Journal of Cardiovascular Surgery最新文献

Endovascular treatment of peripheral arterial disease has emerged as a minimally-invasive alternative to surgical intervention and has often become the first-line therapy. The patency of these interventions has shown promise but has remained variable depending upon the location, length of lesion and device used for a particular treatment. Specifically, one of the most common locations that is treated with endovascular means for chronic-limb threatening ischemia is the femoropopliteal region. This area of the arterial tree is highly exposed to movements such as flexion, extension, and rotational torque; as such, placing metallic stents can result in kinking and damage to the stent, and subsequently the artery, over time. Stent characteristics are defined according to the metal property that composes them. Nitinol has been experimented with for use in the arterial tree since the 1980s namely because of its uniquely elastic mechanical properties, which were ideal for sustaining its shape within an anatomic area prone to positional variability. More recently, nitinol stents were introduced in an interwoven fashion, the design of which creates a scaffold of structure for the elastic property of the metal to remain reinforced within highly flexible arteries. This review article discusses the available literature and evidence behind the use of these interwoven nitinol stents in lower extremity peripheral arterial interventions.

Introduction: Criteria and optimal timing for carotid artery revascularization have been polarizing subjects for investigators and clinicians dedicated to carotid artery atherosclerotic disease. A topical review was performed with the purpose of 1) providing an overview of the evidence on the definition of index event and on the definition of delay of intervention; 2) summarizing the rationale for the current definition for the optimal timing for carotid intervention, and 3) drawing a sketch for future directions implementing the aspect of timing in daily clinical practice.

Evidence acquisition: A literature search was performed using the Medline database and the following query ("Endarterectomy, Carotid"[Mesh]) AND ("Stroke" [Mesh] OR Symptomatic) AND "Randomized Controlled Trial"). A comprehensive review of manuscripts addressing timing of intervention was also performed.

Evidence synthesis: A total of eleven RCTs were identified and data on index event definition, timing of intervention and BMT were resumed. The definition of the index event can have a significant impact on the delay times but has (surprisingly) received little attention. Different definitions in itself may be correct, but in terms of stroke prevention, it is most important to understand and emphasize that the risk of recurrent stroke. The optimal timing of CEA after stroke remains an important but unresolved question. No prospective, randomized study has ever been undertaken to specifically determine which patients and when they might safely undergo expedited CEA after recent stroke.

Conclusions: Collecting data on events during waiting time to intervention and developing reporting standards for these waiting times seem to be the key for unraveling this controversy.

The type of closure after carotid endarterectomy (CEA), whether with patching primary closure or eversion resulting optimal results, remains somewhat controversial. We conducted a PubMed literature review search comparing CEA with patching versus CEA with primary closure versus eversion CEA over the past four decades with emphasis on randomized controlled trials and systematic/meta-analysis and large single center or multicenter studies. The data showed that routine carotid patching can be recommended over primary closure (level 1 evidence); however, CEA with primary closure can be used for large internal carotid arteries (ICAs)>6 mm. Moreover, selective patching with CEA lacks level 1 evidence support. No significant differences were noted among the various patch materials used (e.g., synthetic patches like dacron, ACUSEAL, PTFE, pericardial patches and vein patches) and in the stroke/death rates between eversion carotid endarterectomy (ECEA) and conventional CEA (CCEA) with patching. In addition, no significant restenosis rates were noted between CEA with patching and ECEA; however, CEA with primary closure had higher late restenosis rates. There is level 1 evidence to support CEA with patching or eversion over primary closure and there is also no significant difference between the use of various patches.

Introduction: The aim of this review was to assess the evidence supporting an association between asymptomatic carotid stenosis (ACS) with impaired cognitive function due to chronic cerebral hypoperfusion and/or silent cerebral embolization.

Evidence acquisition: PubMed/Medline, Embase and the Cochrane databases were searched up to December 1, 2022 to identify studies focusing on the association between ACS and cognitive function, as well as the mechanisms involved.

Evidence synthesis: A total of 49 studies were identified. The evidence supports an association between ACS and progressive cognitive deterioration. The mechanisms involved in the cognitive decline associated with ACS include cerebral hypoperfusion and silent cerebral embolization. Irrespective of the mechanism involved, severe ACS is associated with a progressive decline in several aspects of cognitive function, including global cognition, memory and executive function.

Conclusions: Patients with ACS are at increased risk of developing a progressive decline in their cognitive function. The evidence from the present systematic review suggests that it may be inappropriate to consider ACS patients developing cognitive dysfunction as "asymptomatic". Besides stroke, myocardial infarction and death rates, future studies should include evaluation of cognitive function as part of their outcomes.

Atherectomy as an endovascular modality to treat peripheral arterial disease has gained traction over the past 10 years. Unlike most other available technologies, atherectomy works by physically debulking atherosclerotic plaque via a variety of mechanisms being the femoropopliteal segment the most targeted one. The aims of this review were to detail the types of atherectomy available, existing evidence available for atherectomy use in the femoropopliteal segment as compared to other interventions, critical appraisal of its current use and the possible influences on its indication. Future steps regarding atherectomy usage and data presentation are also described.

Background: The frozen elephant trunk (FET) technique enables repair of aortic arch pathology, with possibility for endovascular treatment of distal thoracic aortic disease. We aimed to study outcomes of FET repair of complex aortic arch disease at a Scandinavian tertiary referral center.

Methods: All patients who underwent FET repair of the aortic arch 2006-2020 were included. Survival, complication and reintervention rate, and aortic remodeling were analyzed.

Results: Fifty patients were included: 23 complex thoracic aortic aneurysms involving the aortic arch (TAA), 19 with chronic aortic dissections (CAD) (16 Stanford type A, 3 type B) and 8 acute aortic dissections (AAD) (7 Stanford type A, 1 type B). Thirty-day mortality was: TAA=22% (N.=5), CAD=5% (N.=1), AAD=37% (N.=3). Rate of disabling stroke: TAA=22% (N.=5), CAD=5% (N.=1), AAD=25% (N.=2). Rate of permanent spinal cord injury: TAA=9% (N.=2), CAD=5% (N.=1), AAD=0%. 5-year survival: TAA=53%, CAD=83%, AAD=63%. 5-year reintervention-free survival was TAA=83% and CAD=36%. There were no reinterventions in the AAD group. 13/19 (68%) of CAD patients underwent distal stent graft extension during follow-up. On last CT follow-up (median 32 months), 78% of CAD had false lumen thrombosis along the stent graft and 11% in the abdominal aorta. In thoracic aorta there was a mean 64% expansion (P<0.001) of true and 39% reduction (P=0.007) of false lumen diameter. In abdominal aorta, both true and false lumen expanded.

Conclusions: Despite the advantages of the FET technique, repair of extensive aortic arch disease remains associated with high rates of mortality and major neurologic complications. FET repair of CAD induces favorable remodeling in the thoracic aorta.

Background: Literature is scarce on the course of iliac endograft limb apposition after endovascular aortic aneurysm repair (EVAR), which is why this study was conducted.

Methods: A retrospective observational imaging study was performed to measure iliac apposition of endograft limbs on the first post-EVAR computed tomography angiography (CTA) scan and on the latest available follow-up CTA scan. With center lumen line reconstructions and CT-applied dedicated software, the shortest apposition length (SAL) of the endograft limbs was assessed as well as the distance between the end of the fabric and the proximal border of the internal iliac artery or the endograft-internal artery distance (EID).

Results: Ninety-two iliac endograft limbs were eligible for measurements, with a median follow-up of 3.3 years. At the first post-EVAR CTA, the mean SAL was 31.9±15.6 mm, and the mean EID was 19.5±11.8. At the last follow-up CTA, there was a significant decrease in apposition of 10.5±14.1 mm (P<0.001) and a significant increase in EID of 5.3±9.5 mm (P<0.001). A type Ib endoleak developed in three patients due to a reduced SAL. The apposition was <10 mm in 24% of limbs at the last follow-up vs. 3% at the first post-EVAR CTA.

Conclusions: This retrospective study documented a significant decrease in post-EVAR iliac apposition over time, partly due to retraction of iliac endograft limbs at mid-term CTA follow-up. Further research is required to identify whether regular determination of iliac apposition may predict and prevent type IB endoleaks.

Background: For descending thoracic aortic aneurysms (TAA) in proximity of the aortic arch, debranching of the left subclavian artery (LSA) may be necessary to extend proximal sealing in zone 2. The aim of this study was to determine the added proximal apposition length gained from LSA debranching during thoracic endovascular aortic repair (TEVAR).

Methods: This multicenter retrospective study (2010-2020) included patients who underwent elective TEVAR in zone 2 for a degenerative TAA where the LSA was surgically debranched. The endograft position on the first postoperative computed tomography angiography (CTA) scan was assessed using post-processing software. The analysis included the shortest apposition length (SAL), the tilt of the proximal edge of the endograft, and the distance between the endograft and the left common carotid artery. Clinical endpoints (neurological complications and endoleaks) at 30 days were also reported.

Results: Twenty-two patients were included. The median interval between TEVAR and the first postoperative CTA was 3 days (2-10 days). Median SAL was 9.2 mm (1.3-26.4 mm), of which 8.6 mm (1.3-16.2 mm) was gained proximal of the LSA, including the LSA orifice. In 12 patients (55.5%) the SAL was <10 mm. The median tilt was 18.3° (13.9°-22.2°). Seven endoleaks were reported on the first CTA: 1 type Ia, 2 type Ib, 3 type II, and 1 type III.

Conclusions: Debranching the LSA adds valuable sealing length in zone 2, but the SAL was still relatively short in many patients, putting these patients at risk for a future type Ia endoleak. Accurate assessment of the circumferential apposition on postoperative CTA follow-up in these high-risk patients with short, complex landing zones seems mandatory. Evaluation of apposition in a larger population with longer follow-up is advised.

Background: Extracorporeal membrane oxygenation (ECMO) is frequently used for emergency support in patients with profound cardiogenic shock (CS) of all etiologies. However, no controlled study investigating ECMO in myocardial infarction (AMI)-induced CS is available.

Methods: Retrospective analysis of patients experiencing AMI induced CS; ECMO therapy vs. non ECMO therapy. A total of 476 patients with AMI-induced CS were investigated. One hundred twenty-seven patients (26.7%) received emergency veno-arterial ECMO support, 349 patients did not receive ECMO support. Patients were propensity score matched based on relevant clinical and laboratory factors and revealed 127 matched pairs.

Results: Mean age of patients was 65.0±12.3 years and mean Syntax score was 25.9±7.3 in the full unmatched patient population. Survival at 1, 3 and 5 years after CS was 45.6%, 43.5%, and 41.3% in the ECMO group and 17.4%, 15.8%, and 14.9% in the full unmatched control group (log-rank: P<0.001). After propensity score matching, 1-, 3-, and 5-year survival was 14.4%, 13.5%, and 11.2% in the matched control group (P<0.001). Cox regression analysis identified ECMO support (HR: 2.57; 95% CI: 1.89-3.50; P<0.001) and completeness of revascularization (HR: 1.89; 95% CI: 1.74-2.34, P=0.003) to be independent predictors for long term survival.

Conclusions: Extracorporeal life support by ECMO significantly increased survival in patients with AMI-induced CS. ECMO insertion increased survival probability 2.57-fold and should be considered as first line treatment in patients with profound AMI-induced CS.