Search Results (51)

Advancements in endovascular stent graft design have enabled the treatment of distal aortic arch pathologies. However, the length of the proximal landing zone remains a limitation, especially with vascular anomalies like an aberrant right subclavian artery (ARSA) posing additional challenges. A 78-year-old patient underwent computed tomography angiography (CTA), which revealed progressive enlargement of a distal aortic arch aneurysm located beyond an ARSA that coursed between the esophagus and trachea. Following evaluation by the multidisciplinary Aortic Team, a hybrid procedure was planned. A right carotid-to-ARSA bypass was performed and a Castor single-branched stent graft (CSBSG) was deployed in the aortic arch with its side branch directed into the left subclavian artery (LSA), thereby covering the origin of the ARSA. To prevent a type II endoleak, plug embolization of the ARSA origin was subsequently performed. CSBSG is a feasible treatment for distal aortic arch aneurysms, even in the presence of vascular anomalies such as ARSA. Full article

Background/Objectives: Surgical aortic valve replacement effectively relieves left ventricular afterload and promotes reverse remodeling in patients with severe aortic stenosis. The Perceval prosthesis offers a hybrid approach, combining complete annular decalcification with sutureless deployment. This design allows for reduced operative times and potentially larger effective orifice areas. However, comparative data with conventional stented bioprosthetic valves remain limited, particularly regarding reverse remodeling, hemodynamic performance, and long-term clinical outcomes. Methods: In this retrospective cohort study, 115 patients underwent aortic valve replacement with either the Perceval valve (n = 44) or conventional stented bovine pericardial valves (n = 71). Results: The Perceval group showed a 100% procedural success rate with no in-hospital mortality, significantly shorter cardiopulmonary bypass and cross-clamp times, larger effective orifice areas, and a lower incidence of patient–prosthesis mismatch. Both groups demonstrated favorable left ventricular mass regression and reverse remodeling. The rates of paravalvular leakage, permanent pacemaker implantation, and redo aortic valve replacement were comparable between groups. Multivariate Cox regression identified the follow-up indexed left ventricular mass as an independent predictor of major adverse cardiac and cerebral events. Conclusions: In this study, the Perceval valve was associated with promising hemodynamic characteristics and procedural efficiencies, particularly in cases with small aortic annuli and during minimally invasive procedures. The valve was associated with reverse ventricular remodeling and clinical outcomes that appeared similar to those of conventional stented bioprostheses. These observations suggest it may represent a potential alternative option for surgical aortic valve replacement in appropriate clinical scenarios. However, randomized control trials are needed to confirm these associations. Full article

Objective: To evaluate the impact of a prosthetic and native aorta proximal landing zone (PLZ) for hybrid thoracic aorta repair with a stent graft deployed in the Zone 0 ascending aorta. Methods: Retrospective analysis of 100 patients who underwent Zone 0 hybrid thoracic aorta repair between 2005 and 2022, at a single institution. Fifty-eight (58%) had a Dacron PLZ (ascending aorta replacement with debranching), and forty-two (42%) had a native ascending aorta PLZ (off-pump aortic arch debranching). All the surviving patients had at least one radiological follow-up. Results: Patients with a native aorta PLZ were older (p = 0.01) and had higher rates of pulmonary disease (p = 0.01) and chronic kidney disease (p = 0.01) and a higher Logistic EUROscore (p = 0.02). In-hospital mortality was similar between the two groups (2.3% vs. 1.7%; p = 0.68). Retrograde aortic dissection was observed in four (9.2%) of the native PLZ group. The mean follow-up was 37 ± 22 months in the Dacron PLZ group and 42 ± 20 months in the native PLZ group (p = 0.05). At 1,3, and 5 years, freedom from Type Ia endoleak was significantly higher in patients with a Dacron PLZ: 100% vs. 96 ± 0.3%, 100% vs. 85 ± 1%, and 100% vs. 66 ± 1.3% (p = 0.03). Despite this, the 1-, 3-, and 5-year survival was similar between groups: 100% vs. 96 ± 0.4%, 90 ± 1% vs. 89 ± 0.6%, and 66 ± 1% vs. 64 ± 2%. (p = 0.96). Conclusions: Endograft deployment in a prosthetic ascending aorta is a safe and durable option for aortic repair. A Dacron PLZ is associated with a lower rate of Type Ia endoleak and can prevent retrograde aortic dissection when compared with native aorta. Full article

Median Arcuate Ligament Syndrome, also known as Dunbar’s syndrome, is a rare condition caused by stenosis of the celiac artery (CAS) through the fibrous arch connecting the diaphragmatic branches. It manifests as postprandial abdominal pain, nausea, vomiting, weight loss and increased epigastric tenderness. The condition most commonly affects young females without coexisting vascular comorbidities. Diagnosis is difficult due to the non-specific symptoms, often overlapping with other gastrointestinal diseases. Standard investigations include duplex ultrasound, computed tomography angiography (CTA) and contrast-enhanced magnetic resonance imaging (CE-MRA). Treatment mainly consists of surgical release of the arch ligament, which can be performed by open, laparoscopic or robotic methods. Surgery is often supported by celiac truncal stenting for residual stenosis, which significantly improves vascular flow. Alternative approaches include visceral plexus blocks and novel hybrid techniques, such as a combination of ligament release and endovascular treatment of the celiac trunk. In severe cases, vascular by-passes are recommended. The aim of this paper is to discuss the clinical manifestations, diagnostic possibilities, therapeutic options and directions for further research on MALS from the perspective of a vascular surgeon. It emphasizes the need for a multidisciplinary approach, including collaboration between the surgeon, radiologist, gastroenterologist and psychologist, which enables comprehensive disease management and improved quality of life for patients. In addition, the need for further development of diagnostic and therapeutic methods for early diagnosis and effective treatment was pointed out. Full article

Background and Objectives: Post-transplant anastomotic pseudoaneurysms are a rare but serious complication of renal transplantation, typically requiring graft sacrifice. This case report demonstrates a novel hybrid approach for managing a mycotic pseudoaneurysm while preserving graft function. Case report: A 56-year-old male developed a pseudoaneurysm at the anastomotic site after cadaveric kidney transplantation, presenting with recurrent infections and declining renal function. Imaging confirmed the pseudoaneurysm. A hybrid strategy combining femoral–femoral bypass with a polytetrafluoroethylene graft, percutaneous transluminal angioplasty with stenting, and coil embolization was performed. Results: The intervention successfully isolated the pseudoaneurysm and preserved graft function. Post-procedure, serum creatinine levels improved, stabilizing at 2.3 mg/dL during follow-up. Imaging confirmed no residual flow in the aneurysm, and vascular complications were absent. Conclusions: This report highlights a successful combined surgical and endovascular approach for treating mycotic pseudoaneurysms, preserving graft function and restoring limb blood flow. This strategy offers a promising alternative for managing complex post-transplant complications, though long-term outcomes require further evaluation. Full article

Background/Objectives: The frozen elephant trunk (FET) technique was introduced as a possible single-stage procedure for treating aortic arch pathologies. However, up to a third of patients are reported to need subsequent completion (extension). This retrospective analysis aimed to evaluate the impact of early (within 30 days; EC group) versus late (>30 days; LC group) endovascular completion with thoracic endovascular aortic repair (TEVAR) in patients treated with FET. Methods: A single-center, retrospective analysis of all consecutive patients for the period between June 2017 and December 2023 who underwent FET and received endovascular extension was conducted. Indications for endovascular extension were aneurysms of the descending aorta, aneurysmal progress, endoleak, malperfusion, distal stent-induced new entry (dSINE), and aortic rupture. Results: A total of 37 of 232 FET patients received endovascular extension (15.9%). Average age at the time of TEVAR was 63.3 ± 10.3 years. There was an increase in the maximum total aortic diameter post-FET from 40.8 ± 9 mm to 45.1 ± 14 mm prior to TEVAR. Only 14 patients (37.8%) had the desired complete occlusion of the false lumen or aneurysm prior to extension; 23 (62.2%) still had relevant perfusion of the false lumen or aneurysm. The EC and LC groups were defined by time between FET and TEVAR: a mean of 4.8 ± 5.2 days in the EC group and 18.4 ± 18 months in the LC group. The EC group had markedly more complex procedures, reflected in intensive care (10.7 ± 6.9 vs. 0.1 ± 0.3 days, p < 0.001) and hospitalization (22.4 ± 14.0 vs. 8.1 ± 5.6 days, p = 0.003) durations. There was one early death due to multiorgan failure in the EC group and there were none in the LC group. There were no major cardiac events in either group. In the EC group, seven patients (50%) suffered from postoperative respiratory failure and four (28.6%) developed acute kidney failure requiring dialysis. Only one patient in the LC group (4.3%) experienced complications. During follow-up, another three patients (21.4%) of the EC group died, but none of the LC group did. Post-extension aortic remodeling was similar in both groups, with complete occlusion achieved in 27 cases (72%) during early follow-up and increased to 90.6% after a mean of 22.0 ± 23.4 months. Conclusions: Following aortic arch repair using FET, there is still a need for second-stage repair in 16% of patients. Endovascular completion post-FET is safe and feasible with a technical success rate of 100%, but early completion is associated with greater morbidity and mortality. TEVAR extension surgery may be better delayed, if possible, until after recovery from the hybrid arch repair. Full article

Hybrid coronary revascularisation (HCR) integrates coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) to combine the benefits of minimally invasive surgery and advanced stent technology. Typically, HCR involves off-pump left internal mammary artery (LIMA) to left anterior descending artery (LAD) bypass via minimally invasive direct coronary artery bypass (MIDCAB), complemented by PCI to non-LAD vessels. This approach avoids a full sternotomy and cardiopulmonary bypass while preserving the advantages of surgical revascularisation. Patient selection for HCR should be guided by a multidisciplinary heart team, targeting those with severe LAD disease and suitable non-LAD lesions for PCI. This review outlines the surgical techniques, anticoagulation strategies, and procedural sequencing employed in HCR, along with real-world outcomes from observational studies and randomised trials. While current evidence supports the safety and feasibility of HCR in appropriately selected patients, further large-scale randomised trials are needed to clarify its role in comparison to standalone CABG or PCI. Full article

Objectives: Acute type A aortic dissection (ATAAD) is a life-threatening condition that requires emergent surgical intervention. Numerous surgical approaches exist for ATAAD, and controversy remains regarding the optimal arch interventions for ATAAD patients. Aortic Arch Interventions: Approaches to ATAAD repair include hemiarch repair or extended arch repairs, including the hemiarch with a hybrid stent implantation, such as the AMDS hybrid Prosthesis, total arch replacement (TAR), and the use of an elephant trunk and frozen elephant trunk. While indications for each procedure exist, such as entry tears in the arch, arch aneurysms, and head vessel communications for TAR and malperfusion and a reduced risk of distal anastomotic new entry tears in Debakey I aortic dissection for the AMDS and frozen elephant trunks, the optimal intervention depends on numerous factors. Surgeon and center experience, resource availability, patient risk, and anatomy all contribute to the decision-making process. TAR has improved in safety over the years and has been demonstrated to be comparable to the hemiarch repair in terms of safety in many settings. TAR may also prevent adverse remodeling and can effectively treat more distal diseases, the presence of arch tears, arch aneurysms, and branch vessel involvement or malperfusion. Conclusions: Numerous surgical approaches exist to manage ATAAD, allowing for the surgeon to tailor the repair to the individual patient and pathology. TAR allows for single or staged repair of extensive pathologies and can address distal entry tears, the aneurysmal arch, and head vessel pathologies. In cases with malperfusion, an AMDS can be used in many cases. The management strategy for ATAAD should always involve performing the best surgery for the patient, although in cases where a total arch is indicated but cannot be performed safely by a non-aortic surgeon, the safest approach may be to perform a hemiarch initially and to plan for an elective arch reoperation in the case it is required following close surveillance. Full article

Objectives: The impact of long-term complications after robotic hybrid coronary revascularization (HCR), including persistent angina, repeat revascularization, and myocardial infarction (MI), remains limited. This study aims to determine the risk factors for coronary events after robotic HCR and their time-varying effects on outcomes. Methods: We identified all consecutive patients who underwent robotic HCR at our institution. Baseline characteristics were explored as possible risk factors for angina, MI, and repeat revascularization with stents at any time during the follow-up. Results: A total of 875 patients (mean age 71.1 ± 11.1 years) were included. After a median follow-up of 3.32 years (IQR 1.18–6.34 years), angina occurred in 134 patients (15.3%), repeat revascularization with stents in 139 patients (15.8%), and MI in 36 patients (4.1%). The hazard rates for all outcomes increased with follow-up time, with a notable early rise around two years of follow-up for angina and, to a lesser extent, repeat revascularization. The risk factors were the lack of radial artery graft use, black race, diabetes, obesity, chronic obstructive pulmonary disease, low ejection fraction <50%, severe left main coronary artery stenosis (>50%), and more than three-vessel disease. Conclusions: Optimization of modifiable periprocedural risk factors may positively impact long-term prognosis in patients undergoing robotic HCR. Full article

The involvement of the aortic arch in thoracic aortic aneurysms (TAA), or acute aortic dissections (AAD), represents a challenging clinical entity, mandating a meticulous surgical plan, tailored to each individual case. The advent of endovascular techniques and the introduction of modern arch protheses have led to the implementation of the frozen elephant trunk (FET) technique. This one-step hybrid operation consists of a total aortic arch replacement combined with an antegrade delivery of a stent–graft for the descending aorta, which acts as a proximal landing zone facilitating a potential distal endovascular reintervention. In this manner, this technique addresses acute and chronic arch disease with an acceptable morbidity and mortality. Several FET prosthetic devices are available on the global market and have exhibited favourable outcomes, although with some disadvantages in complex cases; similarly, the hybrid procedure described in this review has also been associated with complications, such as coagulopathy and neurological and graft-related events. The purpose of this review is to thus provide key insights into successful hybrid aortic arch replacements and to discuss useful tips and relevant considerations regarding its use. Full article

Background: The frozen elephant trunk method combines the implantation of a Dacron prosthesis with a self-expanding stent graft, which allows for complex repairs of the aortic arch and thoracic aorta in one procedure. Despite the advantages of hybrid treatment for aortic arch aneurysms, in Poland, only a few such surgeries are performed annually compared to in Western countries. The aim of this study was to demonstrate the 8-year outcomes of treatment at the center where the Aortic Team operates, which is one of the centers in Poland with the most extensive experience in hybrid FET treatment. Methods: Patients who underwent frozen elephant trunk surgery for chronic and acute pathologies of the aortic arch and thoracic aorta between March 2016 and March 2024 were comprehensively analyzed retrospectively. Frozen elephant trunk procedures were performed under three consecutive clinical conditions: acute aortic dissection, chronic aortic dissection and redo surgery. Results: A total of 40 patients (median age: 60 years (53–66), 67.5% male) were admitted to our hospital and underwent an FET procedure. The median Euroscore II was 25.9% and the 30-day mortality was 7.5%. The 1-year and 5-year mortalities were the same, equal to 15%, with mortality cases observed only in the first and second groups of consecutive patients during the first two months of follow-up. Spinal cord injury was observed in 2.5% of patients. Conclusions: The FET technique can be successfully used to treat aortic aneurysms with optimal results and low complication rates. The surgery length, including the cardiopulmonary bypass and aortic cross-clamp times, decreased significantly with increasing experience. Full article

Chronic total occlusions (CTOs) represent a challenging scenario in coronary artery disease (CAD). The prevalence of CTOS in patients undergoing coronary angiography underscores the need for effective diagnostic and therapeutic strategies. Coronary angiography, while essential, offers limited insights into lesion morphology, vessel course, and myocardial viability. In contrast, coronary imaging techniques—including optical coherence tomography (OCT), intravascular ultrasound (IVUS), and coronary computed tomography angiography (CCTA)—provide comprehensive insights for each stage of CTO percutaneous coronary intervention (PCI). OCT facilitates the assessment of plaque morphology and stent optimization, despite low evidence and several limitations in CTO-PCI. IVUS offers deeper penetration, allowing managing proximal cap scenarios and guiding subintimal navigation. CCTA provides a non-invasive, three-dimensional view of coronary anatomy, enabling the precise evaluation of myocardial mass at risk and detailed procedural planning. Despite their individual limitations, these imaging modalities have enhanced the success rates of CTO-PCI, thus reducing procedural and long-term complications and improving patient outcomes. The future of CTO management lies in further technological advancements, including hybrid imaging, artificial intelligence (AI) integration, and improved fusion imaging. These innovations promise to refine procedural precision and personalize interventions, ultimately improving the care of patients with complex coronary artery disease. Full article

Multiple strategies for tandem severe carotid artery stenosis are reported: bilateral carotid artery endarterectomy (CEA), bilateral carotid artery stenting (CAS), and hybrid procedures (CEA and CAS). The management is controversial, considering the reported high risk of periprocedural stroke, hemodynamic distress, and cerebral hyperperfusion syndrome. We present the case of a 64-year-old patient with severe symptomatic bilateral internal carotid artery stenosis (95% stenosis on the left internal carotid artery with recent ipsilateral watershed anterior cerebral artery–medial cerebral artery (ACA-MCA) and medial cerebral artery–posterior cerebral artery (MCA-PCA) ischemic strokes and 90% stenosis on the right internal carotid artery with chronic ipsilateral frontal ischemic stroke) managed successfully with staged CEA within a 3-day interval. The patient had a history of coronary angioplasty and stenting. Strategies for brain protection included shunt placement after the evaluation of carotid stump pressure, internal carotid backflow, and near-infrared spectroscopy. A collagen and silver-coated polyester patch was used to complete the endarterectomy using a 6.0 polypropylene continuous suture in both instances. Management also included neurological consults after extubation, dual antiplatelet therapy, head CT between the two surgeries, myocardial ischemia monitoring, and general anesthesia. Staged CEA with a small time interval between surgeries can be an option to treat tandem symptomatic carotid artery stenosis in highly selected patients. The decision should be tailored according to the patient’s characteristics and should also be made by a cardiology specialist, a neurology specialist, and an anesthesia and intensive care physician. Full article

Acute limb ischemia due to limb-graft occlusion (LGO) after fenestrated endovascular aneurysm repair (FEVAR) and acute bypass graft occlusion with an ePTFE graft pose critical challenges, necessitating prompt intervention to prevent limb loss. This paper discusses two cases of acute limb ischemia treated with a hybrid approach using the AngioJet™ Ultra Thrombectomy System as an adjunct to Fogarty thrombectomy. Case I involved a 69-year-old male post-FEVAR with contralateral iliac limb graft occlusion of the fenestrated Anaconda™, while Case II featured a 70-year-old male (ASA IV) post-bypass surgery (iliopopliteal arterial bypass with ePTFE Graft) with acute bypass graft occlusion. Both cases underwent successful recanalization using the AngioJet™ Ultra Thrombectomy System (ZelanteDVT™ 8F catheter, Solent™ Proxi 6F catheter) (Boston Scientific, Marlborough, MA, USA), combined with adjunctive techniques including Fogarty thrombectomy, balloon angioplasty, stenting, and local lysis. Immediate postoperative and follow-up assessments after 6 months revealed restored limb perfusion and improved clinical outcomes, with palpable pulses and improved ulcer healing. The aim of this treatment strategy is not only to alleviate limb ischemia but also to preserve future options in the event of graft failure. The use of the AngioJet™ Thrombectomy System in cases of LGO aims not only to clear the thrombus load but also to avoid the need for graft relining. In the case of acute arterial bypass graft occlusion in a patient with ASA IV, the goal of using the thrombectomy device is to preserve the native vessels for future procedures, such as long infragenual bypass, in addition to limb salvage. These cases demonstrate the efficacy of a hybrid surgical approach in managing acute limb ischemia following graft occlusion following FEVAR and bypass surgery. Long-term follow-up will further elucidate the durability of these interventions and their impact on limb salvage and overall patient outcomes. By combining mechanical thrombectomy with adjunctive techniques, such as balloon angioplasty and stenting, this hybrid approach offers a comprehensive solution to acute limb ischemia, addressing both the underlying occlusive pathology and ensuring optimal limb perfusion. Furthermore, the utilization of the AngioJet™ Ultra Thrombectomy System provides a minimally invasive yet effective method for thrombus removal, reducing procedural time and potential complications associated with open surgical techniques. As such, this approach represents a valuable addition to the armamentarium of treatments for acute limb ischemia, particularly in cases of graft occlusion following complex endovascular and bypass procedures. Full article

Background: Percutaneous coronary intervention (PCI) with a drug-eluting stent (DES) for chronic total coronary occlusions (CTOs) improves clinical symptoms and quality of life. However, data on drug-coated balloon (DCB)-based PCI in CTO lesions are limited. Methods: A total of 200 patients were successfully treated for CTO lesions, either with DCB alone or in combination with DES (DCB-based PCI). They were compared with 661 patients who underwent second-generation DES implantation for CTO from the PTRG-DES registry (DES-only PCI). The endpoint was major adverse cardiovascular events (MACEs), which included a composite of cardiac death, myocardial infarction, stent or target lesion thrombosis, target vessel revascularization, and major bleeding at 2 years. Results: In the DCB-based PCI group, 49.0% of patients were treated with DCB only and 51.0% underwent the hybrid approach combining DCB with DES. Bailout stenting was performed in seven patients (3.5%). The DCB-based PCI group exhibited fewer stents (1.0; IQR: 0.0–1.0 and 2.0; IQR: 1.0–3.0, p < 0.001), shorter stent lengths (6.5 mm; IQR: 0.0–38.0 mm and 42.0 mm; IQR: 28.0–67.0 mm, p < 0.001), and lower usage of small stents with a diameter of 2.5 mm or less (9.8% and 36.5%, p < 0.001). Moreover, the DCB-based PCI group had a lower rate of MACEs than the DES-only PCI group (3.1% and 13.2%, p = 0.001) at 2-year follow-up. Conclusions: The DCB-based PCI approach significantly reduced the stent burden, particularly in the usage of small stent diameters, and resulted in a lower risk of MACEs compared to DES-only PCI in CTO lesions. Full article