Journal of vascular surgery
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Aortic aneurysm repair is a high-risk surgical procedure. Patients are often elderly, with multiple comorbidities that predispose them to perioperative morbidity. Use of endovascular aneurysm repair (EVAR) has increased due to reduced early perioperative risk. This study assessed whether preoperative cardiopulmonary exercise testing (CPET) could be used to predict morbidity and hospital length of stay (LOS) after aortic aneurysm repair. ⋯ Cardiorespiratory fitness holds significant clinical value before aortic aneurysm repair in predicting postsurgical complications and duration of critical care and hospital LOS. Preoperative measurement of fitness could then direct clinical management with regard to operative choice, postoperative resource allocation, and informed patient decision making.
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Case Reports
Hybrid repair of a Kommerell diverticulum associated with a right aortic arch and a left descending aorta.
This report describes the first successful case of a hybrid endovascular approach for management of aneurysmal Kommerell diverticulum arising from the left descending aorta in a right aortic arch. This patient also had dilatation of the ascending aorta and a small aortic arch aneurysm. This three-step procedure consisted of (1) ascending aorta replacement with total debranching using a handmade quarto-branched composite graft; (2) endovascular exclusion of Kommerell diverticulum and the aortic arch aneurysm by covering the whole aortic arch; and (3) coil embolization against the root of the left subclavian artery. The patient had no complications at 16 months after completion.
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Fenestrated-branched stent grafts have been developed as a minimally invasive, endovascular alternative for the treatment of complex aortic aneurysms in high-risk patients. However, the manufacture of these devices can take as long as 6 to 12 weeks, and therefore, they cannot be used to treat aortic emergencies. We reviewed our experience with surgeon-modified, fenestrated-branched stent grafts (sm-FBSGs) in high-risk patients who presented as emergencies with ruptured or symptomatic complex aortic aneurysms. ⋯ Sm-FBSG may play an important role in the treatment of select patients with symptomatic or ruptured complex aortic aneurysms who are at prohibitive risk for open surgery and in whom endovascular repair cannot be delayed to allow implantation of a custom-made commercial device. Until an off-the-shelf fenestrated-branched device is created that does not require a prolonged waiting period, this may be the best option to treat patients with symptomatic or ruptured complex aneurysms that are at excessively high surgical risk.
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This study assessed the vascular distribution of stroke after thoracic endovascular aortic repair (TEVAR) and its relationship to perioperative death and neurologic outcome. ⋯ Perioperative stroke after TEVAR is primarily an embolic event. Although infrequent, stroke was associated with significant morbidity and death, particularly among those with strokes involving the PC circulation.
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Repair of patients with extent I and II thoracoabdominal aortic aneurysms (TAAAs) is associated with significant morbidity and mortality, whereas repair of more distal extent III and IV TAAAs has a lower risk of paraplegia and death. Therefore, we describe an approach using thoracic endovascular aneurysm repair (TEVAR) as the index operation to convert extent I and II TAAAs to extent III and IV TAAAs amenable to subsequent open aortic repair to minimize patient risk. ⋯ A staged hybrid approach to extensive TAAAs combining proximal TEVAR, followed by interval open distal TAAA repair, is safe and appears to be an effective alternative to traditional open repair. This approach may decrease the significant morbidity associated with single-stage open extent I and II TAAA repairs and may be applicable to multiple TAAA etiologies.