Roberto Chiesa

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

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Publications (276)623.13 Total impact

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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 · 2.40 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; DOI:10.1111/aas.12415 · 2.36 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.
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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
  • 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; DOI:10.1016/j.jvs.2014.06.007 · 2.98 Impact Factor
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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.
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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. DOI:10.1093/cvr/cvu091.144 · 5.81 Impact Factor
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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.
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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; 28(7). DOI:10.1016/j.avsg.2014.06.003 · 1.03 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; 60(3). DOI:10.1016/j.jvs.2014.03.256 · 2.98 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; 28(3). DOI:10.1053/j.jvca.2014.01.008 · 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. · 1.37 Impact Factor
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    ABSTRACT: The purpose of this study is to report updated clinical and aortic remodeling results from the Study for the Treatment of complicated Type B Aortic Dissection using Endoluminal repair (STABLE) trial, a prospective, multicenter study evaluating safety and effectiveness of a pathology-specific endovascular system (proximal stent graft and distal bare metal stent) for the treatment of complicated type B aortic dissection. All 86 enrolled patients (mean age, 59 years; 73.3% men) were treated within 90 days of symptom onset (55 with acute dissections and 31 with nonacute dissections). Inclusion criteria were branch vessel obstruction/compromise, impending rupture as evidenced by periaortic effusion/hematoma, resistant hypertension, persistent pain/symptoms, or aortic growth ≥5 mm within 3 months (or transaortic diameter ≥40 mm). Remodeling of the dissected aorta, including thrombosis of the false lumen and changes in the true lumen, false lumen, and transaortic diameter, were assessed in patients with available computed tomographic imaging through 2 years. The 30-day mortality rate was 4.7% (4/86) in the overall patient group (5.5% in acute patients and 3.2% in non-acute patients). Freedom from all-cause mortality was 88.3% at 1 year and 84.7% at 2 years (no significant difference between acute and nonacute patients). From baseline to 2 years, the true lumen diameter increased significantly in the descending thoracic aorta and the more distal abdominal aorta, along with a decrease in the false lumen diameter in both aortic segments. A majority of patients had either a stable or shrinking transaortic diameter in the thoracic (80.3% at 1 year and 73.9% at 2 years) or abdominal aorta (79.1% at 1 year and 66.7% at 2 years). Transaortic growth (>5 mm) occurred predominantly in acute dissections. Consistently, a shorter time from symptom onset to treatment was found to predict transaortic growth in the abdominal aorta (P = .03). Endovascular repair of complicated type B aortic dissection with the use of a composite construct demonstrates favorable early clinical outcomes and aortic remodeling. However, patients treated in the acute setting may be prone to aortic growth and may require close observation. Follow-up through 5 years is ongoing.
    Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 02/2014; DOI:10.1016/j.jvs.2013.12.038 · 2.98 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. · 1.37 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. · 1.37 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 01/2014; 2014. DOI:10.1093/mmcts/mmu003
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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; · 1.03 Impact Factor

Publication Stats

3k Citations
623.13 Total Impact Points

Institutions

  • 2002–2014
    • Università Vita-Salute San Raffaele
      Milano, Lombardy, Italy
  • 1995–2014
    • San Raffaele Scientific Institute
      Milano, Lombardy, 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
  • 2008
    • University of Barcelona
      • Department of Medicine
      Barcino, Catalonia, Spain
  • 2007
    • The Catholic University of America
      Washington, Washington, D.C., United States
  • 1981–1995
    • University of Milan
      • Department of Internal Medicine
      Milano, Lombardy, Italy