8 age-matched control subjects and eight healthy young volunteers. Eighty-two patients had a saccular aneurysm, and 18 had a fusiform aneurysm. External diameter/aneurysm length ratio and sac depth/neck width ratio of the fusiform aneurysms were constant at 0.76 ± 0.18 and 0.23 ± 0.09, whereas those of saccular aneurysms, especially those involving the outer curvature, were higher and more variable. Vortex flow was always present in the aneurysms, resulting in low WSS. When the sac depth/neck width ratio was less than 0.8, peak WSS correlated inversely with luminal diameter even in the saccular aneurysms. When this ratio exceeded 0.8, which was the case only with the saccular aneurysms, such correlation no longer existed and WSS was invariably low. Fusiform aneurysms elongate as they dilate, and WSS is lower as the diameter is larger. Saccular aneurysms dilate without proportionate elongation, and they, especially those occupying the inner curvature, have higher and variable sac depth/neck width ratio. When this ratio exceeds 0.8, WSS is low regardless of diameter, which may explain their malignant clinical behavior. Copyright © 2016 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

Arch bar stabilization of endotracheal tubes in children with facial burns.

PubMed

Perrotta, V J; Stern, J D; Lo, A K; Mitra, A

1995-01-01

Endotracheal tube stabilization in children with facial burns can be difficult. Several methods rely on straps or complex devices that apply undesirable pressure to the face, potentially destroying skin grafts and making wound care difficult. Techniques that rely on a single wire or suture can be unreliable. Presented here is the arch bar method of endotracheal tube stabilization, which appears to be free of these problems. This method employs a standard dental arch bar secured to four maxillary teeth with 24-gauge stainless steel wire. The endotracheal tube is anchored to the arch bar with two pieces of wire or suture material. The arch bar method of endotracheal tube stabilization was used on three patients in the burn center at St. Christopher's Hospital for Children. Wound care and successful skin grafting were performed without difficulty. No complications related to the arch bars occurred.

Stent Repair for Complex Coarctation of Aorta.

PubMed

Suárez de Lezo, José; Romero, Miguel; Pan, Manuel; Suárez de Lezo, Javier; Segura, José; Ojeda, Soledad; Pavlovic, Djordje; Mazuelos, Francisco; López Aguilera, José; Espejo Perez, Simona

2015-08-24

This study sought to determine whether several anatomic or evolving characteristics of the coarctation may create challenging conditions for treatment. Stent repair of coarctation of aorta is an alternative to surgical correction. We analyzed our 21-year experience in the percutaneous treatment of complex coarctation of aorta. Adverse conditions for treatment were as follow: 1) complete interruption of the aortic arch (n = 11); 2) associated aneurysm (n = 18); 3) complex stenosis (n = 30); and 4) the need for re-expansion and/or restenting (n = 21). Twenty patients (33%) belonged to more than 1 group. Ten interruptions were type A and 1 was type B. The mean length of the interrupted aorta was 9 ± 11 mm. The associated aneurysms were native in 8 patients and after previous intervention in 10 patients. Aneurysm shapes were fusiform in 8 patients and saccular in 10. The following characteristics defined complex stenosis as long diffuse stenosis, very tortuous coarctation, or stenosis involving a main branch or an unusual location. Patients previously stented at an early age, required re-expansion and/or restenting after reaching 16 ± 5 years of age. Two patients had died by 1-month follow-up. The remaining 58 patients did well and were followed-up for a mean period of 10 ± 6 years. Late adverse events occurred in 3 patients (5%). All remaining patients are symptom-free, with normal baseline blood pressure. Imaging techniques revealed good patency at follow-up without associated aneurysm or restenosis. The actuarial survival free probability of all complex patients at 15 years was 92%. Stent repair of complex coarctation of aorta is feasible and safe. Initial results are maintained at later follow-up. Copyright © 2015 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

The first fifty consecutive Bentall operations with a prefabricated tissue-valved aortic conduit: a single-center experience.

PubMed

Baraki, Hassina; Al Ahmad, Ammar; Sarikouch, Samir; Koigeldiev, Nurbol; Khaladj, Nawid; Hagl, Christian; Pichlmaier, Maximillian; Haverich, Axel; Shrestha, Malakh

2010-05-01

Composite replacement is the standard treatment for the repair of aortic aneurysm with aortic valve pathology. With improved long-term durability and no requirement for long-term anticoagulation, tissue-valved conduits have become increasingly popular. Herein are reported the results achieved with 50 consecutive 'Bentall' operations, using the first commercially available prefabricated stentless tissue-valved conduit (Vascutek BioValsalva). Between September 2007 and September 2009, a total of 50 patients (10 females, 40 males; mean age 65 +/- 7 years) received a BioValsalva conduit. Concomitant procedures included coronary artery bypass grafting (CABG; n = 15), other valve (n = 5), and aortic arch replacement with circulatory arrest (n = 20; three of these had an additional frozen elephant trunk). Four of the procedures were re-operations. A six-month follow up with echocardiography and clinical examination was completed in 25 patients. The 30-day mortality was 8% (4/50). Three of these patients underwent concomitant procedures. The cardiopulmonary bypass (CPB) and cross-clamp times were 178 +/- 30 min and 106 +/- 7 min, respectively. The triple-layered vascular graft proved to be hemostatic, without suture-line bleeding. Both, the initial and follow up echocardiography showed no valvular insufficiency, with a mean gradient of 13 +/- 5 mmHg. All patients were in NYHA class I-II. The BioValsalva prefabricated tissue-valved conduit showed very good early results. The ischemic time required to construct a 'home-made' stentless tissue-valved conduit was eliminated, thus reducing the cross-clamp time. The conduit also offered the hemodynamic advantages of a stentless valve.

Detection of thoracic aortic prosthetic graft infection with 18F-fluorodeoxyglucose positron emission tomography/computed tomography.

PubMed

Tokuda, Yoshiyuki; Oshima, Hideki; Araki, Yoshimori; Narita, Yuji; Mutsuga, Masato; Kato, Katsuhiko; Usui, Akihiko

2013-06-01

To investigate the diagnostic value of (18)F-fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) in detecting thoracic aortic prosthetic graft infection. Nine patients with clinically suspected thoracic aortic graft infection underwent FDG-PET/CT scanning. In these patients, the diagnoses could not be confirmed using conventional modalities. The patients' clinical courses were retrospectively reviewed. On the basis of surgical, microbiological and clinical follow-up findings, the aortic grafts were considered infected in 4 patients and not infected in 5. All 4 patients with graft infection (root: 2 cases, arch: 1 case and descending: 1 case) eventually underwent in situ re-replacement. Two of the 4 patients also had abdominal grafts; however, only the thoracic grafts were replaced because uptake was low around the abdominal grafts. The maximal standardized uptake value (SUVmax) in the perigraft area was higher in the infected group than in the non-infected group (11.4 ± 4.5 vs 6.9 ± 6.4), although the difference was not statistically significant. According to the receiver operating characteristic analysis, SUVmax >8 appeared to be the cut-off value in distinguishing the two groups (sensitivity: 1.0 and specificity: 0.8). FDG-PET/CT is useful for confirming the presence of graft infection by detecting high uptake around grafts and excluding other causes of inflammation. An SUVmax value greater than 8 around a graft suggests the presence of graft infection. In addition, FDG-PET/CT can be used to clarify the precise extent of infection. This is especially useful if multiple separated prosthetic grafts have been implanted.

Managing a Mycotic Thoracoabdominal Aneurysm: The Importance of Molecular Diagnostics.

PubMed

Bayliss, Christopher D; Booth, Karen L; Williams, Robin; Dark, John H; Gould, Kate F

2017-11-01

Pneumococcal mycotic aneurysms are rare and associated with significant mortality and morbidity. Early intravenous antibiotic therapy and surgical intervention is the mainstay of treatment. Pneumococci frequently autolyze in blood cultures, making microbiological diagnosis challenging. We present the case of a man in his mid 70s with multiple thoracoabdominal mycotic aneurysms. Surgery was performed to a threatening saccular aortic arch aneurysm. Samples were sent for microbiological analysis and all were culture negative. The samples were then referred for bacterial 16S ribosomal RNA sequencing, which revealed evidence of infection with Streptococcus pneumoniae. Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Asthma mimic: Case report and literature review of vocal cord nodule associated with wheezing.

PubMed

Kashif, Muhammad; Singh, Tushi; Aslam, Ahsan; Khaja, Misbahuddin

2017-01-01

Asthma is a heterogeneous disease, usually characterized by chronic airway inflammation. Various clinical conditions can mimic asthma, such as foreign body aspiration, subglottic stenosis, congestive heart failure, diffuse panbronchiolitis, aortic arch anomalies, reactive airway dysfunction syndrome, chronic obstructive pulmonary disease, retrosternal goiter, vocal cord tumors, other airway tumors, and vocal cord dysfunction. Upper airway obstruction can be a life-threatening emergency. Here, we present the case of a 58-year-old female with recurrent hospital visits for wheezing and exacerbations of asthma, who was later found to have a vocal cord nodule confirmed to be squamous cell carcinoma, which was mimicking like asthma.

Left arm underdevelopment secondary to an isolated left subclavian artery in tetralogy of Fallot.

PubMed

Carnero Alcázar, Manuel; Marianeschi, Stefano; Ruiz Alonso, Enrique; García Torres, Enrique; Comas, Juan V

2010-02-01

The anomalous origin of the left subclavian artery is known to be associated with right aortic arch and tetralogy of Fallot. In our case, the left subclavian artery arose from the left pulmonary artery. Therefore, the left arm was perfused by poorly oxygenated blood from pulmonary arteries and some retrograde vertebral artery flow. Thus, the left arm was cyanotic and less developed than the right one. The patient underwent surgical repair with complete correction of tetralogy of Fallot and reimplantation of the left subclavian artery to the left carotid artery. 2010 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

An unusual cause of ischemia after coronary bypass grafting!!

PubMed

Hammami, Rania; Charfeddine, Salma; Elleuch, Nizar; Fourati, Hela; Abid, Leila; Kammoun, Samir

2018-01-01

Coronary subclavian steal syndrome is an uncommon cause of ischemia recurrence after coronary artery bypass grafting. Endovascular treatment of subclavian artery stenosis or occlusion is increasingly common and appears to offer a safe and effective alternative to surgical revascularization. We report a case of recurrent angina after coronary artery bypass grafting for critical subclavian artery stenosis. The anomalous origin of the vertebral artery from the aortic arch was an indication for endovascular treatment. We discuss the diagnostic difficulties and the management pitfalls of subclavian artery angioplasty in this syndrome. Copyright © 2017 Sociedade Portuguesa de Cardiologia. Publicado por Elsevier España, S.L.U. All rights reserved.

Induced Pectus Carinatum.

PubMed

Maddali, Madan Mohan; Valliattu, John; Kandachar, Pranav Subbaraya; Thomas, Eapen; Nishant, Arora Ram

2016-05-01

During the surgical repair of a truncus arteriosus with aortic arch interruption and pulmonary artery origin stenosis, a Contegra conduit was implanted as part of reconstruction of the pulmonary artery in a small infant. There was a mismatch between the conduit size and the patient that resulted in protrusion of the conduit between the sternal edges. To accommodate the conduit inside the thoracic cavity, traction was applied to the sternum that was gradually released over a period of time guided by transesophageal echocardiography-derived cardiac output data, as well as continuous hemodynamic parameters. doi: 10.1111/jocs.12734 (J Card Surg 2016;31:357-360). © 2016 Wiley Periodicals, Inc.

Design automation of load-bearing arched structures of roofs of tall buildings

NASA Astrophysics Data System (ADS)

Kulikov, Vladimir

2018-03-01

The article considers aspects of the possible use of arched roofs in the construction of skyscrapers. Tall buildings experience large load from various environmental factors. Skyscrapers are subject to various and complex types of deformation of its structural elements. The paper discusses issues related to the aerodynamics of various structural elements of tall buildings. The technique of solving systems of equations state method of Simpson. The article describes the optimization of geometric parameters of bearing elements of the arched roofs of skyscrapers.

[Intraparotid first branchial arch cyst: complex diagnostic and therapeutic process].

PubMed

Gilabert Rodríguez, R; Berenguer, B; González Meli, B; Marín Molina, C; de Tomás Palacios, E; Buitrago Weiland, G; Aguado del Hoyo, A

2013-01-01

First branchial arch cysts are uncommon. Therefore, together with its variable clinical and age presentation they are often misdiagnosed at first. The treatment is surgical, requiring a correct procedure to avoid future recurrences. In this paper we describe a typical case of first branchial arch cyst in which as described in other reports, we first made several misdiagnoses and therefore an inadequate treatment and lastly, with the correct diagnosis, we performed a meticulous complete excision under facial nerve monitoring.

Comprehensive Aristotle score: implications for the Norwood procedure.

PubMed

Sinzobahamvya, Nicodème; Photiadis, Joachim; Kumpikaite, Daiva; Fink, Christoph; Blaschczok, Hedwig C; Brecher, Anne Marie; Asfour, Boulos

2006-05-01

Aristotle score is emerging as a reliable tool to measure surgical performance. We estimated the comprehensive Aristotle score for the Norwood procedure, correlated it with survival, and considered its impact on surgical management of hypoplastic left heart syndrome. Comprehensive Aristotle score was retrospectively calculated for 39 consecutive Norwood procedures performed from 2001 to 2004. Survival was estimated by the Kaplan-Meier method. The Aristotle scores ranged from 14.5 to 23.5 (mean, 19.12 +/- 2.52; median, 19.5). The score was 20 or greater in 44% (17 of 39) of cases. The most frequent patient-adjusted factors were aortic atresia (n = 16), interrupted aortic arch (n = 9), mechanical ventilation to treat cardiorespiratory failure (n = 19) and shock resolved at time of surgery (n = 13). Hospital mortality was 58.8% (10 of 17) in case of score of 20 or more and 9.1% (2 of 22) for score less than 20 (p = 0.0014). From 2003 on, all patients with a score less than 20 survived. Actuarial estimate of survival at 1 year is 56.2% +/- 7.9% and there have been no late deaths after 1 year. One-year survival is much lower (p = 0.001) for patients with scores of 20 or greater (29.4% +/- 11.05%) compared with those whose scores were less than 20 (77.3% +/- 8.9%). This study shows significant correlation of comprehensive Aristotle score with hospital mortality and late survival after Norwood palliation. It suggests that operative survival on the order of 90% may be achieved in patients with comprehensive complexity scores of less than 20. Efforts should be devoted to improve survival of high-risk patients (score > or = 20).

Transforce lingual appliances pre-adjusted invisible appliances simplify treatment.

PubMed

Clark, William John

2011-01-01

Transforce lingual appliances are designed to be used in conjunction with conventional fixed appliances. Lingual arch development is normally followed by bonded fixed appliances to detail the occlusion. Alternatively Transforce appliance treatment is an efficient method of preparing complex malocclusions prior to a finishing stage with invisible appliances. This approach is ideal for adult treatment, using light continuous forces for arch development with appliances that are comfortable to wear. Sagittal and Transverse appliances are designed for arch development in a range of sizes for contracted arches. They can be used to treat all classes of malocclusion and are pre-adjusted fixed/removable devices for non-compliance treatment. Force modules with nickel titanium coil springs enclosed in a tube deliver a gentle, biocompatible continuous force with a long range of action. They are excellent for mixed dentition and ideal for adult arch development. There are multiple sizes for upper and lower arch development and a sizing chart may be placed over a study model for correct selection, eliminating the need for laboratory work.

Presentation of obstructive left heart malformations in infancy.

PubMed Central

Abu-Harb, M; Wyllie, J; Hey, E; Richmond, S; Wren, C

1994-01-01

This study documents the presentation of acutely life threatening congenital heart disease in infancy in order to assess the performance of screening examinations soon after birth and at 6 weeks of age. All cases of obstructive left heart malformations presenting in infancy in one health region from 1987-91 were analysed retrospectively. Altogether, 120 infants presented with either hypoplastic left heart syndrome, interruption of the aortic arch, coarctation of the aorta, or aortic valve stenosis. Twelve became symptomatic or died within 24 hours. Thirty four had an abnormal neonatal examination, eight of whom were referred. Six more became symptomatic before discharge. Ninety four babies went home, 51 developed heart failure before 6 weeks, and another seven died without diagnosis. Twenty five of 36 (69%) reaching 6 weeks without diagnosis had a second examination which was abnormal in 17. Two babies died undiagnosed after 6 weeks and the other 18 presented at up to 11 months of age. The neonatal and 6 week examinations perform poorly as screening tests for congenital heart disease. A normal neonatal examination does not exclude life threatening congenital heart disease. Images PMID:7820713

Fourth branchial complex anomalies: a case series.

PubMed

Shrime, Mark; Kacker, Ashutosh; Bent, John; Ward, Robert F

2003-11-01

Anomalies of the fourth branchial arch complex are exceedingly rare, with approximately forty cases reported in the literature since 1972. The authors report experience with six fourth arch anomalies. Retrospective chart review of six consecutive patients presenting to the pediatric otolaryngology service at a tertiary care center with anomalies referable to the fourth branchial arch. All six patients presented within the first or second decade of life. All six had left-sided disease. Four patients presented with recurrent neck infection, one with asymptomatic cervical masses, and one with a neck mass and respiratory compromise. One patient had prior surgery presented with a recurrence. Diagnosis of fourth arch anomalies was suggested or confirmed by computed tomography and flexible laryngoscopy. Treatment was surgical in five patients; one patient is awaiting surgery. Surgical procedures included resection of the mass and endoscopic cauterization of the inner opening of the cyst. The presentation of a cervical mass, especially with recurrent infections and especially on the left side, in a child in the first or second decade of life heightens suspicion for an anomaly of the fourth branchial arch. Diagnosis can be difficult, but is aided by the use of flexible laryngoscopy, Computed tomography (CT) scanning and ultrasonography. Surgical resection of the cyst and cauterization of its pyriform sinus opening should be undertaken to minimize recurrence.

Quantity and location of aortic valve complex calcification predicts severity and location of paravalvular regurgitation and frequency of post-dilation after balloon-expandable transcatheter aortic valve replacement.

PubMed

Khalique, Omar K; Hahn, Rebecca T; Gada, Hemal; Nazif, Tamim M; Vahl, Torsten P; George, Isaac; Kalesan, Bindu; Forster, Molly; Williams, Mathew B; Leon, Martin B; Einstein, Andrew J; Pulerwitz, Todd C; Pearson, Gregory D N; Kodali, Susheel K

2014-08-01

This study sought to determine the impact of quantity and location of aortic valve calcification (AVC) on paravalvular regurgitation (PVR) and rates of post-dilation (PD) immediately after transcatheter aortic valve replacement (TAVR). The impact of AVC in different locations within the aortic valve complex is incompletely understood. This study analyzed 150 patients with severe, symptomatic aortic stenosis who underwent TAVR. Total AVC volume scores were calculated from contrast-enhanced multidetector row computed tomography imaging. AVC was divided by leaflet sector and region (Leaflet, Annulus, left ventricular outflow tract [LVOT]), and a combination of LVOT and Annulus (AnnulusLVOT). Asymmetry was assessed. Receiver-operating characteristic analysis was performed with greater than or equal to mild PVR and PD as classification variables. Logistic regression was performed. Quantity of and asymmetry of AVC for all regions of the aortic valve complex predicted greater than or equal to mild PVR by receiver-operating characteristic analysis (area under the curve = 0.635 to 0.689), except Leaflet asymmetry. Receiver-operating characteristic analysis for PD was significant for quantity and asymmetry of AVC in all regions, with higher area under the curve values than for PVR (area under the curve = 0.648 to 0.741). On multivariable analysis, Leaflet and AnnulusLVOT calcification were independent predictors of both PVR and PD regardless of multidetector row computed tomography area cover index. Quantity and asymmetry of AVC in all regions of the aortic valve complex predict greater than or equal to mild PVR and performance of PD, with the exception of Leaflet asymmetry. Quantity of AnnulusLVOT and Leaflet calcification independently predict PVR and PD when taking into account multidetector row computed tomography area cover index. Copyright © 2014 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

Quality of Life after Surgery for Stanford Type A Aortic Dissection: Influences of Different Operative Strategies.

PubMed

Ghazy, Tamer; Eraqi, Mohamed; Mahlmann, Adrian; Hegelmann, Helena; Matschke, Klaus; Kappert, Utz; Weiss, Norbert

2017-06-22

Outcome of surgery for acute Stanford type A aortic dissection extends beyond mortality and morbidity. More than one operative strategy is available but little is known regarding their influence on quality of life. This study analyzes the influence of defensive and aggressive operative strategies on the patients' midterm quality of life (QoL). From July 2007 to July 2010, 95 patients underwent surgery for acute Stanford type A aortic dissection in our institution. Patients who survived the procedure, gave consent to inclusion in the institution prospective registry, completed at least 2-years of follow-up protocol, and answered two quality of life questionnaires (SF-36 and WHO-QOL-BREF) were included in the study. Patients were divided into two groups according to operative strategy: defensive (DS) with replacement of the ascending aorta only, and aggressive (AS) with replacement of the ascending aorta, aortic arch with/out a frozen elephant trunk procedure. The preoperative, operative, postoperative and the midterm QoL were analyzed and compared. 39 patients were included in the study. The DS group had a shorter operative time (184 ± 54 versus 276 ± 110 minutes respectively, P = .001). The AS group had higher incidence of dialysis (31% versus 4% respectively, P = .038). The midterm QoL analysis showed a collective lower value than the normal population. In the SF-36, DS performed better in all categories but with no statistical significance. In the WHO-QOL-BREF, DS performed significantly better in the global life quality and psychological health categories (P = .038 and .049 respectively). In Stanford type A aortic dissection, adopting an aggressive surgical strategy does not improve the quality of life in midterm follow-up compared to a defensive strategy. Unless the clinical setting dictates an aggressive management strategy, a defensive strategy can be safely adopted.

Low contrast media volume in pre-TAVI CT examinations.

PubMed

Kok, Madeleine; Turek, Jakub; Mihl, Casper; Reinartz, Sebastian D; Gohmann, Robin F; Nijssen, Estelle C; Kats, Suzanne; van Ommen, Vincent G; Kietselaer, Bas L J H; Wildberger, Joachim E; Das, Marco

2016-08-01

To evaluate image quality using reduced contrast media (CM) volume in pre-TAVI assessment. Forty-seven consecutive patients referred for pre-TAVI examination were evaluated. Patients were divided into two groups: group 1 BMI < 28 kg/m(2) (n = 29); and group 2 BMI > 28 kg/m(2) (n = 18). Patients received a combined scan protocol: retrospective ECG-gated helical CTA of the aortic root (80kVp) followed by a high-pitch spiral CTA (group 1: 70 kV; group 2: 80 kVp) from aortic arch to femoral arteries. All patients received one bolus of CM (300 mgI/ml): group 1: volume = 40 ml; flow rate = 3 ml/s, group 2: volume = 53 ml; flow rate = 4 ml/s. Attenuation values (HU) and contrast-to-noise ratio (CNR) were measured at the levels of the aortic root (helical) and peripheral arteries (high-pitch). Diagnostic image quality was considered sufficient at attenuation values > 250HU and CNR > 10. Diagnostic image quality for TAVI measurements was obtained in 46 patients. Mean attenuation values and CNR (HU ± SD) at the aortic root (helical) were: group 1: 381 ± 65HU and 13 ± 8; group 2: 442 ± 68HU and 10 ± 5. At the peripheral arteries (high-pitch), mean values were: group 1: 430 ± 117HU and 11 ± 6; group 2: 389 ± 102HU and 13 ± 6. CM volume can be substantially reduced using low kVp protocols, while maintaining sufficient image quality for the evaluation of aortic root and peripheral access sites. • Image quality could be maintained using low kVp scan protocols. • Low kVp protocols reduce contrast media volume by 34-67 %. • Less contrast media volume lowers the risk of contrast-induced nephropathy.

What to Do with the Spring Ligament.

PubMed

Steginsky, Brian; Vora, Anand

2017-09-01

The spring ligament complex is an important static restraint of the medial longitudinal arch of the foot and its failure has been associated with progressive flatfoot deformity. Reconstruction of the spring ligament complex is most appropriate in stage II posterior tibial tendon dysfunction, before severe peritalar subluxation and rigid deformity develops. Although an understanding of the spring ligament complex and its contribution to medial arch stability has grown, there is no unanimously accepted surgical technique that has consistently demonstrated satisfactory outcomes. This article reviews the pathoanatomy of the spring ligament complex and the role of spring ligament reconstruction in acquired flatfoot deformity, and highlights current research. Copyright © 2017 Elsevier Inc. All rights reserved.

Doppler-guided retrograde catheterization system

NASA Astrophysics Data System (ADS)

Frazin, Leon J.; Vonesh, Michael J.; Chandran, Krishnan B.; Khasho, Fouad; Lanza, George M.; Talano, James V.; McPherson, David D.

1991-05-01

The purpose of this study was to investigate a Doppler guided catheterization system as an adjunctive or alternative methodology to overcome the disadvantages of left heart catheterization and angiography. These disadvantages include the biological effects of radiation and the toxic and volume effects of iodine contrast. Doppler retrograde guidance uses a 20 MHz circular pulsed Doppler crystal incorporated into the tip of a triple lumen multipurpose catheter and is advanced retrogradely using the directional flow information provided by the Doppler waveform. The velocity detection limits are either 1 m/second or 4 m/second depending upon the instrumentation. In a physiologic flow model of the human aortic arch, multiple data points revealed a positive wave form when flow was traveling toward the catheter tip indicating proper alignment for retrograde advancement. There was a negative wave form when flow was traveling away from the catheter tip if the catheter was in a branch or bent upon itself indicating improper catheter tip position for retrograde advancement. In a series of six dogs, the catheter was able to be accurately advanced from the femoral artery to the left ventricular chamber under Doppler signal guidance without the use of x-ray. The potential applications of a Doppler guided retrograde catheterization system include decreasing time requirements and allowing safer catheter guidance in patients with atherosclerotic vascular disease and suspected aortic dissection. The Doppler system may allow left ventricular pressure monitoring in the intensive care unit without the need for x-ray and it may allow left sided contrast echocardiography. With pulse velocity detection limits of 4 m/second, this system may allow catheter direction and passage into the aortic root and left ventricle in patients with aortic stenosis. A modification of the Doppler catheter may include transponder technology which would allow precise catheter tip localization once the catheter tip is placed in the aortic root. Such technology may conceivably assist in allowing selective coronary catheterization. These studies have demonstrated that Doppler guided retrograde catheterization provides an accurate method to catheterization the aortic root and left ventricular chamber without x-ray. In humans, it may prove useful in a variety of settings including the development of invasive ultrasonic diagnostic and therapeutic technology.

Hostile Thoracic Aortic Aneurysm Treated by Fenestrated Thoracic Stentgraft with Proximal Sealing in Ishimaru Zone 0.

PubMed

Sousa, Joel; Neves, João; Riambau, Vicente; Teixeira, José

2017-01-01

Thoracic endovascular aortic aneurysm repair (TEVAR) is an established treatment for thoracic aortic disease in both the acute and elective setting, with such a widespread use that almost 50% of all thoracic aortic surgery in Europe is performed by these means. Nonetheless, the feasibility of TEVAR is determined by several anatomic factors, and the suitability of the proximal and distal landing zones remain one of the main limitations to its use. The advent of custom-made thoracic stent grafts widened the endovascular options in some challenging anatomies. The authors present a case report of a descending thoracic aortic pseudo-aneurysm, with no suitable proximal landing zone, successfully treated by means of a custom- -made fenestrated thoracic stent graft. Male patient, 57 years old, with multiple cardiovascular risk factors and past medical history of coronary hearth disease, pulmonary emphysema and high speed trauma 20 years before. The patient was referred after being diagnosed with an asymptomatic saccular pseudo-aneurysm of the descending thoracic aorta, with 50mm of largest diameter and located at the level of the aortic isthmus. Inadequate proximal sealing was evident, even if deliberate left subclavian and carotid coverage were performed. Due to the prohibitive open surgical risk, and taking into account the post-traumatic etiology of the lesion, an endovascular solution was planned. The patient was therefore sequentially treated by means of a left carotid- subclavian bypass followed by custom-made fenestrated TEVAR, with a single fenestration for both the left common carotid artery and brachiocephalic trunk, granting proper sealing in the distal ascending aorta (Ishimaru zone 0). Rapid pacing was used during the implantation, with heart frequency of 180 bpm and systolic pressures of 40mmHg, allowing for a more precise deployment with no windsock effect. The procedure was successful and uneventful, with no intra-operative endoleaks, birdbeaks or retrograde dissections. There are no reported complications at 6 months follow-up. Custom-made fenestrated thoracic stentgrafts are an accessible, reproducible and safe therapeutic option when dealing with hostile thoracic arch anatomies, and should be considered as a minimally-invasive effective solution in selected cases.

Neutrophil/Lymphocyte ratio and association with arch intervention in patients with hypoplastic left heart syndrome undergoing hybrid procedure.

PubMed

Mitchell, Elizabeth; Cheatham, John P; Sisk, James M; Nicholson, Lisa; Holzer, Ralf; Galantowicz, Mark; Cua, Clifford L

2014-01-01

Hybrid procedure is an alternative initial palliation for patients with hypoplastic left heart syndrome (HLHS). One major complication with this procedure is stenosis in the aortic arch isthmus possibly due to inflammation from the patent ductus arteriosus (PDA) stent. In adult studies, neutrophil/lymphocyte (N/L) ratio has been used as a marker for increased inflammation and has been associated with increased risk for coronary artery stent stenosis. The goal of this study was to determine if there were differences in N/L ratio between patients with HLHS undergoing hybrid procedure that required an arch intervention (AI-Group) vs. those that did not require an intervention (NAI-Group). Retrospective chart review was performed on patients with HLHS undergoing hybrid procedure between July 2002 and January 2013. Complete blood counts as well as differentials were recorded at four time periods: 1 day prehybrid palliation, one day posthybrid palliation, 1 week posthybrid palliation, and 3 weeks posthybrid palliation. One hundred six patients were evaluated (AI-Group = 38, NAI-Group = 68). AI-Group generally had a higher N/L ratio vs. NAI-group and this was significant immediately 1 day posthybrid palliation: AI-Group vs. NAI-Group, prehybrid (2.95 ± 2.62 vs. 2.44 ± 1.71), 1 day posthybrid (5.95 ± 4.16 vs. 4.34 ± 3.87, P < .05), 1 week posthybrid (2.72 ± 3.01 vs. 2.28 ± 2.12), and 3 weeks posthybrid (1.85 ± 1.24 vs. 1.45 ± 1.16), respectively. Lymphocyte percentage was significantly lower in the AI-Group vs. NAI-Group 3 weeks posthybrid palliation (33.00 + 11.30% vs. 40.65 + 16.82%). Patients that required an arch intervention after hybrid palliation had a higher N/L ratio immediately after the procedure. This may signify increased inflammatory reaction that places these patients at risk for stenosis. Future studies are needed to determine if N/L ratio is a robust marker to risk stratify patients undergoing the hybrid procedure for arch complications. © 2014 Wiley Periodicals, Inc.

Initial experience with xenograft bioconduit for the treatment of complex prosthetic valve endocarditis.

PubMed

Roubelakis, Apostolos; Karangelis, Dimos; Sadeque, Syed; Yanagawa, Bobby; Modi, Amit; Barlow, Clifford W; Livesey, Steven A; Ohri, Sunil K

2017-07-01

The treatment of complex prosthetic valve endocarditis (PVE) with aortic root abscess remains a surgical challenge. Several studies support the use of biological tissues to minimize the risk of recurrent infection. We present our initial surgical experience with the use of an aortic xenograft conduit for aortic valve and root replacement. Between October 2013 and August 2015, 15 xenograft bioconduits were implanted for complex PVE with abscess (13.3% female). In 6 patients, concomitant procedures were performed: coronary bypass (n=1), mitral valve replacement (n=5) and tricuspid annuloplasty (n=1). The mean age at operation was 60.3±15.5 years. The mean Logistic European system for cardiac operating risk evaluation (EuroSCORE) was 46.6±23.6. The median follow-up time was 607±328 days (range: 172-1074 days). There were two in-hospital deaths (14.3% mortality), two strokes (14.3%) and seven patients required permanent pacemaker insertion for conduction abnormalities (46.7%). The mean length of hospital stay was 26 days. At pre-discharge echocardiography, the conduit mean gradient was 9.3±3.3mmHg and there was either none (n=6), trace (n=6) or mild aortic insufficiency (n=1). There was no incidence of mid-term death, prosthesis-related complications or recurrent endocarditis. Xenograft bioconduits may be safe and effective for aortic valve and root replacement for complex PVE with aortic root abscess. Although excess early mortality reflects the complexity of the patient population, there was good valve hemodynamics, with no incidence of recurrent endocarditis or prosthesis failure in the mid-term. Our data support the continued use and evaluation of this biological prosthesis in this high-risk patient cohort.

Disease Beyond the Arch: A Systematic Review of Middle Aortic Syndrome in Childhood.

PubMed

Rumman, Rawan K; Nickel, Cheri; Matsuda-Abedini, Mina; Lorenzo, Armando J; Langlois, Valerie; Radhakrishnan, Seetha; Amaral, Joao; Mertens, Luc; Parekh, Rulan S

2015-07-01

Middle aortic syndrome (MAS) is a rare clinical entity in childhood, characterized by a severe narrowing of the distal thoracic and/or abdominal aorta, and associated with significant morbidity and mortality. MAS remains a relatively poorly defined disease. This paper systematically reviews the current knowledge on MAS with respect to etiology, clinical impact, and therapeutic options. A systematic search of 3 databases (Embase, MEDLINE, and Cochrane Central Register of Controlled Trials) yielded 1,252 abstracts that were screened based on eligibility criteria resulting in 184 full-text articles with 630 reported cases of childhood MAS. Data extracted included patient characteristics, clinical presentation, vascular phenotype, management, and outcomes. Most cases of MAS are idiopathic (64%), 15% are associated with Mendelian disorders, and 17% are related to inflammatory diseases. Extra-aortic involvement including renal (70%), superior mesenteric (30%), and celiac (22%) arteries is common, especially among those with associated Mendelian disorders. Inferior mesenteric artery involvement is almost never reported. The majority of cases (72%) undergo endovascular or surgical management with residual hypertension reported in 34% of cases, requiring medication or reintervention. Clinical manifestations and extent of extra-aortic involvement are lacking. MAS presents with significant involvement of visceral arteries with over two thirds of cases having renal artery stenosis, and one third with superior mesenteric artery stenosis. The extent of disease is worse among those with genetic and inflammatory conditions. Further studies are needed to better understand etiology, long-term effectiveness of treatment, and to determine the optimal management of this potentially devastating condition. © American Journal of Hypertension, Ltd 2015. All rights reserved. For Permissions, please email: journals.permissions@oup.com.