Roberto Chiesa

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

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Publications (293)675.7 Total impact

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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;
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    Annals of Vascular Surgery 08/2014; 28(6):1370–1371. · 0.99 Impact Factor
  • Annals of Vascular Surgery 08/2014; 28(6):1372–1373. · 0.99 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;
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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.
    The Journal of cardiovascular surgery. 07/2014;
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    ABSTRACT: Atherosclerotic plaque rupture with thrombosis is a major cause of cardiovascular events. The natural history of plaque progression is still unknown and the plaque destabilization unpredictable. We have recently suggested that P2X7 purinergic receptor expressed in carotid plaques (CP) might play a role a role in the pathogenesis of atherosclerosis. P2X7 activation by ATP leads to a broad spectrum of effects, including membrane blebbing, tissue factor (TF)-dependent thrombosis in mice, metalloproteases (MMPs) activation and release. MMPs deregulation may alter extracellular matrix network, affect vascular smooth muscle cell (VSMC) migration, contributing to plaque rupture. To study the P2X7 pathway role in MMPs regulation and in CP progression to thrombosis we developed functional models. We setup and characterized an ex-vivo tissue culture model, using human explants from either atherosclerotic (CP) or not (internal mammary artery, IMA) vessels of patients submitted to carotid endoarterectomy or to coronary artery bypass surgery. The preservation of vascular features in ex-vivo culture was verified at different time points (from 24 hours to 15 days) by evaluating the morphology (Hematoxylin/Eosin, Movat's), and the expression of wall cells (aSMA, sm22, Vimentin, CD68, FSP1) and extracellular matrix markers (Collagen type I), of P2X7, MMP9 and TF by confocal microscopy and/or biochemistry. ATP quantification and gel zymography in tissue protein extracts and culture supernatants evaluated the metabolic activity and the MMPs-related gelatinolysis of cultured vessels. A time frame of 4 days was identified as the maximum for structurally and functionally preserved vessel ex-vivo culture; functional loss was seen at day7, morphology alteration at days 10 and 15. P2X7 and MMP9 were previously detected in CP intima-media, thus to perform targeted functional studies we obtained VSMC from ateromasic areas of CP and from IMA. IMA fragments released cells for up to 3 months, CP for up to 2 months. VSMC were characterized similarly to tissue cultures; when freshly-explanted or at passage1, VSMC displayed P2X7, MMP9 molecules expression and gelatinolytic activity. At further passages P2X7 was undetected or unmounted on membrane, MMP9 expression and gelatinolysis absent. Treatment with ATP (50-200mM, 24hours), P2X7 antagonists (KN62, A74003) affected cell metabolism and gelatinolysis but not P2X7 expression. Our data showed that CP and IMA ex-vivo cultures and primary VSMC in vitro cultures represent suitable functional models to investigate the role of P2X7-MMP9 pathway in vascular pathology.
    Cardiovascular research. 07/2014; 103(suppl 1):S85.
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    ABSTRACT: Hybrid repair (HR) of thoracoabdominal aortic aneurysm (TAAA) and dissection (TAAD), consisting of rerouting renovisceral branches followed by endograft aortic repair, has been shown to be a feasible option. It is especially appealing in patients unfit for both open and total endovascular repair. In order to determine the role of dissecting etiology and intraoperative variables as risk factors for graft-related complications in visceral debranching, we retrospectively analyzed the clinical outcomes, patency rate and hemodynamic alterations of the renovisceral debranching grafts in our series.
    Annals of cardiothoracic surgery. 07/2014; 3(4):393-9.
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    ABSTRACT: Aortoesophageal (AEF) and aortobronchial (ABF) fistulae are uncommon but invariably fatal if left untreated. Mortality rates of open surgery remain prohibitive. Thoracic endovascular aortic repair (TEVAR) was shown to be a valid alternative to control bleeding in emergency, allowing a reduction of perioperative mortality. However, it entails a significant risk of late sequelae, namely endograft contamination and sepsis, related to the untreated esophageal leak. Aim of this study is to present initial results of a combined "hybrid" (endovascular and open) strategy to treat AEF and ABF.
    Annals of Vascular Surgery 06/2014; · 0.99 Impact Factor
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    ABSTRACT: The aim of this study was to assess the safety and short-term effectiveness of a novel hybrid vascular graft used to address renal revascularization during open thoracoabdominal aortic aneurysm (TAAA) repair, performing a sutureless distal anastomosis. Between 2012 and 2013, 25 patients (16 men; mean age, 66 ± 8 years) underwent revascularization of one (24 patients) or both (one patient) renal arteries with the Gore Hybrid Vascular Graft (GHVG; W. L. Gore and Associates, Flagstaff, Ariz) during open TAAA repair. Specific indications included remote location of the ostium of the renal artery, severe atherosclerotic wall degeneration, focal dissection, and stenosis. All surviving patients underwent computed tomography angiography and follow-up visit at 1 month. Preoperative characteristics, intraoperative data, and short-term results were compared with those of 49 concurrent TAAA patients operated on within the same period by standard renal revascularization (SRR) techniques. All GHVG target renal vessels (26 of 26) were successfully revascularized without technical concerns. No significant differences were found between GHVG and SRR groups in preoperative and intraoperative data, except for a relative prevalence of aortic dissection (28% vs 6%; P = .026) and renal artery stenosis (44% vs 12%; P = .003) in the GHVG group and for intraoperative renal bare stenting that was predominantly used in the SRR group (12% vs 28%; P = .036). The 30-day mortality was 4% in both groups. Postoperative acute renal failure (doubling of creatinine level and creatinine level >3.0 mg/dL) occurred in two GHVG patients (8%) and seven SRR patients (14%; P = not significant). Perioperative peak decrease of estimated glomerular filtration rate was lower in the GHVG group (26 ± 18 mL/min/1.73 m(2) vs 37 ± 22 mL/min/1.73 m(2); P = .034). At 1-month computed tomography angiography, renal artery patency was 92% for the GHVG vessels, 91% for the contralateral to GHVG renal vessels, and 92% for the SRR group arteries. No GHVG-related complications requiring reintervention or cases of new-onset renal failure requiring dialysis were observed at follow-up. Renal revascularization during open TAAA repair by the GHVG with distal sutureless anastomosis is feasible, especially in cases of aortic dissection, remote location of the renal vessel, and severe atherosclerotic disease of the ostium. Short-term results are satisfactory, at least comparable to those of SRR. Larger series and longer follow-up are needed to assess clinical advantages and durability of this new device.
    Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 04/2014; · 3.52 Impact Factor
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    ABSTRACT: To evaluate the role of intrathecal lactate as an early predictor of spinal cord injury during thoracoabdominal aortic aneurysmectomy. Observational study. University hospital. Forty-four consecutive patients scheduled to undergo thoracoabdominal aortic aneurysmectomy. Two patients had a type-B dissecting aneurysm while the other 42 patients suffered from degenerative aneurysm. None. During surgery, samples of cerebrospinal fluid and arterial blood were withdrawn simultaneously to evaluate lactate concentration. Samples were collected at 4 fixed times during and after surgery: T1 (beginning of the intervention), T2 (15 minutes after aortic cross-clamping), T3 (just before unclamping), T4 (end of surgery). Mean lactate levels in cerebrospinal fluid rose consistently and steadily from the beginning of the intervention until after surgery (T1 = 1.83 mmol/L), T2 = 2.10 mmol/L, T3 = 2.72 mmol/L, T4 = 3.70 mmol/L). Seven patients developed spinal cord injury; two of them had delayed injury occurring 24 hours after the end of surgery; the remaining 5 had early onset. In this group of 5 patients, preoperative cerebrospinal fluid lactate levels were significantly (p = 0.04) higher than those of the other 37 patients preoperatively (2.12 ± 0.35 v 1.79 ± 0.29 mmol/L). Preoperative cerebrospinal lactate concentration is elevated in patients who will develop early-onset spinal cord injury after thoracoabdominal aortic aneurysmectomy. This may allow a better stratification of these patients, suggesting a more aggressive strategy of spinal cord function preservation, such as systematic reimplanting of intercostal arteries, and possibly obtaining a better outcome.
    Journal of cardiothoracic and vascular anesthesia 04/2014; · 1.06 Impact Factor
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    ABSTRACT: The aim of this article was to review indications, techniques, and outcomes of a series of open repair for aortic occlusive disease. Between 1991 and 2013, 1071 patients (917 men, 154 women; mean age 62.6 years) underwent open repair for aortoiliac occlusive disease. According to TASC II classification, 123 patients (11.5%) had type B lesions, 343 (32%) type C, and 605 (56.5%) type D. Among type D lesions, 138 patients had Leriche's Syndrome with complete aortic occlusion. Nine hundred and eight aortobifemoral bypasses, 114 axillo-bifemoral bypasses, 42 aortic endarterectomies with patch aortoplasty, and 7 thoracobifemoral bypasses were performed. Associated endarterectomy of abdominal aorta was required in 191 patients (18.5%), of the femoral arteries in 297 (28.7%). Perioperatively mortality was 0.6%; perioperative morbidity included cardiac (3.4% of patients), respiratory (2.6%), as well as acute renal insufficiency (2.6%). There were 26 (2.5%) cases of intraoperative distal embolization, 9 (0.8%) of acute graft thrombosis and 9 (0.8%) of bleeding requiring surgical revision within the first 24 hours after surgery. Sixty-one groin complications were reported in 57 patients (5.3%). During a mean follow-up time of 74 months (range 1-264), calculated actuarial occlusion-free survival at 12, 24, and 36 months was 94.8%, 91.8% and 87.2%, respectively. The limb-salvage rate in patients with critical limb ischemia was 87.3%. There were 11 (1%) graft infections. Open repair is a ductile strategy and may be tailored according to the patient clinical condition and disease anatomy. Long-term patency is excellent with low perioperative mortality and reasonable morbidity rates.
    The Journal of cardiovascular surgery 04/2014; 55(2 Suppl 1):57-68. · 1.51 Impact Factor
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    ABSTRACT: Aim: Endovascular repair has surpassed open surgical treatment as the most common procedure in patients with abdominal aortic aneurysms (AAA), yet its applicability remains limited to those with aortoiliac anatomy suitable for the introduction and deployment of the devices. The current study was performed to assess the safety and efficacy of INCRAFT® (Cordis Corporation, Bridgewater, NJ), an ultra-low-profile device for the treatment of AAA. Methods: The INNOVATION study is a first in human prospective, multicenter trial involving 6 centers in Europe. From March 2010 to June 2011 60 patients with asymptomatic AAA were treated with the INCRAFT® bifurcated Stent-Graft System. The main inclusion criteria were a proximal aortic neck of 15 mm or more in length and up to 27 mm in diameter; iliac landing zones greater than 10 mm in length and between 9 and 18 mm in diameter; an access vessel large enough to accept the 14F outer diameter of the delivery system; and an aortic bifurcation >18 mm in diameter. The primary endpoint was technical success at one-month; one-year safety endpoints included the absence of device- or procedure-related major adverse events; absence of type I or III endoleaks; and maintenance of device integrity through one year of follow-up. Results: Among 60 patients treated at six centers, the primary endpoint was met in 56 of 58 patients (97%; 95% CI, 88-100%) who came back for one month follow-up, two patients did not come back for their one month follow-up assessments but remained enrolled in the study. Fifty-six had one-year follow-up data showing 100% freedom from aneurysm enlargement with absence of type I and III endoleaks in all patients. There were two patients (3.6%) with a type Ia endoleak which was successfully treated with secondary endovascular intervention in both occasions. Core laboratory evaluation of the postoperative imaging studies documented absence of endograft migration, stent fracture, or limb occlusion. A single patient (1.8%) died within one year due to sepsis unrelated to the AAA. Conclusion: The results of the INNOVATION study with the INCRAFT® Stent-Graft are encouraging, with satisfactory clinical outcome and device durability through one-year of follow-up. The INCRAFT® device is a novel ultra-low-profile endograft that holds promise to broaden the patient population eligible for endovascular aneurysm repair.
    The Journal of cardiovascular surgery 02/2014; 55(1):51-9. · 1.51 Impact Factor
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    ABSTRACT: Aim: In the last two decades, results of endovascular aortic repair (EVAR) for the treatment of infrarenal abdominal aortic aneurysms (AAAs) have significantly improved thanks to the evolution of stent-grafts and endovascular delivery systems. However, further development is still needed to reduce the incidence of complications and secondary reinterventions. We present our initial experience with the Treovance abdominal aortic stent-graft (Bolton Medical, Barcelona, Spain), a new-generation trimodular endovascular device, developed to increase flexibility, lower profile, improve deployment and sealing mechanisms. Methods: We treated 8 patients with anatomically suitable non-ruptured AAA. Results: Primary technical success was obtained in all patients, and no 30-day device-related complications nor deaths were reported. One patient experienced graft limb occlusion at 3 months, and underwent surgical conversion. At 1-year follow-up (completed in 6 patients), no device-related complications nor type I or III endoleak were observed. Conclusion: Initial personal experience with the Treovance abdominal stent-graft was satisfactory with regard to technical success and short-term clinical results. This new-generation endovascular device performed well even in angulated or heavily calcified anatomies.
    The Journal of cardiovascular surgery 02/2014; 55(1):77-84. · 1.51 Impact Factor
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    ABSTRACT: The objective was to evaluate a 13-year single-centre experience of arch endovascular aortic repair using the hybrid approach. Between 1999 and 2013, 491 patients were treated with endografts for thoracic aortic pathologies. The aortic arch was involved in 179 (36.5%) patients (128 men; mean age 70.2 ± 10.8 years, range 27-84). A hybrid approach was performed for all Zone 0 and 1 procedures and in nearly half of Zone 2 procedures. Early and mid-term outcomes were reviewed retrospectively. Overall primary technical success (24 h) was achieved in 162 (90.5%) of the 179 cases; 2 deaths and 15 Type 1 endoleaks were observed. Clinical success at 30 days was achieved in 161 (89.9%) of the 179 patients, with a mortality rate of 4.5% (8/179). Short-term clinical success at 6 months was achieved in 169 (94.4%) of the 179 patients; the rates for the different landing zones did not differ significantly. At a mean follow-up of 27.3 ± 15.7 months (range 1-94), the mid-term clinical success was 165 (92.2%) of the 179 patients; the rates among the different proximal zones did not differ significantly. In selected patients, early and mid-term outcomes of arch endovascular aortic repair using the hybrid approach are promising; however, mortality and morbidity are not negligible. Our results may have practical implications for the ongoing evaluation of the hybrid procedure in the aortic arch, as well as for patients fit for traditional surgery.
    Multimedia manual of cardiothoracic surgery : MMCTS / European Association for Cardio-Thoracic Surgery. 01/2014; 2014.
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    ABSTRACT: Introduction Aortoesophageal (AEF) and aortobronchial (ABF) fistulae are uncommon but invariably fatal if left untreated. Mortality rates of open surgery remain prohibitive. Thoracic endovascular aortic repair (TEVAR) was shown to be a valid alternative to control bleeding in emergency, allowing a reduction of perioperative mortality. However, it entails a significant risk of late sequelae, namely endograft contamination and sepsis, related to the untreated esophageal leak. Aim of this study is to present initial results of a combined “hybrid” (endovascular and open) strategy to treat AEF and ABF. Materials and methods From 2006 to 2013, 8 patients (6 males, mean age 63 ± 13 years) were operated at our Institution for primary and secondary AEF (7 patients) or ABF (1 patient) by means of a combined approach: emergent endovascular exclusion of the aortic rupture, followed by staged open surgical repair of the esophageal or bronchial lesion with associated intercostal muscle flap interposition. Follow-up was available in all patients (mean 34 ± 26 months). Results TEVAR was successfully performed in all cases in emergency due to active bleeding or hemodynamic instability. Stabilization of hemodynamic parameters was obtained in all patients. Open surgical stage was performed either directly after TEVAR (n = 1), or after a mean delay of 6.9 ± 3.5 days (n = 7). No perioperative sepsis, bleeding or death was observed. At follow-up, 7 patients were alive (87.5%). One patient died 1 year after the procedure due to sudden cardiocirculatory arrest of unknown origin. Another patients experienced two hospitalizations, at 3 and 8 months after the procedure, for recurrent fever requiring prolonged intravenous antibiotic therapy. No conversion or aortic bleeding was recorded during follow-up. Conclusions Immediate TEVAR, followed by staged open repair of the esophageal or bronchial defect with intercostal muscle flap interposition appears to be a feasible treatment of AEF and ABF. Despite initial results are encouraging, further data on wider cohorts with longer follow-up are necessary to confirm the efficacy and durability of this strategy.
    Annals of Vascular Surgery 01/2014; · 0.99 Impact Factor
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    ABSTRACT: To determine whether renal perfusion with cold crystalloid solution enriched with histidine-tryptophan-ketoglutarate (Custodiol; Dr Franz-Kohler Chemie GmbH, Bensheim, Germany) provides better protection against renal ischemic injury than cold lactated Ringer's solution in patients undergoing thoracoabdominal aortic aneurysm open repair. We analyzed a prospectively compiled database containing all 111 consecutive patients who underwent thoracoabdominal aortic aneurysm open repair at our center from 2008 to 2011. A cohort of 104 consecutive patients was identified of which 50 (48%) had renal perfusion with Custodiol and 54 (52%) with lactated Ringer's solution. Propensity score matching based on baseline clinical variables, which were expected to influence renal outcomes, was performed to correct for any bias that may have been associated with the use of Custodiol. Acute kidney injury (AKI) as defined by Kidney Disease Improving Global Outcomes guidelines and perioperative estimated glomerular filtration rate were compared in the two groups. Independent predictors of AKI were also identified by multivariate analysis. After propensity score matching, we were able to match 42 Custodiol cases one-to-one with those receiving perfusion with lactated Ringer's solution. Overall 30-day mortality was 5.9%; temporary hemodialysis or continuous veno-venous hemofiltration was needed in 4.8% of the patients without any case of dialysis at discharge. Freedom from AKI was significantly increased in the Custodiol group (38.1% vs 9.5%; P = .002) despite longer total renal ischemic time (51.5 ± 16.4 minutes vs 43.6 ± 16.0 minutes; P = .05). By analysis of variance for repeated measures, a significant upward trend of perioperative estimated glomerular filtration rate was observed in the Custodiol group (group × time interaction = F3,66; P < .001), and by multivariate analysis, Custodiol perfusion was the only independent predictor of non-AKI (P = .04). The use of Custodiol was safe and provided improved perioperative renal function compared with lactated Ringer's solution. Randomized trials are needed to confirm these data and to assess their clinical consequences.
    Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 12/2013; · 3.52 Impact Factor
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    ABSTRACT: The aim of this study was to determine predictors of improved quality of life and claudication in patients undergoing spinal cord stimulation (SCS) for critical lower limb ischemia. We retrospectively analyzed 101 consecutive patients with few meter claudication and nonhealing ulcer who underwent definitive SCS. These patients were selected among 274 SCS patients treated at our center from 1995 to 2012. All presented with non-reconstructable critical leg ischemia (NR-CLI) and underwent supervised exercise therapy, best medical care and regular ulcers standard or advanced medications for at least 1 month before SCS implantation. We measured self-perceived quality of life using the SF-36 questionnaire. Patients with an improved walking distance of at least 30 meters after SCS had significant improvement on SF-36 questionnaire scores. We considered 30 meters as the cut-off for clinically significant improvement in pain-free walking distance, and we defined this value as functional success. Logistic regression was applied to assess baseline and other patient variables as possible predictors of functional success. Neither perioperative mortality nor significant complications were found. At a median follow-up of 69 months (range 1-202 months), mortality, major amputation, and minor amputation were 8.9%, 5.9%, and 6.9%, respectively. Functional clinical success was reported in 25.7% of cases. Independent predictors of functional success at univariate analysis included delay between the onset of the ulcer and SCS (P < 0.001) and the pain-free walking distance before SCS (P < 0.002). The only predictive factor of functional success at multivariate analysis was the delay between the onset of ulcer and SCS (median delay in patients with and without functional success was 3 and 15 months, respectively). In particular, comparable to pain-free walking distance before SCS, the success rate decreased by 40% for each month elapsed from onset of ulcer to SCS. In our series of patients who underwent SCS, reduced delay between the onset of ulcer and SCS was associated with improved quality of life and walking distance. Larger series are required to confirm these data and to assess clinical implications.
    Annals of Vascular Surgery 12/2013; · 0.99 Impact Factor
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Publication Stats

3k Citations
675.70 Total Impact Points

Institutions

  • 2002–2014
    • Università Vita-Salute San Raffaele
      Milano, Lombardy, Italy
  • 1995–2014
    • San Raffaele Scientific Institute
      Milano, Lombardy, Italy
    • University of Pavia
      • Department of Internal Medicine and Therapeutics
      Pavia, Lombardy, Italy
    • University of Verona
      Verona, Veneto, Italy
  • 2010
    • Università degli Studi di Siena
      Siena, Tuscany, Italy
  • 1999–2010
    • Ospedale di San Raffaele Istituto di Ricovero e Cura a Carattere Scientifico
      Milano, Lombardy, Italy
    • Università degli Studi di Sassari
      • Dipartimento di Scienze Biomediche
      Sassari, Sardinia, Italy
  • 2007
    • The Catholic University of America
      Washington, Washington, D.C., United States
  • 1985–1999
    • University of Milan
      • Department of Internal Medicine
      Milano, Lombardy, Italy
  • 1990–1995
    • Università degli Studi di Brescia
      • Department of Clinical and Experimental Sciences
      Brescia, Lombardy, Italy