Endovascular Treatment of Aortoiliac Aneurysms With the Bell-Bottom Technique: A Systematic Review and Meta-Analysis.

OBJECTIVE: Aneurysmal degeneration of the common iliac artery (CIA) can pose a challenge to achieve distal landing zone sealing at the time of endovascular abdominal aortic aneurysm repair (EVAR). The aim of this study was to summarize the current literature regarding the bell-bottom technique (BBT) for ectatic CIAs during EVAR. METHODS: This study was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Eligible articles were identified through a comprehensive search of PubMed, Scopus, and Cochrane Central published until April 2023. A meta-analysis was conducted using the random effects model and the I2 statistic was used to assess for heterogeneity. The primary endpoints were type Ib/III endoleak, graft occlusion/limb embolization, and reintervention rate. Secondary endpoints included perioperative adverse events and mortality. RESULTS: Overall, twenty-six studies and 4332 patients with flared limbs were included. The pooled estimate for type Ib/III endoleak was 4% (95% CI: 2-6, I2 = 85.6%), for reintervention rate was 9% (95% CI: 6-12, I2 = 90.4%), and for overall mortality was 10% (95% CI: 4-19, I2 = 97.3%). No aneurysm related deaths were recorded. Comparative analysis showed similar type Ib/III endoleak, graft occlusion, and reintervention rates between the EVAR BBT, iliac branch endoprosthesis (IBE), and embolization of the internal iliac artery followed by extension of the iliac limb to the external iliac artery (EIE) groups. CONCLUSIONS: The use of flared limbs could be considered a reasonable first line choice for EVAR cases with CIA ectasia as it is simpler, allows for future IBE or EIE and does not increase the risk for type Ib/III endoleak or graft occlusion. Further comparative studies with longer follow-up are needed.

Understanding Type II Endoleak: A Harmless Imaging Finding or a Silent Threat?

Type II endoleak (T2EL) represents a challenging clinical entity following endovascular abdominal aortic aneurysm repair (EVAR). Although several studies have suggested that T2ELs are related to an increased risk of aneurysm sac growth and subsequent rupture, the exact role that T2ELs play in long-term outcomes remains debatable. Understanding the pathophysiology, diagnostic modalities, and management options of T2ELs is important for patients' safety and proper resource utilization. While conservative management may be suitable for asymptomatic patients with a stable aneurysm size, interventional approaches, including transarterial embolization, direct sac puncture embolization and open conversion have been described for patients with persistent T2EL associated with sac expansion. However, more research is needed to better determine the clinical benefit of such interventions. A thorough evaluation of all endoleak types before T2EL treatment would be reasonable for patients with T2ELs associated with sac expansion. Further studies are needed to refine treatment strategies aimed at minimizing T2EL-related complications. Collaborative efforts among vascular specialists, radiologists, and researchers are of paramount importance to address this ongoing clinical challenge.

Arteriovenous Fistula Maturation in Patients with Ipsilateral Versus Contralateral Tunneled Dialysis Catheter: A Systematic Review and Meta-analysis.

BACKGROUND: Although it is evident that a prior history of tunneled dialysis catheter (TDC) affects arteriovenous fistula (AVF) function, it is unclear whether its location (contralateral versus ipsilateral to AVF) has any effect on AVF maturation and failure rates. We aimed to document this possible effect. METHODS: This systematic review and meta-analysis were performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies comparing outcomes between patients with contralateral TDC (CONTRA group) and those with ipsilateral one (IPSI group) were examined for inclusion. A random effects model meta-analysis of the odds ratio (OR) was conducted. Primary outcomes were AVF functional maturation, assisted maturation, and failure rates. RESULTS: Four eligible studies comprising 763 patients were included in the meta-analysis. There were no significant differences in terms of AVF functional maturation (OR: 1.49; 95% confidence interval [CI]: 0.64-3.47; I2 = 83.4%), assisted maturation (OR: 0.59; 95% CI: 0.29-1.19; I2 = 61.4%), and failure rates (OR: 0.67; 95% CI: 0.29-1.58; I2 = 83.3%) between the 2 study groups. CONCLUSIONS: TDC laterality seems not to affect fistula maturation rate in patients requiring TDC placement and concurrent AVF creation, but rather, vein- and patient-related characteristics might play a more important role in choosing TDC access site. Further studies are needed to validate these results.

A Unique Case Of A Giant Popliteal Artery Aneurysm Presenting As Popliteal Mass.

INTRODUCTION: Popliteal artery aneurysms (PAA) can be very challenging, especially in cases of very large PAAs, with a minimal number of case reports published in the literature. METHODS: This is a case report of a 68-year-old male patient with hypertension, hyperlipidemia, diabetes, and schizophrenia who was found to have a giant (10x8x6cm) partially thrombosed PAA, treated with interposition polytetrafluoroethylene (PTFE) graft via a posterior approach. RESULTS: Under general anesthesia, the patient was placed in a prone position, and an extended lazy "S" incision was made on the popliteal fossa. After obtaining proximal and distal exposure, the aneurysm sac was skeletonized, preserving the popliteal vein and the tibial nerve. After proximal and distal control was obtained, the patient was systemically heparinized, and the aneurysm sac was opened. Some genicular branches were ligated inside the aneurysm, and part of the aneurysm sac was excised. A 7 mm PTFE graft was used for reconstruction in an end-to-end fashion. Suction drains were placed in the popliteal space, and the fascia and skin were approximated. The patient was discharged home on the 2nd postoperative day on aspirin and statin with ultrasound surveillance. The patient has remained asymptomatic during follow-up with a patent graft. CONCLUSIONS: Open surgical repair constitutes the gold standard of care for huge PAAs to prevent distal thromboembolic events and mass pressure effects from the aneurysm. Documentation of additional experience with open repair of huge PAAs would be beneficial and could help clinical decision-making.

Basilic vein tunnel transposition versus elevation transposition for brachiobasilic arteriovenous fistula creation: A systematic review and meta-analysis.

This study aimed to compare basilic vein tunnel transposition (BVTT) to basilic vein elevation transposition (BVET) technique for superficialization of a basilic arteriovenous fistula. This is a systematic review and meta-analysis comparing outcomes between BVTT and BVET for brachiobasilic arteriovenous fistula (AVF) creation. Primary endpoints were primary patency at several time intervals during follow-up and postoperative local complications, whereas secondary endpoints included primary assisted patency and secondary patency. A random effects model meta-analysis was conducted, and the I2 statistic was used to assess heterogeneity. Nine eligible studies were identified, including 543 patients (247 in the BVTT group and 296 in the BVET group). BVTT group was associated with inferior primary patency rate at 6 months compared to BVET group (three studies; OR: 0.43; 95% CI: 0.22-0.83; I2 = 0%; p = 0.012). However, primary patency rates were similar between the two study groups at 12 months (six studies; OR: 0.64; 95% CI: 0.33-1.22; I2 = 40.7%; p = 0.176), and at 24 months (six studies; OR: 0.86; 95% CI: 0.32-2.29; I2 = 74.9%; p = 0.764). No significant differences in terms of primary assisted patency, secondary patency, and postoperative complications were detected between the groups. More specifically, wound infection (BVTT: n = 9/150; BVET: n = 6/186; OR: 1.39; 95% CI: 0.48-4.06; I2 = 0%; p = 0.542) and healing of the scar, particularly regarding arm edema (BVTT: n = 18/100; BVET: n = 27/165; OR: 1.11; 95% CI: 0.57-2.18; I2 = 0%; p = 0.755) and hematoma formation (BVTT: n = 14/173; BVET: n = 42/209; OR: 0.40; 95% CI: 0.13-1.19; I2 = 49%; p = 0.101), did not differ significantly between the two study groups. BVET achieved superior primary patency at 6 months compared to BVTT, but this benefit seems to be lost during longer follow-up intervals. Therefore, both surgical techniques provide similar long-term outcomes.

Long-Term Outcomes of Open Versus Endovascular Treatment for Abdominal Aortic Aneurysm: Systematic Review and Meta-Analysis With Reconstructed Time-to-Event Data.

BACKGROUND: The advent of endovascular techniques has revolutionized the care of patients with uncomplicated abdominal aortic aneurysms. This analysis compares the overall survival and the freedom from reintervention rate between open surgical repair (OSR) and endovascular repair (EVAR) in patients undergoing elective abdominal aortic aneurysm (AAA) repair. METHODS: PubMed, Scopus, and Cochrane databases were searched for studies including patients who underwent either OSR or EVAR for uncomplicated AAA. All randomized controlled trials and propensity-score-matched cohort studies reporting on the outcomes of interest were considered eligible for inclusion. The systematic search of the literature was performed by 2 independent investigators in accordance with the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. We conducted 1-stage and 2-stage meta-analyses with Kaplan-Meier-derived time-to-event data and meta-analysis with a random-effects model. RESULTS: Thirteen studies met our eligibility criteria, incorporating 13 409 and 13 450 patients in the OSR and EVAR arms, respectively. Patients who underwent open repair had improved overall survival rates compared with those who underwent EVAR (hazard ratio [HR]=0.93, 95% confidence interval [CI]=0.88-0.98, p=0.004) during a mean follow-up of 53.8 (SD=29.8) months and this was validated by the 2-stage meta-analysis (HR=0.89, 95% CI=0.8-0.99, p=0.03, I2=62.25%). Splitting timepoint analysis suggested that EVAR offers better survival outcome compared with OSR in the first 11 months following elective intervention (HR=1.37, 95% CI=1.22-1.54, p<0.0001), while OSR offers a significant survival advantage after the 11-month timepoint and up to 180 months (HR=0.84, 95% CI=0.8-0.89, p<0.0001). Similarly, freedom from reintervention was found to be significantly better in EVAR patients (HR=1.28, 95% CI=1.14-1.44, p<0.0001) within the first 30 days. After the first month postrepair, however, OSR demonstrated higher freedom-from-reintervention rates compared with EVAR that remained significant for up to 168 months during follow-up (HR=0.73, 95% CI=0.66-0.79, p<0.0001). CONCLUSIONS: Despite the first-year survival advantage of EVAR in patients undergoing elective AAA repair, OSR was associated with a late survival benefit and decreased risk for reintervention in long-term follow-up. CLINICAL IMPACT: Open surgical repair for uncomplicated abdominal aortic aneurysm offers better long-term outcomes in terms of survival and freedom from reintervention rate compared to the endovascular approach but in the first year it carries a higher risk of mortality. The novelty of our study lies that instead of comparing study-level effect estimates, we analyzed reconstructed individual patient-level data. This offered us the opportunity to perform our analyses with mathematically robust and flexible survival models, which was proved to be crucial since there was evidence of different hazard over time. Our findings underline the need for additional investigation to clarify the significance of open surgical repair when compared to the latest endovascular devices and techniques within the evolving era of minimally invasive procedures.

De novo acute type B aortic dissection in two patients with previous infrarenal endovascular aortic aneurysm repair with EndoAnchors.

Acute aortic dissection in the immediate postoperative period after endovascular abdominal aortic aneurysm repair (EVAR) has been linked to technical factors such as excessive endograft oversizing or aortic wall injuries during the procedure. In contrast, dissections that occur later are more likely to be de novo. Regardless of their etiology, aortic dissection can extend into the abdominal aorta, causing collapse and occlusion of the endograft with devastating complications. To the best of our knowledge, no studies have reported on aortic dissection in EVAR patients in whom EndoAnchors (Medtronic, Minneapolis, MN) had been used. We present two cases of de novo type B aortic dissection after EVAR with entry tears in the descending thoracic aorta. In both of our patients, the dissection flap appeared to stop abruptly at the site of endograft fixation with the EndoAnchors, suggesting that EndoAnchors might prevent the propagation of aortic dissection beyond the EndoAnchor fixation level and thus protect the EVAR from collapse.

Treatment of arteriovenous access pseudoaneurysms using ultrasound guided balloon assisted thrombin injection: Two cases and systematic review of the literature.

BACKGROUND: Arteriovenous fistula pseudoaneurysm (AVF-PSA) is a common complication, usually caused during dialysis cannulation, which traditionally has been treated with open and less frequently endovascular techniques. Thrombin injection, although established in the treatment of arterial pseudoaneurysms, has barely been used in the treatment of AVF-PSA, due to concerns for AVF thrombosis or proximal embolization. METHODS: A systematic review was performed according to the PRISMA 2020 guidelines. PubMed and Cochrane Central databases were reviewed and all clinical reports on AVF-PSA balloon assisted percutaneous thrombin injection through July 2022 were included. The electronic search yielded five case reports. Due to between-study differences and small sample size, the findings were summarized from each report, but the results were not pooled. Additionally, we present our own experience on two patients with AVF-PSA that were treated with balloon assisted percutaneous thrombin injection. RESULTS: A total of five case reports (no of patients: 7, including ours) were included for review. Most of the patients were male (n = 6) and the mean age was 65.9 years. The average size of the PSA was 1.6 cm. In all cases a balloon was inflated to prevent thrombin and thrombotic material intrusion into the fistula lumen, prior to thrombin injection. In one patient n-butyl cyanoacrylate and Lipiodol were used, due to thrombin non availability. Recurrence was reported in only one patient, and average follow-up is 16 months. CONCLUSIONS: Thrombin injection with concomitant balloon inflation seems to be a safe and effective treatment for arteriovenous fistula pseudoaneurysms. Future studies should be aimed at evaluating the long-term outcomes of such minimally invasive techniques.

Geniculate Artery Endovascular Embolization Post-Total Knee Arthroplasty for Hemarthrosis Treatment: A Systematic Review of the Literature.

PURPOSE: To provide an updated systematic review on the use of geniculate artery embolization (GAE) in the management of recurrent hemarthrosis post-total knee arthroplasty (TKA). MATERIALS AND METHODS: A systematic literature review was conducted, and all clinical reports in the English language from inception to July 2022 were identified. References were manually reviewed to identify additional studies. Demographics, procedural techniques, post-procedural complications, and follow-up data were extracted and analyzed using STATA 14.1. RESULTS: A total of 20 studies (9 case reports, 11 case series; n= 214) were included for review. In all cases, patients underwent coil embolization of one or more geniculate arteries. Procedure success was reported in 94.8% (n=203/214) of cases without perioperative adverse events. Improvement of symptoms was seen in 72.6% (n=119/164) of cases, with 30.7% (n=58/189) of cases requiring repeat embolization. Recurrent hemarthrosis occurred in 22.2% (n=22/99) of cases over a mean follow-up of 48 months. CONCLUSION: GAE appears to be a safe and effective treatment for recurrent hemarthrosis following TKA. Future studies in the form of randomized controlled trials should be conducted to further evaluate such embolization techniques and compare outcomes between GAE and standard techniques. CLINICAL IMPACT: Conservative management of post total knee arthroplasty (TKA) hemarthrosis is successful in only one third of cases. Geniculate artery embolization (GAE) has recently gained attention due to its minimally invasive nature compared to open or arthroscopic synovectomy promising faster rehabilitation, decreased infection rates and less additional surgeries. The purpose of this article was to summarize current literature, provide an updated review on the use of GAE in the management of recurrent hemarthrosis post-TKA and describe immediate and long-term outcomes in an effort to help optimize current treatment algorithms.

Endovascular Repair of Popliteal Artery Injury Post-total Knee Arthroplasty is Safe and Effective: A Case Report and Systematic Review of the Literature.

BACKGROUND: Popliteal artery pseudoaneurysms are a rare but serious complication following total knee arthroplasty that have been traditionally managed with open surgical repair. Endovascular stenting, while relatively new, offers a promising alternative that is less invasive and may reduce the risk of perioperative complications. METHODS: A systematic literature review was conducted, and all clinical reports in the English language from inception to July 2022 were identified. References were manually reviewed to identify additional studies. Demographics, procedural techniques, postprocedural complications, and followup data were extracted and analyzed using STATA 14.1. Additionally, we present a case of a patient with a popliteal pseudoaneurysm treated with a covered endovascular stent. RESULTS: A total of 14 studies (12 case reports, 2 case series; n = 17) were included for review. In all cases, a stent-graft was placed across the popliteal artery lesion. In 5 out of 11 cases, popliteal artery thrombus was present and treated with adjacent modalities (i.e., mechanical thrombectomy, balloon angioplasty, etc.). Procedure success was reported in all cases without perioperative adverse events. Stents remained patent over a median followup of 32 weeks (interquartile range: 36). In all but one case, the patients experienced immediate symptom relief and had an uneventful recovery. For our case, at the 12-month followup the patient was asymptomatic, and ultrasound demonstrated vessel patency. CONCLUSIONS: Endovascular stenting is a safe and effective treatment for popliteal pseudoaneurysms. Future studies should be aimed at evaluating the long-term outcomes of such minimally invasive techniques.