Roberto Chiesa

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

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Publications (323)723.34 Total impact

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    ABSTRACT: Background: To investigate the predictors of blood count changes and coagulation parameters alterations after thoracic aortic endovascular repair (TEVAR). Methods: 50 patients (41 males, age 72 ± 7 years) submitted between 2007 and 2009 to elective TEVAR for non-dissecting aortic lesions, without major associated surgical procedures, were analyzed. Blood count and coagulation parameters were recorded pre-operatively and daily up to postoperative day 5. The volume of new thrombus formed after TEVAR (TV) was calculated comparing pre- and post-operative computed tomography scans with a semi-automatic method by two independent examiners. Pre- intra-, and post-operative variables, including TV, were tested for a possible effect on changes in laboratory values and transfusion requirements using a stepwise multiple regression model analysis. Results: In the multivariable model, TV and associated surgical procedures were significantly associated with maximum platelets decrease (P = 0.021, and P = 0.029, respectively), while only TV remained a significant predictor for maximum prothrombin time increase (P = 0.003). Maximum aneurysm diameter (P = 0.041), procedural time (P = 0.027), and TV (P = 0.047) were also significant predictors of transfusion requirement. Conclusions: TEVAR is associated with consumption of platelets and coagulative factors, which seems to be associated with the amount of perioperative aneurysm thrombosis. The latter may also help to predict perioperative transfusion requirement.
    No preview · Article · Jan 2016 · The Journal of cardiovascular surgery
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    ABSTRACT: Despite the improved understanding of spinal cord anatomy and spinal cord ischemia pathophysiology, the rate of debilitating postoperative paraparesis or paraplegia is still not negligible after procedures for thoracic or thoracoabdominal aortic disease. Single studies have demonstrated the role of different treatment modalities to prevent or treat spinal cord ischemia. A multimodal approach, however, is advocated by most authors. Even after the employment of endovascular techniques become routine, the rate of spinal cord ischemia after treatment of thoracoabdominal aortic pathology remained unchanged over time. Spinal cord ischemia is often treatable by different means that concur to improve indirect spinal perfusion through collateral circulation; it should, therefore, be managed promptly and aggressively due to its potential reversibility. Ongoing technical improvements of non-invasive diagnostic tools may allow a better preoperative assessment of the spinal vascular network and a better planning of both open and endovascular thoracic or thoracoabdominal repair.
    No preview · Article · Jan 2016 · The Journal of cardiovascular surgery
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    ABSTRACT: Many years following transplantation, heart transplant recipients may require noncardiac major surgeries. Anesthesia in such patients may be challenging due to physiological and pharmacological problems regarding allograft denervation and difficult immunosuppressive management. Massive hemorrhage, hypoperfusion, renal, respiratory failure, and infections are some of the most frequent complications related to thoracic aorta aneurysm repair. Understanding how to optimize hemodynamic and infectious risks may have a substantial impact on the outcome. This case report aims at discussing risk stratification and anesthetic management of a 54-year-old heart transplant female recipient, affected by Marfan syndrome, undergoing thoracic aorta aneurysm repair.
    Full-text · Article · Jan 2016 · Annals of Cardiac Anaesthesia
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    ABSTRACT: Purpose: To describe the use of vascular plugs to close a complex type Ib endoleak following the sandwich procedure used in conjunction with endovascular thoracoabdominal aortic aneurysm (TAAA) repair. Case report: A 59-year-old man with a 6.5-mm TAAA was treated with initial deployment proximally of 2 Zenith TX2 stent-grafts. In preparation for the sandwich technique to preserve flow to the celiac trunk, a 10×100-mm Viabahn covered stent was delivered from a brachial access into the celiac trunk unprotected by the sheath of the introducer. The trigger wire system became snagged on the struts of the distal aortic stent-graft; when the wire was pulled, the proximal end of the Viabahn migrated outside the aortic stent-graft, which migrated upward. The main body extension intended for the aortic component of the sandwich technique was deployed close to the distal end of the aneurysm sac, but a large type Ib endoleak formed in the gutter between the Viabahn, aortic extension, and sac wall. The leak perfused the celiac trunk, and the procedure was terminated. Increasing sac size on 3-month imaging prompted closure of the leak with 2 type II Amplatzer vascular plugs aiming to occlude the endoleak outflow into the Viabahn and the endoleak outflow at the site of the gutter. Imaging follow-up at 6 months demonstrated successful exclusion of the TAAA with no residual endoleak and excellent perfusion of the celiac trunk. Conclusion: Transarterial treatment of complex endoleaks is feasible when preceded by meticulous imaging and detailed preprocedural planning.
    No preview · Article · Nov 2015 · Journal of Endovascular Therapy
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    ABSTRACT: We present a case of endovascular repair of a giant iliac artery pseudoaneurysm following simultaneous pancreas-kidney transplantation. A 64-year-old female presented to the emergency room with right flank pain 10 months after kidney and pancreas transplantation on the right iliac axis. Investigations revealed a 9.5 cm pseudoaneurysm originating from the anastomosis between the graft renal artery and the external iliac artery. The pseudoaneurysm was successfully excluded emergently with a covered stent graft preserving the normal perfusion and function of both transplanted organs. Endovascular repair may be a good and low-invasive option in selected patients with transplant renal artery pseudoaneurysm.
    No preview · Article · Oct 2015 · The Journal of cardiovascular surgery
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    No preview · Article · Oct 2015 · The Journal of cardiovascular surgery
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    ABSTRACT: Objective: Aortic neck dilation has been reported after endovascular aneurysm repair (EVAR) with self-expanding devices. With a core laboratory analysis of morphologic changes, this study evaluated midterm results of aortic neck evolution after EVAR by endograft with no chronic outward force. Methods: This was a multicenter registry of all patients undergoing EVAR with the Ovation endograft (TriVascular, Santa Rosa, Calif). Inclusion criteria were at least 24 months of follow-up. Standard computed tomography (CT) scans were reviewed centrally using a dedicated software with multiplanar and volume reconstructions. Proximal aortic neck was segmented into zone A (suprarenal aorta/fixation area), zone B (infrarenal aorta, from lowest renal artery to the first polymer-filled ring), and zone C (infrarenal aorta, at level of the first polymer-filled ring/sealing zone). Images were analyzed for neck enlargement (≥2 mm), graft migration (≥3 mm), endoleak, barb detachment, neck bulging, and patency of the celiac trunk and superior mesenteric and renal arteries. Results: Inclusion criteria were met in 161 patients (mean age, 75.2 years; 92% male). During a mean follow-up period of 32 months (range, 24-50), 17 patients died (no abdominal aortic aneurysm-related death). Primary clinical success at 2 years was 95.1% (defined as absence of aneurysm-related death, type I or type III endoleak, graft infection or thrombosis, aneurysm expansion >5 mm, aneurysm rupture, or conversion to open repair). Assisted primary clinical success was 100%. CT scan images at a minimum follow-up of 2 years were available in 89 cases. Patency of visceral arteries at the level of suprarenal fixation (zone A) was 100%. Neither graft migration nor barb detachment or neck bulging was observed. None of the patients had significant neck enlargement. The mean change in the diameter was 0.18 ± 0.22 mm at zone A, -0.32 ± 0.87 mm at zone B, and -0.06 ± 0.97 mm at zone C. Changes at zone B correlated significantly with changes at zone C (correlation coefficient, 0.183; P = .05), whereas no correlation was found with zone A (correlation coefficient, 0.000; P = 1.0). Conclusions: No aortic neck dilation occurred in this series at CT scan after a minimum 24-month follow-up. This may suggest that aortic neck evolution is not associated with EVAR at midterm follow-up when an endograft with no chronic outward radial force is implanted.
    Full-text · Article · Sep 2015 · Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter

  • No preview · Article · Sep 2015 · The Journal of cardiovascular surgery
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    ABSTRACT: The aim of this case report is to present an endovascular treatment of a residual post-dissection Crawford type III thoraco-abdominal aneurysm (TAA). A 60-year-old man, who had suffered from acute type B aortic dissection (TBAD) 8 years ago and had already been treated for both descending thoracic and infrarenal aortic aneurysm with open repair, presented with a 61mm post-dissection TAA. The aneurysm was successfully excluded with a staged fully endovascular procedure by employing two multibranched custom-made stent grafts deployed into the false lumen. The first stent-graft with a proximal monobranch was created to perfuse the right renal artery via the true lumen. The latter, with a triple branch design, was meant to perfuse the visceral arteries and left renal artery arising from the false lumen. Available branched custom-made stent-grafts for the treatment of degenerative TAA can be employed also in post TBAD aneurysms so as to simplify the procedure. The branched stent-grafts could be deployed within an enlarged false lumen provided that a suitable distal landing zone is available as well as that the visceral vessels can be perfused from the false lumen. A proximal branch for perfusing one of the lumens of the dissection from the proximal tear can be an alternative solution to creating neofenestrations.
    No preview · Article · Sep 2015 · The Journal of cardiovascular surgery
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    ABSTRACT: Objectives: The aim was to describe and analyze the management of hemothorax (HTX) and the occurrence of respiratory complications after endovascular repair of thoracic aortic rupture (TEVAR). Methods: This was a multicenter study with retrospective analysis. Between November 2000 and December 2012, all patients with confirmed HTX due to rupture of the descending thoracic aorta treated with TEVAR were included. Respiratory function (acid base status, Pao 2, Paco 2, lactate, and respiratory index) was monitored throughout hospitalization. Primary endpoints were survival and post-operative respiratory complications. Results: Fifty-six patients were treated. The mean age was 62±21 years (range 18-92 years). Etiology included traumatic rupture (n=23, 41%), atherosclerotic aneurysm (n=20, 36%), Debakey type IIIa dissection (n=8, 14%), and penetrating aortic ulcer (n=5, 9%). The primary technical success of TEVAR was 100%. The in hospital mortality rate was 12.5% (n=7). Hemothorax was drained in 21 (37.5%) cases. In hospital respiratory complications occurred in 23 (41%) patients who required a longer intensive care unit stay (days 2.3±0.7 vs. 1.9±0.8, p=.017), and hospitalization (26±17 vs. 19±17, p=.021). Those who developed post-operative respiratory complications had lower pre-operative PO2 values (mmHg, 80±24 vs. 91±21, p=.012). Respiratory complications and in hospital mortality did not differ among aortic pathologies (p=.269 and p=1.0, respectively), nor did in hospital mortality differ between patients with and without respiratory complications (13% vs. 12%; p=.990). Conclusions: Thoracic aortic rupture still has a high mortality rate. Respiratory complications have not been eliminated by endovascular repair. HTX evacuation may have had a positive influence on the survival in these patients. Although traumatic and degenerative ruptures are two significantly different scenarios, survival and respiratory outcomes were similar and were not affected by the underlying aortic disease.
    No preview · Article · Sep 2015
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    Full-text · Article · Sep 2015

  • No preview · Article · Aug 2015 · Annals of Vascular Surgery
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    ABSTRACT: Objective: To evaluate whether variants of the eNOS gene are associated with endothelial and metabolic responses to L-arginine (L-arg) supplementation. Material and methods: We examined a single nucleotide polymorphism of the eNOS gene (rs753482-A>C) to investigate the effects of this variant on endothelial function (EF), colony-forming unit-endothelial cell (CFU-EC) number, asymmetric-dimethylarginine (ADMA) level, insulin sensitivity index (ISI), and insulin secretion (IS) in a post hoc analysis of the L-arg trial. The L-arg trial (6.4g/day for 18months) was a single-center, randomized, double-blind, parallel-group, placebo-controlled, phase III trial in individuals with impaired glucose tolerance and metabolic syndrome. followed by a 12-month extended follow-up period after termination of the study drug (NCT 00917449). Results: At baseline, EF, CFU-EC numbers, ADMA levels, and ISI were impaired in subjects carrying minor allele C (both heterozygotes, AC and homozygotes, CC) as compared to subjects carrying major allele A (homozygotes, AA) (p<0.01). Compared to placebo, L-arg increased EF, CFU-EC numbers, and ISI, and improved ADMA levels and IS (p<0.01). The greatest improvements were found in AA subjects treated with L-arg, while the worst results were found in AC+CC subjects treated with placebo. In the placebo-treated subjects, EF, CFU-EC, ISI, and IS were significantly lower and ADMA was significantly higher in AC+CC subjects than in AA subjects. Conclusions: Treatment with L-arg induced similar improvements in EF, CFU-EC numbers, ADMA levels, ISI, and IS in both AA subjects and AC+CC subjects. The presence of minor allele resulted in the worst prognosis in terms of EF, CFU-EC numbers, ADMA levels, ISI, and IS during the 30-month observation period.
    No preview · Article · Aug 2015 · Metabolism: clinical and experimental

  • No preview · Article · Aug 2015 · Annals of Vascular Surgery
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    Full-text · Article · Aug 2015 · JACC. Cardiovascular imaging
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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.
    Full-text · Article · Jul 2015 · Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter

  • No preview · Article · Jun 2015 · Journal of Vascular Surgery
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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.
    Full-text · Article · Jun 2015 · European Heart Journal Cardiovascular Imaging
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    ABSTRACT: Objective: The aim of this study was to investigate outcomes of patients treated with endovascular repair (ER) with the use of fenestrated and branched stent grafts or open surgery (OS) for thoracoabdominal aortic aneurysm (TAAA) in a current series of patients. Methods: All TAAA patients undergoing repair at three centers between January 2007 and December 2014 were included in a prospective database. Patients were stratified according to treatment by ER or OS, and outcomes were compared using propensity score matching (1:1). Covariates included age, sex, aneurysm extent, hypertension, coronary disease, chronic pulmonary disease, diabetes, and renal function. The primary end points were mortality and paraplegia. Secondary end points included any spinal cord ischemia (SCI), renal and respiratory insufficiency, and a composite of these complications or death at 30 days. All-cause survival and freedom from reintervention were compared in the two groups. Results: Of 341 patients, 84 (25%) underwent ER and 257 underwent OS (75%). After propensity score matching (65 patients per group), no significant differences were observed in rates of 30-day mortality (7.7% in ER and 6.2% in OS; P = 1) and paraplegia (9.2% and 10.8%; P = 1). Any SCI, renal insufficiency, and respiratory insufficiency were 12.3% and 20% (P = .34), 9.2% and 12.3% (P = .78), and 0% and 12.3% (P = .006) in ER and OS, respectively. The incidence of the composite end point was significantly lower in ER patients (18.5% in ER vs 36.0% in OS; P =.03). According to Kaplan-Meier estimates, all-cause survival at 24 months was 82.8% in ER and 84.9% in OS, with rates unchanged at 42 months (P = .9). Rates of freedom from reintervention were 91.0% vs 89.7% at 24 months and 80.0% vs 79.9% at 42 months in ER vs OS, respectively (P = .3). Conclusions: A propensity score analysis in patients with TAAA undergoing repair suggests an early benefit from ER compared with OS with regard to the composite end point because of reduced 30-day respiratory complications. No significant differences were found in SCI and renal insufficiency at 30 days and in survival and reintervention rates at midterm.
    Full-text · Article · Jun 2015 · Journal of Vascular Surgery

  • No preview · Article · May 2015 · Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter

Publication Stats

4k Citations
723.34 Total Impact Points

Institutions

  • 2002-2015
    • Università Vita-Salute San Raffaele
      • Faculty of Psychology
      Milano, Lombardy, Italy
  • 1995-2015
    • San Raffaele Scientific Institute
      Milano, Lombardy, Italy
    • Policlinico San Matteo Pavia Fondazione IRCCS
      Ticinum, Lombardy, Italy
  • 1979-2012
    • University of Milan
      • Department of Internal Medicine
      Milano, Lombardy, Italy
  • 2007
    • The Catholic University of America
      Washington, Washington, D.C., United States
  • 2001
    • Università degli Studi di Torino
      • Department of Medical Science
      Torino, Piedmont, Italy
    • Ospedale di San Raffaele Istituto di Ricovero e Cura a Carattere Scientifico
      Milano, Lombardy, Italy
  • 2000
    • Università degli Studi dell'Aquila
      • SS in Vascular Surgery
      Aquila, Abruzzo, Italy
  • 1998
    • University of Pavia
      • Department of Internal Medicine and Therapeutics
      Ticinum, Lombardy, Italy