Sen, Indrani

Treatment of atherosclerotic occlusive disease of the infrarenal aorta poses several challenges. Traditionally, open surgery has been the preferred method of treatment in standard risk patients, although, it is burdened by high morbidity and mortality. There are many classifications to establish the patient risk for surgery. Among the most common is the American College of Cardiology (ACC)/American Heart Association (AHA) classification. ACC/AHA high-risk patients benefit from the increase in endovascular technology and skills. The treatment modality of atherosclerotic aortic disease has shifted towards a minimally invasive approach, including kissing stents, covered endovascular reconstruction of the aortic bifurcation (CERAB) and, aorto-uniiliac stent grafts. When there is an involvement of vital branches such as the inferior mesenteric (with concomitant occluded superior mesenteric artery) or the renal arteries, Chimney- CERAB technique has been successfully utilized to overcome this challenge. We present three patients with aortoiliac occlusive disease (AIOD) successfully treated with the chimney- CERAB technique to preserve a large inferior mesenteric artery in the setting of occlusion/near occlusion of the other mesenteric vessels.

Objective The aim of this study was to analyze malpractice claims for aortic pathologies and to assess if there has been a change in rate of malpractice lawsuits with evolution of endovascular therapy. Methods Malpractice lawsuits were individually screened and compiled from the Westlaw database from 2000 to 2017 through use of relevant search terms. Data were collected of allegations, diagnoses, and outcomes of each case and compared. Results 268 unique cases were included in this study, with aneurysms (54%, n = 145) and dissection (35%, n = 94) making up the majority. There was a defendant verdict in 53% (n = 141), plaintiff verdict in 24% (n = 65), and settlements in 23% (n = 62) of lawsuits. Litigation was higher in the Midwest and Northeast. There was a gradual decline in litigation overall, however endovascular case numbers remained constant. There was negligible difference in the primary allegation underlying the litigation for various aortic pathologies, time to litigation and award between open and endovascular procedures. Conclusion The proportion of litigation for clinical negligence in endovascular cases amongst all vascular surgical lawsuits is increasing. As novel methods of endovascular therapy emerge, it is imperative that physicians remain vigilant to legal considerations to minimize malpractice risk.

Background: Acute aortic syndrome (AAS) includes aortic dissection (AD), intramural hematoma (IMH) and penetrating aortic ulcer (PAU) and confers high rates of aortic related events. However, the risk of cardiovascular (CV) events in this patient group is unknown. The aim of this study was to define the rates of CV events in an incident cohort of AAS patients. Methods: Medical records and death certificates of all Olmsted County, MN residents with a diagnosis of AAS from 1995-2015 were reviewed and compared to age- and sex- matched population controls. Primary outcome was non-aortic CV mortality. Secondary outcome was overall mortality and first time non-fatal CV event (myocardial infarction (MI), heart failure (HF) or stroke). Events were analyzed using Cox proportional hazards regression adjusting for comorbidities. Results: Of 133 patients with AAS (77 AD, 21 IMH, 35 PAU) 57% were male, median age was 72 (SD 14) and median follow-up was 10 years. Overall survival in AAS cases and controls was 62% versus 83% at 5 years and 44% versus 60% at 10 years (adj HR 1.8, p<.001, 95% CI 1.3-2.4). CV death occurred in 21 (29%) of 73 AAS decedents due to HF (9), MI (5), other cardiac causes (5), stroke (1) and peripheral vascular disease (1). CV-related survival at 5 and 10 years after AAS diagnosis (91% and 81%) was not significantly different from controls (95% and 86%) after adjustment for comorbidities (adj HR 1.8, p=.1, 95% CI 0.9-3.6). AAS was associated with an increased risk of any first time CV event (adj HR 2.6, p<.001, 95% CI 1.6-4.4; Figure), first time diagnosis of MI (adj HR 2.8, p<.001, 95% CI 1.7-4.7) and HF (adj HR 3.2, p<.001, 95% CI 1.6-6.2) but not stroke. When excluding acute events within 14 days of diagnosis, AAS was still associated with a significantly higher mortality (adj HR 1.6, p=.011, 95% CI 1.1-2.4) and an increased risk of any first time CV event (adj HR 2.2, p=.018, 95% CI 1.1-4.1), first time MI (adj HR 2.2, p=.012, 95% CI 1.2-4.1) and HF (adj HR 2.9, p=.006, 95% CI 1.4-6.2) but not stroke. Conclusions: AAS is associated with a higher overall mortality and an increased risk of any first time CV event, first time MI and HF that persists beyond the acute phase. These data highlight the risk of CV events among those with AAS and implicate the need for long-term cardiovascular management in these patients.

Background Aortic syndromes (ASs), including aortic dissection, intramural hematoma, and penetrating aortic ulcer, carry significant acute and long-term morbidity and mortality. However, the contemporary incidence and outcomes of AS are unknown. Methods and Results We used the Rochester Epidemiology Project record linkage system to identify all Olmsted County, MN, residents with AS (1995–2015). Diagnostic imaging, medical records, and death certificates were reviewed to confirm the diagnosis and AS subtype. Age- and sex-adjusted incidence rates were estimated using annual county-level census data. Survival for patients with AS was compared with age- and sex-matched controls using Cox regression to adjust for comorbid conditions. We identified 133 patients with AS (77, aortic dissection; 21, intramural hematoma; and 35, penetrating aortic ulcer). Average age was 71.8 years (SD=14.1), and 57% were men. The age- and sex-adjusted incidence was 7.7 per 100 000 person-years, was higher for men than women (10.2 versus 5.7 per 100 000 person-years), and increased with age. Among subtypes, the incidence of aortic dissection was highest (4.4 per 100 000 person-years), whereas the incidence of penetrating aortic ulcer and intramural hematoma was lower (2.1 and 1.2 per 100 000 person-years). Overall, the incidence of AS was stable over time ( P trend=0.33), although the incidence of penetrating aortic ulcer seemed to increase from 0.6 to 2.6 per 100 000 person-years ( P =0.008) with variability over the study interval. Patients with AS had more than twice the mortality rate at 5, 10, and 20 years when compared with population-based controls (5-, 10-, and 20-year mortality 39%, 57%, and 91% versus 18%, 41%, and 66%; overall adjusted mortality hazards ratio=2.1; P <0.001). Survival was lower than expected up to 90 days after AS diagnosis and did not differ significantly by subtype or by 5-year strata of diagnosis. Conclusions Overall, the incidence of aortic dissection and intramural hematoma has remained stable since 1995, despite the decline noted for other cardiovascular disease. AS confers increased early and long-term mortality that has not changed. These data highlight the need to improve long-term care to impact the prognosis of this patient group.