Chronic Limb-Threatening Ischaemia (CLTI)
James Michael Forsyth in How to Be a Safe Consultant Vascular Surgeon from Day One, 2023
The lung function tests reveal he has an obstructive lung disease pattern. The vascular anaesthetist advises that aortic surgery is possible, but it would be high risk. The patient himself would rather avoid major open surgery if at all possible, but he does not think he can cope with his symptoms at the moment and does not feel conservative management is appropriate because he can barely walk 20 m before his claudication forces him to stop and rest ….“In this case then I think bilateral common femoral endarterectomies with iliac stents is a suitable compromise. I would consider dual consultant operating (one for each groin) to make the operation faster. I would also work collaboratively with the anaesthetist, and perhaps a spinal/epidural approach would be better given his bad chest. If this were the plan I would also stop the patient's clopidogrel and switch him to aspirin to allow the spinal approach.”
Stent-Graft Repair of Aortic Aneurysms
Richard R Heuser, Giancarlo Biamino in Peripheral Vascular Stenting, 1999
Surgical repair of thoracic aortic aneurysms (TAA) is associated with significant morbidity and mortality. This, in turn, has led to surgeons’ reluctance to offer treatment to many patients. In addition, there are indeed ‘inoperable’ cases because of major comorbidities, making the risks of thoracic aortic surgery truly prohibitive. The need for a less invasive treatment alternative was thus imperative and rather clear, resulting in the current evolution of endovascular stent-graft techniques. Such interventions can offer TAA patients hope where none existed before. They carry the promise to revolutionize the whole field of thoracic aortic surgery, and will have a major impact on management paradigms and therapeutic indications for several pathologic conditions affecting the aortic arch and descending thoracic aorta.
The cardiovascular system
C. Simon Herrington in Muir's Textbook of Pathology, 2020
Acute dissection and rupture leads to sudden death and in-hospital mortality remains high. Aortic cystic medial degeneration is associated with both hypertension and genetic diseases. It is histologically impossible to tell them apart. Studies have identified numerous genes involved in the TGF-β signalling pathway that are associated with thoracic aortic aneurysm and dissection. Additional studies identify genetic variants associated with an increased risk of bicuspid aortic valve, abdominal aortic aneurysm, and fibromuscular dysplasia. With increased availability of low-cost genetic testing, clinicians are now able to not only definitively diagnose some vascular syndromes but also provide information on the risk of disease in other family members. Current guidelines on the management of thoracic aortic disease recommend that the ascending aorta be replaced when it reaches 5.5 cm in diameter. In familial cases this size criterion may need to be reduced, signifying a recommendation to operate on patients with smaller aortic sizes. Females have been found to have worse outcomes compared to males. Decisions are made depending on symptoms, location, size, and familial pattern. Both open and endovascular repair options are available. Aortic surgery in the present era is very safe and its benefits outweigh the associated risks. Conventional graft replacement surgery and endovascular therapy have significantly improved prognosis. Survivors are at lifelong risk for more thoracoabdominal aortic aneurysms, further dissection, or aortic rupture so continued surveillance is essential.
Pre-implantation genetic testing for Marfan syndrome using mini-sequencing
Published in Journal of Obstetrics and Gynaecology, 2022
Sirivipa Piyamongkol, Krit Makonkawkeyoon, Vorasuk Shotelersuk, Opas Sreshthaputra, Tawiwan Pantasri, Rekwan Sittiwangkul, Theera Tongsong, Wirawit Piyamongkol
The genetic basis of Marfan syndrome is from various mutations within the fibrillin-1 (FBN-1) gene, with over 400 mutations having been reported. About a quarter of MFS are a result of de novo mutations (Robinson et al. 2002). The FBN-1 gene is 230-kb in size, located on 15q21.1 (Lee et al. 1991). The FBN-1 gene is composed of 65 exons, encoding a 2871 amino acid long profibrillin. Profibrillin is then cleaved into FBN-1 by the furin convertase enzyme. Structural defects in fibrillin protein caused decreased vascular strength (Robinson et al. 2006). Some Marfan patients require emergency surgery for aortic root dissection and many need prophylactic aortic root replacement. Aortic surgery is a major surgical procedure with a high intraoperative and postoperative mortality risk even in experienced centres (Fletcher et al. 2020). Permanent paraplegia is one of the most devastating complications with an incidence of 3–5% in elective cases and 19% in emergency cases (Robinson et al. 2006). In addition, re-operative cardiac surgery is not uncommon in Marfan syndrome patients with aortopathy due to dissection of other parts of the aorta (Fletcher et al. 2020).
Aortic Arch. The Final Frontier in Cardiac Surgery
Published in Journal of Investigative Surgery, 2019
Dimos Karangelis, Apostolos Roubelakis, Dimitris Mikroulis, Matthew Panagiotou
Complex thoracic aorta pathology may involve aneurysm or dissection of the ascending aorta and may extend to the aortic arch and descending aorta. It therefore represents a challenge for cardiac surgeons. During the last decades we have witnessed significant technical achievements in the field of aortic surgery, which enabled surgeons to operate on the aortic arch with acceptable morbidity and mortality rates. Two important and worth mentioning milestones were a) the technique of deep hypothermia and circulatory arrest (DHCA) first described by Drew in 19593 and later introduced as common practice in aortic surgery by Griepp and colleagues in 19794 and b) the antegrade selective cerebral perfusion by the Stanford team of Frist and colleagues,5 who introduced brachiocephalic perfusion with low cardiopulmonary bypass flow during the arrest period. These techniques are combined with the surgical procedures currently used in aortic arch plus ascending and/or descending aortic surgery.
Visceral oxidative stress during antegrade cerebral perfusion and lower body circulatory arrest
Published in Acta Chirurgica Belgica, 2019
Ertekin Utku Ünal, Emre Kubat, Başak Soran Türkcan, Erman Kiriş, Aslı Demir, Bahadır Aytekin, Boğaçhan Akkaya, Uğur Aksu, Ayşen Aksöyek
Two limitations of our study have to be mentioned. One is the short duration of ischemia in the study group. Longer durations may reveal clinical complications in this type of surgery. The other possible limitation is the lack of a control group providing ‘distal perfusion’. Distal perfusion strategy is almost never performed if more and longer times are not anticipated. In our institution, the primary strategy of aortic surgery is to perform the operation without distal perfusion as widely applied in current practice. The only comparable results of the study group have been revealed after defining two groups regarding to 50th percentile of ACP duration. However, further studies with longer durations of ischemia and comparison with distal perfusion may provide more accurate results regarding oxidative stress.
Related Knowledge Centers
- Abdominal Aortic Aneurysm
- Acute Aortic Syndrome
- Aorta
- Aortic Dissection
- Aortic Rupture
- Abdomen
- Thorax
- Atherosclerosis
- Retroperitoneal Space
- Vascular Bypass