Surgical Technology International
40th Anniversary Edition
May 2022 - ISSN:1090-3941
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Micro-Invasive 3D Endoscopic Mitral Valve Surgery
Daniele Maselli, MD, Saverio Nardella, MD,Gianluca Santise, MD, Annarita Iavazzo, MD, Luigi Chiariello, PhD, Professor, Mediterranea Cardiocentro, Napoli, Italy
1530
Since its introduction in 1995, minimally invasive mitral valve surgery (MIMVS) has been shown to be a valid alternative to conventional sternotomy and several studies have reported excellent clinical outcomes. While MIMVS is now a commonly performed procedure, it is still difficult to standardize. We proprose here a "road to safer surgery", and offer some tips and tricks that could be useful in its learning and performance, and may help surgeons minimize the risk of major complications. With the introduction of 3D vision with a 3D videothoracoscope for 4K stereoscopic acquisition, a medical LCD ultra-HD monitor and active 3D glasses, it is possible to obtain a very realistic view of the surgical field and the mitral valve anatomy, while significantly reducing the learning curve. We describe the procedure step-by-step, with details from the pre-operative phase to the end of the operation. The procedure is structured in consecutive stages: patient induction and positioning, thoracoscopic access and port placement, surgical field exposure, and operative technique.
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Latest Advances in Transcatheter Aortic Valve Implantation (2022)
Vedat Tiyerili, MD, Dagmar Sötemann, MD, Christina Grothusen, MD, Johannes Blumenstein, MD, Helge Möllmann, MD, Clemens Eckel, MD, Department of Cardiology, St. Johannes-Hospital Dortmund, Dortmund, Germany, Marc Ulrich Becher, MD, Department of Cardiology, University of Bonn, Bonn, Germany, Holger Nef, MD, Department of Cardiology, University of Giessen, Giessen, Germany
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Since the last decade, transcatheter aortic valve implantation (TAVI) has become the treatment of choice in patients with symptomatic severe aortic stenosis (AS) who are ineligible or at higher risk for surgery. Due to the high safety profile of current device generation, TAVI has emerged as a qualified alternative to surgical aortic valve replacement (SAVR) in patients with classic aortic stenosis and intermediate surgical risk, severe bicuspid aortic valve stenosis, and isolated pure aortic regurgitation. Moderate aortic stenosis, with and without concomitant heart failure with reduced ejection fraction, are under investigation in randomized controlled clinical trials from which we will gain exciting insights on the best timing of TAVI to protect the left ventricle from further functional deterioration due to increasing AS. In these cases, a meticulous diagnostic approach including advanced imaging is becoming more and more important. Current evidence on antithrombotic strategies after TAVI is weak, contributing to poor levels of standardization and high variability in daily clinical practice. This review will provide a short overview of recent clinical trials including best timing for TAVI with moderate AS and antithrombotic strategies after TAVI with current and future TAVI generations.
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Thoracic Endovascular Aortic Repair Using the C-TAG® Device with ACTIVE CONTROL System
Michele Antonello, MD, PhD, Associate Professor, Francesco Squizzato, MD, Elda Chiara Colacchio, MD, Andrea Spertino, MD, Franco Grego, MD, PhD, Full Professor, Michele Piazza, MD, PhD, Associate Professor, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Vascular and Endovascular Surgery Clinic, Padova University, School of Medicine, Padova, Italy
1509
Objective: To describe our experience with the Gore® C-TAG® endograft with ACTIVE CONTROL System (ACS) (W.L. Gore & Associates, Inc., Flagstaff, AZ, USA) in thoracic aortic repair, focusing on deployment accuracy and aortic wall apposition.
Methods: All patients who underwent thoracic endovascular aortic repair (TEVAR) using the Gore® C-TAG® endograft with ACS from September 2017 to September 2021 were enrolled in a dedicated database and retrospectively analysed. We collected anatomic data on aortic arch angulation and tortuosity, proximal and distal landing zones, and the target for deployment accuracy. Proximal and distal deployment accuracies (PDA and DDA) were measured through intraoperative digital subtraction angiography (DSA), and postoperative computed tomography angiography (CTA) was required to define endograft apposition to the aortic wall.
Results: Twenty-eight patients who underwent TEVAR with the Gore® C-TAG® with ACS at our institution were selected for this study: 46% presented with a type 3 aortic arch and a proximal landing zone < 3 was used in 53% of cases. Mean PDA and DDA were 1.89 ± 3.5 mm and 0.6 ± 1.4 mm, and were obtained in 93% and 100% of procedures, respectively. Mean proximal and distal wall apposition were 91 ± 17% and 98 ± 5.9%. Fifteen patients required an associated planned procedure, either to revascularize supra-aortic vessels when PLZ was < 3 or to assure optimal distal fixation with EndoAnchors™ (Medtronic, Minneapolis, MN, USA) delivery in selected cases. Two patients required reintervention during the same hospitalisation because of type 1a endoleak onset. No further reinterventions were needed during follow-up.
Conclusions: Our single-centre analysis found promising results using the Gore® C-TAG® with ACS, with an optimal accuracy in deployment and wall apposition at both proximal and distal landing zones.
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Frozen Elephant Trunk Completion: Endovascular Extension in The Distal Thoracic Aorta
Steven J.G. Leeuwerke, MD, Ben R. Saleem, MD, PhD, Clark J. Zeebregts, MD, PhD, Professor, University Medical Center Groningen, Groningen, The Netherlands, Patrick Bohan, BA, MLitt, Terumo Aortic, Sunrise, Florida, Jamie Clucas, BSc, Terumo Aortic, Glasgow, United Kingdom, Michel M.P.J. Reijnen, MD, PhD, Professor, Rijnstate Hospital, Arnhem, The Netherlands1519
Introduction: Complex pathologies involving the aortic arch can be treated using the frozen elephant trunk (FET) technique, which is versatile and continues to be improved with different innovations to further reduce, for example, circulatory arrest time and the need for hypothermia. FET may or may not be a definitive repair, however. Distal extension or completion—especially endovascular—is common but not well described in the literature. This review describes the considerations that are necessary during FET planning and preparation, how pathology specifics and sizing decisions will affect the subsequent need for treatment, and how outcomes might be better reported to improve understanding of the advantages and limitations of the technique.
Materials and Methods: This literature review was performed to identify reports of second-stage endovascular completion after FET repair, and included any literature that described such interventions after index FET, for any aortic arch pathology.
Results: Secondary intervention after FET is an important parameter to establish the success or failure of the index procedure. However, unplanned extensions are often reported with insufficient detail and follow up, and studies rarely differentiate between unplanned or adjunctive procedures. In addition, prediction of the need for extension is complicated by the response of the pathology to the index procedure.
Conclusion: FET is a versatile, established surgical technique that allows for several applications in different pathologies and innovative adaptations. How, when, and why FET is extended needs to be reported in greater detail, with specific consideration given to the interaction of FET and endovascular devices in sizing, integrity, and possible complications.
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Comparison of Interwoven Nitinol and Drug-Eluting Stents for Endovascular Treatment of Femoropopliteal Artery Disease
Jâd Abi-Khalil, MD, Parla Astarci, PhD, Maxime Elens, MD, Cardiovascular and Thoracic Surgery Department, Cliniques Universitaires St-Luc, Brussels, Belgium
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Background: Interwoven nitinol stents (INS) and drug-eluting stents (DES) were designed to improve the mid- and long-term results of femoropopliteal (F-P) angioplasty. The aim of this study was to systematically compare these stents.
Methods: Between 2015 and 2017, 62 patients with symptomatic peripheral artery disease of the F-P segment treated by INS or DES were identified from a prospectively maintained institutional database. The primary outcome measure was one-year primary patency; secondary outcomes were in-stent restenosis (ISR), stent occlusion, target lesion revascularization (TLR) and mortality.
Results: The mean follow-up was 26.9 ± 11.2 months. No statistically significant difference in primary patency at one year was observed (88.6% vs. 88.9%). Throughout follow-up, overall rates of ISR (5.7% vs. 11.1%, p = 0.645), stent occlusion (25.7% vs. 7.4%, p = 0.094) and TLR (25.7% vs. 18.5%, p = 0.505) were statistically equivalent between the groups. Mortality reached 14.3% in the INS group and 3.7% in the DES group, but this difference was not statistically significant (p=0.196). Multivariable analysis revealed significant correlations between ISR and stent occlusions; popliteal lesion localization (p = 0.016) and poor below the knee vessel outflow (p < 0.001).
Conclusion: In the short- and mid-term, the use of an INS or DES in the F-P arterial segment did not result in a difference in primary patency rate, stent occlusion, restenosis, re-intervention or mortality. The overall data do not provide any evidence to favor one stent over the other.
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Biological Valves Impervious to Calcification: Is this Holy Grail a Cup Ready to Drink?
Alessandro Ricci, MD, PhD, Luca Paolo Weltert, MD, Giovanni Lucertini, MD, Giulia Ciccarelli, MD, Raffaele Scaffa, MD, Andrea Salica, MD, Salvatore D’Aleo, MD, Lorenzo Guerrieri-Wolf, MD, Samuel Fusca, MD, Alessandro Bellisario, MD, Ruggero De Paulis, MD, PhD, Professor, European Hospital, Heart Surgery Division, Rome, Italy
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An indefinitely lasting bioprosthesis that does not require anticoagulation treatment is the holy grail of substitutive heart surgery. However, this goal is not yet in sight with the present state of technology. Over the past few years, tremendous advances have been achieved regarding tissue anticalcification processes, hemodynamic performance and future-proofing by ensuring compatibility with transcatheter valve-in-valve procedures. The Inspiris Resilia valve (Edwards Lifesciences, Irvine, CA) was designed to incorporate all of these enhancements. It is now leaving the experimental phase and is being tested in the real world. We present here a comprehensive review of the evolution of biological prostheses, details of new anticalcification technologies, and early results of published studies as well as the experience at the European Hospital (Rome, Italy), the site of the first European implant and a leading center in various protocols. In our two years of experience with the Inspiris Resilia, there have been no cases of structural valve deterioration, endocarditis, detachment or periprocedural complication, and gradients seem to be superior to those with the previous generation of Edwards valves. While longer-term experience is clearly needed, the results thus far are encouraging.
The Covered Endovascular Reconstruction of the Aortic Bifurcation (CERAB) Technique for Aorto-Iliac Occlusive Disease
Omar MA Abdelbaqy, Msc, Rijnstate Hospital, Arnhem, The Netherlands, Suzanne Holewijn, PhD, Rijnstate Hospital, Arnhem, The Netherlands, Clark J Zeebregts, MD, PhD, Professor, University of Groningen, Groningen, The Netherlands, Michel MPJ Reijnen, MD, PhD, Professor, TechMed Centre, University of Twente, Enschede, The Netherlands
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Endovascular treatment options of aorto-iliac occlusive disease have emerged, leading to better outcomes in more complex pathology, which typically involves a reconstruction of the aortic bifurcation. The Covered Endovascular Reconstruction of Aortic Bifurcation (CERAB) configuration was introduced in 2013, in an attempt to optimize outcomes, when compared to the kissing stent configuration, which was traditionally the preferred endovascular technique for this pathology. CERAB aims to optimize geometry, and with that the arterial flow patterns that are associated with loss of patency. In CERAB, the aortic bifurcation is reconstructed using three balloon-expandable covered stents in a tight connection with each other and with an appropriate wall apposition, thereby minimizing geometrical mismatch (Fig. 1a–c). The reconstruction can be extended on both sides and could be combined with chimney, or parallel, grafts in aortic side branches that need to be preserved. In the current paper, the details of the CERAB technique are described and supported by evidence derived from pre-clinical studies that confirm the more optimal geometry and flow patterns compared to kissing stents. Also, a summary is provided of published clinical evidence, including technical and clinical outcomes of the technique. These data show promising early results, with patency rates in line with those achieved with open surgery, also in patients with extensive disease. Finally, the potential modes of failures and future developments are discussed.
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The Feasibility and Applicability of Percutaneous Deep Vein Arterialization in Peripheral Artery Disease
Krystina N. Choinski, MD, Nicholas J. Stafford, MD, Ajit G. Rao, MD, Assistant Professor, Justin M. George, MD, Peter L. Faries MD, FACS, Rami O. Tadros, MD, FACS, RPVI, Associate Professor, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, New York, Prakash Krishnan, MD, Associate Professor, Department of Interventional Cardiology, The Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, New York
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Peripheral artery disease (PAD) can often present with chronic limb threatening ischemia (CLTI), including ischemic rest pain and severe tissue loss. Progression of PAD can lead to “no option” or end-stage disease in which there are no traditional open or endovascular interventions available for revascularization. This cohort of patients have a poor prognosis, with a major amputation rate of 40% and mortality of up to 20% at six months. For this patient population, surgical deep vein arterialization (DVA) is offered as an attempt to provide blood flow to the distal preserved venous bed and reverse the ischemic process. Surgical DVA has traditionally been offered as an option and was pioneered by Herb Dardik.
The evolution of endovascular technology has allowed for percutaneous DVA (pDVA). Using ultrasound and fluoroscopic guidance, an arteriovenous channel is created between a tibial artery and vein and reinforced with covered stent grafts to increase distal limb perfusion with the goals of improving wound healing and amputation-free survival. Lysis of venous valves with a valvulotome also aids with reversal of flow into the distal venous system. Investigations of percutaneous deep vein arterialization are underway with one device, the LimFlow System (LimFlow SA, Paris, France), which is undergoing feasibility trials. Here we present the current clinical indications, feasibility, results, and our institutional experience with the use of percutaneous deep vein arterialization.
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Endovenous Laser Ablation (EVLA) for Treatment of Varicose Veins: A Comparison of EVLA with 1470 nm and 1940 nm Lasers
Mark S Whiteley, MS FRCS(Gen), The Whiteley Clinic, Stirling House, Guildford, Surrey, UK
1565
Introduction: Endovenous laser ablation (EVLA) using 1470 nm, which targets water as its chromophore, has become the standard endovenous thermal treatment for incompetent truncal veins. Recently, there has been growing interest in the use of 1940 nm, due to the greater absorption by water.
This increased absorption has led to claims that, with the longer wavelength, less power is needed to achieve the same biological effect during treatment, resulting in fewer adverse post-operative sequelae.
Methods: Review of the current literature comparing 1940 nm and 1470 nm EVLA, which includes both laboratory-based and clinical studies. Reports on the use of 1920 nm were combined with those on 1940 nm.
Results: Increased absorption of the longer wavelength by water results in more thermal damage closer to the EVLA device. Thus, there may be an advantage to using the longer wavelength in EVLA of thin-walled veins at low power. However, in saphenous veins, which have thicker walls, there is little evidence that this different energy distribution in the vein wall makes any clinical difference. Reduced pain is likely to be due to reduced power during treatment. This is likely to result in more long-term failures of ablation using 1940 nm.
Conclusion: There is a difference in the distribution of thermal damage in the vein wall between EVLA at 1470 nm and 1940 nm. However, there is little evidence of any clinically significant difference when used in incompetent saphenous veins. Clinical studies looking for a difference need to report the size and wall thickness of the treated vein, the power used as well as the energy per centimetre (LEED), and long-term ablation rates in addition to early post-operative pain, induration, paraesthesia and ecchymosis. Also, power loss in different laser / fibre systems and technical differences, such as those that might allow blood to remain in the vein being treated, need to be considered.
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