1. Endovascular aortic repair with multilayer graft for aortic dissection – results from NextCardio
V.S. Costache1, D. Dorobantu2, S. Sultan3, A. Costache1, A. Voican1 and H. Moldovan4
“Lucian Blaga” University of Sibiu- Faculty of Medicine1, victorscostache@gmail.com
“C.C. Iliescu” Institute of Cardiovascular Diseases2 – Bucharest
National University of Ireland3- Galway
“Titu Maiorescu” University Bucharest- Faculty of Medicine4
Background: The multilayer flow modulator (MFM) has shown promising results in the treatment of complex aortic pathologies, especially when branch arteries are involved, including a few reported cases of dissection. We present our single center experience and results with this technique.
Methods: Patients with complex type A or B dissections were selected for MFM repair as per device indications of use and were followed prospectively.
Results: A total of 13 consecutive patients with aortic dissection, were treated with an MFM endoprosthesis in our institution. Indications included: type B dissection (n = 10), residual type B after type A surgical correction (n = 2), and one acute type A after surgical correction requiring intervention for malperfusion. One patient requred drainage for pericardial effusion and one had distal aortic and bilateral iliac thrombosis, due to femoral access complication which required urgent revascularization by axillary-femoral bypass.
There were early two reinterventions in the same patient, detailed above resulting in a reintervention free survival of 85% at 3 years. Initial procedural success was 100% with no branch occlusions during follow-up.
Conclusion: MFM endovascular grafts are a safe option in the treatment of complex aortic dissections, with low mortality and good procedural success. Further studies and longer follow-up are needed to establish the role of MFM devices in the management of aortic dissection.
2. Automated Suturing In Less Invasive Aortic And Mitral Valve Replacement Surgery: Reliable Surgical Ergonomics, Reduced Handling Of Exposed Needles And Shorter Cardiopulmonary Bypass Duration
S. J. Sauer1, J.A. Siordia Jr2, V.S. Costache3, C.J. Lutz4 and P.A. Knight2
1LSI Solutions, Victor, NY, USA
2University of Rochester Medical Center, Rochester, NY, USA, jsiordia@lsisolutions.com
3LB University of Sibiu, Next Cardio Project, Sibiu, Romania,
4 St. Joseph’s Hospital, Syracuse, NY, USA
Objective: To provide more patients with the unsurpassed durability of surgically implanted prosthetic heart valves coupled with the benefits of minimally invasive surgery, faster and more reliable suture delivery options are needed. This study highlights the first 44 patients treated with new automated precision suturing technology that can reduce procedure times and exposed needles.
Methods: Through extensive ex vivo tissue and cadaver experimentation, a manually controlled, adjustable shaft dual needle device was developed for placement of 2-0 polyester pledgeted horizontal mattress sutures in aortic and mitral annular tissue. A second device expedites suture placement through the prosthetic cuff. Automated device needles are retracted into protective sheaths until advanced by squeezing the lever. Forty-two isolated aortic and 2 mitral valve replacements were performed using ∼5–6 cm intercostal right anterior or lateral mini-thoracotomy incisions and video guidance. Simulated valve replacements were studied using porcine hearts to compare prosthetic installation times of non-automated to second generation automated technology.
Results: Automated aortic and mitral annular suturing was effective in all patients and applicable for both bioprosthetic and mechanical valves. In several patients, aortic cross clamp times of approximately one hour were achieved with first generation automated suturing technology, which required more time for intraoperative loading than the current iteration. Recently released second generation technology demonstrated additional time savings. Targeted patient outcomes, including early extubation and ambulation, plus reduced intensive care and hospital duration, were observed. Simulator porcine heart model testing comparing automated vs. non-automated suturing for mitral valve replacements showed mean time savings of ∼19 minutes. The automated technology eliminated 24 to 44 exposed traditional needles, each handled at least six separate times during valve installation.
Conclusions: Procedure reliability and protracted cardiopulmonary bypass times have slowed the advancement of less invasive cardiac surgery. This new automated suturing technology for minimally invasive aortic and mitral valve replacement surgery enabled excellent outcomes in the initial 44 patients and offers encouragement regarding reliability, procedure duration and reduced exposure to unprotected sharp needles.
3. Automated AVR and MVR Suturing via Mini-Thoracotomy: First 50+ Patient Series
P.A. Knight1, J.A. Siordia1 and J.A. Sauer1,2
1University of Rochester Medical Center, Rochester, NY, jsiordia@lsisolutions.com
2LSI SOLUTIONS, Victor, NY
Purpose: Heart valve replacement surgery must become much less invasive to provide optimized patient outcomes. New techniques and technologies are necessary to facilitate rapid, reproducible procedures that yield both favorable recovery and long-term clinical success. Automated technology enables ergonomic remote suture placement and excellent valve function through less traumatic access.
Methods: One senior academic cardiac surgeon successfully performed the first 47 minimal access aortic valve replacement (AVR) and 4 mitral valve replacement (MVR) procedures using new automated suturing technology. 4–5 cm intercostal incisions and video guidance provided excellent exposure. With the first suturing device positioned on the targeted annular tissue, a squeeze of the lever delivered a sub-annular pledgeted 2-0 polyester 3.5 mm wide horizontal mattress suture through the annulus. A second device delivered the suture through the prosthetic sewing cuff. Three aortic root enlargements and one saphenous vein graft re-implantation were performed concomitantly based on intraoperative findings.
Results: In this initial clinical series, automated aortic annular suture placement through mini-thoracotomy access was achieved in all patients. Automated suturing through prosthetic sewing cuffs was effective in both bioprosthetic and mechanical valves. Intraoperative and subsequent echocardiographic studies demonstrated excellent prosthetic function. Early extubation (sometimes in the operating room), rapid ambulation (usually within 24 hours), minimized intensive care unit stay (less than 2 days) and early hospital discharge (targeted for postoperative day 3) were realized in most of these patients. Avoiding “sternal precautions” allowed for rapid return to normal function even in the morbidly obese. Patient satisfaction and functional capacity was excellent at the 3–4-week postop visit.
Conclusion: Minimally invasive cardiac surgery is a worthy goal for the patient and the surgeon. This ongoing initial evaluation, now exceeding 50 patients, of new enabling technology for annular suturing via mini-thoracotomy access was encouraging without compromise to patient safety or surgical ergonomics. Automated suturing technology yielding excellent prosthetic function and postoperative recovery may hasten the adoption of minimally invasive AVR and MVR, while allowing the use of more cost-effective and durable conventional prostheses.
4. Treatment of abdominal aortic aneurisms with the bifurcated Streamliner device – results from NextCardio
V.S. Costache1, D.M. Dorobantu2, C. Goia1, A. Costache1, A. Voican1 and A. Molnar3
“Lucian Blaga” University of Sibiu- Faculty of Medicine1, victorscostache@gmail.com
“C.C. Iliescu” Institute of Cardiovascular Diseases – Bucharest2
“Iuliu Hatieganu” University of Medicine and Pharmacy Cluj-Napoca- Faculty of Medicine3
Background: The Streamliner multilayer flow modulator device has shown promising results in the treatment of complex aortic pathologies, especially when branch arteries are involved. We present our single center experience with bifurcated Streamliner devices in infrarenal and juxtarenal abdominal aneurisms.
Methods: Patients without surgical indication were included, based on a case-to-case evaluation. Death, aortic/branch reinterventions and complications were among the endpoints collected at up to 3 years.
Results: A total of 15 consecutive patients were treated with the Streamliner technique in our institution for abdominal aortic aneurysms. Indications included: abdominal infrarenal aneurysm (n = 8), abdominal juxtarenal aneurysm (n = 7). There were cases of post-op renal impairment and no cases of post-op stroke or paraplegia.
There were 2 deaths, non-related to aortic pathology, and two reinterventions (same patient) during follow-up, resulting in a reintervention-free survival of 74% [38–91] at 3 years. One death was due to acute coronary event, the second was of unknown cause.
Conclusions: The new Streamliner bifurcated device can be safely used in extensive abdominal aneurisms even when the renal arteries are involved, with no observed branch occlusions. The use of the bifurcated technique has the potential of offering an effective treatment of all complex aortic morphologies (short/long neck, angulated neck) associated with infrarenal and juxtarenal aneurisms.
This research is supported by the Competitiveness Operational Programme 2014-2020, financed from European Regional Development Fund and by the Romanian Government under the project “Next generation computer aided research in cardiovascular disease management–NEXTCardio”, project code: COP p_37_701.
5. Carotid Bypass: a safe solution for high-risk patients with severe bilateral carotid stenosis
C.C. Mutu1,2, S. Costea2, E. Ciobanu3, R. Hulpus1,3 and V.S. Costache1
“Lucian Blaga” University of Sibiu1, cosminmutu@yahoo.com
Academic Emergency Hospital of Sibiu-Neurology, România2
Polisano European Hospital, Sibiu, România3
Background and aims: The long-term results after carotid artery stenting (CAS) and carotid endarterectomy (CEA) are in debate. Carotid bypass (CB) with great saphenous vein [GSV] or is an alternative treatment for patients with severe bilateral atherosclerotic carotid stenosis. The aim of this study was to investigate early and late outcomes associated with CB in this population.
Methods: We present a prospective study based on observation of 23 patients (mean age 61.6 years) who received internal carotid artery (ICA) bypass surgery from March 2014 to December 2015 for the treatment of severe carotid stenosis. At month 3, 6, 12 and yearly after, a cervical ultrasonography exam was performed. The average duration of observation was 19 months (6 to 24 months’ period).
Results: 22 patients had ICA stenosis >70%, 1 patient presented stenosis between 60–70%. 5 (22%) patients presented the opposite ICA occlusion, 12 (52%) the opposite side ICA severe stenosis and 6 presented moderate contralateral stenosis. 18 (78.3%) patients were symptomatic presenting transient or previous ischemic stroke, 5 (21.7%) were asymptomatic, atherosclerotic carotid disease being discovered during investigations for coronary stenting. Perioperative complications (none fatal) occurred in 1 (4.3%) patient (1 cervical hematoma requiring drainage), while 4 patients presented cardiac paroxysmal arrhythmia. There were no neurological complications or restenosis during follow-up.
Conclusions: Carotid bypass is an efficient and safe surgical technique for high risk patients with severe carotid atherosclerotic disease that are not eligible for CEA or CAS, with acceptable peri-procedural complications and excellent long-term patency rates.
6. Current approaches for complex aortic arch diseases – TEVAR. MFM and hybrid procedures
H. Moldovan1, R. Niculescu2, S. Balanescu3, C. Spanu4, D. Popescu5, M. Craciun6, S. Rurac7, G. Vasile8, A. Ionescu9, T. Cebotaru10, C. Popa11, M. Militaru12, A. Molnar13 and V.S. Costache14
SANADOR Hospital Bucharest (1,2,4,5,6,7,8,9)
MONZA Hospital Bucharest (3,10,11), smbala99@hotmail.com
Constanta Clinical Hospital12
N.Stancioiu Heart Institute – Cluj Napoca13
“Lucian Blaga” University, Sibiu14
Background: Compared to open surgical treatment, isolated endoprosthesis (TEVAR) or multilayer flow modulator (MFM) or hybrid approaches for complex thoracic aortic diseases with implication of the aortic arch became recently more and more common in current treatment protocols in many specialized centers.
These methods proved to have lower morbidity and mortality, with good short and long term outcome.
Objectives: To evaluate these techniques and results in complex thoracic aorta disease involving the aortic arch such as: aneurysms of the thoracic aorta and type B Stanford aortic dissection.
Methods: Between 2004–2017, 26 patients were diagnosed and treated for complex thoracic aorta disease, mainly type B Stanford aortic dissection (20 patients – 76,92%) and thoracic aorta aneurysms (6 patients 23,1%). 24 of them were men (92, 3%) and 2 (7,7%) were female with a mean age 54 yo (27 – 78 yo). Main cardiovascular risk factors were severe or poorly controlled arterial hypertension and systemic atherosclerosis. After angio-CT evaluation scans, inadequate landing proximal zone indicated the need for surgical revascularization of one or more aortic arch vessels in 8 patients (30.7%) prior to endovascular repair. Aortic arch vessels were bypassed in a surgical operating room, followed by the endovascular procedures in a cath lab. Occasionally the by-pass procedure was performed in the cath-lab after the decision to cover both the left common carotid and left subclavian artery with the EVG. The EVG used are: Medtronic Valiant in 6 cases, Evita Open – jotec in 3 and Endomed in 1 case. In 13 cases MFM stents were used.
Results: The technical success was achieved in all cases. No deaths occurred so far in-hospital or at 30-day follow-up. No endoprosthesis migration was noticed in those patients in which FU CT was performed. There were 4 cervical hematomas with no special treatment (50%) of those with debranching. 3 patients required CSF drainage (one with total coverage of the descending thoracic aorta from the left common carotid to the celiac trunk). One patient required drainage for pericardial effusion and one had distal aortic and bilateral iliac thrombosis, due to femoral access complication which required urgent revascularization by axillo-femoral bypass.
There were no neurological complications (paraplegia, stroke), no acute renal failure, no infection and no need for surgical conversion.
The longest follow up is more than 13 years and all treated patients are alive.
Conclusion: Isolated endoprosthesis (TEVAR), multilayer flow modulator (MFM) or hybrid procedures are a safe option in the treatment of complex aortic type B dissections different etiology (TAA, of post-traumatic, severe high BP) and thoracic aorta aneurysms involving the aortic arch, with low mortality and good procedural success. Further studies and longer follow-up are needed to establish the role of this complex procedures in the management of aortic dissection and aneurysms.
This research is supported by the Competitiveness Operational Programme 2014-2020, financed from European Regional Development Fund and by the Romanian Government under the project “Next generation computer aided research in cardiovascular disease management–NEXTCardio”, project code: COP p_37_701.
7. Minimally invasive approach for acute lesions of the mitral valve – should sternotomy be abandoned?
V.S. Costache1,2, C. Condac1, E. Ciobanu1, S. Batar1, C. Leatu1 and R. Hulpus1
1Polisano European Hospital Sibiu
2Lucian Blaga University Sibiu, victorscostache@gmail.com
Background: Minimally invasive approach to mitral valve surgery is used today in many centers all around the world with excellent results. Available studies show better results compared to conventional surgical approach such as reduced pain, early recovery, low mortality and better cosmetic appearance.
Methods: We analyzed two cases treated with success last month by minimally invasive approach for acute lesions of the mitral valve in Polisano European Hospital Sibiu. The first case was a 26-year-old female with a history of tonsillitis, postpartum with fetus prematurely born with caesarean section of necessity who suddenly developed an acute pulmonary edema due to acute endocarditis with severe mitral regurgitation secondary to ruptured chordae tendineae. The second patient was a 57-year-old man with severe mitral regurgitation secondary to ruptured Chordae without coronary heart disease with mild renal insuficiency at admission. The two patients benefited of minimally invasive mitral surgery.
Results: For the first patient, a replacement of the mitral valve with a mechanical prosthesis Saint Jude no. 27. was practiced through a minimally invasive approach (right mini-thoracotomy). Postop the patient had a very good subsequent evolution under antibiothics with remission of the inflammatory syndrome but the implantation of a pacemaker for a total AV block was needed. The patient was discharged two weeks post (prolonged admission for total block management.) A mitral annuloplasty with a complete ring and insertion of 4 Gore-tex neochordae through a minimally invasive approach – right miniatricotomy in the IVth intercostal space was performed for the second patinet. The postop evolution was simple with very good ultrasound result – no regurgitation, an average gradient of 6 mmHg.The patient left the hospital 8 days later.
Conclusion: Minimally invasive approach for acute lesions of the mitral valve has proven durable in our small series but future research should warrant validation in larger cohorts.
Screening out patients who are not appropriate for performing minimally invasive surgery is mandatory. Preop detailed planning of surgical procedure is desirable minimally invasive surgery being time-consuming.
8. Trans-ventricular mitral replacement and geometric reconstruction of the left ventricle for giant inferior left ventricle aneurysm after posteroinferiorly myocardial infarction with severe mitral regurgitation
H. Moldovan1, S. Rurac1, R. Deac1, D. Popescu1, V. Jitari4, C. Scarlat1, A. Ionescu1, R. Niculescu1, C. Spinu1, G. Vasile1, E. Nechifor1, L. Iliuta3 and E. Rusu2
SANADOR Hospital1
Titu Maiorescu University, Faculty of Medicine2, elenarusu98@yahoo.com
UMF Carol Davila3
Constanta University Hospital4
This article presents a case study of a 47-year-old male with giant inferior left ventricular aneurysm. Aneurysms involving the inferior wall of the left ventricle are relatively rare, and the combination of severe mitral insufficiency as well as inferior wall myocardial infarction usually has a very poor prognosis.
This patient has a stenosis on the proximal LAD and occlusion of the first marginal branch of the circumflex artery. The Echocardiography show a gigantic posterior aneurysm of the left ventricle with a global ejection fraction of 20%. The aneurysmal cavity was larger than the functional left ventricle cavity. Severe mitral regurgitation due to papillary muscles traction.
The patient was in functional NYHA class IV.
The surgical correction was: resection of the aneurysm, trans-ventricular mitral replacement, geometric reconstruction of the left ventricle with a composite patch and left mammary artery by- pass graft on the LAD.
Postoperatively the patient was assisted with intra-aortic balloon pomp and levosimendan.
The evolution was good despite the catastrophic body mass of 140 Kg.
After follow up of 2 years, the patient is asymptomatic, with EF 45% and normal function of the mitral prosthesis.
9. Results of the treatment of stenotic carotid artery disease concomitent with heart surgery
V. Raicea1, L Moraru1,2,3, K. Brinzaniuc2,3 and H. Suciu1,2,3
Clinic of Cardio-Vascular Surgery1
Institute of Cardio-Vascular Diseases and Transplantation Tirgu-Mures2
University of Medicine and Pharmacy Tirgu-Mures3, dr.liviu.moraru@gmail.com
The purpose of this study was to assess the results of the treatment for carotid artery lesions done in the same time with heart surgery by applying these two surgical methods of carotid “eversional” endarterectomy or “patch angioplasty”, wich are the main techniques used for hemodinamically semnificative carotid artery stenosis.
During 2015–2016 in our clinic there were treated with these methods 33 patients (26 males and 7 females) with the average age in between 50–70 years. The eversional techniques was used to 15 patients and the patch angioplasty technique was applied for 18 patients using “autologous vein” in 14 patients, “Core-matrix” in 3 patients and “bovine pericardium” in 1 patient. The ischemic cerebral times were lower in the “eversional” group (average 18 minutes vs 30 minutes), and only in the “patch angioplasty” group the surgery was done with cerebral protection by intravascular “shunt”. The associated lesions were coronary artery disease (27 patients) aortic valve disease (5 patients) and mitral valve disease (1 patient). Postoperatively there were two transient cerebral events and one death.
We can state that both techniques are efficient and they may be used with good results, the “patch” angioplasty method being indicated for complex carotid artery lesions associated with controlateral stenosis of the internal carotid artery meanwhile the “eversional” endarterectomy method is indicated for more localized stenosis associated or not with kinking or coiling but with good retrograde carotid blood flow.
10. Eversional endarterectomy versus patch angioplasty in stenotic carotid artery disease
L Moraru1,2,3, V. Raicea1, K. Brinzaniuc2,3 and H. Suciu1,2,3
Clinic of Cardio-Vascular Surgery1, vraicea2000@yahoo.fr
Institute of Cardio-Vascular Diseases and Transplantation Tirgu-Mures2
University of Medicine and Pharmacy Tirgu-Mures3
The aim of the study is to evaluate the results of the treatment for stenotic carotid artery disease of 50–99% by using these two surgical technique for carotid endarterectomy, wich are the standard procedure for symptomatic patients or for the selected patients with an asymptomatic high-grade carotid stenosis.
During 2015–2016 in our clinic there were treated with these methods 33 patients (21 males and 12 females) with the average age in between 40–75 years. The patch angioplasty technique was used for 22 patients and the eversional techniques was applied to 11 patients. The angioplasty patch was made by “Core-matrix” in 12 patients, “bovine pericardium” in 6 patients and “autologous vein” in 4 patients. In the “eversional” group was no used cerebral protection with intravascular “shunt. Despite that the ischemic cerebral times were bigger in the “patch” group (average 31 minutes vs 19 minutes), there were no deaths or cerebral events postoperatively.
We can conclude that both methods are safe and they may be used with success in selected patients, the “eversional” endarterectomy technique for localized stenosis associated or not with coiling or kinking but with good backward carotid blood flow and the “patch” angioplasty technique for more complex lesions associated with controlateral stenosis of the extra- or intracranial carotid artery system.
11. Endovascular treatment of abdominal aortic aneurysms – actual strategy and follow up
I. Droc1 and R. Dammrau2
Army’s Center for Cardiovascular Diseases, Bucharest,Romania1, idroc2005@yahoo.com
Praxis für Gefäß und Thoraxchirurgie, Rolf Dammrau & kollegen, Duren, Germany2
Purpose: to assess the short and medium term safety and efficacy of endovascular abdominal aortic aneurysms repair (EVAR) in high-risk patients.
By helping patients avoid abdominal surgery, EVAR minimizes the perioperative impairment of cardiac, pulmonary, renal and gastrointestinal function. The greatest potential benefit is in high-risk patients who have large aneurysms and who are poorly suited to any of the current surgical alternatives.
Material and method: We report the results of 55 elective EVAR (endovascular abdominal aortic repair) procedures performed in two vascular surgical centers in Romania and Germany. The mean follow up was 18 months with CT-scan, duplex ultrasound and contrast-enhanced ultrasound.
Results: The prosthesis used were 16 E-vita Abdominal XT, 12 Excluder, 8 Talent, 7 PowerLink, 3 Endurant and 9 custom made fenestrated or branched from Jotec. Primary-assisted technical success rate was 100%. There was 1 non-AAA-related late death. Conversion to open repair was performed in 1 case, as a late conversion for a type III endoleak (at 15 months after EVAR) with aneurysm sac enlargement >8 mm.
Conclusion: These results show that in the modern era of abdominal aortic aneurysm treatment EVAR is safe and effective in high-risk patients, at least during the short to intermediate term.
Key words: endovascular therapy, aortic stent graft, minimally invasive surgery
12. Initial Results of Surgical Therapy for Obstructive Hypertrophic Cardiomyopathy
L.F. Dorobantu1, P. Spirito2, R. Ticulescu1, M. Alexandrescu1, R. Jurcut3,4, B.A. Popescu3,4, A. Fruntelata1, R. Adam4, G. Cerin5, T. Cebotaru1 and P. Ferrazzi6
Cardiac Surgery, Spitalul Monza, Bucharest, Romania1, ludorobantu@gmail.com
Cardiology, Ente Ospedaliero Ospedali Galliera, Genoa, Italy2
Cardiology, “Prof. Dr. C.C. Iliescu” Emergency Institute of Cardiovascular Diseases, Bucharest, Romania3
“Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania4
Cardiology, Clinica S. Gaudenzio, Novara, Italy5
Surgery, Policlinco di Monza, Italy6
Objective: Surgical myectomy dramatically improves quality of life in patients with obstructive hypertrophic cardiomyopathy (HCM) when performed by experienced surgeons at referral institutions. Therefore, we considered it of interest to report here our initial experience with surgical myectomy in Bucharest, Romania.
Methods: At our institution, between May 2015 and September 2016, 17 consecutive patients with obstructive HCM and heart failure symptoms limiting quality of life, age 26 to 67 years (median 47), underwent transaortic septal myectomy associated with cutting of fibrotic secondary mitral valve (MV) chordae, in the absence of additional surgical procedures.
Results: Preoperatively, 6 patients (35%) were in New York Heart Association functional class III-IV and 11 (65%) patients were in class II, basal ventricular septal thickness ranged from 15 to 37 mm (mean 23 + 6 mm), peak LV outflow gradient under basal conditions or with provocative maneuvers ranged from 60 to 160 mm Hg (median 103 mmHg), and grade 3 or 4 MV regurgitation was present in 10 (58%) of the 17 patients. There were no hospital deaths within 30 days after surgery. Each of the 6 patients who were preoperatively in class III-IV, postoperatively had no or mild heart failure symptoms. The remaining 11 patients were free of functional limitation after surgery. Postoperative basal septal thickness ranged from 12 to 17 mm peak LV outflow gradient ranged from 4 to 32 mmHg and was lower than 30 mmHg in 16 (94%) of the 17 patients, in the remaining patient the gradient decreased from 160 mmHg preoperatively to 35 mmHg postoperatively. MV regurgitation was absent or mild in 16 patients after surgery, and remained moderate-to-severe (grade 3) in one. An average of 3 MV secondary chordae was resected.
Conclusions: Transaortic ventricular septal myectomy substantially improved symptoms, abolished the LV outflow gradient, and reduced or abolished MV regurgitation in over 90% of our patients with obstructive HCM.
13. Early Carotid Endarterectomy as therapy of patients with symptomatic severe carotid stenosis, a case series report
C.C. Mutu1,2, O. Bardac1, E. Ciobanu3, A. Costache1,3, V.I. Suciu2 and V.S. Costache1,3
“Lucian Blaga” University of Sibiu- Faculty of Medicine1, cosminmutu@yahoo.com
Academic Emergency Hospital of Sibiu, Neurology Clinic, CVASIC Research Center, România2
Univeristy L. Blaga Sibiu, Sibiu, România3
Background and aims: Carotid artery stenting and carotid endarterectomy are the techniques used in treating severe carotid stenoses. CEA is considered the first line of treatment for severe, symptomatic carotid artery stenosis. CEA is recommended in the next 2 weeks after a transient ischemic attack or an ischemic stroke. The aim in this article is presenting a first analysis of outcomes of CEA.
Methods: We designed a prospective, ongoing, in progress of enrolling, long-term observational study of patients who were treated using CEA technique for severe carotid stenosis, in the first two weeks after their neurological event (TIA or ischemic stroke). Carotid ultrasonography was performed at 3, 6, 12 months, then yearly after surgery. The surgical procedure was performed in the Cardiovascular Department of Polisano Hospital, Sibiu, Romania, and follow-up ultrasound examinations in the Academic Emergency Hospital, Sibiu.
Results: We present 35 patients (mean age 66 years), enrolled starting February 2014 until December 2016. 31 patients were with severe ICA stenosis (>70%) of which 6 had preoclusive stenosis (≥95%). 4 patients had 60–69% ICA stenosis. 25 patients (71.4%) had previous TIA and 16 patients (64%) had ischemic stroke. Early perioperative incidents (none fatal) occurred in 3 patients (8%): 1 ipsilateral ischemic stroke (remitted by thromboaspiration), 1 hypertensive crisis and 1 pneumonia. There were no neurological complications or restenosis discovered during follow-up.
Conclusions: CEA is an efficient and safe technique for patients with severe carotid atherosclerotic disease. CEA has acceptable peri-procedural incident risk levels and high patency rate.
14. Aorto Bi/Uni - Femoral Infected By Pass – A Review of Therapeutic Possibilities
I.-M. Cazan1, L.G. Baroi1, C. Strobescu-Ciobanu1 and R.F. Popa1
1“Gr. T. Popa” University of Medicine and Farmacy, Iasi, rfpopa2008@yahoo.com
The 1–6% percentage of prosthetic infection is difficult to quantify due to the possibility of late onset infections (greater than 10 years). The infection of the aorto – uni/bifemoral by-pass represents one of the most serious complications in vascular surgery, it being associated with an up to 50% mortality rate, up to 20% amputation rate, and an reoccurrence of infection of up to 22%.
We are going to discuss a series of cases of localised unilateral infection, situated in Scarpa’s triangle. The infections appeared either during the first 3 months after the initial implantation of the graft, or later after 2 years. The cases span over a period of 10 years covering a total number of 226 patients with aorto-uni(bi)lateral grafts. Our treatment of choice was to use autologous material (superficial femoral vein), as replacement for the partially infected graft. Another surgical treatment chosen was mioplasty with rectus abdominis. The patients received pre- and postoperative intravenous antibiotics in accordance to the cultures taken from the infected wound, up to a period of 2–3 weeks, followed by another 6 weeks of oral antibiotics after discharge.
The major advantage of the femoral veins is its high resistance to infection (the re-infection was zero). Localized partial graft infections are a reality, confirmed by clinical, biological, ultrasound examinations, intra-operative explorations and postoperative results achieved by selective surgical resection.
15. Technical options for the surgical management of extracranial carotid artery aneurysms
L.G. Baroi1, R.F. Popa1 and C. Strobescu-Ciobanu1
1“Gr. T. Popa” University of Medicine and Farmacy, Iasi, rfpopa2008@yahoo.com
Over a period of five years in Vascular Surgery Clinic – Hospital “St. Spiridon” Iasi, Romania, were operated five patients with atherosclerotic aneurysm of internal carotid artery – extracranial portion. Three cases were a surgical emergency: one case of expansive hematoma caused by a diagnostic puncture and two cases with signs of acute hemorrhagia due to rupture of the aneurysm, showing progressive expansion of aneurysm. Two cases were presented with phenomena of local compression (dysphonia, dyspnea).
Patients were examinated preoperatively by Doppler ultrasound and spiral CT angiography. All patients received surgical treatment. Surgery consisted on partial aneurysmectomy, restoration of the internal carotid artery by venous graft interposition in three cases, end-to-end anastomosis in one case and venous patch angioplasty in one case. In all cases was used an intraluminal shunt Pruitt-Inahara. Three patients were followed at one month postoperatively by CT angiography and at 1, 3, 6, 12, 24 months by echo-Doppler, two of whom were followed by echo-Doppler to a month. No intraoperative deaths recorded. Primary permeability was 100%.
Classic surgical treatment remains the method of choice in the management of the internal carotid artery aneurysm extracranial portion complicated by rupture. Vein graft is preferred for interposition (less chance of infection). MR angiography or angio-CT three-dimensional spiral reconstruction allow an anatomical view of the aneurysm. Duplex ultrasound can be used as first intention in the preoperative diagnosis and postoperative follow-up.
16. Extremity vascular trauma management always a challenge
C. Strobescu-Ciobanu1, I.-M. Cazan1, L.G. Baroi1 and R.F. Popa1
1“Gr. T. Popa” University of Medicine and Farmacy, Iasi, rfpopa2008@yahoo.com
Vascular traumatic lesions require immediate transfer, exploration and treatment in a Vascular Surgery Department. These lesions can be life and limb threatening. The management implies two main targets: active bleeding cessation and restoring vascular continuity with acute ischemia remission.
The paper is based on a retrospective study on 63 consecutive patients admitted in the Vascular Surgery Department for extremity vascular trauma, between 2011 and 2016. Patients were mostly male (82,50%), from the countryside (77,77%), age median being 45 years. The mechanisms were diverse. 55.50% of vascular lesions were caused by wounds (stabbed, cut), the other 44,50% being due to blunt trauma (crush mechanism, vehicle trauma, sprains, fractures). Both upper and lower limb were involved equally. Most frequently affected arteries were brachial (21cases) and axillar artery (13cases) for the upper limb and respectively popliteal (12 cases) and femoral artery (8 cases) for the lower limb. The arterial lesions were accompanied in 13 cases by nervous lesions and in 14 cases by venous lesions. In 5 cases the entire vascular-nervous bundle was involved. Patients benefited from angioplasty, termino-terminal anastomosis, interpositions, bypasses or just exploration and in situ haemostasis. 81,53% cases had favourable evolution, 13,84% needed major amputations and 6,15% patients died.
Prolonged ischemia, hemorrhagic shock, reperfusion syndrome accompanied by renal or hepatic impairment are factors that highly correlate with amputation and death.
17. Predictors of poor quality of life in Patients who had Primary Lower Limb Deep Venous Thrombosis
F.A. Shaikh1, S Nazeer1, N.A. Siddiqui1 and Z. Sophie1
1Aga Khan University Hospital (AKUH), Karachi, Pakistan, fareed.shaikh@aku.edu
Introduction: Prolonged swelling and pain are frequently encountered sequels of deep venous thrombosis (DVT). There are studies from developed nations which report worsened long term quality of life after DVT, but literature from low income countries is scarce.
Objective: To determine predictors of poor long term quality of life as measured by Veins Quality of Life questionnaire in patients who had primary lower limb deep venous thrombosis.
Methodology: This study was conducted at department of surgery, Aga Khan University Hospital, Karachi. All adult patients (16 to 75 years), admitted in hospital with primary lower limb DVT from Jan 2005 to Dec 2012 were included. Those with missing records were excluded. Participants visited clinic where evaluation regarding post thrombotic syndrome was done using Vilalta score and self-reported quality of life was assessed using VEINES quality of life questionnaire.
Results: Of 125 patients included, 57 (45.6%) were males. Mean age was 41.3 +/- 9.2 years. Mean follow up was 699 +/- 585 days. Post-thrombotic syndrome (PTS) was present in 49 (39.2%). Mean score of VEINES Quality of Life questionnaire was 48.11 +/- 10.65. At univariate level Ileofemoral DVT, complete occlusion of vein, development of PTS, poor control of INR, poor compliance with compression stockings and obesity turned out to be significant. Severity of PTS, Ileofemoral DVT and poor control of therapeutic anticoagulation were only independent predictors in our study.
Conclusion: Prevention and management of post-thrombotic syndrome and compliance with anticoagulation and potentially improve quality of life of those who suffered from DVT.
18. Surgical treatment in combined carotid and coronary disease
I. Droc, S. Deaconu1, E. Dumitru1, C. Buzila1, V. Murgu1 and L. Stan1
1Central Military hospital, Bucharest, Romania, idroc2005@yahoo.com
Introduction: Lacking randomised trials, a major controversy remains the optimal management of patients who present concomitant carotid and coronary artery disease.
Objective: The main question is whether staged or simultaneous endarterectomy (CEA) will reduce peri-operative morbidity and mortality after cardiac surgery. The reported results were encouraging using either of the two strategies, but there is no consensus as to which is preferable. Recently carotid artery angioplasty with stenting (CAS) represents a potential alternative to CEA mostly in ‘high-risk for CEA patients. CAS offers a less invasive, safer therapeutic option for cardiac patients who underwent or will underwent CABG. In some particular situations a strategy of CAS + CABG might be harmful. In particular, the need for dual antiplatelet therapy after CAS can be balanced with avoiding unnecessary bleeding complications after cardiac surgery.
Material and method: During a 1-year period, between 01.01.2012 – 31.12.2012, 375 consecutive patients were referred for coronary surgery. 49 patients (13.3%) were found to have combined carotid and coronary disease. 37 patients (10%) underwent staged carotid endarterectomy (CEA) and coronary artery bypass grafting (CABG), with a mean of 30 ± 6 days between the interventions, and 12 patients (3.3%) underwent CABG and CEA simultaneously. Outcomes were assessed in both groups in terms of morbidity and all-cause mortality.
Results: The mean age was 62.8 ± 4.7 years and 32 patients (65%) were males. The majority of the cases (82%) presented triple vessel disease and 16.7% had left main disease. The carotid disease was unilateral in 43 patients (87.7%) and bilateral in 2 (4%). 36 patients (74.0%) were neurologically asymptomatic. In the staged CEA – CABG group 1 patient had a stroke (2.7%), 2 patients myocardial infarction (5.4%) and 2 patients died of other causes (5.4%). In the combined CEA-CABG group 1 patient (8.5%) died of non-cardiovascular related causes. The reported overall morbidity and mortality after staged procedures is 19.2%(Randall, 2006) and after simultaneous procedure is 17.4% (Rutherford 2005).
Conclusion: In conclusion, the presence of carotid stenosis is per se a marker of risk. Previous or simultaneous CEA/CABG prevents stroke better than delayed CEA. An individual surgical approach based on specific risk profiles is recommended. There is a need for a randomized controlled trial focusing on combined or staged surgical approach or endovascular therapy.
19. Endovascular management of the failing low limbs bypasses – Clinical Republican Hospital experience
E. Bernaz1,2, R. Cemirtan2, S. Ungureanu1,3, A. Turcan2, D. Jardan2 and T. Melnic4
1State Medical University of Medicine and Pharmacy “Nicolae Testemitanu”, Republic of Moldova, ed.bernaz@gmail.com
2Department of Vascular and Endovascular Surgery, Republican Clinical Hospital, Chisiniau, Republic of Moldova
34th Surgical Department, Republican Clinical Hospital, Chisiniau, Republic of Moldova
4On Clinic Moldova)
Objective: Asses the endovascular treatment efficiency in failing low limb bypasses.
Materials and methods: This clinical prospective study began in 2016 and includes by now 12 patients, aged 55–72 years, all males, with III Fontaine -4th Rutherfort (ABI < 0.4) ischemia – 3 patients, IIB Fontaine -3rd Rutherfort (ABI < 0.8) ischemia – 11 patients. ABI, duplex scanning and/or angiography were used preoperatively and in postoperative surveillance (at 1, 3 and 6 months).
Results: The study revealed 2 cases (16.6%) with common iliac artery stenosis above the central anastomosis in ilio-femural bypass(IFB), 1 case (8.3%) with external iliac artery stenosis above the cross-over IFB, 2 cases (16.6%) with venous femuro-popliteu bypass(FPB) stenosis, 3 cases (25%) with popliteal artery stenosis at the level of distal FPB anastomosis, 2 cases (16.6%) with politeal artery stenosis below the distal FPB anastomosis, 2 cases (16.6%) with tibial arteries stenosis/occlusion and a patent FPB. The patients with lesions in the aorto-iliac segment were treated by brachial approach, the infrainghinal lesions by cross-over femoral approach. 66% of the patients were operated with PTA and stenting; 4 patients with popliteal artery (P3) and tibial arteries stenosis/occlusion – PTA alone.
Results: The immediate postoperative results were assessed by clinical evaluation and ABI measurement. Postoperative ABI was >0.9 for all the patients; overall mortality and procedural related mortality were null. Complications: 1 case with infrainghinal hematoma treated conservatively.
Conclusions: The endovascular revascularizations are reasonable and efficient methods of treatment in failing low limbs bypasses. Brachial approach is a safe option in iliac lesions.
20. Catheter-directed thrombolysis for the salvage of the acute lower ischemic limbs
G. Țăranu1, A. Rata1,2, M. Manda1, A. Tutelcă3 and M. Ionac1,2
1Clinic of Vascular Surgery and Reconstructive Microsurgery, “Pius Branzeu” Emergency Hospital, Timișoara, mihai.ionac@gmail.com
2Department of Methodology of Scientific Research, Vascular Surgery and Microsurgery, “Victor Babes” University of Medicine and Pharmacy, Timișoara
3Department of Radiology, “Pius Branzeu” Emergency Hospital, Timișoara
Objective: Acute lower limb ischemia (ALI) may be treated by open or endovascular surgery. The aim of the presentation is to present the results of catheter-directed thrombolysis (CDT) in the treatment of ALI.
Materials and methods: From March 2016 until March 2017 we performed 36 CDTs in 10 females (27.77%) and 26 males (72.23%), aged between 29 and 91 (median age of 69,97). Indications included arterial thrombosis – 31 cases (86.11%), occluded bypass – 4 cases (11.11%) and 1 thrombosed popliteal aneurysms (2.7%). The access site was: ipsilateral femoral artery – 26 cases (72.23%), brachial artery – 7 cases (19.44%) and femoral crossover (8.33%). Adjunctive percutaneous interventions were performed in 8 cases – 7 balloon PTAs (19.44%) and 1 balloon PTA with stent placement (2.77%).
Results: We noted 11 immediate complications: 5 in-hospital deaths (13.88%), 1 stroke (2.77%), 2 myocardial infarctions (5.55%) and 3 groin hematomas (8.33%). The limb salvage rate at 3 months was 75% (27/36).
Conclusions: Thrombolysis combined with other endovascular techniques improves the effectiveness of the method and may save limbs that otherwise would be amputated.
21. The evolution and challenges of carotid surgery procedures in a regional vascular service
G. Tăranu1, A Rata1,2, N. Roicov1 and M. Ionac1,2
1Clinic of Vascular Surgery and Reconstructive Microsurgery, “Pius Branzeu” Emergency Hospital, Timișoara, mihai.ionac@gmail.com
2Department of Methodology of Scientific Research, Vascular Surgery and Microsurgery, “Victor Babes” University of Medicine and Pharmacy, Timișoara
Objective: The increasing number of strokes from carotid territory worldwide, with Romania in top positions and the social and economic burden due to consecutive disability requires clear guidelines for treatment and recovery. Screening in general population has become obsolete and was replaced with risk scorecards. Despite the fact that GALA study showed no differences between general and local anesthesia, there is still an ongoing debate between vascular surgeons regarding this topic, especially about neurological assessment during surgery. Cerebral hyperperfusion syndrome (CHS), treatment of post-CEA hypertension, revascularization after stroke are other topics that this presentation aims to discuss.
Materials and methods: In the last 8 years we performed 292 CEAs, using in 81% of the cases the eversion technique. Major complications included 3 in-hospital deaths due to postoperative acute stroke and one due to uncontrollable CHS, with an overall mortality of 1,7%.
Results: Minor complications included hematoma 7.19% of cases and cranial nerves lesions 3.7% of cases. Challenges in establishing a surgical treatment in carotid disease included severe difficulties in referral of the patients with surgical indication from neurology departments. The surgical treatment evolved from general to local anesthesia, from patch angioplasty to eversion endarterectomy, from asymptomatic to symptomatic patients, including emergency CEAs.
Conclusions: There is still a great need to advocate the beneficial role of CEA in selected asymptomatic and symptomatic to the referral neurologists and cardiologists.
22. Introducing endovascular procedures in the vascular surgery practice – initial results
G. Taranu1, N. Roicov1, A. Manesc1, A. Rata1,2, A. Covaci1, A. Tutelca3 and M. Ionac1,2
1Clinic of Vascular Surgery and Reconstructive Microsurgery, “Pius Branzeu” Emergency Hospital, Timișoara, mihai.ionac@gmail.com
2Department of Methodology of Scientific Research, Vascular Surgery and Microsurgery, “Victor Babes” University of Medicine and Pharmacy, Timișoara
3Department of Radiology, “Pius Branzeu” Emergency Hospital, Timișoara.
Introduction: Percutaneous therapy has been gradually adopted as an alternative to primary amputation in persons unsuitable as surgical candidates or has been used as a primary procedure. Although there has been an explosion in endovascular technology worldwide, in Romania these procedures are traditionally and incidentally performed by interventional radiologists or cardiologists. We present the initial results and challenges of endovascular procedures in a regional vascular service.
Materials and methods: Between Jan. 2016 and April 2017, a total of 259 patients (173 men – 66.79% and 86 females – 33.21%, aged between 29 and 91) were treated by endovascular procedures. There were performed a total of 263 procedures: 92 balloon angioplasties (34.98%), 49 balloon angioplasties and stenting (18.63%), 36 catheter-directed intraarterial thrombolysis (13.89%), 1 renal artery angioplasty (0,3%) and 2 EVAR procedures (0,77%) and 83 diagnostic angiographies (32.04%).
Results: In the angioplasty +/- stenting groups we obtained an immediate success rate of 97,6% at 30 days. In 2 cases, we abandoned the endovascular surgery and converted to open surgery. The follow-up was on a period of 1 to 5 months, with an average of 3 months. During the follow-up period the complications were: 2 major amputations and a restenosis case after a balloon angioplasty that benefited from re-intervention and stenting.
Conclusion: Endovascular techniques should be indicated and performed by the vascular surgeons, that are able to set a correct indication for treatment, are able to expand these indications as experience grows and are able to deal with intra and postprocedural complications.
23. The Vasculoplastic Concept for Higher Rates of Limb Salvage
A. Rață1,2, S. Barac1,2, G. Țăranu2, A. Nistor1 and M. Ionac1,2
1“Victor Babeș” University of Medicine and Pharmacy Timișoara, mihai.ionac@gmail.com
2Clinic of Vascular Surgery and Reconstructive Microsurgery, “Pius Branzeu” Emergency Hospital Timișoara
Introduction: The number of lower limb amputations due to vascular disease is continuously rising. Despite successful revascularization, there is a group of patients that may underwent amputation due to large ischemic soft tissue defects. The vasculoplastic concept combines the skills and techniques of vascular and plastic surgery. It consists of revascularization and ischemic wound reconstruction through plastic surgical techniques.
Materials and methods: We performed a retrospective study on 352 patients (80 females – 22.72% and 272 males – 77.27%) who underwent infragenicular bypass procedures, between 2006 and 2012. Median age was 66.37, ranging between 25 and 90. Most of the patients presented with rest pain and gangrene (Leriche-Fontaine stages IIB – 16.76%, III – 25.85%, and IV – 55.1%). The outflow sites for revascularization were: posterior tibial artery 42.89%, peroneal artery 39.48%, anterior tibial artery 10.79%, and tibial-peroneal trunk 6.81%. Long saphenous vein graft was used in most of the procedures. Analysis of graft patency, limb salvage and patient survival was performed; the primary endpoint was the rate of major amputations and the secondary endpoints were the mortality and morbidity at 1, 3, 6 and 12 months. The early patency rate (within 30 days) was 94.32%. At 12 months, the patency rate was 79.2%. 14 patients died at 30 days and 12 patients within the follow-up period of 36 months.
Between the same period we performed 31 plastic procedures in patients with stage IV disease.
Results.We performed 5 free flaps (3 lattisimus dorsi and 2 serratus anterior), 8 local perforator flaps (7 peroneal and 1 tibial anterior perforator) and 19 fascio-cutaneous flaps. After a mean follow up of 36 months 11% of the reconstructions (3 perforator flaps) failed, but the overall percentage of limb salvage was 78.6%.
Conclusion: The vasculoplastic approach combines the skills and techniques of vascular and plastic surgery and improves the overall limb salvage rate, avoiding major amputation.
24. Mesenteric Infarction – Simplified Technique of Antegrade Superior Mesenteric Artery Embolectomy: Report of Two Cases and Review of the Literature
O.D Bardac
First Surgical Clinic, Sibiu County Emergency University Hospital, obardac@gmail.com
Introduction: Acute mesenteric ischemia (AMI) represents one of the relatively rare causes of acute abdomen. Its incidence rises with age being more frequent in the elderly. Although the early recognition of AMI could bring important benefits regarding patients survival in most of the cases the intestinal gangrene is already installed at the moment of presentation. The average mortality rate is around 70% being as high as 90% in cases where the intestinal infarction is installed. The aim of this paper is to present a literature review of the AMI and to propose a simplified technique of antegrade distal superior mesenteric artery (SMA) embolectomy that can be easily performed by the general surgeon.
Materials and methods: Two cases of mesenteric infarction were reviewed retrospectively. In both cases an extensive necrosis of the small bowel due to acute SMA occlusion was noted. The segmental enterectomy with anastomosis was accompanied by a SMA embolectomy. A good arterial blood flow was obtained in both cases but only one of our patients recovered. For the second patient, the severe septic shock proved to be irreversible. AMI remains a severe condition with extremely poor prognosis.
Key words: acute mesenteric ischemia, superior mesenteric artery, embolectomy, enterectomy
25. Vascular patch material alternatives from surgical wound in carotid endarterectomy
R. Cemirtan2, E. Bernaz1,2, S. Ungureanu1,3, D. Jardan2, T. Melnic4 and V.S. Costache5
1State Medical University of Medicine and Pharmacy “Nicolae Testemitanu”, Republic of Moldova, ed.bernaz@gmail.com
2Department of Vascular and Endovascular Surgery, Republican Clinical Hospital, Chisiniau, Republic of Moldova
34th Surgical Department, Republican Clinical Hospital, Chisiniau, Republic of Moldova
4On Clinic Moldova)
5“Lucian Blaga” University of Sibiu, Faculty of Medicine
Introduction: Stroke is the 3rd leading cause of death among the adult population. Carotid artery stenosis is responsible for 25–30% of ischemic strokes. According to the latest guidelines, carotid endarterectomy is still the treatment of choice, comparing with carotid artery stenting and has a proven benefit in carotid artery stenosis >70%. It is a fact that carotid artery patch reduces the risk of restenosis, which is significantly less (p < 0.01) in biological patches, compared with synthetic ones. At the same time, suppurative complications of the surgical wound can be devastating when synthetic patch is used. The great saphenous vein is the best autologous vascular material, but it must be preserved for cardiac surgery or arterial peripheral bypasses. Vascular patch material alternatives identification, desirable from the same cervical access wound, is needed.
Materials and methods: This is a prospective clinical study, beginning from 2015. A total of 22 patients, 18 (81,8%) men and 4 (7,2%) women, aged 38–69 years, underwent a unilateral carotid endarterectomy with autologous vascular patch material from the cervical surgical wound. In 11 (50%) cases we used as a vascular material patch the superior thyroid artery, in 8 (36,4%) – the double walled external jugular vein, in 2 (9%) – the double walled facial vein and in 1 (4,6%) case the occluded and endarterectomized external carotid artery. All interventions were performed under general surgery and in 16 (72,7%) cases, the Pruit-F3 carotid shunt was used.
Results: Overall 30-day mortality was null. All patients were evaluated neurologically and by Doppler-ultrasound in the postoperative period, after 30, 90 and 180 days. There were no strokes or transient ischemic attacks. One wound hematoma occurred, but was managed conservatively. All carotid arteries were patent, free of restenosis. In the group of superior thyroid artery the T3, T4 and TSH hormones have been normal.
Conclusions: The autologous vascular patch material from surgical wound can be used and have surgical, biological and economic advantages.
26. Sternotomy in cardiac surgery: the end of an era?
F.L. Dorobantu1, C. Popa1, F. Steiu1, A. Dermengiu1, M. Ghiulea1, A. Muresan1, C. Steiu1, O. Ghenu1, A. Fruntelata1 and T. Cebotaru1
1Monza Hospital, Bucharest, Romania, ludorobantu@gmail.com
Introduction: The median sternotomy still represent the main access way for cardiac surgery. The complications, like mediastinitis or the simply mechanical dehiscence, still have important mortality/morbidity rates. In our unit we are using alternative access ways, right anterior thoracotomy (RAT) or upper hemisterotomy (UHS).
Materials and methods: Between Aug 2013- Jan 2016 we operated 381 patients using alternative access ways: 185 mitral vave plasties using RAT, 72 aortic valve replacements (AVR) using UHS and 68 using RAT, 16 aortic replacements using UHS and 4 RAT, and 36 MIDCAB using left minithoraotomy.
Results: In hospital mortality 1,04%, mean ICU stay 3 days; no woond complications were noted.
Conclusions: Alternative access ways may represents a better alternative to median sternotomy in cardiac surgery.
27. Endovascular treatment of varicose veins using steam ablation
I. Droc1 and R. Milleret2
1Central Military Hospital, Bucharest, Romania, idroc2005@yahoo.com
2Vascular Surgery Department, Clinique Saint Jean, Montpellier, France
Introduction: Steam is the latest of the thermal endovenous techniques to enter clinical use. It was introduced in 2008 as a cheaper but as effective alternative to laser and radio-frequency. The principle is to inject in the vein pulses of water vapors at 120°C, each pulse delivering 60 joules of energy in the lumen. Steam is injected under pressure: the first pulse dislodges the blood, the next ones heat the vein wall. A stainless-steel catheter of 5F gauge is used, it is flexible enough to navigate through tortuosities without using a guide wire. Two lateral holes close to the tip eject the steam, avoiding the risk of heating deep veins when heating the junctions. A comparative animal study by S. Thomis and all. showed that immediate shrinking was more pronounced with steam than with Closure Fast ® radio frequency catheter and 1470 nm TULIP fiber® laser. Perivenous damage was less seen, although the number of cases was not sufficient to obtain statistical significance. R.Milleret published the results of a multicenter study performed in France. Obliteration rate at 6 months was 96%. A multicenter study of tributary ablation showed, with less pigmentation and inflammatory reactions than after foam sclerotherapy with 97% closure rate at 6 months. A second generation device allows elective ablation of tributaries and reticular veins (Miravas®).
Materials and methods: We present a retrospective study on one year period (jan.2015-jan 2016) in one single center (Army’s center for cardiovascular surgery, Bucharest) on 46 pat., with the mean age of 42. The veins treated were internal saphenos vein 39 pat (84.8%), external saph.vein 4(8.7%) and reinterventions 3(6,5%). The follow up was at 7days, 3 months, 6 months and one year by duplex scan. 96% of veins treated were occluded at one year.
Conclusion: Steam ablation is a safe alternative to other thermal techniques. It can be applied to treat great saphenous vein or small saphenous vein, as well as tributaries or reinterventions after surgery.
28. Major Risk Factors Influencing the Surgical Outcome Among 207 Consecutive Patients with Infrarenal Aortic Aneurysm
A. Molnar1,2, C. Trifan1,2, D. Săcui1, V.S. Costache3 and H Moldovan4,5
1Cardiovascular Surgery Clinic, “Niculae Stancioiu” Heart Institute, Cluj-Napoca Romania, adimolnar45@yahoo.com
2“Iuliu Hatieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania
3“Lucian Blaga” University of Sibiu, Romania
4“Titu Maiorescu” University, Bucharest, Romania
5Sanador Hospital, Bucharest, Romania
Introduction: Abdominal aortic aneurysms represent a common ilness, with an increasing prevalence in the last years. Unfortunately, the mortality rate in ruptured abdominal aortic aneurysms has also increased. The aim of this retrospective study was to determine the risk factors that might influence the surgical outcome of these patients, especially the perioperative survival.
Materials and methods: In this study, we included 207 consecutive patients with infrarenal aortic aneurysm, who underwent elective repair (for chronic aortic aneurysm) or emergency repair (for ruptured aortic aneurysm), in the Cluj-Napoca Cardiovascular Surgery Clinic between January 2003 and December 2016. We studied the associated diseases and perioperative complications among the studied population.
Results: The perioperative mortality in the elective repair group was 5.3% (7/132), while in the emergency repair group was 46,66% (35/75).
Conclusions: Ruptured abdominal aortic aneurysm continues to represent a dramatic condition associated with substantial risks and high mortality. It is therefore necessary that selective screening is performed and elective repair is indicated for the improvement of the survival rate of patients with infrarenal aortic aneurysm.
29. Minimally invasive cardiac surgery-Anesthesia point of view
C. Condac1 and E. Busila1
1Departament of Anesthesiology, European Hospital Polisano, costi_cyg@yahoo.com
Introduction: Minimally invasive cardiac surgery (MICS) provides many advantages over standard approaches, starting with less surgical trauma, reduced scar, lesser pain, shorter ICU and hospital stay with improved postoperative recovery. The Anesthesiologist’s job becomes more demanding and challenging with the variety of cardiac lesions, techniques and surgical incisions, continuous evolving with the innovations in MICS.
Materials and methods: Preoperative evaluation could reveal important risk factors (aortic ateroma, congestive cardiac failure, pulmonary hypertension, chronic lung disease, previous cardiac surgery) and reconsider surgical approach. Research for hiatal hernia and varices would preclude the use of transesophageal ecocardiography (TEE). Evaluation of pulmonary function and arterial blood gas are required for single-lung ventilation: not recommended in patients with resting hypercarbia (PaCO2 >50 mmHg), hypoxia (PaO2 <65 mmHg on room air) significantly lower forced vital capacity, and forced expiratory volume in 1 s. In addition to traditional open heart surgery, MICS monitoring intraoperative with transesophageal echocardiographic probe and external defibrillator pads. If the surgeon opts for superior vena cava (SVC) cannulation then the central venous catheter should be place in the left side to prevent mechanical and infectious complication.
Conclusion: The anethestic management goals are hemodynamic stability with smooth induction (propofol/fentanyl or remifentanil) inhalational anesthesia with supplemental short-acting opioids, and avoidance of long-acting vagolytic muscle relaxant with desired timely extubation. Carbon dioxide insufflation gives extra challenges in a patient with one-lung ventilation. Regional anesthesia in MICS remain limited in local infiltration due to systemic heparinization and increased risk of neuraxial hematoma and consequences.
30. Cortical lateralization and cardiac autonomic control Insights from insular stroke and epilepsy
V. Constantinescu1, O. Detante2, C. Arsenescu-Georgescu3, I Constantinescu1, D Matei4, P. Defaye5, C.D. Popescu1 and D.I. Cuciureanu1
1Neurology Department, Faculty of Medicine, University of Medicine and Pharmacy Iasi, Romania, victorcons@yahoo.com
2Neurology Department, Stroke Unit, University Hospital of Grenoble, University Grenoble Alpes, France
3Cardiology Department, Cardiovascular Diseases Institute, University of Medicine and Pharmacy Iasi, Romania
4Department of Biomedical Sciences, Faculty of Medical Bioengineering, University of Medicine and Pharmacy Iasi, Romania
5Cardiology Department, Arrhythmia Unit, University Hospital of Grenoble, University Grenoble Alpes, France
Introduction: Autonomic nervous system dysfunction is a common complication of stroke. Human studies and experimental data showed a hemispheric lateralization of autonomic activity concerning the forebrain and particularly the insular cortex. Insular cortex involvement is associated with more pronounced autonomic imbalance leading to life threatening arrhythmias and sudden death.
Materials and methods: We present two case reports of insular infarction in young patients without any cardiac comorbidity, illustrating a specific lateralized function of insula and its influence on the sympatho-vagal balance that implied differentiated therapeutic management after stroke. The right insular stroke was associated to sympathetic activation and left insular stroke was associated to parasympathetic predominance. The same lateralization of autonomic function with opposite effects on sympatho-vagal balance was also reported in two insular epilepsy cases, illustrating the fact that, beyond the controlling network, the cortical modulation of the autonomic nervous system is asymmetric.
Conclusions: Identifying high risk patients prone to develop neurogenic cardiac complications, by better understanding of dysautonomia pathophysiology and consequent implementation of prophylactic and therapeutic interventions may significantly reduce mortality rate in stroke and epilepsy.
31. Studying the antiarrhythmic effect of ranolazine in minim-invasive cardiovascular surgical patients
S.C. Batar1, I. Manitiu2,3, F.G Bolea2, C.G. Leatu1 and V.S. Costache2
Polisano European Hospital, Sibiu, Romania1, sergiu.batar@ulbsibiu.ro
Lucian Blaga University, Sibiu, Romania2
County Emergency Teaching Hospital, Sibiu, Romania3
Ranolazine is a selective Na channel blocker, used as antiischemic/antianginal agent used in refractory angina, studied in clinical trials for its antiarrhythmic effects.
Leftheriotis and colleagues studied a group of 74 patients with CAD (coronary artery disease), and sick sinus syndrome or atrioventricular block, that had pacemakers capable of detecting atrial fibrillation (AF) episodes, to conclude that the antiarrhythmic properties might indicate the necessity of its use in ischemic patients with AF. From the MERLIN-TIMI 36 trial we know that it reduces AF burden in non-ST acute coronary syndromes. Two large trials investigated its role: the RAFFAELLO trial showed that higher doses determined lower Atrial Fibrillation (AF) recurrence, but further data is needed, and in the HARMONY trial, combined therapy with dronedarone reduced AF burden by 59.1 percent. The trial conducted by Kosiknas and colleagues showed that patients reciving a single 1500 mg dose combined with amiodarone intravenous had a higher conversion rate, while Tsanaxidis et al. showed a faster sinus rhythm conversion with the combination of the two drugs. While some evidence is accumulated that ranolazine also has effects in treating ventricular arrhythmias, several groups study its effect on AF in postinterventional cardiovascular surgery patients.
Hammond et al. concluded in 2015 that adding ranolazine to standard therapy was associated independently with significant decrease in postoperative AF, after CABG, valve or combination surgeries. Simopoulous et al. enrolled 41 CABG patients to compare amiodarone alone vs. combined with ranolazine, to determine that ranolazine accelerates mean time to sinus rhythm conversion.
Considering this background, we sought necessary to assess the effects of ranolazine combined with amiodarone and/or betablockers in the group of patients that had minim-invasive valvular (mitral or aortic valve) or aortic surgery, because of the need to find antiarrhythmic agents with minimal effects on heart rate and blood pressure, in a single-center, prospective study.
32. Infective endocarditis on the aortic valve associated with acute myocardial infarction and left ventricle dysfunction with mitral regurgitation caused by triple vessel coronary atherosclerosis
H. Moldovan1, S. Rurac1, D. Popescu1, F. Matache1, A. Ionescu1, R. Niculescu1, G. Vasile1, E. Nechifor1, S. Balanescu4, O. Chioncel3 and E. Rusu2
SANADOR Hospital1
Titu Maiorescu University, Faculty of Medicine2
C. C. Iliescu Institute of Cardiovascular Disease3
Elias University Hospital4, smbala99@hotmail.com
A 61-year-old man presented with severe chest pain. He had suffered from persistent fever, muscle pain, arthralgia, and dyspnea on exertion (New York Heart Association class III) for one and a half months prior to admission. He had been treated with several antibiotics almost one month prior to admission. On the day of admission, he had acute coronary syndrome with three vessels coronary disease. Transthoracic echocardiography demonstrated left ventricular ejection fraction of 30% with severe mitral regurgitation and aortic regurgitation and an 18 mm vegetation on the aortic valve. Blood cultures identified Streptococcus Galloliticus.
The diagnosis was acute myocardial infarction and mitral regurgitation associated with infective endocarditis (IE). The incidence of acute coronary syndrome caused by three vessels coronary disease is quite low in patients with native valves endocarditis. More often is due to an embolic mechanism. The patient was operated: Aortic valve replacement with a mechanical prosthesis, mitral annuloplasty and quadruple coronary artery by – pass grafts. Postoperatively the patient was assisted with intra-aortic balloon pomp and received levosimendan. Also, CVVHDF was used for 51 ours. After 3 weeks, the ejection fraction was 60%, the prosthesis was normal and the patient in a good condition without inflammatory syndrome. At 6 month and 2 years the patient was in a stable condition follow-up echocardiography showed almost normal left ventricle function, normal aortic prosthesis function and no mitral regurgitation, and the patient has been living a normal life without any complications.
33. Are skip incisions better than long incision for single stage basilic transposition fistula?
F.A. Shaikh1, S. Nazeer1, N.A. Siddiqui1 and Z. Sophie1
1 Aga Khan University Hospital (AKUH), Karachi, Pakistan, fareed.shaikh@aku.edu
Introduction: End stage renal disease is an important health delinquent. Although basilic vein transposition via long incision technique is a renowned technique but it is not free from wound related complications. Whereas skip incision technique is thought to have lower wound related complications but to the best of our knowledge never compared with long incision technique. So we conducted this study to compare both techniques.
Material & Methods: This was a retrospective cohort study. Based on our inclusion criteria, we included 162 patients who underwent basilic vein transposition AVF (115 in long and 47 in skip incision group) from January 2011 till December 2015 at Aga Khan University, Pakistan. ERC approval was taken. SPSS 19 was used. Wound related complications, maturation time, duration of surgery and primary patency at a follow up of 12 months were recorded.
Results: Both the groups were comparable regarding baseline variables. Incidence proportion of wound infection, hematoma and dehiscence was higher in long incision group, however it was statistically insignificant. Primary patency at 12 months in skip vs long incision group was 87.2% vs. 73.9% (p-value:0.12). The Mean maturation time for fistula was 52 +/- 10 days and 54 +/- 10 days in Skip and Long incision group respectively (p-value: 0.30). Duration of surgery was comparable in both.
Conclusion: Although skip technique does not have significant benefit over long technique based on these results, but it is a valid alternative. RCT is required to better differentiate between these two.
34. Evaluation of the Risk of Heart Disease and Premature Death in a Roma Population in Olt County
A.F. Stefureac
Slatina Emergency County Hospital, fel.stef@yahoo.com
In the cohort clinical trial “Evaluation of the Risk of Heart Disease and Premature Death in a Roma Population in Olt County”, we propose to study the total cardiovascular risk in the Roma population, starting from the observation that the incidence of cardiovascular disease is increased in comparison to the general population and life expectancy is lower. Our goal is to identify the psychosocial and genetic factors in these patients. We will also study the correlation between risk factors, cardiovascular events and short-term treatment (1 year). We will evaluate the following risk factors: sex, age, smoking, diet, alcohol consumption, pregnancy, central obesity, dyslipidemia, type 2 diabetes, dystiroidia, chronic kidney disease, autoimmune diseases, calculating the total cardiovascular risk. Patients are enrolled from the Slatina County Emergency Hospital and from a private clinic and the medical data will be statistically analyzed and integrated. As a analysis method we will use the anamnesis, a questionnaire on living and working conditions, physical examination, ECG, echocardiography in the Roma population compared to general population.
35. Carotid artery stenting – the current era
C. Setacci
University of Siena, Italy, carlo.setacci@unisi.it
The Crest data as Eva 3s, ICCS and Space trials have demonstrated that carotid artery stenting (CAS) works very well between 30 days and 4 years. The real difference between carotid endarterectomy (CEA) and CAS in term of neurologic events is related to periprocedural period (0-30 days).
CAS today could be, in selected case s as “ primary choice treatment” if we perform a correct selection of the patients with an optimal technique.
The preprocedural evaluation of the aortic arch and supra-aortic vessels is crucial in order to select the correct common carotid engagement, the embolic protection device and the better design of the stent. Is really important the choice of a tailored procedure for every patient.
In presence of adverse anatomy (type II or III aortic arch, irregular contour of proximal common carotid artery -CCA, or kinking or coiling of CCA) do not try too hard or for too long time. In these situations we have the possibility to choose the correct guiding catheter: long shuttle sheath or uncommon access (brachial, radial or ulnar).
We know very well that not all plaques are the same and is really important to choose a correct stent in relation to patient symptoms, plaque characteristic, stent technical features, lesion lenght and complexity and proximal vessels morphology. Some relevant issues are related to poor stent scaffolding, i.e. intra-strut plaque prolapse and post-procedural embolic events.
Lesions in the carotid arteries are often anatomically and morphologically very challenging and stroke prevention by plaque coverage with dedicated stent is indicated.
We can perform a CAS IVUS or OCT guided in order to identify some possible embolic source to correct during the procedure.
In the real world are present today different stenting strategies
• Open cell design for treating tortuosity of the supraortic vessels
• Closed cell for the prevention of plaque prolapse
• Hybrid cell in order to combine scaffolding and conformability
NEW STENT GENERATION:
The C-Guard Stent (InspireMD, Boston, MA – USA)
The C-Guard carotid artery stent is an innovative monorail, self-expanding, OC, nitinol carotid stent covered by a polyethylene terephthalate (PET) micromesh. This coverage allows the device to prevent the embolization by plaque and thrombus particles during and after the Carotid Stenting procedure.
The stent has a crossing profile of 2mm and an external diameter of 6F, it’s compatible with any 8F catheter and any distal EPD.
C-Guard Carotid stent is indicated for Carotid stenting procedures on patients with vessel diameter included between 4.8 and 9.0mm at the level of the lesion (available diameters from 6 to 10mm and lengths from 20-60mm). The PET micromesh has a thickness of 20µ and a porosity of 150-180µ.
The Roadsaver stent (terumo)
The Roadsaver stent is a new carotid stent with dual layer design to reduce the free-cell area in a closed cell structure with a porosity of 450 µ.
This is an innovative self-expanding, repositionable stent with permanent CBAS heparin bounded on all device surfaces.
Nitinol composition allows excellent wall apposition and conformability to tortuous anatomies.
Roadsaver stent is a 5 French, low-profile rapid exchange delivery system, it’s compatible with any 8F catheter and any distal EPD.
The Roadsaver stent is indicated for Carotid stenting procedures on patients with vessel diameter included between 4.0 and 9.0mm at the level of the lesion (available diameters from 5 to 10mm and lengths from 20-40mm). The double layer micromesh designed has a free-cell size from 375 to 500 µ.
Another crucial point si the embolic protection device selection and management. The choice of the proximal protection with a simulation of a surgical procedure could protect the brain (the embolic load you may generate is absolutely unpredictable).
Obviously, in order to improve CAS results, is crucial the operators selection to avoid the scientific evidence gap between registries and evidence coming from high volume centers and randomized controlled trials results.
We have to avoid an inappropriate approach to CAS related to poor specific competence, inadequate training and inadequate materials with devastating sequelae in term of 1) wrong patient selection and indication, 2) incapacity to manage complications.
36. Management of symptomatic and asymptomatic popliteal venous aneurysms
C. Sessa
Groupe Hospitalier de Grenoble. Grenoble, France, c.sessa@ghm-grenoble.fr
Popliteal venous aneurysms (PVAs) are an uncommon but potential source of serious thromboembolic complications and should be ruled out: (1) during work up for superficial or deep vein insufficiency; (2) in patients presenting with a first episode of pulmonary embolism (PE) or a history of repeated PE and no obvious embolic source or thromboembolic risk factors.
We published in 2000 our experience in the management of 25 PVAs and proposed the following guidelines: surgery is indicated in all symptomatic PVAs because of the high risk of recurrent PE with anticoagulation therapy alone. Patients with asymptomatic saccular or large (> 20 mm) fusiform aneurysms should also be treated surgically, regardless of the presence of thrombus, because of the unpredictable risk of thromboembolic complication. Asymptomatic patients with small fusiform (≤ 20 mm) and thrombus-free PVAs may remain under close surveillance, with surgery performed if a thrombus is detected in the aneurysm, if the aneurysm enlarges, or if thromboembolic complications occur. Tangential aneurysmectomy with lateral venorrhaphy is the treatment of choice for saccular PVA. Aneurysm resection with preservation of venous continuity is recommended when tangential aneurysmectomy cannot be satisfactorily performed, as well as for patients with fusiform aneurysms.
More recently, in 2013 Maldonado-Fernandez et al. reviewed in conjunction with their series, other publications over the last 10 years to determine whether these recommendations have undergone any changes based on the new findings. “We found 91 cases in addition to the 117 cases described by Sessa and colleagues as well as the 4 contributed by our group. Conclusions: The most recent publications confirm the recommendations made by Sessa et al. more than 10 years ago. Thus, no further changes should be made to the current approach to treatment of venous aneurysms.”
37. Surgical Treatment of Subacute Ventricular Free Wall Ruptures
L. Stoica1, G. Tinică1, D. Popoutanu1 and G. Grădinariu1
The Institute of Cardiovascular Diseases, Prof. Dr. George IM Georgescu” Iasi, Romania,1 lucistoica66@yahoo.com
Introduction: Ventricular free wall rupture after acute myocardial infarction or after coronary angioplasty represents an extremely serious complication for which surgery is the only effective option.Virtual mortality in the absence of surgical treatment approaches 100%. Early recognition and admission in a specialized center offers best prognostic for the patient.The literature concerning this condition is limited to small series of cases reports which warrants greater focus on reporting this condition.
Material and methods: We treated by surgery in our center 11 cases of ventricular free wall rupture between 2009-2017. Six cases occured >48h after acute myocardial infarction and 5 cases as a complication of coronary angioplasty as emergency treatment for acute myocardial infarction. One patient had ventricular septal defect associated with the inferior right ventricle wall rupture. Surgical treatment consisted of: suture using teflon bands – 1 case, suture using teflon bands and wall contention with glued pericardial patch – 2 cases, contention using glued pericardial patch sutureless – 5 cases of which one had associated the ventricular septal defect closure and 3 cases with simple hemopericardial evacuation post angioplasty. Surgery was made off pump and on pump with cross clamping or not. One patient died following surgery.
Conclusions: Prompt and correct diagnosis of ventricular wall rupture can be achieved by echocardiography and is essential for increasing survivability. Contention with pericardial glued patch, sutureless and if possible off pump is a safe, simple and reproducible technique with good long time prognosis in our experience.
38. Initial experience of complete percutaneous EVAR
S. Furkalo1, E. Vlasenko1, I. Khasianova1 and V. Smorzhevskiy1
1National Institute of Surgery and Transplantology, Kiev, Ukraine
furkalosn@gmail.com
Increase in the number of endovascular interventions, including prescription of antiplatelet and anticoagulant therapy, led to the creation of devices for endovascular closure of artery, the aim of which is to reduce the number of complications from the puncture site.
Materials and methods: Our initial experience of the use of devices includes 7 cases, where devices for percutaneous suturing of femoral arteries Prostar XL were used, which allowed performing percutaneous EVAR (PEVAR) completely as endovascular without surgical access to common femoral arteries. In two patients the method of percutaneous suturing was used on one, and in five – on two sides. In all patients were implanted bifurcation endoprostheses “Endurant-II”-Medtronic, the diameter of delivering system of the main part and contralateral leg was 18 F.
Results: In 9 cases out of 12 the suturing process was successful with achievement of effective hemostasis. In 3 cases was performed conversion and the puncture site was sutured by the surgery method. In both cases occurred the thread break when the second knot was tied. Wounds in all cases healed by primary tension, in no case of endovascular suturing were observed complications. Patients were activated in 12–18 hours after the surgery. Fewer analgesics were required in the postoperative period. Especially it was indicative in patients with unilateral endovascular suturing, when there was asymmetry of pain – severe pains from the side of classical access and practically their complete absence from the side of endovascular suturing. The time of access and closure of the puncture hole was significantly reduced: using open method this time for one access was 24 to 95 minutes (average of 46,5 minutes), with the use of suturing device 8-17 minutes (average of 12,3 minutes). Blood loss during complete endovascular endoprosthesis replacement of aorta was 20 ml per procedure, which did not lead to change in hemoglobin in the postoperative period, while the decrease in hemoglobin on the first day after endoprosthesis replacement using open accesses averaged 25 g/l.
Thus, the effectiveness of suturing of the puncture site of femoral artery using Prostar XL was 80%, which corresponds to the literature data at the stage of mastering the method. Despite 3 cases of conversion, all patients after endovascular suturing of the puncture site were discharged at earlier time.
Conclusions: PEVAR is effective and safe, significantly reduces the time of intervention, shortens the patient’s stay in the hospital, allowing to restore the full volume of movements in the hip joints in the first 24 hours after the surgery, creates additional comfort for the patient. There were no complications, which threaten life or worsen its quality during this procedure in our patients. Three cases of conversion were not accompanied by significant bleeding and did not require additional anesthesia methods other than local infiltration.
39. Chronic mesenteric ishemia – endovascular diagnostics and treatment
V.A. Kondratiuk1 and I.V. Khasianova1
1National Institute of Surgery and Transplantology Kiev, Ukraine
furkalosn@gmail.com
Chronic mesenteric ischemia is a fairly frequent manifestation of multifocal atherosclerosis, involving unpaired visceral arteries. In view of variety and often blurring symptoms, diagnostics is often not in time and the results of surgical treatment are ambiguous.
In this work we present the results of endovascular treatment in 37 patients (25 men and 12 women) with clinic manifestations of chronic mesenteric ischemia, in which were found critical stenosis of unpaired visceral arteries, associated with extravasal compression – 7 (19%), atherosclerotic – 27 (73%) or inflammatory – 2 (8%) lesions. There were performed 8 balloon angioplasty and 29 stenting of celiac trunk and/or superior mesenteric artery. In 3 cases results of balloon angioplasty were satisfactory, in 3 cases recurrence of stenosis required further stenting, in 2 cases – surgical treatment. Within 1 year after stenting in 4 (11%) cases occurred the need of repeated angioplasty concerning restenosis in a stent, in other cases after stenting were obtained satisfactory clinical and angiographic results.
Conclusions: Primary stenting of affected artery is an effective method that allows with minimal invasiveness to remove clinically significant stenosis of visceral arteries of intravasal and extravasal genesis. Balloon angioplasty is effective in case of intravasal lesions, but primary stenting should be preferred at increased probability of restenosis.
40. Endovascular interventions at lower limbs critical ischemia
P. Gyndych1 and I. Khasianova1
1National Institute of Surgery and Transplantology, Kiev, Ukraine
furkalosn@gmail.com
Critical limb ischemia (CLI) is a clinical syndrome that is manifested by ischemic pain at rest or by tissue defects, such as – non-healing ulcers and/or gangrene as a result of severe lesions of arteries of lower limbs. CLI has a high short-term risk of loss of limbs and cardiovascular events.
Material and methods: It was analised 86 patients with obliterating atherosclerosis of arteries of lower limbs, who underwent angioplasty of arteries of lower limbs by endovascular method.
Of 84 observations in 53 (61.7%) cases the patients were male. The patients age was 67.8 ± 8.3 years in average. Diabetes mellitus was recorded in 54 (62.8%) patients. Hypertension was noted in 64 (74.4%) patients, 15 (17.5%) patients suffered previous myocardial infarction. Trophic tissue changes were noted in 35 (40.1%) patients.
Results and discussion: Of 86 patients, 32 (37.2%) patients were operated on arteries above the knee, 54 (61.8%) – below the knee. Totally 40 stents were implanted (in iliac-femoral segment and popliteal artery), in 7 cases was used drug-eluting balloon, 5 stents in tibial arteries. In 6 cases, ante-retrograde intervention was performed to recanalize the chronic tibial occlusion. Four patients underwent thrombolysis at acute thrombosis. In 2 cases were performed hybrid interventions.
In 8 (9.3%) cases were performed repeated interventions (3 at recurrence of disease above the knee, 5 – below) diuring a 1 year follow-up. During the observation period, one major amputation was performed after an unsuccessful attempt of thrombolysis at acute thrombosis.
Conclusions:
1. In order to choose the optimal treatment for patients with critical ischemia, it is necessary to evaluate the patient’s condition with the involvement of vascular, endovascular surgeons and, often, cardiologist.
2. In complex and multilevel lesions of vessels of lower limbs, it is advisable to consider hybrid approaches to treatment with the use of endovascular and traditional surgical approaches.
3. In patients with diabetes mellitus and/or necrotic changes in foot tissues should be taken into account zones of blood supply of tibial arteries in order to obtain the optimal result.
4. Due to the development of new technologies in the treatment of patients can be considered approaches with the use of stents and drug-coated balloons, as well as biodegradable stents.
41. 10-year experience of endovascular repair of abdominal aneurysms
S. Furkalo1, V. Smorzhevsky1, I. Khasianova1 and E. Vlasenko1
1National Institute of Surgery and Transplantology, Kiev, Ukraine
furkalosn@gmail.com
Nowadays there are 2 main methods of aortic aneurysm treatment – classic open surgical repair and endovascular. In the last few years, the creation of new endoprostheses, development of fenestrated and branched devices significantly expanded endovascular possibilities.
Aim: To evaluate immediate and long-term results of endovascular repair of abdominal aorta aneurysms (EVAR), frequency of complications and need for repeated interventions.
Materials and methods: We analyzed the immediate and long-term results of 120 EVAR patients. Procedures on the abdominal aorta were associated with aneurysm of abdominal aorta in 118 cases. One patient had an iatrogenic aorto-caval fistula. And in one case there was dissection of aorta in infrarenal region. The average age of patients was 67.5 years, patients over 65 years of age were more than 50%. The most common comorbidities included coronary heart disease and hypertension. Most of patients were of average and high surgical risk. 95% interventions were performed under epidural anesthesia.
Results and discussion: In 100% cases was achieved a positive technical result. The operation time ranged from 20 to 140 minutes and depended on anatomical features and component part of graft. 30-day death rate was 0%. None of the cases required conversion. In the early postoperative period there was not any major cardiac or cerebral complication. All complications of the early period were associated with access sites, their number was significantly reduced after the introduction of lateral approaches and amounted 0 in patients with fully endovascular operation.
In the long-term period (from 1 to 10 years) in 5 patients was noted aneurysmal sac growth was fixed in 7% cases in period 1–3 year, in 17% in period >4 year and in 18% in long-term period > 6–7 year. The need of repeated interventions was fixed in 5.8% with one case of open conversion in 10 years graft. No one aneurism-related death was noticed during long-term period, 6 patients died from different causes not related to aneurysms.
Conclusions: EVAR is a good alternative to traditional open surgery. Low surgical trauma, short operation time and minimal number of postoperative complications make this method especially valuable in the group of patients at high risk. However, the likelihood of late complications due to the progression of disease and change in anatomy of aneurysm requires close monitoring of patients for life after EVAR.
42. Bioresorbable coronary stents implantation in patients with acute and chronic coronary occlusion. Optical coherence tomography examination
S. Furkalo1, P.A. Gindich and I. Khasianova1
1National Institute of Surgery and Transplantology, Kiev, Ukraine
furkalosn@gmail.com
The indication for bioresorbable coronary stents (BVS) use not certain in few lessions subsets, including ACS, CTO, and not standard for this category of patients.
Objective: To explore the possibility and safety of BVS in patients with acute and chronic coronary occlusion and feasibility of using the method of optical coherence tomography (OCT) in this category of patients.
Material and Methods of research: We analyzed data from 12 patients with ACS and acute coronary occlusion and 13 patients with CTO of one of main epicardial artery where stenting was performed with implantation of biodegradable stents “Absorb” (Abbott Vascular, USA).
In CTO group of patients 9 (69.2%) have II-III CCS functional class and 2 patients (15.4%) previously undergo CABG and stenting. The age of patients was 58.6 ± 6.1 years, 11 patients were male. Multivessel disease was in 5 (38.5%) patients. Left ventricular ejection fraction was 52.5 ± 3.3%. Before interventions patients received a loading dose of clopidogrel or ticagrelor.
16 (64%) patients before during and after BVS implantation underwent optical coherence tomography (OCT) examination (Illumina, St. Jude Medical (USA) for the visualization of intravascular structures and optimization of stent implantation.
Results and discussion: In patients with ACS 50% of patients had multivessel disease. The BVS implantation success was 100%, thrombolysis in myocardial infarction 3 flow was restored in 10 (83.3%). It was implanted 1.16 BVS per patient with middle length 22.1 mm. In our series of patients there was no death, stent thrombosis, or significant complications.
CTO recanalisation was performed with antegrade approach in 9 patients and retrograde approach was applied in 4 patients (30.7%). Left anterior descending CTO recanalisation and BVS stenting was performed in 5 cases (38.5%), the right coronary artery intervention – in 8 patients (61.5%). In all cases, the implantation of biodegradable stents was successful, 1.23 BVS per patient were implanted. The length of stented segment was 36.4 ± 8.1 mm. No acute complications were fixed. According to the OCT images in 4 (40%) CTO and 3 (50%) ACS patients was recorded struts malapposition or underexpantion and in 2 cases – edge dissection, which required postdilatation or one more stent implantation.
Conclusions: The use of biodegradable stents in coronary artery stenting in patients with acute and chronic occlusion can be successfully applied, but requires optimal apposition and smoothing of the stent in the arteries, which is critical given the state of the patients, structure and shape of the stent struts.
Intravascular visualisation with OCT carries important information about the size and morphology of the lesions and allows optimizing the results of stenting.
In settings of patients with artery occlusions the rate of BVS malapposition and underexpantion may be higher then in ordinary cases and OCT can be of great use.
43. Endovascular treatment of patients with multifocal atherosclerosis
S. Furkalo1, I.V. Khasianova, V.I. Smorzhevskii1, P.A. Hyndych1 and V.A. Kolesnik1
1National Institute of Surgery and Transplantology, Kiev, Ukraine
furkalosn@gmail.com
Introduction: Involvement of several vascular regions in the atherosclerotic process is accompanied by unfavorable clinical course and prognosis, and traditional surgical treatment may be associated with increased risk of complications and mortality. The aim of study was to analyze the immediate results and long-term effectiveness of endovascular and combined methods in the treatment of multifocal atherosclerosis.
Material and methods: The study included 175 patients with advanced atherosclerosis and combined lesion of several vascular regions, where were performed only endovascular (119 patients) interventions and 56 patients, where were performed endovascular and open surgeries. 78 patients had endovascular surgeries in one session. 38 patients were treated conservatively.
Combined lesions of coronary and renal arteries were noted in 58 cases. Combined lesion of carotid and coronary arteries was recorded in 45 patients. In 34 cases the interventions were performed with combination of coronary pathology and obliterating atherosclerosis of lower limbs. Combined lesion of coronary arteries and aneurysm of abdominal aorta was recorded in 21 patients.
In other cases surgical interventions were performed with various combinations of lesions of kidney, peripheral carotid and coronary arteries both in 2 and more vascular regions.
Of the total number of 102 patients the results of long-term follow-up were observed in the period from 6 months to 4 years. As patients were observed at various time ranges, the analysis of survival and negative events was analyzed using the Kaplan-Meier actuarial method.
Immediate results: As a result of interventions, 2 patients died, 1 case of TIA and 1 stroke were fixed, 2 patients had AMI. Within 30 days one patient was transferred to constant dialysis.
Long-term results: we recorded eight cases of cardiovascular deaths, within 24 months. The need for revascularization during 36 months was the same in the groups of medical and surgical treatment – 23%. 21 patients, due to the progression of atherosclerosis and restenosis, underwent repeated endovascular interventions. Comparing the frequency of combined negative cardiovascular events (death, AMI, all cases of stroke) in surgical and conservative groups with the use of actuarial method, it is necessary to note significantly lower parameters in the group of patients who underwent endovascular interventions – 13% compared to the same parameter in the group of conservative treatment – 82.4%.
Conclusions:
1. Isolated endovascular and combined interventions in the group of patients with multifocal atherosclerosis are the optimal strategy.
2. The condition of patients with multifocal atherosclerosis at long-term follow-up is determined primarily by the progression of atherosclerosis and occurrence of restenosis of stented segments.
3. Obviously, prolonged conservative treatment of patients with multifocal atherosclerosis, especially with the combination of coronary and brachiocephalic lesions, does not have prospects.
