Roberto Chiesa

Università Vita-Salute San Raffaele, Milano, Lombardy, Italy

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Publications (293)705.03 Total impact

  • R Chiesa
    The Journal of cardiovascular surgery 10/2015; 56(5):685. · 1.37 Impact Factor
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    JACC. Cardiovascular imaging 08/2015; 8(8):980-982. DOI:10.1016/j.jcmg.2014.07.029 · 6.99 Impact Factor
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    ABSTRACT: Carotid endarterectomy is the most effective treatment for reducing the risk of stroke in patients with significant carotid stenosis. Few studies have focused on the failure rate of regional anesthesia. Data of all patients undergoing carotid endarterectomy (June 2009 to December 2014) in a single center were collected. Combined deep and superficial cervical plexus block or superficial plexus block alone was used according to the attending anesthesiologist's choice and the patient's characteristics (eg, dual antiplatelet or anticoagulation therapy). Intraoperative remifentanil (0.025-0.05 μg/kg/min) was administered to maintain an adequate level of comfort, responsiveness, and cooperation. General anesthesia was planned only in the case of major contraindications or the patient's refusal of locoregional anesthesia. The primary end point of our study was the incidence of intraoperative conversion from locoregional to general anesthesia. A total of 2463 carotid endarterectomies were included in the analysis. Regional anesthesia was initially chosen in 2439 patients, whereas 24 patients received planned general anesthesia. In seven cases, regional anesthesia was converted to general anesthesia because of severe agitation of the patient (before clamping in four cases, after carotid clamping in two cases, and after declamping in one case). A shunt was used in 302 patients (12.3%) because of neurologic deterioration at the carotid clamping test. Intraoperative complications were emergent repeated surgical procedures in 13 cases (0.53%) because of acute neurologic deterioration, 1 intraoperative acute myocardial infarction (0.04%), and 3 cases (0.04%) of hemodynamically relevant supraventricular tachyarrhythmia. No intraoperative death occurred. In-hospital mortality was 0.12% (three patients). Major stroke occurred in 23 patients (0.93%); minor stroke occurred in 16 patients (0.65%). The combined stroke and death rate was 1.62% (40 patients). In our practice, carotid endarterectomy under regional anesthesia is safe and associated with a very low rate of conversion to general anesthesia. Copyright © 2015 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.
    Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 07/2015; DOI:10.1016/j.jvs.2015.03.074 · 2.98 Impact Factor
  • Journal of Vascular Surgery 06/2015; 61(6):33S. DOI:10.1016/j.jvs.2015.04.060 · 2.98 Impact Factor
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    ABSTRACT: Thoracic endovascular aortic repair (TEVAR) is commonly considered as a valid alternative to surgery. Endoleaks occurrence is one of the principal limitations of TEVAR. Transoesophageal echocardiography (TEE) is often adopted in adjunct to fluoroscopy and angiography (ANGIO) during stent-graft implantation. In the present study, we compare intraprocedural ANGIO, TEE, and contrast-enhanced TEE (cTEE), and we also evaluate their accuracy in early endoleaks detection and characterization. Fifty-four patients with thoracic aortic disease suitable for TEVAR were prospectively enrolled in the study. After stent placement, the result of the procedure was assessed by ANGIO, TEE, and cTEE. The use of contrast (Sonovue, Bracco) significantly improved TEE quality (P = 0.0001). cTEE was superior in entry tears, false and true lumen and aneurysm thrombosis identification, and microtears and ulcer-like projections detection before stent deployment. After stent deployment, cTEE was more accurate than TEE and ANGIO in the detection of slow flow in the false lumen and in the aneurismal sac (P = 0.0001), and in the remaining flow identification (P = 0.0001). Notably, cTEE is more accurate in the endoleaks detection (P = 0.0001) and in the incomplete stent expansion diagnosis and need for a further balloon inflation (P 0.002), or a further stent implantation (P 0.006), compared with TEE and ANGIO. TEVAR procedures are improved by the complimentary use of contrast fluoroscopy, multiplane TEE with Doppler flow interrogation, and cTEE. This triple imaging approach provides additional information in all phases of the procedure improving safety of stent-grafting and the procedural outcomes. Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2015. For permissions please email: journals.permissions@oup.com.
    European Heart Journal Cardiovascular Imaging 06/2015; DOI:10.1093/ehjci/jev118 · 3.67 Impact Factor
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    Journal of Vascular Surgery 06/2015; 61(6):31S-32S. DOI:10.1016/j.jvs.2015.04.056 · 2.98 Impact Factor
  • Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 05/2015; 61(5):1380-1. DOI:10.1016/j.jvs.2015.01.047 · 2.98 Impact Factor
  • Journal of vascular and interventional radiology: JVIR 04/2015; 26(4). DOI:10.1016/j.jvir.2014.12.021 · 2.15 Impact Factor
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    ABSTRACT: The Zenith Alpha thoracic endograft (William Cook Europe, ApS, Bjaeverskov, Denmark) is a new low-profile thoracic endograft that has recently become commercially available in Europe. The reduced profile offers potential benefits and extended applicability, especially in patients with small or diseased iliofemoral vessels. The aim of this study was to evaluate the safety and efficacy of thoracic endovascular aortic repair performed with the new Zenith Alpha thoracic endograft. From November 2013 to the present, Zenith Alpha thoracic stent grafts have been employed to treat 42 patients (31 men; median age, 71 years; range, 54-83 years) suffering from descending thoracic aortic disease: 34 degenerative aneurysms, 4 aortic ulcers, 2 false aneurysms following prior thoracic open repair, and 2 traumatic blunt injuries. The mean proximal neck length was 25 mm (range, 17-40 mm), with a mean access vessel diameter of 6.7 mm (range, 6-11 mm). In 11 cases, aortoiliac occlusive disease (TransAtlantic Inter-Society Consensus type B and C lesions) was present. The proximal landing was in zone 1 in 2 cases, in zone 2 in 25 cases, in zone 3 in 11 cases, and in zone 4 in 4 cases. Fifty-one endografts (45 proximal components and 6 distal components) were deployed in 42 patients. The endografts were deployed safely and effectively from one surgical femoral access site in all cases. In patients with associated aortoiliac disease, no adjunctive procedures for device insertion, except for predilation with balloon angioplasty in two cases, were required. No major complications related to the devices were observed in any of the patients during the postoperative course, and there was no perioperative mortality, paraparesis, or paraplegia. At 30 days, morbid events included one case of major stroke, two cases of transient acute renal failure, and one case of postimplantation syndrome. No access-related complications were recorded. Computed tomography performed within 6 months was obtained in 39 patients and confirmed 100% clinical success without device-related complications. No type I endoleaks or bird's beak effects were documented. Our early experience shows that deployment of the new Zenith Alpha endograft from a surgical femoral access is safe and effective in treating thoracic aortic aneurysms, aortic ulcers, and traumatic blunt injuries, even in patients with small or diseased access vessels. Endograft conformance to the aorta and exclusion of the aneurysm were satisfactory. Long-term durability remains to be evaluated. Copyright © 2015 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.
    Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 04/2015; DOI:10.1016/j.jvs.2015.02.049 · 2.98 Impact Factor
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    ABSTRACT: Knowledge of the spinal cord (SC) vascular supply is important in patients undergoing procedures that involve the thoracic and thoraco--abdominal aorta. However, the SC vasculature has a complex anatomy, and teaching is often based only on anatomical sketches with highly variable accuracy; historically, this has required a "leap of faith" on the part of aortic surgeons. Fortunately, this "leap of faith" is no longer necessary given recent breakthroughs in imaging technologies and post--processing software. Imaging methods have expanded the non--invasive diagnostic ability to determine a patient's SC vascular pattern, particularly in detecting the presence and location of the artery of Adamkiewicz. CT is the imaging modality of choice for most patients with thoracic and thoraco--abdominal aortic disease, proving especially useful in the determination of feasibility and planning of endovascular treatment. Thus the data set required for analysis of spinal cord vascular anatomy is usually already available. We have concentrated our efforts on CT angiography, which offers particularly good imaging capabilities with state--of--the--art multidetector scanners. Multi--detector row helical CT provides examinations of an extensive range in the cranio--caudal direction with thin collimation in a short time interval, giving excellent temporal and spatial resolution. This paper provides examples of the SC vasculature imaging quality that can be obtained with 64 row scanners and appropriate postprocessing. Knowledge of the principal anatomical features of the SC blood supply of individual patients undergoing open or endovascular thoraco--abdominal procedures has several potential benefits. For open surgery, analysis of the SC vasculature could tell us the aortic region that feeds the Adamkiewicz artery and thus needs to be reimplanted. For endovascular procedures, we can determine whether the stent graft will cover the Adamkiewicz artery, thus avoiding unnecessary coverage. CT data can also be used to stratify risk of spinal cord ischemia and guide the selective use of spinal cord injury prevention strategies.
    The Journal of cardiovascular surgery 04/2015; · 1.37 Impact Factor
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    ABSTRACT: Extent IV thoracoabdominal aortic aneurysm (TAAA) open repair is considered relatively safer to repair than other extents of TAAA in terms of both perioperative mortality and spinal cord ischemia. Our purpose is to report our experience and to perform a literature review regarding extent IV TAAA open repair in order to provide an updated benchmark for comparison with any other alternative strategy in this aortic segment. From 1993 to 2015 we performed 736 open repairs for TAAA (177 extent I, 196 extent II, 141 extent III, 222 extent IV). In extent IV group there were 164 men (73.9%) and the mean age was 67.4 ± 9.3 years (range 32--84). The aneurysm etiology was degenerative in 198 patients (95.6%). Twelve patients (5.4%) underwent emergent operation. Totally abdominal approach was used in 22.0% of the cases. Until 2006 left heart bypass (LHBP) and cerebrospinal fluid drainage (CSFD) were almost never performed during extent IV repair. Since 2006 we changed our approach with a more aggressive use of LHBP (22.9%) and CSFD (43.4%) in 83 consecutive extent IV. Renal arteries perfusion was performed with 4°C Ringer's solution until 2009 and with 4°C Custodiol solution since September 2009 to date. Literature search was performed on several databases (PubMed, BioMedCentral, Embase, and the Cochrane Central Register of clinical trials). Research was updated on March 1th 2015. Perioperative mortality in our overall group of TAAA and in the extents IV was 10.7% and 4.9%, respectively (P .01);; spinal cord ischemia rate 11.4% and 2.7%, respectively (P .0001). In the extents IV treated between 2006 and 2015 we observed a further trend of outcomes improvement with a rate of perioperative mortality and spinal cord ischemia of 1.2%, and 2.4%, respectively. Database searches yielded a total of 767 articles. Excluding non--pertinent titles or abstracts, we retrieved in complete form and assessed 27 studies according to the selection criteria. Nine studies were further excluded because of our pre specified exclusion criteria. The final 18 manuscripts included a total of 2098 patients. In this group median mortality rate was 4.8% (interquartile range 3.0--6.0) and the mean incidence of spinal cord ischemia was 1.56 ±1.54%. Perioperative outcomes after extent IV TAAA open repair were significantly better compared to our overall TAAA series. A more aggressive use of CSFD, LHBP and renal perfusion with Custodiol solution allowed a further trend of outcomes improvement in our series of extent IV TAAA open repair. Literature analysis confirmed during extent IV open repair very satisfactory preoperative outcomes with rates of mortality and spinal cord ischemia dropped to under 5% and 2%, respectively.
    The Journal of cardiovascular surgery 04/2015; · 1.37 Impact Factor
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    ABSTRACT: Infectious thoracic aortitis is a rare disease, especially since the incidence of syphilis and tuberculosis has dropped in western countries. However, the risk to develop an infectious aortitis and subsequent mycotic aneurysm formation is still present, particularly in case of associated endocarditis, sepsis, and in immunosuppressive disorders. Moreover, the number of surgical and endovascular thoracic aortic repairs is continuously increasing, and infective graft complications are observed more frequently. Several etiopathogenetic factors may play a role in thoracic aortic and prosthetic infections, including hematogenous seeding, local bacterial translocation, and iatrogenous contamination. Also, fistulization with the esophagus or the bronchial tree is commonly associated with these diseases, and it represents a dramatic event requiring a multidisciplinary management. Knowledge on underlying microorganisms, antibiotic efficacy, risk factors, and prevention strategies has a key role in the management of this spectrum of infectious diseases involving the thoracic aorta. When the diagnosis of a mycotic aneurysm or a prosthetic graft infection is established, treatment is demanding, often including a number of surgical options. Patients are usually severely compromised by sepsis, and in most cases they are considered unfit for surgery for general clinical conditions or local concerns. Thus, results of different therapeutic strategies for infectious diseases of the thoracic aorta are still burdened with very high morbidity and mortality. In this manuscript, we review the literature regarding the main issues related to thoracic infectious aortitis and aortic graft infections, and we report our personal series of patients surgically treated at our institution for these conditions from 1993 to 2014.
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    ABSTRACT: To learn upon incidence, underlying mechanisms and effectiveness of treatment strategies in patients with central airway and pulmonary parenchymal aorto-bronchial fistulation after thoracic endovascular aortic repair (TEVAR). Analysis of an international multicentre registry (European Registry of Endovascular Aortic Repair Complications) between 2001 and 2012 with a total caseload of 4680 TEVAR procedures (14 centres). Twenty-six patients with a median age of 70 years (interquartile range: 60-77) (35% female) were identified. The incidence of either central airway (aorto-bronchial) or pulmonary parenchymal (aorto-pulmonary) fistulation (ABPF) in the entire cohort after TEVAR in the study period was 0.56% (central airway 58%, peripheral parenchymal 42%). Atherosclerotic aneurysm formation was the leading indication for TEVAR in 15 patients (58%). The incidence of primary endoleaks after initial TEVAR was n = 10 (38%), of these 80% were either type I or type III endoleaks. Fourteen patients (54%) developed central left bronchial tree lesions, 11 patients (42%) pulmonary parenchymal lesions and 1 patient (4%) developed a tracheal lesion. The recognized mechanism of ABPF was external compression of the bronchial tree in 13 patients (50%), the majority being due to endoleak formation, further ischaemia due to extensive coverage of bronchial feeding arteries in 3 patients (12%). Inflammation and graft erosion accounted for 4 patients (30%) each. Cumulative survival during the entire study period was 39%. Among deaths, 71% were attributed to ABPF. There was no difference in survival in patients having either central airway or pulmonary parenchymal ABPF (33 vs 45%, log-rank P = 0.55). Survival with a radical surgical approach was significantly better when compared with any other treatment strategy in terms of overall survival (63 vs 32% and 63 vs 21% at 1 and 2 years, respectively), as well as in terms of fistula-related survival (63 vs 43% and 63 vs 43% at 1 and 2 years, respectively). ABPF is a rare but highly lethal complication after TEVAR. The leading mechanism behind ABPF seems to be a continuing external compression of either the bronchial tree or left upper lobe parenchyma. In this setting, persisting or newly developing endoleak formation seems to play a crucial role. Prognosis does not differ in patients with central airway or pulmonary parenchymal fistulation. Radical bronchial or pulmonary parenchymal repair in combination with stent graft removal and aortic reconstruction seems to be the most durable treatment strategy. © The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
    European journal of cardio-thoracic surgery: official journal of the European Association for Cardio-thoracic Surgery 11/2014; DOI:10.1093/ejcts/ezu443 · 2.81 Impact Factor
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    ABSTRACT: One of the most commonly used hypnotics is propofol. Several studies performed in cardiac surgery suggested an increased mortality in patients receiving a propofol-based total intravenous anaesthesia. Furthermore, the possibility of infections and the 'propofol syndrome' have suggested that propofol might be dangerous. Nonetheless, propofol is widely used in different settings because of its characteristics: fast induction, rapid elimination, short duration of action, smooth recovery from anaesthesia, few adverse effects, no teratogenic effects, characteristics that have undoubtedly contributed to its popularity. The effect of propofol on survival is unknown. We decided to carry out a meta-analysis of all randomized controlled studies ever performed on propofol vs. any comparator in any clinical setting.
    Acta Anaesthesiologica Scandinavica 10/2014; 59(1). DOI:10.1111/aas.12415 · 2.31 Impact Factor
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    ABSTRACT: The aim of this study is to describe our clinical experience with an extra-large self expandable stent specifically designed to treat aortic lesions (E-XL, Jotec, Hechingen, Germany), now commercially available in Europe. The E-XL was used at our Institution in 14 patients (mean age, 56 ± 12 years; 9 males) with the following indications: improve proximal fixation (4 cases), type I endoleak (2 cases), aortic dissection with static malperfusion (1 case) and dynamic malperfusion (7 cases). Early results have been shown to be safe and effective in different clinical settings, including in emergency cases. This peculiar aortic stent could be useful in the armamentarium of the endovascular surgeon.
    The Journal of cardiovascular surgery 10/2014; 56(1). · 1.37 Impact Factor
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    ABSTRACT: Reinterventions following previous ascending aorta and aortic arch repair are uncommon, but technically challenging and often burdened with high morbidity and mortality. The aim of this article is to present a single--Center experience in the treatment of this complex pathology, using different surgical approaches.
    The Journal of cardiovascular surgery 09/2014; 55(6). · 1.37 Impact Factor
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    Annals of Vascular Surgery 08/2014; 28(6):1370–1371. DOI:10.1016/j.avsg.2014.06.041 · 1.03 Impact Factor
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    Annals of Vascular Surgery 08/2014; 28(6):1372–1373. DOI:10.1016/j.avsg.2014.06.045 · 1.03 Impact Factor
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    ABSTRACT: This study evaluated the 2-year safety and effectiveness of the European First-in-Human INNOVATION trial for the INCRAFT AAA Stent Graft system (Cordis Corp, Bridgewater, NJ), an ultra-low-profile device for the treatment of abdominal aortic aneurysms.
    Journal of Vascular Surgery 07/2014; 61(1). DOI:10.1016/j.jvs.2014.06.007 · 2.98 Impact Factor
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    L Bertoglio · D Logaldo · E M Marone · E Rinaldi · R Chiesa
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    ABSTRACT: The INCRAFT® AAA Stent---graft System is the advanced EVAR technology for the treatment of infrarenal abdominal aneurysms. This new system is designed to address the unmet needs of current endografts by combining unique features and adding new refinements compared to existing endografts delivered through a flexible and 14 Fr. ultra---low system. the INCRAFT AAA Stent---graft System introduces innovative features without deviating from proven stent---graft design principles. It is a three---piece modular system, made of low porosity polyester and segmented nitinol stents. However, the introduction of cap free and partial proximal repositioning enhances the ability of the device to better match individual aortoiliac anatomy with a high deliverability and placement accuracy in a easy to use system. Moreover, It allows to "customize" the implant during the procedure with bilateral in---situ length adjustment features. The present data from the ongoing clinical trials confirm excellent results with this system, but post---market studies will be necessary to verify the effectiveness of this system in the real---world setting.

Publication Stats

3k Citations
705.03 Total Impact Points

Institutions

  • 2002–2015
    • Università Vita-Salute San Raffaele
      • Faculty of Psychology
      Milano, Lombardy, Italy
  • 1995–2014
    • San Raffaele Scientific Institute
      Milano, Lombardy, Italy
    • Policlinico San Matteo Pavia Fondazione IRCCS
      Ticinum, Lombardy, Italy
  • 2007
    • The Catholic University of America
      Washington, Washington, D.C., United States
  • 2000–2001
    • Ospedale di San Raffaele Istituto di Ricovero e Cura a Carattere Scientifico
      Milano, Lombardy, Italy
    • Università degli Studi dell'Aquila
      • SS in Vascular Surgery
      Aquila, Abruzzo, Italy
  • 1981–1996
    • University of Milan
      • Department of Internal Medicine
      Milano, Lombardy, Italy