A comparison of thoracoabdominal aortic aneurysms open repair in patients with or without “shaggy aorta”

ObjectiveIn the field of thoracoabdominal aortic aneurysm (TAAA) open surgical repair (OSR), some preoperative characteristics are established risk factors for adverse outcomes, whereas others are supposed to be relevant, but their role still need to be defined; among them, the presence of “shaggy aorta” (SA), an extensive and irregular atheroma within the aorta. The aim of this study is to report the results of a single-center large cohort of patients treated with OSR for TAAA with SA, comparing the outcomes with patients affected by TAAA without SA, and analyzing the impact of the scores for SA on the outcomes.MethodsAll consecutive patients receiving OSR for TAAA between 2012 and 2021 were retrospectively analyzed. Clinical data from patients with degenerative TAAA were included and analyzed for preoperative characteristics and postoperative outcomes; patients with ruptured TAAA, and patients with aortic dissection were excluded from the analysis. Patients with degenerative aortic aneurysm, thrombus measurement in non-aneurysmal aortic segments (≤40 mm), atheroma thickness ≥5 mm, and finger-like thrombus projection were included in the SA group, whereas the others were included in the non-shaggy aorta group (NSA group). The SA group and NSA group were compared using a propensity-matched comparison. Preoperative computed tomography scans of patients in the SA group were also stratified according to SA grading scores.ResultsA total of 58 patients with SA were identified (male, n = 43 [74.1%], mean age 70.1 ± 7.8 years) among 497 patients with TAAA treated with open surgical repair. After propensity matching, there were 57 patients in the SA group and 57 in the NSA group with correction of all differences in baseline characteristics. Patients in the SA group presented significantly higher in-hospital mortality (SA group, 14.0% vs NSA group, 3.5%; P = .047), postoperative acute renal failure (Risk, Injury, Failure, Loss of kidney function, and End-stage kidney disease [RIFLE], 3-5) (SA group, 21.1% vs NSA group, 5.3%; P = .013), and postoperative embolization (SA group, 28.1% vs NSA group, 8.8%; P = .008). Spinal cord ischemia and stroke rate were not significantly influenced by the presence of SA. In the SA group, 16 patients (27.6%) with end-organ embolization were compared with 42 patients (72.4%) without a documented embolization considering the grade of aortic “shagginess” and no significant difference was identified (P = .546).ConclusionsDespite a better knowledge of the SA disease, new classifications, and intraoperative adjuncts, TAAA patients with SA treated with OSR have worse postoperative outcomes if compared with patients without SA. The presence of SA is a risk factor itself, whereas the grade of “shagginess” seems not to impact on postoperative outcomes.     

Detection of “functional” valves in reversed saphenous vein bypass grafts: Identification with duplex ultrasonography

Purpose: Although venous valve lesions have been cited as a mechanism of graft failure, the fate of venous valves in reversed saphenous vein (RSV) bypass grafts is unclear. The basis for this uncertainty is the difficulty in postoperative identification and follow-up of valve sites and the infrequent pathologic submission of vein graft lesions. This report describes the features of “functional” valves (FV) visualized in RSV grafts by ultrasonic duplex scanning.Methods: Sixty-six RSV infrainguinal vein grafts were prospectively studied with duplex ultrasonography from January 1992 to December 1995. Grafts were studied at 1, 2, 3, 4, 6, 9, 12, 18, and 24 months, then annually. FV identification was based on a characteristic ultrasound Doppler waveform and color flow pattern and visualization of the leaflets by B-mode imaging. The waveform consists of end-systolic valve closure followed by variable degrees of reflux. Immediate postoperative reactive hyperemia precludes detection, because flow reversal in the graft is needed for identification.Results: Since August 1994, 14 FV have been identified in 11 (17%) of 66 RSV grafts. The mean time to FV recognition after implantation was 10 months (range, 1 to 52 months), and the average follow-up was 15 months. One valve was completely competent. Seven (50%) of the FV were associated with the development of a <50% diameter reducing stenosis by Doppler velocity criteria. None of the FV has required intervention.Conclusions: “Functional” vein valves in RSV grafts are common and can be identified by ultrasonic duplex imaging. Awareness of the characteristics of FV during routine duplex graft surveillance will undoubtedly increase detection. The variable time course to identification of FV and duration of “function” warrants continued follow-up to determine the relationship of these valves to the development of stenotic lesions and graft failure. (J Vasc Surg 1997;25:522-7.)     

Thrombosed abdominal aortic aneurysm associated with an extensively “shaggy” aorta repaired anatomically via a thoracoabdominal approach with supraceliac aortic clamping: Report of a case

A 76-year-old man with a history of multiple laparotomies and severe coronary artery disease was referred to our hospital after the sudden development of pain and numbness in the lower extremities. Computed tomography showed a thrombosed abdominal aortic aneurysm and diffuse aortic atherosclerosis; compatible with a “shaggy aorta.” A good response to thrombolytic therapy permitted elective scheduling of abdominal aortic surgery after coronary artery bypass grafting. We operated via an extended left retroperitoneal approach through a thoracoabdominal incision. Epiaortic ultrasonography revealed that only the supraceliac aorta was free of mobile thrombi and had minimal plaque; we therefore placed a proximal aortic cross-clamp there. Anatomic aortic reconstruction was then performed successfully using an aorto-biiliac graft to restore adequate distal blood flow. There were no vital-organ ischemic complications, and the postoperative course was satisfactory.     

Editorial comment regarding “Total aortic arch replacement using the frozen elephant trunk technique with <Emphasis Type=Italic>J Graft Open Stent Graft</Emphasis> for distal aortic arch aneurysm”

Total aortic arch replacement using the frozen elephant trunk (FET) technique has gained worldwide popularity, because it has simplified the treatment of complicated thoracic aortic lesions. The most effective use of FET has been total arch repair for acute-type A aortic dissection because of its particularly favorable prognosis. However, the use rate for true aneurysm in 2016 was half of the total 2150 cases using FET. The widespread use of FET is attributable to its ease of use. The incidence of FET-related paraplegia has decreased with the use of total aortic arch replacement but is still higher than in classic total arch replacement with distal arch anastomosis. A prospective multicenter study for FET is necessary.     

Intraoperative single-shot “3-in-1” femoral nerve block with ropivacaine 0.25%, ropivacaine 0.5% or bupivacaine 0.25% provides comparable 48-hr analgesia after unilateral total knee replacement

PURPOSE: To compare analgesia after intraoperative single shot "3-in-1" femoral nerve block (FNB) in combination with general anesthesia using ropivacaine 0.25%, ropivacaine 0.5% with bupivacaine 0.25% for total knee replacement (TKR). METHODS: We performed a randomized, double-blind study in 48 patients for elective TKR under general anesthesia. Patients were randomized to one of four groups (C: sham block, R1: "3-in-1" FNB using 30 mL of ropivacaine 0.25%, R2: "3-in-1" FNB using 30 mL of ropivacaine 0.5%, B: "3-in-1" FNB using 30 mL of bupivacaine 0.25%). Verbal pain score (VPS) both at rest and movement were assessed for 48 hr after TKR (0=none; 1=mild; 2=moderate; 3=severe). Total morphine consumption and its associated side effects, duration of hospitalization after operation were also compared. RESULTS: There were no differences in patients' physical characteristics, intraoperative morphine usage, operation time, tourniquet time or length of hospitalization between the four groups. When compared with group C, the VPS was significantly lower in groups R1, R2 and B at one, four, eight, 24 and 48 hr after TKR (P <0.05). The morphine requirement of groups R1, R2 and B were also significantly lower when comparing with group C up to 48 hr postoperatively (P <0.05). There were no significant differences in VPS and postoperative morphine requirement at any time between groups R1, R2 and B. CONCLUSION: "3-in-1" FNB with ropivacaine provided analgesia that was clinically comparable to that of bupivacaine up to 48 hr after TKR. Increasing the concentration of ropivacaine from 0.25% to 0.5% failed to improve the postoperative analgesia of "3-in-1" FNB.     

“Men are always scared to test with their partners … it is like taking them to the Police”: Motivations for and barriers to couples’ HIV counselling and testing in Rakai,Uganda: a qualitative study

Introduction

Uptake of couples’ HIV counselling and testing (couples’ HCT) can positively influence sexual risk behaviours and improve linkage to HIV care among HIV-positive couples. However, less than 30% of married couples have ever tested for HIV together with their partners. We explored the motivations for and barriers to couples’ HCT among married couples in Rakai, Uganda.

Methods

This was a qualitative study conducted among married individuals and selected key informants between August and October 2013. Married individuals were categorized by prior HCT status as: 1) both partners never tested; 2) only one or both partners ever tested separately; and 3) both partners ever tested together. Data were collected on the motivations for and barriers to couples’ HCT, decision-making processes from tested couples and suggestions for improving couples’ HCT uptake. Eighteen focus group discussions with married individuals, nine key informant interviews with selected key informants and six in-depth interviews with married individuals that had ever tested together were conducted. All interviews were audio-recorded, translated and transcribed verbatim and analyzed using Nvivo (version 9), following a thematic framework approach.

Results

Motivations for couples’ HCT included the need to know each other''s HIV status, to get a treatment companion or seek HIV treatment together – if one or both partners were HIV-positive – and to reduce mistrust between partners. Barriers to couples’ HCT included fears of the negative consequences associated with couples’ HCT (e.g. fear of marital dissolution), mistrust between partners and conflicting work schedules. Couples’ HCT was negotiated through a process that started off with one of the partners testing alone initially and then convincing the other partner to test together. Suggestions for improving couples’ HCT uptake included the need for couple- and male-partner-specific sensitization, and the use of testimonies from tested couples.

Conclusions

Couples’ HCT is largely driven by individual and relationship-based factors while fear of the negative consequences associated with couples’ HCT appears to be the main barrier to couples’ HCT uptake in this setting. Interventions to increase the uptake of couples’ HCT should build on the motivations for couples’ HCT while dealing with the negative consequences associated with couples’ HCT.