Faculty Bibliography

OBJECTIVES:Isolated ascending aortic aneurysm (iAA) is usually treated by open graft repair requiring sternotomy, cardiopulmonary bypass (CPB) and cardioplegia. This approach carries significant mortality in older patients or those presenting with comorbidities. We report an original series of patients presenting with iAA and treated with epiaortic wrapping by using a synthetic mesh. This less invasive aortic repair technique allows reducing the aortic diameter to a predefined value and is performed without CPB. METHODS:Data from patients presenting with an iAA and treated with the wrapping technique (WT) by polypropylene/polyester mesh from November 2006 to July 2015 were collected. The end-points that were analysed included maximal aortic transverse diameter, perioperative mortality and morbidity, survival, freedom from reinterventions and aortic valve function during follow-up. The maximal aneurysm transverse diameter was analysed based on contrast-enhanced computed tomography (CTA) or magnetic resonance (MR) performed preoperatively, and during the follow-up. RESULTS:The off-pump WT was used in 33 cases with no perioperative mortality. The median radiological follow-up was 33.47 (range: 1-106) months. Overall, the WT achieved a 30% diameter reduction. The mean preoperative and postoperative ascending aortic transverse diameter was 5.5 cm [standard deviation (SD): 0.6] and 3.7 cm (SD: 0.30), respectively (P = 0.001). In addition, CTA or MR follow-up showed stable diameters at the level of the aortic root and the distal ascending aorta. No death occurred during the follow-up. At 5 years, the estimated freedom rate from reinterventions of the aortic root and ascending aorta was 94%. CONCLUSIONS:This series shows that the WT with a polypropylene/polyester mesh allows safe off-pump treatment of patients with iAA. Mid- and long-term results are promising. This technique could be an attractive alternative, especially for patients unfit for aortic surgery with CPB and cardioplegia.

Learning Objectives 1. To learn when and how supraceliac aortic control is applied 2. Technical tips for interventions during aortic control 3. To learn about complications during aortic control Endovascular aneurysm repair (EVAR) is being increasingly used to treat ruptured abdominal aortic aneurysms (RAAAs). Approximately 25% of RAAAs suffer complete circulatory collapse before or during the procedure. Their survival depends on obtaining and maintaining supraceliac balloon control until the endograft is fully deployed. This is accomplished with a sheath-supported compliant balloon inserted via the groin contralateral to the side to be used for insertion of the endograft main body. After the main body is fully deployed, a second balloon is placed within the endograft and the first balloon is removed so that extension limbs can be placed at the contralateral side. A third balloon can be placed via the contralateral side and ipsilateral extensions can be deployed as necessary. This technique of supraceliac balloon control is important to achieve good outcomes with RAAAs. In addition to minimizing blood loss, this technique minimizes visceral ischemia and maintains aortic control until the aneurysm rupture site is fully excluded

Learning Objectives 1. To learn what the PERICLES registry is 2. To learn about the outcomes of the PERICLES registry The aim of the performance of the chimney technique for the treatment of complex aortic pathologies (PERICLES) registry was to provide the latest pooled evidence about chimney grafts in pararenal pathologic processes and to evaluate if the sceptisicm about the grafts is justified. Overall, data of 517 patients (398 of whom were treated at European vascular centres and 119 at US centres) who underwent chimney EVAR between 2008 and 2014 were reviewed. The mean number of chimney grafts placed was 1.7 per patient (overall 898 target aortic branch vessels). In total, 49.2% of the chimney grafts were balloon-expandable covered stents and 39.6% were self-expanding covered stents. Primary chimney graft patency was 94.1%. The mean aortic aneurysm diameter was significantly decreased to 61.2+/-19.7 mm from 65.9+/-16.5 mm, p.001. The technical success was 97.1%. The mean new neck/seal length after placement of the chimney grafts increased from 4.8+/-7.4 mm to 21.1+/-12.7 mm. Persistent type IA endoleak rate was 2.9%. The 30-day mortality rate for the elective cases was 3.7%. The present global experience with the chimney/snorkel graft underlines the complementary role of parallel grafts and supports wider usage and further evaluation. Based on the mid-term results, it seems that the widespread scepticism is not justified

Standard approaches to lower extremity arteries may be rendered difficult or unusable because of scarring or infection, or both. This article describes unusual alternative approaches to facilitate lower extremity bypasses that would normally require approaches to the common femoral, deep femoral, or popliteal arteries. Techniques are described for using the distal external iliac artery, the distal two-thirds of the deep femoral artery, and the above-knee and below-knee popliteal artery approached laterally.