Abstract: PurposeTo assess the safety and efficacy of the sandwich technique for complex aortic aneurysms.MethodsBetween October 2008 and March 2012, 78 patients (70 men; mean age 73.3 years) undergoing complex thoracic or abdominal endovascular aneurysm repairs were treated with the sandwich technique when the aneurysm features did not fulfill the requirements for standard endovascular techniques or total aortic arch replacement. Two thirds of the population was treated for aortoiliac aneurysm (52, 66.7%). There were 15 (19.2%) thoracoabdominal aneurysms, 6 (7.7%) isolated iliac artery aneurysms, 3 (3.8%) arch aneurysms, and 2 (2.6%) abdominal aortic aneurysm with non-diseased, short common iliac arteries bilaterally. Five (6.4%) symptomatic patients were submitted to endovascular repair in the urgent setting.ResultsTechnical success was 98.7%; one procedure was aborted when both renal arteries could not be cannulated. Over a mean 17-month follow-up (range 1–42), primary patency was high (96.7%) and mortality low ...

Abstract: Surgical treatment of pediatric acute traumatic aortic injury (TAI) after blunt chest trauma is standard of care. Use of endovascular stent grafts for treatment of TAI in adults is common but has important limitations in children. We sought to describe the use of balloon-expandable covered endovascular stents for treatment of TAI in children and adolescents. Participants of the multicenter Coarctation of the Aorta Stent Trial (COAST) had access to investigational large-diameter, balloon-expandable, covered stents (covered Cheatham-platinum stents; NuMed, Inc., Hopkinton, New York) on an emergency-use basis. From 2008 through 2011, 6 covered stents were implanted in 4 patients at 3 COAST centers for treatment of TAI. Median patient age was 13.5 years (range 11 to 14) and weight was 58 kg (40 to 130). All patients sustained severe extracardiac injuries that were judged to preclude safe open surgical repair of TAI. Median aortic isthmus and stent implantation balloon diameters were 16.4 mm (13.2 to 19) and 19 mm (16 to 20), respectively. Stent implantation was technically successful in all attempts. Complete exclusion of aortic wall injury was achieved in all cases. There were no access site complications. At a median follow-up of 24 months, there was 1 early death (related to underlying head trauma) and 1 patient with recurrent aortic aneurysm who required additional stent implantation. In conclusion, balloon-expandable covered-stent implantation for treatment of pediatric TAI after blunt trauma is generally safe and effective. Availability of this equipment may alter the standard approach to treatment of pediatric TAI.

Abstract: Acute aortic syndrome refers to a spectrum of acute life-threatening aortic abnormalities requiring prompt recognition and treatment. Although underlying pathologies are diverse, presenting signs and symptoms are often indistinguishable clinically, underscoring the role of imaging to make the correct diagnosis. Computed tomography (CT) angiography, a safe and accessible imaging modality, is paramount in accurately confirming or excluding critical aortic lesions, defining location and extent, and describing associated complications. Electrocardiographic gating further improves diagnostic precision of CT, providing motion-free 3- and 4-dimensional imaging of the entire aorta. This article reviews the imaging spectrum and state-of-the-art CT for patients presenting with acute aortic syndrome.

Abstract: Syphilitic aortic aneurysm is a rare occurrence in the antibiotic era, making the diagnose assumption even more infrequent. Nonetheless, this pathology can appear and should be suspected in patients with aortic aneurysm. We report a case of a 57-year old patient who presents with neurosyphilis and, in the following study, a large ascending aorta aneurysm is identified. The authors discuss the diagnostic challenge, the epidemiologic concerns, surgical indication and treatment and subsequent follow-up.

Abstract: We report on three out of 270 consecutive patients (1.1%) suffering from coronary artery obstruction or occlusion at the end of transcatheter aortic valve implantation (TAVI). The partial or total obstruction of the coronary artery seen in the post-implantation aortography was accompanied by haemodynamic instability and electrocardiographic changes typical for myocardial ischaemia. Immediate percutaneous coronary intervention with stent implantation was successful in two cases, while in the third case it was not possible to cross the occluded right coronary artery. Emergency coronary artery bypass grafting was performed resulting in uneventful myocardial recovery. All patients were discharged home. These cases highlight the awareness of this rare, life-threatening complication of TAVI, which is in need of a dedicated heart team involved not only in decision-making, but also in the procedure itself.

Abstract: There is limited information about the size change of a knitted Dacron graft (Gelseal™) used in the thoracic aorta. We evaluated the diameters of the Gelseal™ grafts at a long-term follow-up for 3.7 ± 1.3 years (1–5.9 years; median, 4.0 years), which were used for replacement of the ascending aorta in 59 patients with acute aortic dissection. The early and late dilatation rates (LDRs) of the prosthetic grafts were calculated retrospectively based on the graft diameter at the level equivalent to the ascending aorta on the pre-discharge computed tomography (CT) scans and follow-up CT scans performed every year after surgery. Immediately after surgery (15 ± 7 days), the early dilatation of the Gelseal™ grafts was 26.0 ± 6.0% with significant correlations with the number of post-operative days (R= 0.500, P= 0.003). At the follow-up for 3.7 ± 1.3 years, the LDR was 10.5 ± 6.6%, which was also significantly correlated with the number of the post-operative years (R= 0.608, P= 0.001). Linear regression analysis indicated that the annual dilatation rate was 3.23%. During the follow-up, we have experienced no redo surgery due to graft fracture or false aneurysm formation at the anastomosis sites associated with the graft dilatation. In conclusion, the Gelseal™ graft used in the ascending aorta demonstrates a small but continuous increase in the diameter, up to 5 years after implantation, without any adverse events.

Abstract: Acute dissection of the aorta can be life-threatening. As a presenting manifestation of aortic dissection, neurologic complications such as paraplegia are rare. Herein, we report the case of a 51-year-old man who presented with sudden-onset paraplegia and ischemia of the legs, with no chest or back pain. His medical history included coronary artery bypass grafting. Physical examination revealed pulseless lower extremities, and computed tomography showed aortic dissection from the ascending aorta to the common iliac arteries bilaterally. A lumbar catheter was inserted for cerebrospinal fluid drainage, and axillary arterial cannulation was established. With the use of cardiopulmonary bypass, the aortic dissection was corrected, and the previous coronary artery grafts were reattached. The surgery restored spinal and lower-extremity perfusion, and the patient walked unaided from the hospital upon his discharge 5 days later. Although acute aortic dissection presenting as paraplegia is rare, it should be considered in patients who have pulseless femoral arteries bilaterally and sudden-onset paraplegia, despite no pain in the chest or back. Prompt diagnosis and intervention can prevent morbidity and death.

Abstract: We present the case of a 60-year old man who complained of severe dysphagia caused by a double aortic arch (DAA) with a right-sided descending thoracic aorta. The left-sided aortic arch had a compressive segment located between the left subclavian artery and the descending thoracic aorta. Using left third thoracotomy, the segment, which caused compression of the oesophagus, was ligated and divided. After the operation, the patient was completely relieved of his symptoms. We concluded that the removal of the compressive portion of the left aortic arch and the ligation of the ligamentum arteriosum are the only treatment measures needed in such cases.

Abstract: A 47-year-old woman with a history of myomectomies and uterine artery embolization 15 years previously presented with increasing menorrhagia and dysmenorrhea. Magnetic resonance imaging (MRI) demonstrated multiple enhancing fibroids, extensive uterine supply from what appeared to be patent uterine arteries, and significant supply from what appeared to be the left ovarian artery. Aortography demonstrated no ovarian supply, but extensive collateral supply from distal branches of the inferior mesenteric artery (IMA), with further collateral supply from the anterior division of both internal iliac arteries. There was no filling of the uterine arteries distal to the coils. Embolization was performed with technical and clinical success. This case highlights the potential for recruitment of collateral vessels following coil embolization and is the first reported case of successful fibroid embolization from distal IMA branches.

Abstract: PurposeTo demonstrate the role of endovascular approaches to the ascending aorta in the post-transplant context.Case ReportsThree patients (2 women and 1 man aged 52, 68, and 43 years, respectively...

Abstract: A 65-year-old black woman with hypertension and type 2 diabetes mellitus presented to her local hospital with acute chest discomfort. She had no history of connective tissue disease or family history of aortic catastrophes. An ECG showed inferior ST-segment elevation. Coronary angiography revealed multiple high-grade lesions in the right coronary artery (RCA) with evidence of thrombus (Movie I in the online-only Data Supplement). There were also critical stenoses in the left coronary system. Percutaneous coronary intervention of the RCA with 3 bare metal stents was successful in establishing Thrombolysis in Myocardial Infarction grade 3 flow, but deployment of the fourth stent was complicated by proximal RCA dissection with extension into the aortic sinuses (Figure 1 and Movie II in the online-only Data Supplement). Despite obliteration of the RCA dissection with the stent, persistent dye staining of the ascending aorta was present on final angiographic views (Figure 2). A computed tomography scan performed 2 days later showed an ascending aorta intramural hematoma (IMH;Figure 3). Plans were made for complete surgical revascularization in 6 weeks, and she was discharged. Aside from several brief episodes of chest discomfort in the first week after discharge, she remained asymptomatic. Three weeks after the initial event, the patient presented for a second opinion at our institution. Figure 1. Left anterior oblique angiographic view of the right coronary artery. An intracoronary guidewire (arrowhead) …

Abstract: Mid-aortic syndrome, an uncommon acquired or congenital condition characterized by segmental narrowing of the abdominal or distal descending thoracic aorta, is frequently accompanied by ostial stenosis of the aorta's branches If left untreated, it can result in life-threatening complications secondary to severe hypertension We report the case of a 3-year-old girl with congenital mid-aortic syndrome, who was diagnosed by chance in the course of a viral illness, and whose high blood pressure values were first dismissed as inaccurate Attempts to achieve medical or endovascular control of her hypertension were unsuccessful She was thereafter successfully treated by aorto–aortic bypass grafting, resection of the stenotic segments of both renal arteries, and implantation of the patent arterial segments into the graft

Abstract: Acute aortic dissection is very uncommon in pregnant women and the acute type A aortic dissection carries a high mortality rate outside specialized centres. There are a few cases reported with successful outcomes for the mother and the foetus from major cardiac centres. We are reporting our first experience of acute aortic dissection during the third trimester of pregnancy in a patient with Marfan features, profound haemodynamic compromise on arrival and a bovine aortic arch. Both the mother and the baby are doing well two years postoperatively.

Abstract: Ostial lesions, including aorta-ostial lesions and Medina 001 bifurcation lesions, are known to create difficulty in precise stent placement. There are many techniques used to help in precise ostial stent placement; these include using multiple angiographic views to assist in placement, the use of the Ostial Pro device, the aorta flowing wire technique, Szabo (anchor-wire) techniques, the T-stent and small protrusion (TAP) technique, the cross-over 1-stent technique, and new dedicated ostial stents. In this review, we summarize these different techniques and show that there is no universal technique that allows for perfect ostial stent placement.

Abstract: For many patients with abdominal aortic aneurysm, unsuitable anatomy of the infrarenal aortic neck precludes endovascular aortic aneurysm repair or causes type I endoleak after the procedure. In an attempt to overcome these challenges, we retrospectively examined the usefulness of aortic banding as an adjunctive procedure to endovascular repair in 8 patients who had an abdominal aortic aneurysm with a complex infrarenal aortic neck. The procedures were performed with the patients under general anesthesia and involved making an 8-cm upper-midline laparotomy incision to expose the aneurysmal aorta. Three patients underwent aortic banding before endovascular repair; the other 5 underwent banding after the repair because of persistent type I endoleak. After banding, the abdominal aortic aneurysm was successfully excluded in all 8 patients. Long-term follow-up (mean, 38 ± 20 mo) revealed no type I endoleak and no procedure-related complications. In patients who have an abdominal aortic aneurysm with complex infrarenal neck anatomy or a refractory type I endoleak, performing aortic banding as an adjunctive procedure to endovascular aortic repair appears to be a safe strategy with good long-term results.

Abstract: Mycotic ascending aortic pseudoaneurysm (AAP) is an uncommon but surgically challenging problem with high morbidity and mortality rates. We describe endovascular repair of an acute mycotic AAP in a high-risk patient. A 45-year old man, HIV serum positive, chronic hepatitis HBV and HCV related, presented, after two sternotomies, with a fast growing 11 × 6 cm AAP that was sealed with two Gore Exluder aortic cuffs, inserted from the left axillary artery. Nine months control CT continued to show no endoleak with shrinking of the AAP.

Abstract: Accurate preoperative assessment of the aortic annulus dimension is crucial for the success of transcatheter aortic valve implantation (TAVI). All the available imaging modalities, however, have some weak points, and the ‘gold standard’ to be used is still under debate. In this context, the recent work by Dr Blanke and coworkers is a commendable attempt to develop a standardized, easy to reproduce method for the identification and measurement of the aortic annulus [1, 2]. A very interesting finding of this study is the close correlation found between the preoperative cross-sectional area (CSA) of the virtual ring passing through the nadir of the three aortic cusps and the postoperative CSA. This observation would suggest that preoperative determination of the CSA could help in predicting the final form and size of the aortic annulus in most TAVI patients [1]. However, the behaviour of the aortic root and aortic annulus is not always predictable based on the preoperative exams [3]. This is partly due to intrinsic anatomic properties of the aortic root—the ‘virtual ring’ is largely inhomogeneous, coursing through the muscular septum, the membranous septum and the mitro-aortic curtain. Moreover, leaflet and annular calcifications are often asymmetrical, adding further complexity to any attempt to predict the final shape of the prosthetic valve, the displacement of the native calcified leaflets and the sealing of the annulus around the prosthesis. A very good exemplification of this problem is given by the bicuspid aortic valve, which is usually ovoidal and heavily calcified, and may fail to adapt to the circular transcatheter valve [4]. For this reason, we have developed a simple method to analyse the reaction of the aortic root to the balloon inflation, and to obtain a dynamic measure of the CSA. In the uncertain cases (‘borderline’ annulus, important discrepancy between TEE and CT measurements, massive and/or eccentric calcifications), we proceed to a ‘calibrated’ balloon valvuloplasty. A conventional valvuloplasty balloon (Cristal Balloon, Balt, Montmorency, France) is inflated with a diluted contrast agent through a threeway stopcock. When the waist generated on the balloon profile by the aortic annulus is stretched, the stopcock is closed and an aortography is performed to exclude the presence of aortic regurgitation. The amount of contrast agent used to inflate the balloon is carefully recorded, and the balloon is deflated and withdrawn. On the bench, the balloon is inflated again to the same volume, and is then sized with a sizing plate (Amplatzer sizing plate, AGA Medical Italia, Milan, Italy). This simple manoeuvre allows us to accurately measure the aortic annulus, to estimate the risk of postoperative paraprosthetic leakage and to check the relationships between the dislocated aortic valve leaflets and the coronary arteries ostia. In our experience, this procedure has led to a change in the size of the percutaneous prosthesis in three patients, and to the conversion to transapical approach in two patients needing a 29 mm prosthesis. In conclusion, we believe that the CT protocol described by Blanke could greatly enhance our ability to evaluate the anatomy of the aortic root preoperatively. In doubtful cases, however, calibrated balloon valvuloplasty could add fundamental dynamic information, allowing us to ‘feel’ the aortic annulus while measuring it [3].

Abstract: We report 2 cases of congenital pericardial defect with ruptured acute type A aortic dissection. Case 1: An 83-year old man presented with sudden chest and back pain, and computed tomography (CT) showed acute aortic dissection with left pleural massive effusion. Because of his unstable haemodynamic condition with low blood pressure, an emergency operation was performed. We observed small amounts of bloody pericardial effusion, massive left-sided bloody pleural effusion and a partial left-sided pericardial defect of the pulmonary artery. The ascending aorta was replaced. The postoperative course was uneventful. Case 2: A 79-year old man presented with fainting followed by cardiac arrest and was resuscitated. Chest CT showed acute aortic dissection and massive haemothorax. Emergency operation was attempted, but was given up. We observed partial left-sided pericardial defect of the pulmonary artery. Further, we reviewed 6 cases of congenital pericardial defect with ruptured acute aortic dissection, including our 2 cases. In all the cases, the patients did not develop cardiac tamponade but had massive haemothorax due to congenital pericardial defects leading to confusion in diagnoses and surgical strategies. Therefore, it may be necessary to consider congenital pericardial defects before performing an operation in case of acute type A aortic dissection with massive haemothorax.

Abstract: Mutations of the ACTA2 gene, which encodes the smooth muscle cell-specific isoform of α-actin protein, have recently been found to be among the most common genetic abnormalities observed in patients with familial thoracic aortic aneurysms/dissection (TAAD). Other reported vascular manifestations caused by these mutations include premature coronary artery disease and stroke. We report a young adult who presented with an acute brachial artery occlusion and was subsequently found to have aortopathy and an ACTA2 mutation. This expands the spectrum of vascular disease associated with ACTA2 mutation to include acute limb ischemia.

Abstract: PURPOSE: To describe the endovascular management of a spontaneous rupture of the visceral abdominal aorta. CASE REPORT: A 69-year-old man presented as an emergency with a ruptured non-aneurysmal visceral abdominal aorta that extended from just below the celiac trunk to the right renal artery; the superior mesenteric artery (SMA) appeared to be occluded. The rupture was presumed to be due to a penetrating atherosclerotic ulcer. An endovascular approach was devised in which an Excluder aortic cuff would be deployed immediately below the origin of the celiac artery, covering the ruptured aortic segment and the occluded SMA. However, a second cuff was required distally to seal the rupture. To maintain perfusion to the right renal artery, a Viabahn stent-graft was deployed into the renal artery using the periscope technique. A stent was also required in the celiac trunk, which had been inadvertently covered. The patient had an uneventful recovery; follow-up imaging at 1 year revealed no endoleak and resolution of the hematoma. CONCLUSION: Spontaneous rupture of a non-aneurysmal visceral abdominal aorta is extremely challenging and potentially fatal. Endovascular management using the periscope stent-graft technique to facilitate aortic stent-grafting may offer an attractive bailout option with satisfactory early results.

Abstract: Blunt traumatic abdominal aortic dissection is extremely rare and potentially deadly. We present the case of a 62-year-old man involved in a frontal car crash. After emergency undergoing laparotomy for bowel injuries, he was referred to our hospital due to acute ischemia of bilateral lower extremities on day 3 after the trauma. Computed tomography and aortography showed an aortobiiliac dissection with complete occlusion. This injury was successfully treated by endovascular treatment with “kissing”-technique stent placement, which appears to be a safe, effective, and minimally invasive treatment.

Abstract: Ruptured sinus of Valsalva aneurysm is an uncommon condition with variable manifestation that results in aortocardiac shunt. The presentation may range from an asymptomatic murmur to cardiogenic shock. The initial diagnosis is established or suspected by two-dimensional echocardiography and colour flow Doppler. Transesophageal echocardiography is especially helpful in delineating the anatomy of the aneurysm and its connections to other chambers. The gold standard diagnostic method for ruptured sinus of Valsalva aneurysm is cardiac catheterization and aortography. Recent reports have suggested a potential role of cardiac computed tomography in establishing diagnosis in such cases. The high spatial resolution of cardiac computed tomography provides anatomical details of the ruptured aneurysm by depicting a jet of contrast materials extending from the aneurysm and adjacent cardiac chamber. In addition, cardiac computed tomography provides a comprehensive cardiac evaluation including coronary artery anatomy, and the presence of other associated cardiac or vascular anomalies.