Reconstruction of infrarenal abdominal aortic occlusion using the Culotte stenting technique: a case report

Patients with clinically significant infrarenal abdominal aortic atherosclerosis are often encountered in the clinical practice of vascular and endovascular surgeons. In the absence of timely treatment, the ability to work and life quality of patients are sharply reduced, and in some cases, patients require limb amputation. Until recently, the only treatment option for such a lesion was an open surgery. However, a good skill level of endovascular surgeons and the device availability allow today to perform minimally invasive operations with comparable effectiveness and greater safety in comparison with open surgery. We present a case report of successful endovascular treatment of aortic occlusion involving the right and left common and external iliac arteries using Culotte stenting technique with further 12-month follow-up.

A long-term survival rat model of spinal cord ischemia injury: Thoracic aortic occlusion combined with aortic bypass circulation

Objective This study aims to investigate the methods for rat spinal cord ischemia injury models with a high long-term survival rate. Methods The rats were divided into three groups: the treatment group, the control group, and the sham operation group. The treatment group had a blocked thoracic aorta (landing zone 3 by Ishimaru – T11) + aortic bypass circulation for 20 min. In the control group, the thoracic aorta at the landing zone 3 was blocked for 20 min. In the sham operation group, only thoracotomy without thoracic aortic occlusion was performed. The mean arterial blood pressure (MABP) of the thoracic aorta and caudal artery before and after thoracic aortic occlusion was monitored intraoperatively. Spinal cord function was monitored by a transcranial motor evoked potential (Tc-MEP) during the operation. Spinal cord function was evaluated by the BBB scale (Basso, Beattie, & Bresnahan locomotor rating scale) scores at multiple postoperative time points. The spinal cord sections of the rats were observed for 7 days after surgery, and the survival curves were analyzed for 28 days after surgery. Results After aortic occlusion, the MABP of thoracic aorta decreased to 6% of that before occlusion, and the MABP of caudal artery decreased to 63% of that before occlusion in the treatment group. In the control group, the MABP of both thoracic aorta and caudal artery decreased to 19% of that before occlusion. The Tc-MEP waveform of the treatment group disappeared after 6 min, and that of the control group disappeared after 8 min until the end of surgery. There was no change in the Tc-MEP waveform in the sham operation group. The BBB score of the treatment group decreased more obviously than the control group, and there was a significant difference. There was no decrease in the sham group. Spinal cord sections showed a large number of degeneration and necrosis of neurons, infiltration of inflammatory cells, and proliferation of surrounding glial cells in the treatment group. In the control group, multiple neurons were necrotic. The histology of the sham operation group was normal. The 28-day survival rate of the treatment group was 73.3%, which was higher than the control group (40.0%), and there was a significant difference ( p < 0.05). Conclusion Thoracic aortic occlusion combined with aortic bypass is an effective modeling method for rats with accurate modeling effects and high long-term survival rates.

Changes in peripheral arterial blood pressure after resuscitative endovascular balloon occlusion of the aorta (REBOA) in non-traumatic cardiac arrest patients

Background Resuscitative endovascular balloon occlusion of the aorta (REBOA) may be an adjunct treatment to cardiopulmonary resuscitation (CPR). Aortic occlusion may increase aortic pressure and increase the coronary perfusion pressure and the cerebral blood flow. Peripheral arterial blood pressure is often measured during or after CPR, however, changes in peripheral blood pressure after aortic occlusion is insufficiently described. This study aimed to assess changes in peripheral arterial blood pressure after REBOA in patients with out of hospital cardiac arrest. Methods A prospective observational study performed at the helicopter emergency medical service in Trondheim (Norway). Eligible patients received REBOA as adjunct treatment to advanced cardiac life support. Peripheral invasive arterial blood pressure and end-tidal CO2 (EtCO2) was measured before and after aortic occlusion. Differences in arterial blood pressures and EtCO2 before and after occlusion was analysed with Wilcoxon Signed Rank test. Results Five patients were included to the study. The median REBOA procedural time was 11 min and median time from dispatch to aortic occlusion was 50 min. Two patients achieved return of spontaneous circulation. EtCO2 increased significantly 60 s after occlusion, by a mean of 1.16 kPa (p = 0.043). Before occlusion the arterial pressure in the compression phase were 43.2 (range 12–112) mmHg, the mean pressure 18.6 (range 4–27) mmHg and pressure in the relaxation phase 7.8 (range − 7 – 22) mmHg. After aortic occlusion the corresponding pressures were 114.8 (range 23–241) mmHg, 44.6 (range 15–87) mmHg and 14.8 (range 0–29) mmHg. The arterial pressures were significant different in the compression phase and as mean pressure (p = 0.043 and p = 0.043, respectively) and not significant in the relaxation phase (p = 0.223). Conclusion This study is, to our knowledge, the first to assess the peripheral invasive arterial blood pressure response to aortic occlusion during CPR in the pre-hospital setting. REBOA application during CPR is associated with a significantly increase in peripheral artery pressures. This likely indicates improved central aortic blood pressure and warrants studies with simultaneous peripheral and central blood pressure measurement during aortic occlusion. Trial registration The study is registered in ClinicalTrials.gov (NCT03534011).

PV Loops and REBOA During Hemorrhage and Resuscitation

Retrograde Endovascular Balloon Occlusion of the Aorta (REBOA) is frequently used in hemorrhagic shock to facilitate resuscitation. In theory, aortic occlusion increases afterload and focuses perfusion to the coronary arteries and great vessels; also to focus perfusion to the brain. It is, however, unknown exactly how and to what extent REBOA impacts cardiovascular parameters such as preload, afterload and contractility, or coronary artery blood flow. It is also not known how these parameters evolve over time during REBOA as it is shifted from fully to partially occlusive, or weaned down entirely. We aim to use left ventricular Pressure-Volume (PV) loop analysis and directly measure coronary flow in swine as they descend into hemorrhagic shock, are resuscitated with full aortic occlusion with REBOA, transitioned to partial aortic occlusion with REBOA, and then weaned completely off of the REBOA and are resuscitated. We will examine, specifically, measures of preload, afterload, contractility and coronary blood flow during each study time period (baseline, hemorrhagic shock, full aortic occlusion, partial aortic occlusion, and post-occlusion during resuscitation).

Experience of Minimal Invasive Cardiac Surgery for repair of Atrial Septal Defects- A Single Center Study

Background: Atrial Septal Defects (ASD) can be closed surgically using conventional midline sternotomy or minimal invasive technique. This study was done to evaluate the outcome and safety of the minimal invasive cardiac surgical (MICS) approach using right vertical infra axillary incision (RVAI) for the repair of ASD. Methods: We performed a prospective observational cross-sectional analysis on 50 patients who were diagnosed as ASD of various types and not amenable to device closure. Their surgery was done RVAI using central cardiopulmonary bypass. Outcome of the study was evaluated using the following variables: length of the incision, satisfaction of patients, mortality, infection of surgical site, blood transfusion, duration of total operation, intensive care unit (ICU) stay, mechanical ventilation, hospital stay and aortic occlusion. Operations were done between December 2013 to December 2020. All the recruited patients were treated through RVAI as per patient’s choice. Results: Mean age was 11.4± 6.4 years. 18(36%) were male and 32(64%) were female. Body weight ranged from 10 to 65 kg. Mean length of incision was 6.2±0.8 cm. Mean aortic occlusion time was 42±14 min. ASD closed directly, using autologous treated pericardial patch or dacron patch. Mean total operation time was 4.08±0.6 hours and mean mechanical ventilation time was 8.3±5 hours. Average ICU stay was 35.6±6 hours and total hospital stay was 7.2±0.9 days. There was no significant blood loss. Only 10 patients required intravenous (IV) analgesics in the post-operative period. One patient required re-exploration, one conversion to median sternotomy and one suffered from superficial skin infection. There were no operative or late mortalities. Patient satisfaction was excellent. Conclusions: MICS technique using RVAI for surgical repair of ASD revealed a safe procedure and could be performed with excellent cosmetic and clinical outcomes. It provided a good alternative to the standard median sternotomy. Cardiovasc j 2021; 14(1): 37-43