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Papers by Harleen Sandhu

JTCVS Techniques

Objectives: The SPIDER technique for hybrid thoracoabdominal aortic aneurysm repair can avoid tho... more Objectives: The SPIDER technique for hybrid thoracoabdominal aortic aneurysm repair can avoid thoracotomy and extracorporeal circulation. To improve technical feasibility and safety, the new Thoracoflo graft, consisting of a proximal stent graft connected to a 7-branched abdominal prosthesis, was evaluated in a pig model for technical feasibility testing, before implantation in humans. Methods: Retroperitoneal exposure of the infradiaphragmatic aorta, including visceral and renal arteries, was performed in 7 pigs (75-85 kg). One iliac branch was temporarily attached to the distal aorta to maintain retrograde visceral and antegrade iliac perfusion after deployment of the thoracic stent graft segment (SPI-DER technique). The proximal stent-grafted segment was deployed in the thoracic aorta via direct aortic puncture over the wire without fluoroscopy. The graft was deaired before flow via the iliac side branch to the visceral and iliac arteries was established. Visceral, renal, and lumbar arteries were subsequently sutured to the corresponding side branches of the graft. Technical feasibility, operating and clamping time, blood flow, and tissue perfusion in the related organs were evaluated before implantation and after 3 and 6 hours using transit-time flow measurement and fluorescent microspheres. Final angiography or postprocedural computed tomography angiography were performed. Results: Over-the-wire graft deployment was successful in 6 animals without hemodynamic alteration (P ¼ n.s.). In 1 pig, the proximal stent graft section migrated as the guidewire was not removed, as recommended, before release of the proximal fixation wire. Angiography and computed tomography scan confirmed successful graft implantation and transit-time flow measurement confirmed good visceral and iliac blood flow. Fluorescent microspheres confirmed good spinal cord perfusion. Conclusions: Over-the-wire implantation of the Thoracoflo graft using the SPIDER technique is feasible in a pig model. No fluoroscopy was required. For safe implantation, it is mandatory to follow the single steps of implantation. (JTCVS Techniques 2022;15:1-8) Thoracoflo graft prototype with proximal ringshaped stent graft.

JAMA Network Open, 2021

IMPORTANCE Liposomal bupivacaine for pain relief is purported to last 3 days compared with 8 hour... more IMPORTANCE Liposomal bupivacaine for pain relief is purported to last 3 days compared with 8 hours with standard bupivacaine. However, its effectiveness is unknown in truncal incisions for cardiothoracic or vascular operations. OBJECTIVE To compare the effectiveness of single-administration standard bupivacaine vs liposomal bupivacaine in patients undergoing truncal incisions. DESIGN, SETTING, AND PARTICIPANTS This randomized clinical trial enrolled patients undergoing sternotomy, thoracotomy, minithoracotomy, and laparotomy from a single cardiovascular surgery department in an academic medical center between November 2012 and June 2018. The study was powered to detect a Cohen effect size of 0.35 with a power of greater than 80%. Data analysis was performed from July to December 2018. INTERVENTION Patients were randomized to standard bupivacaine or liposomal bupivacaine. MAIN OUTCOMES AND MEASURES Pain was assessed over 3 postoperative days by the Numeric Rating Scale (NRS). Adjunctive opioids were converted to morphine equivalents units (MEU). NRS scores were compared using Wilcoxon rank-sum (3-day area under the curve) and 2-way nonparametric mixed models (daily scale score) to assess time-by-group interaction. Secondary outcomes included cumulative opioid consumption. RESULTS A total of 280 patients were analyzed, with 140 in each group (single-administration standard bupivacaine vs liposomal bupivacaine). Mean (SD) age was 60.2 (14.4) years, and 101 of 280 patients (36%) were women. Irrespective of treatment assignment, pain decreased by a mean of approximately 1 point per day over 3 days (β = −0.87; SE = 0.11; mixed model regression P < .001). Incision type was associated with pain with patients undergoing thoracotomy (including minithoracotomy) reporting highest median (interquartile range [IQR]) pain scores on postoperative days 1 (liposomal vs standard bupivacaine, 6 [4-8] vs 5 [3-7]; P = .049, Wilcoxon rank-sum) and 2 (liposomal vs standard bupivacaine, 5 [4-7] vs 4 [2-6]; P = .003, Wilcoxon rank-sum) but not day 3 (liposomal vs standard bupivacaine, 3 [2-6] vs 3 [1-5]; P = .10, Wilcoxon rank-sum), irrespective of treatment group. Median (IQR) 3-day cumulative NRS was 12.0 (8.0-16.5) for bupivacaine and 13.5 (9.0-17.0) for liposomal bupivacaine (P = .15, Wilcoxon rank-sum) Furthermore, use of opioids was greater following liposomal bupivacaine compared with standard bupivacaine (median [IQR], 41.5 [21.3-73.8] MEU vs 33.0 [17.8-62.5] MEU; P = .03, Wilcoxon rank-sum). On multivariable analysis, no interaction by incision type was observed for mean pain scores or opioid use. (continued) Key Points Question Does liposomal bupivacaine reduce postoperative pain and supplemental opioid use more than standard bupivacaine in cardiothoracic and vascular surgical patients? Findings In this randomized clinical trial including 280 participants, no significant difference in pain control was observed between liposomal vs standard formulation bupivacaine. Meaning These results do not support superior performance of liposomal bupivacaine compared with bupivacaine for postoperative pain control in cardiothoracic and vascular truncal incisions.

European Journal of Vascular and Endovascular Surgery, 2019

, correlations, and multivariate associations, respectively. Results-E-XDP levels were elevated i... more , correlations, and multivariate associations, respectively. Results-E-XDP levels were elevated in patients with AAA compared with controls (p ¼ 6.9e-14), predicted AAA with 98% sensitivity and 88% specificity and correlated with the AAA diameter (r ¼ 0.58, p ¼ 5.3e-05). The association between AAA and increased E-XDP was independent of smoking, comorbidities and prescription drugs (p ¼ 2.6e-06). Levels of E-XDP in patients with only a thin or macroscopically non-existent ILT were lower than those of patients with a large ILT, but remained significantly higher than in controls (p ¼ 0.0026). Concentration of E-XDP correlated with volume of the ILTs in the AAAs (r ¼ 0.75, p ¼ 1.0e-06) and mean ILT stress (r ¼ 0.42, p ¼ 0.017), and was independently raised if coexisting aneurysms existed (p ¼ 0.015). IHC revealed E-XDP expression in the ILT, which was spatially related to luminal neutrophil elastase and neutrophils. Conclusion-Circulating E-XDP is a novel marker of AAA and coexisting aneurysms, and correlates with AAA and ILT volume as well as with the mechanical stress of the ILT.

Journal of Vascular Surgery, 2018

arteries and 19 superior mesenteric arteries) targeted with 44 fenestrations and 17 scallops; 44 ... more arteries and 19 superior mesenteric arteries) targeted with 44 fenestrations and 17 scallops; 44 target vessels were stented with 41 covered stents and 3 bare-metal stents. Median follow-up was 255 days (range, 34-1352 days). Of the 22 completion endoleaks, 12 were type III, one was type IA, and 9 were indeterminate (either type IA or type III; Table). No type I or type III endoleaks were identified on initial postoperative computed tomography angiography. Furthermore, no type I or type III endoleaks were identified on any follow-up imaging. Of 12 patients with at least 6month follow-up, 6 had sac regression, 5 had stable sac diameter, and 1 had sac expansion. The patient with sac expansion underwent reintervention for persistent type II endoleak. There were no aneurysm ruptures or deaths. Conclusions: In patients undergoing FEVAR with the Zenith Fenestrated AAA Endovascular Graft, small, slow type I and type III endoleaks resolve spontaneously and can be safely observed. Continued research is necessary to evaluate long-term outcomes in these patients.

Journal of Vascular Surgery, 2018

Journal of Vascular Surgery, 2018

, to December 31, 2017, were analyzed (Figures 1 and 2). EST interventions were performed under f... more , to December 31, 2017, were analyzed (Figures 1 and 2). EST interventions were performed under fluoroscopic guidance. All ESTs of HFVM were performed under selective catheter angiography and direct injection, but LFVM with direct injection only. Serious complications were defined as any tissue or functional damage caused by direct injection, distal embolization, or tissue reaction. Results: There were 70 patients who had a total of 150 EST procedures for upper extremity VMs (median age, 24.5 years; range, 1-73 years; 44 male, 26 female). Of these, 28 (40%) had EST for HFVM and 42 (60%) for LFVM (total 78 and 72 procedures, respectively). Most used agents were foam sclerosant (STD 3% mixed in ratio 2:8 with air), dehydrated absolute ethanol, and coils. Serious complications as follows: HFVM in five patients (17.9%) or 6.4% of total procedures; three ischemia of fingers and/or hand requiring amputation (Figs 1 and 2), and two skin ulcerations. Serious complication in LFVM occurred in five patients (11.9%) or 6.9% of total procedures: one median nerve injury causing wrist drop requiring nerve grafting and hand therapy, one hand contracture requiring tendon release, and three skin ulcerations. All ulcerations resolved without significant long-term disability. However, the nerve and tendon injuries carried degrees of long-term functional disability. Conclusions: Current EST is relatively safe for upper extremity HFVM where our complication rate of 17.9% compares favorably with the recent literature, possibly owing to the selective use of foam versus alcohol, and improved classification and targeted treatment. For LFVM, significant complications resulted in 11.9% of patients from local toxicity after direct injection. These outcomes will direct treatment strategies to avoid local toxic complications in the hand for both HFVM and LFVM, and to informed consent.

European Journal of Vascular and Endovascular Surgery, 2019

9.6%) and major bleeding (n¼13; 9.6 %). There were no association between stent graft length or s... more 9.6%) and major bleeding (n¼13; 9.6 %). There were no association between stent graft length or subclavian coverage and paraplegia (OR 1.00, 95% CI 0.998-1.01; P¼0.32, and OR 0.56, 95% CI 0.14-2.31; P¼0.42; respectively) or subclavian coverage and stroke (OR 1.40, 95% CI 0.46-4.31; P¼0.56). Reinterventions were required in 27/137 patients (19.7%). Postoperative bleeding was the only major complication associated with reintervention (OR 3.39, 95% CI 1.05-11.0; P¼0.042). Median follow-up time was 18.5 months (range: 0-132 months). The Kaplan-Meier estimated survival was 79.1% at 1 month, 70.8% at 3 months, 64.5% at 1 year, 45.0% at 3 years, and 30.9% at 5 years. Age (HR 1.04; 95 % CI 1.00-1.07; P¼0.044), previous stroke (HR 2.31; 95 % CI 1.17-4.55; P¼0.016), previous aortic surgery (HR 2.17; 95 % CI 1.18-3.99; P¼0.012) as well as postoperative major bleeding (HR 4.29; 95 % CI 2.14-8.60; P¼0.001), postoperative stroke (HR 2.73; 95 % CI 1.43-5.22; P¼0.002), and renal failure (HR 7.82; 95 % CI 2.53-24.19; P¼0.001) were all associated with mortality. Conclusion-This nationwide multicenter study of patients with rDTAA undergoing TEVAR showed acceptable shortterm survival but the long-term survival is rather poor. The postoperative complication rate is high and reinterventions are required in one fifth of patients. Patient selection and optimization are of utmost importance to improve outcome.

Journal of Vascular Surgery, 2020

P ¼ .11). Total and postoperative lengths of stay were nonsignificantly longer with preoperative ... more P ¼ .11). Total and postoperative lengths of stay were nonsignificantly longer with preoperative drain use. Survival analysis among SCI patients revealed decreased survival in patients who had postoperative therapeutic drains placed (Fig). Conclusions: SCI rates have decreased over time, although prophylactic CSF drain use has remained unchanged in the VQI. Among SCI patients, long-term survival was dramatically lower in patients suffering SCI requiring postoperative therapeutic drains compared with those who developed SCI with a preoperative prophylactic drain in place. Similar to myocardial infarction or cerebrovascular accident, for which time to intervention for rescue matters, patients with therapeutic drains may fare worse than prophylactic drain patients because of increased delays in decreasing CSF pressure, leading to secondary spinal cord injury. This and the survival advantage seen with prophylactic drains even in patients suffering SCI should give surgeons pause in considering a selective drain policy.

The Journal of Thoracic and Cardiovascular Surgery, 2019

Objectives: Thoracic aortic graft infection (TAGI) presents a formidable challenge with high mort... more Objectives: Thoracic aortic graft infection (TAGI) presents a formidable challenge with high mortality. We evaluated our 22-year experience managing TAGI with extensive debridement, graft replacement, vascularized tissue coverage, and aggressive antibiotics. Methods: We reviewed all consecutive patients with TAGI from 1991 to 2013. We also compared infected cases versus noninfected reoperative controls using a case-control design. Standard statistical methods were used for descriptive analysis, and Kaplan-Meier for survival analysis. Results: We treated 32 TAGI patients, involving 19 ascending/arch (A/A) and 13 descending/thoracoabdominal (D/TAA) grafts, including 4 endografts. In total, 19 (59.4%) presented with pseudoaneurysm and 11 (34.4%) with aortic fistula. Vascularized tissue (omentum or muscle) coverage was possible in 22 (71.0%) patients. Thirty-day mortality occurred in 3 (9.4%) patients, with no 30-day mortality among those receiving vascularized graft coverage (P ¼ .018). During follow-up, reinfection occurred in 8 patients (25% [4 A/A and 4 D/TAA]). Five-year overall (A/A 45.4% vs D/TAA 28.9%, P ¼ .434) and reinfection-free (A/A 19.2%, D/TAA 27%, P ¼ .409) survival was similar between groups. Long-term mortality was greater after endograft infection (100% vs 25% at 2.5 months, P ¼ .0007) or aortobronchial fistulization (100% vs 37.9% at 6 months, P ¼ .026). Time to reintervention was shorter in infected versus non-infected reoperative cases (31 vs 83 months, P < .0001), but there were no significant differences in long-term mortality after reoperation. Conclusions: TAGI continues to represent a highly morbid surgical challenge. Prompt antimicrobial coverage, debridement, graft replacement, and vascularized graft coverage, yielded best long-term results. Endograft infection and aortobronchial fistula had very poor prognoses.

The Journal of Thoracic and Cardiovascular Surgery, 2019

Background: Coagulopathy in patients undergoing open repair of acute type A aortic dissection usi... more Background: Coagulopathy in patients undergoing open repair of acute type A aortic dissection using cardiopulmonary bypass and hypothermic circulatory arrest is a common complication. Autologous platelet rich plasma is an intraoperative blood conservation technique, which has been shown in previous studies to promote hemostasis, leading to a reduction of blood product transfusions during elective aortic surgery. The purpose of this study is to evaluate the effectiveness of autologous platelet rich plasma as a blood conservation technique during open surgical repair of acute type A aortic dissection. Methods: We reviewed all acute type A aortic dissection cases using hypothermic circulatory arrest, excluding patients presenting in extremis. Perioperative transfusion requirements and clinical outcomes were analyzed. The end points analyzed included early mortality, postoperative stroke, renal dysfunction, prolonged ventilation, coagulopathy, and length of postoperative intensive care unit stay. Parsimonious and saturated propensity scores were calculated for platelet rich plasma use, and all outcomes were propensity adjusted. Results: Between 2003 and 2014, 85 of 391 acute type A aortic dissection repairs used autologous platelet rich plasma. Mean age of patients was 58 AE 15 years, and 70% were male. Obstructive sleep apnea (22% vs 13%, P ¼ .04) and baseline ejection fraction (57% AE 6.7% vs 55% AE 10%; P ¼ .014) were higher in the autologous platelet rich plasma group. Intraoperative propensity-adjusted blood products, 2 units fewer packed red blood cells (P ¼ .001), 4 units fewer freshfrozen plasma (P ¼ .001), 6 units fewer platelets (P ¼ .001), 1.3 units fewer cell-savers (P ¼ .002), and 5 units fewer cryoprecipitate (P ¼ .001) were significantly reduced by autologous platelet rich plasma use. Significant unadjusted reduction in postoperative reoperation for bleeding (8% vs 17%, P ¼ .046) after autologous platelet rich plasma was reported, although propensity adjustment eliminated significance (P ¼ .079). No difference in stroke, cardiac, or renal complications was observed. Postoperative transfusion needed during the first 3 days was significantly reduced in the autologous platelet rich plasma group: 2 units fewer packed red blood cells (P ¼ .13), 2 units fewer fresh-frozen plasma (P ¼ .018), and 5 units fewer platelets (P ¼ .001), when compared with those without autologous platelet rich plasma. Ventilation time was reduced by 3 days (P ¼ .002), and intensive care length of stay was reduced by 3 days (P ¼ .063) after intraoperative autologous platelet rich plasma use. Conclusions: The use of autologous platelet rich plasma in patients undergoing open repair of acute type A aortic dissection was associated with a reduction in Illustration of a repaired ascending and transverse aortic arch. Central Message aPRP reduced perioperative blood transfusion and improved postoperative outcomes with early extubation and shorter length of stay in ATAAD repair. Perspective Harvesting aPRP decreases hyperactivation of platelets and coagulation factors. The use of aPRP is encouraged even in a setting of emergency ATAAD repairs as they may benefit patients by reducing blood transfusion use and adverse postoperative outcomes. See Commentaries on pages 2298 and 2300.

Journal of Vascular Surgery, 2019

43 per 100 mL) were significantly associated with increased risks for CIN (Fig 2). Patients who d... more 43 per 100 mL) were significantly associated with increased risks for CIN (Fig 2). Patients who developed CIN had decreased overall survival compared with patients without CIN at 3 years after intervention (63% vs 89%; P ¼ .002). Conclusions: PVI are associated with low risk of CIN that significantly increases in the presence of CKD. Safe thresholds for contrast volume can be used to minimize the risk especially in patients with advanced CKD.

Journal of Vascular Surgery, 2019

higher match rate than those ranking IVS and another specialty. Compared with other surgical spec... more higher match rate than those ranking IVS and another specialty. Compared with other surgical specialties, those who submitted rank lists to the NRMP for cardiothoracic surgery and IVS had the highest likelihood of ranking another specialty higher. Care must be taken in evaluating applications to determine the applicant's level of interest in vascular surgery as a career.

Journal of Surgery, 2016

Objectives: The management of common carotid artery dissection (CCAD) extending from acute aortic... more Objectives: The management of common carotid artery dissection (CCAD) extending from acute aortic dissection is controversial. This systematic review examines the literature on CCAD secondary to aortic dissection and the association with stroke. Methods: MEDLINE and EMBASE databases were searched using multiple interfaces, including Ovid: Medline, ProSearch, PubMed/PMC, Cochrane Library, Scopus, Google Scholar, and EBSCOhost. All documented cases with an abstract written in English were extracted. Additionally, manual reference search was performed and quality of evidence was assessed. Results: A total of 165 articles, presenting 374 individual patients, were included. The main endpoints of interest included mortality and postoperative neurologic deficits. Thirty-two articles reported carotid artery interventions performed before or after aortic repair. Overall reported stroke incidence after aortic repair was 19.13% and five-year neurologic event-free survival was 54.5%. Overall five-year survival was 71.5%. Conclusions: We did not find evidence to suggest a difference in outcomes for those who underwent intervention for CCAD prior to aortic repair compared to those patients who did not. There is a need for a high index of suspicion for recognition, timely diagnosis, and early repair of proximal aortic dissection to improve the prognosis of these high-risk patients.

The Annals of thoracic surgery, Jan 23, 2018

Sarcopenia may be an indicator of frailty. We used total psoas area index (TPAI) to identify sarc... more Sarcopenia may be an indicator of frailty. We used total psoas area index (TPAI) to identify sarcopenia and evaluated the effect of preoperative TPAI on outcomes following descending thoracic aortic aneurysm (DTAA) repair. DTAA patients between 2007-2015 undergoing thoracic endovascular aortic repair (TEVAR) and open surgical repair (OSR) with available preoperative imaging were analyzed. Sarcopenia was defined as TPAI<6.5cm/m. Adverse event was defined as composite endpoint comprised of three or more multi-system complications, discharge to other than home or death within 30 days. 282/386 DTAA repairs had imaging available for TPAI measurements. 71/282 (25%) underwent TEVAR and 211/282 (75%) received OSR. Preoperative sarcopenia was similar in the 2 groups (OSR: 57% vs. TEVAR: 48%, p=0.188). Risk factors of sarcopenia were age>70-year-old, female, and large body surface area, while heritable thoracic aortic disease was a protective factor. OSR patients with sarcopenia were ol...

The Journal of thoracic and cardiovascular surgery, Jan 6, 2018

The need for intercostal artery (ICA) reattachment in surgery for descending thoracic aortic aneu... more The need for intercostal artery (ICA) reattachment in surgery for descending thoracic aortic aneurysm (DTAA) or thoracoabdominal aortic aneurysm (TAAA) remains controversial. We reviewed our experience over a 14-year period to assess the effects of ICA management on neurologic outcome after DTAA/TAAA repair. Intraoperative data were reviewed to ascertain the status of T3-12 ICAs and L1-4 ICAs. Arteries were classified as reattached, ligated, occluded, or not exposed. Temporality of reattachment or ligation in response to an intraoperative ischemic event (ie, loss of motor evoked potentials [MEPs]) was noted. Adjustment for other predictors of immediate or delayed paraplegia (DP) was performed by multiple logistic regression. The effects of specific artery level and type of reattachment technique were assessed using stratified contingency tables. A total of 1096 DTAA/TAAAs were performed between 2001 and 2014. The mean patient age was 64 ± 15 years, and 37% were female. Spinal cord i...

Journal of Vascular Surgery, 2016

Annals of Cardiothoracic Surgery, 2016

An important goal of surgical repair of type A aortic dissection is to resect the intimal tear. S... more An important goal of surgical repair of type A aortic dissection is to resect the intimal tear. Studies on the fate of residual dissection after acute type A aortic dissection repair in the past decade have driven surgeons to seek procedures to avoid distal reoperation. Aggressive surgical approach with total arch replacement in acute type A dissection has demonstrated lower incidence of distal reoperation and slower aortic growth rate compared to less aggressive ascending/hemiarch repair. Recently, successful results of thoracic endovascular aortic repair (TEVAR) in type B aortic dissection have encouraged surgeons to further attack acute type A aortic dissection with hybrid approach: antegrade endografting in the descending thoracic true lumen as an adjunct to hemiarch or total arch repair. However, is the hybrid approach with simultaneous descending endografting justified in all the acute type A aortic dissection cases? The outcomes of the hybrid approach reported by the several groups have demonstrated 80-100% of false lumen thrombus formation in the proximal descending aorta (stented segment); however, the complete obliteration of the false lumen is only 17-50%. The incidence of distal reoperation/reintervention after hybrid approach is as high as 14% and an adjunctive procedure is often performed. Moreover, there are concerns about additional risks associated with the hybrid procedures, such as spinal cord injury (SCI), stent graft induced new entry and stroke. The data on this new approach are still very limited. Hence, further study is warranted to prove its safety and durability.

Methodist DeBakey Cardiovascular Journal, 2016

The cumulative experience with endovascular aortic repair in the descending thoracic and infraren... more The cumulative experience with endovascular aortic repair in the descending thoracic and infrarenal aorta has led to increased interest in endovascular aortic arch reconstruction. Open total arch replacement is a robust operation that can be performed with excellent results. However, it requires cardiopulmonary bypass and circulatory arrest and, therefore, may not be tolerated by all patients. Minimally invasive techniques have been considered as an alternative and include hybrid arch debranching, parallel stent graft deployment in the chimney and snorkel configurations, and complete endovascular branched reconstruction with multi-branched devices. This review discusses the evolving use of endovascular techniques in the management of aortic arch pathology and considers their relevance in an era of safe and durable open aortic arch reconstruction.

European Journal of Vascular and Endovascular Surgery, 2015

neurologic events included 2 major and one minor stroke (11%). Transient spinal cord ischemia wit... more neurologic events included 2 major and one minor stroke (11%). Transient spinal cord ischemia with full recovery was observed in 2 patients (7%). One myocardial infarction required medical treatment (4%) and 2 renal function impairment (7%) were depicted. Early (<30 day) re-interventions (11%) were performed to treat one access complication, one left ventricle false aneurysm suspicion and one limb ischemia. During follow up (median 12 months), 1 patient (4%) died from a remote TAAA rupture. Two type 2 (7%) and one type 3 endoleaks (4%) were depicted. During follow up, 2 (7%) reinterventions were performed to treat the type 3 endoleak and a septic aortic false aneurysm. Conclusion: The outcomes associated with this new technique are favourable when the procedure is performed in experienced centres. Branched endografting of arch aneurysms should be considered in patients unfit for open surgery.

The Annals of Thoracic Surgery, 2016

Background. Acute type A aortic dissection (ATAAD) is a surgical emergency associated with high m... more Background. Acute type A aortic dissection (ATAAD) is a surgical emergency associated with high mortality and morbidity. We analyzed our 15-year experience in the management of ruptured ATAAD (rATAAD) and non-rATAAD to determine the predictors of early and late mortality. Methods. We reviewed all cases with ATAAD between 1999 and 2014. Patients were grouped into rATAAD and non-rATAAD based on intraoperative confirmation. Clinical data on preoperative characteristics and inhospital and long-term outcomes were analyzed to determine risk factors for early and long-term mortality. Survival was analyzed using Kaplan-Meier and log rank statistics. Results. Of the 489 total ATAAD repairs, 75 patients (15.3%) had rATAAD. The rATAAD patients were older compared with non-rATAAD (64.4 ± 16.2 versus 57.3 ± 14.2 years, respectively; p [ 0.0001) and commonly female (31 of 75 [41.3%] versus 107 of 414 [25.9%], respectively; p [ 0.006). Early mortality was higher among rATAAD patients that among non-rATAAD patients

JTCVS Techniques

Objectives: The SPIDER technique for hybrid thoracoabdominal aortic aneurysm repair can avoid tho... more Objectives: The SPIDER technique for hybrid thoracoabdominal aortic aneurysm repair can avoid thoracotomy and extracorporeal circulation. To improve technical feasibility and safety, the new Thoracoflo graft, consisting of a proximal stent graft connected to a 7-branched abdominal prosthesis, was evaluated in a pig model for technical feasibility testing, before implantation in humans. Methods: Retroperitoneal exposure of the infradiaphragmatic aorta, including visceral and renal arteries, was performed in 7 pigs (75-85 kg). One iliac branch was temporarily attached to the distal aorta to maintain retrograde visceral and antegrade iliac perfusion after deployment of the thoracic stent graft segment (SPI-DER technique). The proximal stent-grafted segment was deployed in the thoracic aorta via direct aortic puncture over the wire without fluoroscopy. The graft was deaired before flow via the iliac side branch to the visceral and iliac arteries was established. Visceral, renal, and lumbar arteries were subsequently sutured to the corresponding side branches of the graft. Technical feasibility, operating and clamping time, blood flow, and tissue perfusion in the related organs were evaluated before implantation and after 3 and 6 hours using transit-time flow measurement and fluorescent microspheres. Final angiography or postprocedural computed tomography angiography were performed. Results: Over-the-wire graft deployment was successful in 6 animals without hemodynamic alteration (P ¼ n.s.). In 1 pig, the proximal stent graft section migrated as the guidewire was not removed, as recommended, before release of the proximal fixation wire. Angiography and computed tomography scan confirmed successful graft implantation and transit-time flow measurement confirmed good visceral and iliac blood flow. Fluorescent microspheres confirmed good spinal cord perfusion. Conclusions: Over-the-wire implantation of the Thoracoflo graft using the SPIDER technique is feasible in a pig model. No fluoroscopy was required. For safe implantation, it is mandatory to follow the single steps of implantation. (JTCVS Techniques 2022;15:1-8) Thoracoflo graft prototype with proximal ringshaped stent graft.

JAMA Network Open, 2021

IMPORTANCE Liposomal bupivacaine for pain relief is purported to last 3 days compared with 8 hour... more IMPORTANCE Liposomal bupivacaine for pain relief is purported to last 3 days compared with 8 hours with standard bupivacaine. However, its effectiveness is unknown in truncal incisions for cardiothoracic or vascular operations. OBJECTIVE To compare the effectiveness of single-administration standard bupivacaine vs liposomal bupivacaine in patients undergoing truncal incisions. DESIGN, SETTING, AND PARTICIPANTS This randomized clinical trial enrolled patients undergoing sternotomy, thoracotomy, minithoracotomy, and laparotomy from a single cardiovascular surgery department in an academic medical center between November 2012 and June 2018. The study was powered to detect a Cohen effect size of 0.35 with a power of greater than 80%. Data analysis was performed from July to December 2018. INTERVENTION Patients were randomized to standard bupivacaine or liposomal bupivacaine. MAIN OUTCOMES AND MEASURES Pain was assessed over 3 postoperative days by the Numeric Rating Scale (NRS). Adjunctive opioids were converted to morphine equivalents units (MEU). NRS scores were compared using Wilcoxon rank-sum (3-day area under the curve) and 2-way nonparametric mixed models (daily scale score) to assess time-by-group interaction. Secondary outcomes included cumulative opioid consumption. RESULTS A total of 280 patients were analyzed, with 140 in each group (single-administration standard bupivacaine vs liposomal bupivacaine). Mean (SD) age was 60.2 (14.4) years, and 101 of 280 patients (36%) were women. Irrespective of treatment assignment, pain decreased by a mean of approximately 1 point per day over 3 days (β = −0.87; SE = 0.11; mixed model regression P < .001). Incision type was associated with pain with patients undergoing thoracotomy (including minithoracotomy) reporting highest median (interquartile range [IQR]) pain scores on postoperative days 1 (liposomal vs standard bupivacaine, 6 [4-8] vs 5 [3-7]; P = .049, Wilcoxon rank-sum) and 2 (liposomal vs standard bupivacaine, 5 [4-7] vs 4 [2-6]; P = .003, Wilcoxon rank-sum) but not day 3 (liposomal vs standard bupivacaine, 3 [2-6] vs 3 [1-5]; P = .10, Wilcoxon rank-sum), irrespective of treatment group. Median (IQR) 3-day cumulative NRS was 12.0 (8.0-16.5) for bupivacaine and 13.5 (9.0-17.0) for liposomal bupivacaine (P = .15, Wilcoxon rank-sum) Furthermore, use of opioids was greater following liposomal bupivacaine compared with standard bupivacaine (median [IQR], 41.5 [21.3-73.8] MEU vs 33.0 [17.8-62.5] MEU; P = .03, Wilcoxon rank-sum). On multivariable analysis, no interaction by incision type was observed for mean pain scores or opioid use. (continued) Key Points Question Does liposomal bupivacaine reduce postoperative pain and supplemental opioid use more than standard bupivacaine in cardiothoracic and vascular surgical patients? Findings In this randomized clinical trial including 280 participants, no significant difference in pain control was observed between liposomal vs standard formulation bupivacaine. Meaning These results do not support superior performance of liposomal bupivacaine compared with bupivacaine for postoperative pain control in cardiothoracic and vascular truncal incisions.

European Journal of Vascular and Endovascular Surgery, 2019

, correlations, and multivariate associations, respectively. Results-E-XDP levels were elevated i... more , correlations, and multivariate associations, respectively. Results-E-XDP levels were elevated in patients with AAA compared with controls (p ¼ 6.9e-14), predicted AAA with 98% sensitivity and 88% specificity and correlated with the AAA diameter (r ¼ 0.58, p ¼ 5.3e-05). The association between AAA and increased E-XDP was independent of smoking, comorbidities and prescription drugs (p ¼ 2.6e-06). Levels of E-XDP in patients with only a thin or macroscopically non-existent ILT were lower than those of patients with a large ILT, but remained significantly higher than in controls (p ¼ 0.0026). Concentration of E-XDP correlated with volume of the ILTs in the AAAs (r ¼ 0.75, p ¼ 1.0e-06) and mean ILT stress (r ¼ 0.42, p ¼ 0.017), and was independently raised if coexisting aneurysms existed (p ¼ 0.015). IHC revealed E-XDP expression in the ILT, which was spatially related to luminal neutrophil elastase and neutrophils. Conclusion-Circulating E-XDP is a novel marker of AAA and coexisting aneurysms, and correlates with AAA and ILT volume as well as with the mechanical stress of the ILT.

Journal of Vascular Surgery, 2018

arteries and 19 superior mesenteric arteries) targeted with 44 fenestrations and 17 scallops; 44 ... more arteries and 19 superior mesenteric arteries) targeted with 44 fenestrations and 17 scallops; 44 target vessels were stented with 41 covered stents and 3 bare-metal stents. Median follow-up was 255 days (range, 34-1352 days). Of the 22 completion endoleaks, 12 were type III, one was type IA, and 9 were indeterminate (either type IA or type III; Table). No type I or type III endoleaks were identified on initial postoperative computed tomography angiography. Furthermore, no type I or type III endoleaks were identified on any follow-up imaging. Of 12 patients with at least 6month follow-up, 6 had sac regression, 5 had stable sac diameter, and 1 had sac expansion. The patient with sac expansion underwent reintervention for persistent type II endoleak. There were no aneurysm ruptures or deaths. Conclusions: In patients undergoing FEVAR with the Zenith Fenestrated AAA Endovascular Graft, small, slow type I and type III endoleaks resolve spontaneously and can be safely observed. Continued research is necessary to evaluate long-term outcomes in these patients.

Journal of Vascular Surgery, 2018

Journal of Vascular Surgery, 2018

, to December 31, 2017, were analyzed (Figures 1 and 2). EST interventions were performed under f... more , to December 31, 2017, were analyzed (Figures 1 and 2). EST interventions were performed under fluoroscopic guidance. All ESTs of HFVM were performed under selective catheter angiography and direct injection, but LFVM with direct injection only. Serious complications were defined as any tissue or functional damage caused by direct injection, distal embolization, or tissue reaction. Results: There were 70 patients who had a total of 150 EST procedures for upper extremity VMs (median age, 24.5 years; range, 1-73 years; 44 male, 26 female). Of these, 28 (40%) had EST for HFVM and 42 (60%) for LFVM (total 78 and 72 procedures, respectively). Most used agents were foam sclerosant (STD 3% mixed in ratio 2:8 with air), dehydrated absolute ethanol, and coils. Serious complications as follows: HFVM in five patients (17.9%) or 6.4% of total procedures; three ischemia of fingers and/or hand requiring amputation (Figs 1 and 2), and two skin ulcerations. Serious complication in LFVM occurred in five patients (11.9%) or 6.9% of total procedures: one median nerve injury causing wrist drop requiring nerve grafting and hand therapy, one hand contracture requiring tendon release, and three skin ulcerations. All ulcerations resolved without significant long-term disability. However, the nerve and tendon injuries carried degrees of long-term functional disability. Conclusions: Current EST is relatively safe for upper extremity HFVM where our complication rate of 17.9% compares favorably with the recent literature, possibly owing to the selective use of foam versus alcohol, and improved classification and targeted treatment. For LFVM, significant complications resulted in 11.9% of patients from local toxicity after direct injection. These outcomes will direct treatment strategies to avoid local toxic complications in the hand for both HFVM and LFVM, and to informed consent.

European Journal of Vascular and Endovascular Surgery, 2019

9.6%) and major bleeding (n¼13; 9.6 %). There were no association between stent graft length or s... more 9.6%) and major bleeding (n¼13; 9.6 %). There were no association between stent graft length or subclavian coverage and paraplegia (OR 1.00, 95% CI 0.998-1.01; P¼0.32, and OR 0.56, 95% CI 0.14-2.31; P¼0.42; respectively) or subclavian coverage and stroke (OR 1.40, 95% CI 0.46-4.31; P¼0.56). Reinterventions were required in 27/137 patients (19.7%). Postoperative bleeding was the only major complication associated with reintervention (OR 3.39, 95% CI 1.05-11.0; P¼0.042). Median follow-up time was 18.5 months (range: 0-132 months). The Kaplan-Meier estimated survival was 79.1% at 1 month, 70.8% at 3 months, 64.5% at 1 year, 45.0% at 3 years, and 30.9% at 5 years. Age (HR 1.04; 95 % CI 1.00-1.07; P¼0.044), previous stroke (HR 2.31; 95 % CI 1.17-4.55; P¼0.016), previous aortic surgery (HR 2.17; 95 % CI 1.18-3.99; P¼0.012) as well as postoperative major bleeding (HR 4.29; 95 % CI 2.14-8.60; P¼0.001), postoperative stroke (HR 2.73; 95 % CI 1.43-5.22; P¼0.002), and renal failure (HR 7.82; 95 % CI 2.53-24.19; P¼0.001) were all associated with mortality. Conclusion-This nationwide multicenter study of patients with rDTAA undergoing TEVAR showed acceptable shortterm survival but the long-term survival is rather poor. The postoperative complication rate is high and reinterventions are required in one fifth of patients. Patient selection and optimization are of utmost importance to improve outcome.

Journal of Vascular Surgery, 2020

P ¼ .11). Total and postoperative lengths of stay were nonsignificantly longer with preoperative ... more P ¼ .11). Total and postoperative lengths of stay were nonsignificantly longer with preoperative drain use. Survival analysis among SCI patients revealed decreased survival in patients who had postoperative therapeutic drains placed (Fig). Conclusions: SCI rates have decreased over time, although prophylactic CSF drain use has remained unchanged in the VQI. Among SCI patients, long-term survival was dramatically lower in patients suffering SCI requiring postoperative therapeutic drains compared with those who developed SCI with a preoperative prophylactic drain in place. Similar to myocardial infarction or cerebrovascular accident, for which time to intervention for rescue matters, patients with therapeutic drains may fare worse than prophylactic drain patients because of increased delays in decreasing CSF pressure, leading to secondary spinal cord injury. This and the survival advantage seen with prophylactic drains even in patients suffering SCI should give surgeons pause in considering a selective drain policy.

The Journal of Thoracic and Cardiovascular Surgery, 2019

Objectives: Thoracic aortic graft infection (TAGI) presents a formidable challenge with high mort... more Objectives: Thoracic aortic graft infection (TAGI) presents a formidable challenge with high mortality. We evaluated our 22-year experience managing TAGI with extensive debridement, graft replacement, vascularized tissue coverage, and aggressive antibiotics. Methods: We reviewed all consecutive patients with TAGI from 1991 to 2013. We also compared infected cases versus noninfected reoperative controls using a case-control design. Standard statistical methods were used for descriptive analysis, and Kaplan-Meier for survival analysis. Results: We treated 32 TAGI patients, involving 19 ascending/arch (A/A) and 13 descending/thoracoabdominal (D/TAA) grafts, including 4 endografts. In total, 19 (59.4%) presented with pseudoaneurysm and 11 (34.4%) with aortic fistula. Vascularized tissue (omentum or muscle) coverage was possible in 22 (71.0%) patients. Thirty-day mortality occurred in 3 (9.4%) patients, with no 30-day mortality among those receiving vascularized graft coverage (P ¼ .018). During follow-up, reinfection occurred in 8 patients (25% [4 A/A and 4 D/TAA]). Five-year overall (A/A 45.4% vs D/TAA 28.9%, P ¼ .434) and reinfection-free (A/A 19.2%, D/TAA 27%, P ¼ .409) survival was similar between groups. Long-term mortality was greater after endograft infection (100% vs 25% at 2.5 months, P ¼ .0007) or aortobronchial fistulization (100% vs 37.9% at 6 months, P ¼ .026). Time to reintervention was shorter in infected versus non-infected reoperative cases (31 vs 83 months, P < .0001), but there were no significant differences in long-term mortality after reoperation. Conclusions: TAGI continues to represent a highly morbid surgical challenge. Prompt antimicrobial coverage, debridement, graft replacement, and vascularized graft coverage, yielded best long-term results. Endograft infection and aortobronchial fistula had very poor prognoses.

The Journal of Thoracic and Cardiovascular Surgery, 2019

Background: Coagulopathy in patients undergoing open repair of acute type A aortic dissection usi... more Background: Coagulopathy in patients undergoing open repair of acute type A aortic dissection using cardiopulmonary bypass and hypothermic circulatory arrest is a common complication. Autologous platelet rich plasma is an intraoperative blood conservation technique, which has been shown in previous studies to promote hemostasis, leading to a reduction of blood product transfusions during elective aortic surgery. The purpose of this study is to evaluate the effectiveness of autologous platelet rich plasma as a blood conservation technique during open surgical repair of acute type A aortic dissection. Methods: We reviewed all acute type A aortic dissection cases using hypothermic circulatory arrest, excluding patients presenting in extremis. Perioperative transfusion requirements and clinical outcomes were analyzed. The end points analyzed included early mortality, postoperative stroke, renal dysfunction, prolonged ventilation, coagulopathy, and length of postoperative intensive care unit stay. Parsimonious and saturated propensity scores were calculated for platelet rich plasma use, and all outcomes were propensity adjusted. Results: Between 2003 and 2014, 85 of 391 acute type A aortic dissection repairs used autologous platelet rich plasma. Mean age of patients was 58 AE 15 years, and 70% were male. Obstructive sleep apnea (22% vs 13%, P ¼ .04) and baseline ejection fraction (57% AE 6.7% vs 55% AE 10%; P ¼ .014) were higher in the autologous platelet rich plasma group. Intraoperative propensity-adjusted blood products, 2 units fewer packed red blood cells (P ¼ .001), 4 units fewer freshfrozen plasma (P ¼ .001), 6 units fewer platelets (P ¼ .001), 1.3 units fewer cell-savers (P ¼ .002), and 5 units fewer cryoprecipitate (P ¼ .001) were significantly reduced by autologous platelet rich plasma use. Significant unadjusted reduction in postoperative reoperation for bleeding (8% vs 17%, P ¼ .046) after autologous platelet rich plasma was reported, although propensity adjustment eliminated significance (P ¼ .079). No difference in stroke, cardiac, or renal complications was observed. Postoperative transfusion needed during the first 3 days was significantly reduced in the autologous platelet rich plasma group: 2 units fewer packed red blood cells (P ¼ .13), 2 units fewer fresh-frozen plasma (P ¼ .018), and 5 units fewer platelets (P ¼ .001), when compared with those without autologous platelet rich plasma. Ventilation time was reduced by 3 days (P ¼ .002), and intensive care length of stay was reduced by 3 days (P ¼ .063) after intraoperative autologous platelet rich plasma use. Conclusions: The use of autologous platelet rich plasma in patients undergoing open repair of acute type A aortic dissection was associated with a reduction in Illustration of a repaired ascending and transverse aortic arch. Central Message aPRP reduced perioperative blood transfusion and improved postoperative outcomes with early extubation and shorter length of stay in ATAAD repair. Perspective Harvesting aPRP decreases hyperactivation of platelets and coagulation factors. The use of aPRP is encouraged even in a setting of emergency ATAAD repairs as they may benefit patients by reducing blood transfusion use and adverse postoperative outcomes. See Commentaries on pages 2298 and 2300.

Journal of Vascular Surgery, 2019

43 per 100 mL) were significantly associated with increased risks for CIN (Fig 2). Patients who d... more 43 per 100 mL) were significantly associated with increased risks for CIN (Fig 2). Patients who developed CIN had decreased overall survival compared with patients without CIN at 3 years after intervention (63% vs 89%; P ¼ .002). Conclusions: PVI are associated with low risk of CIN that significantly increases in the presence of CKD. Safe thresholds for contrast volume can be used to minimize the risk especially in patients with advanced CKD.

Journal of Vascular Surgery, 2019

higher match rate than those ranking IVS and another specialty. Compared with other surgical spec... more higher match rate than those ranking IVS and another specialty. Compared with other surgical specialties, those who submitted rank lists to the NRMP for cardiothoracic surgery and IVS had the highest likelihood of ranking another specialty higher. Care must be taken in evaluating applications to determine the applicant's level of interest in vascular surgery as a career.

Journal of Surgery, 2016

Objectives: The management of common carotid artery dissection (CCAD) extending from acute aortic... more Objectives: The management of common carotid artery dissection (CCAD) extending from acute aortic dissection is controversial. This systematic review examines the literature on CCAD secondary to aortic dissection and the association with stroke. Methods: MEDLINE and EMBASE databases were searched using multiple interfaces, including Ovid: Medline, ProSearch, PubMed/PMC, Cochrane Library, Scopus, Google Scholar, and EBSCOhost. All documented cases with an abstract written in English were extracted. Additionally, manual reference search was performed and quality of evidence was assessed. Results: A total of 165 articles, presenting 374 individual patients, were included. The main endpoints of interest included mortality and postoperative neurologic deficits. Thirty-two articles reported carotid artery interventions performed before or after aortic repair. Overall reported stroke incidence after aortic repair was 19.13% and five-year neurologic event-free survival was 54.5%. Overall five-year survival was 71.5%. Conclusions: We did not find evidence to suggest a difference in outcomes for those who underwent intervention for CCAD prior to aortic repair compared to those patients who did not. There is a need for a high index of suspicion for recognition, timely diagnosis, and early repair of proximal aortic dissection to improve the prognosis of these high-risk patients.

The Annals of thoracic surgery, Jan 23, 2018

Sarcopenia may be an indicator of frailty. We used total psoas area index (TPAI) to identify sarc... more Sarcopenia may be an indicator of frailty. We used total psoas area index (TPAI) to identify sarcopenia and evaluated the effect of preoperative TPAI on outcomes following descending thoracic aortic aneurysm (DTAA) repair. DTAA patients between 2007-2015 undergoing thoracic endovascular aortic repair (TEVAR) and open surgical repair (OSR) with available preoperative imaging were analyzed. Sarcopenia was defined as TPAI<6.5cm/m. Adverse event was defined as composite endpoint comprised of three or more multi-system complications, discharge to other than home or death within 30 days. 282/386 DTAA repairs had imaging available for TPAI measurements. 71/282 (25%) underwent TEVAR and 211/282 (75%) received OSR. Preoperative sarcopenia was similar in the 2 groups (OSR: 57% vs. TEVAR: 48%, p=0.188). Risk factors of sarcopenia were age>70-year-old, female, and large body surface area, while heritable thoracic aortic disease was a protective factor. OSR patients with sarcopenia were ol...

The Journal of thoracic and cardiovascular surgery, Jan 6, 2018

The need for intercostal artery (ICA) reattachment in surgery for descending thoracic aortic aneu... more The need for intercostal artery (ICA) reattachment in surgery for descending thoracic aortic aneurysm (DTAA) or thoracoabdominal aortic aneurysm (TAAA) remains controversial. We reviewed our experience over a 14-year period to assess the effects of ICA management on neurologic outcome after DTAA/TAAA repair. Intraoperative data were reviewed to ascertain the status of T3-12 ICAs and L1-4 ICAs. Arteries were classified as reattached, ligated, occluded, or not exposed. Temporality of reattachment or ligation in response to an intraoperative ischemic event (ie, loss of motor evoked potentials [MEPs]) was noted. Adjustment for other predictors of immediate or delayed paraplegia (DP) was performed by multiple logistic regression. The effects of specific artery level and type of reattachment technique were assessed using stratified contingency tables. A total of 1096 DTAA/TAAAs were performed between 2001 and 2014. The mean patient age was 64 ± 15 years, and 37% were female. Spinal cord i...

Journal of Vascular Surgery, 2016

Annals of Cardiothoracic Surgery, 2016

An important goal of surgical repair of type A aortic dissection is to resect the intimal tear. S... more An important goal of surgical repair of type A aortic dissection is to resect the intimal tear. Studies on the fate of residual dissection after acute type A aortic dissection repair in the past decade have driven surgeons to seek procedures to avoid distal reoperation. Aggressive surgical approach with total arch replacement in acute type A dissection has demonstrated lower incidence of distal reoperation and slower aortic growth rate compared to less aggressive ascending/hemiarch repair. Recently, successful results of thoracic endovascular aortic repair (TEVAR) in type B aortic dissection have encouraged surgeons to further attack acute type A aortic dissection with hybrid approach: antegrade endografting in the descending thoracic true lumen as an adjunct to hemiarch or total arch repair. However, is the hybrid approach with simultaneous descending endografting justified in all the acute type A aortic dissection cases? The outcomes of the hybrid approach reported by the several groups have demonstrated 80-100% of false lumen thrombus formation in the proximal descending aorta (stented segment); however, the complete obliteration of the false lumen is only 17-50%. The incidence of distal reoperation/reintervention after hybrid approach is as high as 14% and an adjunctive procedure is often performed. Moreover, there are concerns about additional risks associated with the hybrid procedures, such as spinal cord injury (SCI), stent graft induced new entry and stroke. The data on this new approach are still very limited. Hence, further study is warranted to prove its safety and durability.

Methodist DeBakey Cardiovascular Journal, 2016

The cumulative experience with endovascular aortic repair in the descending thoracic and infraren... more The cumulative experience with endovascular aortic repair in the descending thoracic and infrarenal aorta has led to increased interest in endovascular aortic arch reconstruction. Open total arch replacement is a robust operation that can be performed with excellent results. However, it requires cardiopulmonary bypass and circulatory arrest and, therefore, may not be tolerated by all patients. Minimally invasive techniques have been considered as an alternative and include hybrid arch debranching, parallel stent graft deployment in the chimney and snorkel configurations, and complete endovascular branched reconstruction with multi-branched devices. This review discusses the evolving use of endovascular techniques in the management of aortic arch pathology and considers their relevance in an era of safe and durable open aortic arch reconstruction.

European Journal of Vascular and Endovascular Surgery, 2015

neurologic events included 2 major and one minor stroke (11%). Transient spinal cord ischemia wit... more neurologic events included 2 major and one minor stroke (11%). Transient spinal cord ischemia with full recovery was observed in 2 patients (7%). One myocardial infarction required medical treatment (4%) and 2 renal function impairment (7%) were depicted. Early (<30 day) re-interventions (11%) were performed to treat one access complication, one left ventricle false aneurysm suspicion and one limb ischemia. During follow up (median 12 months), 1 patient (4%) died from a remote TAAA rupture. Two type 2 (7%) and one type 3 endoleaks (4%) were depicted. During follow up, 2 (7%) reinterventions were performed to treat the type 3 endoleak and a septic aortic false aneurysm. Conclusion: The outcomes associated with this new technique are favourable when the procedure is performed in experienced centres. Branched endografting of arch aneurysms should be considered in patients unfit for open surgery.

The Annals of Thoracic Surgery, 2016

Background. Acute type A aortic dissection (ATAAD) is a surgical emergency associated with high m... more Background. Acute type A aortic dissection (ATAAD) is a surgical emergency associated with high mortality and morbidity. We analyzed our 15-year experience in the management of ruptured ATAAD (rATAAD) and non-rATAAD to determine the predictors of early and late mortality. Methods. We reviewed all cases with ATAAD between 1999 and 2014. Patients were grouped into rATAAD and non-rATAAD based on intraoperative confirmation. Clinical data on preoperative characteristics and inhospital and long-term outcomes were analyzed to determine risk factors for early and long-term mortality. Survival was analyzed using Kaplan-Meier and log rank statistics. Results. Of the 489 total ATAAD repairs, 75 patients (15.3%) had rATAAD. The rATAAD patients were older compared with non-rATAAD (64.4 ± 16.2 versus 57.3 ± 14.2 years, respectively; p [ 0.0001) and commonly female (31 of 75 [41.3%] versus 107 of 414 [25.9%], respectively; p [ 0.006). Early mortality was higher among rATAAD patients that among non-rATAAD patients