Systematic review and meta-analysis of incidence, indications, and outcomes of early open conversions after EVAR for abdominal aortic aneurysms.

INTRODUCTION: The purpose of this study is to report incidence, indications, and outcomes of early open conversions (EOC) after endovascular aortic repair (EVAR), defined as surgical conversion performed within 30 days from the initial EVAR. EVIDENCE AQUISITION: A systematic review of the literature was performed (database searched: PubMed, Web of Science, Scopus, Cochrane Library; last search April 2023). Articles reporting EOC after EVAR comprising at least five patients were included. Meta-analyses of proportions were performed using a random-effects model. EVIDENCE SYNTHESIS: Seventeen non-randomized studies, published between 1999 and 2022, were included. A total of 35,970 patients had previously undergone EVAR, of these 438 patients underwent EOC. Estimated incidence of EOC was 1.4% (95% CI 1.1-1.4; I2=81.66%). Specifically, in the works published before 2010 the incidence was 1.8% (95% CI 1.3-2.4; I2=74.25) while for subsequent ones it was 0.9% (95% CI 0.6-1.1; I2=69.82). Weighted mean age was 74.91 years (95% CI 72.42-77.39; I2=83.11%). Estimated rate of cause determining EOC were: access issue in 27.7% of patients (95% CI 13.8-41.6; I2=88.14%), incorrect placement of the endograft in 20.1% (95% CI 10.2-30.0; I2=76,9%), problems with "delivery system" in 9.0% (95% CI 4.9-13.1; I2=0%), aorto-iliac rupture in 8.6% (95% CI 4.5-12.6; I2=0%), endoprosthesis migration in 7.9% of cases (95% CI 3.3-12.4; I2=22.96%), failure in engaging the contralateral gate in 4.8% (95% CI 1.6-8; I2=0%), "kinking" or "twisting" of endoprosthesis in 3.3% (95% CI 0.6-5.9; I2=0%), graft thrombosis in 3.2% (95% CI 0.6-5.7; I2=0%), type Ia endoleak in 2.9% (95% CI 0.4-5.4; I2=0%), type III endoleak in 2.8% (95% CI 0.3-5.3; I2=0%) and endograft infection in 2.7% (95% CI 0.3-5.2; I2=0%). Intraoperative conversion rate was 91.1% (95% CI 85.8-96.4; I2=66.01%). Early mortality rate after EOC was 14.5% (95% CI 9.1-19.9; I2=48.31%). Mean length of stay (LOS) was 11.94 days (95% CI 6.718-17.172; I2=92.34%). CONCLUSIONS: The incidence of EOC seems to decrease over time. Causes of EOC were mainly related to access problems and incorrect positioning of the endograft. Most of the EOC were performed intraoperatively carrying a high mortality rate.

Endovascular and Surgical Venous Arterialization for No-Option Patients With Chronic Limb-Threatening Ischemia: A Systematic Review and Meta-Analysis.

BACKGROUND: Chronic limb-threatening ischemia (CLTI) is known for its high rates of major amputation and mortality. Conventional revascularization techniques often fail in CLTI patients due to the heavily diseased arteries. Foot vein arterialization (FVA) has been proposed as an alternative technique to provide arterial blood to the foot by using the disease-free venous bed. OBJECTIVES: This systematic review and meta-analysis aimed to determine outcomes of surgical FVA (sFVA) and percutaneous FVA (pFVA) at 6 and 12 months post-procedure. DATA SOURCES: PubMed, Scopus, Web of Science, and the Cochrane Library databases were searched to identify papers reporting clinical outcomes of sFVA and pFVA published between January 1966 and March 2023. METHODS: Databases were searched for eligible studies. A meta-analysis was performed to evaluate the limb salvage rate, overall survival rate, and wound healing rate at 6 and 12 months. RESULTS: A total of 27 studies were included, with 753 patients and 793 limbs. Of the included studies, 16 analyzed the sFVA technique and 11 the pFVA technique. Of the included patients, 86.3% were Rutherford 5/6 in the sFVA group versus 98.4% in the pFVA group. The pooled limb salvage rate at 6 and 12 months was 78.1% and 74.1% in the sFVA group and 81.7% and 78.6% in the pFVA group, respectively. Wound healing rates were not reported in the sFVA group. In the pFVA group, the pooled wound healing rates were 48.1% and 64.5% at 6 and 12 months, respectively. CONCLUSION: This study showed promising results after FVA among a large population of CLTI patients. In high-risk patients, pFVA is a feasible option with favorable limb salvage and wound healing rates.

Real-world outcomes of Cook Zilver PTX in femoro-popliteal district from multicenter experience.

BACKGROUND: The purpose is to evaluate the follow-up outcomes after femoro-popliteal stenting with Cook Zilver PTX in a multicenter experience. METHODS: Collected data from four Units were retrospectively joined and analyzed considering Zilver PTX deployed from August 2009 according to the instruction for use. Patient demographics, preoperative comorbidities, Rutherford classification, arterial characteristics and stent data were considered. Target lesion revascularization (TLR) was defined as reintervention performed for ≥50% diameter stenosis after recurrent clinical symptoms. Primary outcome was the freedom from TLR (ffTLR) and its risk factors. Secondary outcomes were primary patency (PP) of the stent, amputation-free survival (AFS) and their risk factors. RESULTS: Considering 203 patients (mean age: 73.5 years ±10.6; male: 66.5%) and 263 stents (median 2 stents/patient, range 1-5stent/patient), chronic limb-threatening ischemia (CLTI) affected 154 patients (75.9%). The length of the treated lesion was <120 mm in 99 (48.8%), ≥120 mm and <200 mm in 65 (32%) and ≥200 mm in 39 (19.2%) cases, respectively; the reference vessel mean diameter was 5.5±0.7 mm; chronic total occlusion was treated in 153 (75.4%) patients, the popliteal artery was involved in 56 (27.6%) cases and prior endovascular intervention was performed in 27 (13.3%) cases. Two or more crural run-off vessels were patent in 124 (61.1%). Mean follow-up was 23.2 months ±21.3. At 1, 2 and 3 years, the ffTLR was 90.6±4.2%, 86.4±6.1% and 80.4±8.3%, respectively, and the PP was 85.6±5.0%, 74.2±7.6% and 72.7±8.2%, respectively. Negative prognostic factor for ffTLR and PP was the reference vessel diameter (P=0.001 and P<0.001, respectively). At 1, 2 and 3 years, the AFS was 81.8±6.0%, 75.5±7.1% and 74.2±7.5% respectively; coronary artery disease (P=0.041) and CLTI (P=0.011) resulted negative prognostic factors. CONCLUSIONS: In the real-world practice, around 3/4 of patients were treated for CLTI. The rate of ffTLR is high, and PP is substantially lower. A small vessel diameter (<5 mm) is a negative factor for both ffTLR and PP. The rate of AFS is about 75% at 2 years and CLTI and coronary artery disease are negative prognostic factors.

Carotid endarterectomy in asymptomatic octogenarians: Outcomes at 30 days and 5 years.

BACKGROUND: The following study investigated the 30-day and 5-year relative survival rate and freedom from neurological events in asymptomatic carotid stenosis (ACS) octogenarians who had undergone elective carotid endarterectomy (CEA). METHODS: Between January 2008 and June 2014, a retrospective review was conducted on ACS patients who had undergone elective CEA. The patients' sample was divided into two groups: Group A (GA) included octogenarians and Group B (GB) included younger patients. The GA patients were subjected to a risk-scoring system and follow-up. The two groups were compared analysing the following primary endpoints: 30-day mortality, stroke, stroke/death and acute myocardial infarction (AMI); GA patients' survival rate and freedom from neurological events at 5 years. The 30-day secondary endpoints included carotid shunting, redo surgical, need for general anaesthesia with preserved consciousness (GAPC) conversion and length of hospital stay. RESULTS: We identified 620 patients with ACS, of them 144 (23.2%) belonged to the GA and 476 (76.8%) belonged to the GB. No statistical difference between the two groups was found regarding the primary and secondary endpoints. One hundred nineteen of 144 GA patients (82.6%) underwent the follow-up; the median follow-up was 78.3 months. The GA patients' 5-year survival rate was 62%, while freedom from cerebral events was 94.9%. Analysis regarding GA patients' 5-year survival rate revealed a significantly lower percentage among the patients with a severe risk score compared with those with a moderate risk score (respectively, 29.5% vs 67.7%; p = .005). The multivariate analysis showed that chronic obstructive pulmonary disease (COPD) and chronic kidney disease (CKD) were independently associated with lower survival. CONCLUSIONS: The 30-day outcomes of CEA in octogenarians are comparable to those in younger patients. Comprehensive life expectancy and preoperative score, rather than age alone, should be taken into account before performing CEA on octogenarian patients, considering the short- and long-term efficacy in stroke prevention.

The Utility of Intraoperative Contrast-enhanced Ultrasound for Immediate Treatment of Type Ia Endoleak during EVAR: Initial Experience.

Objectives Type Ia endoleak (EL) after endovascular abdominal aortic repair (EVAR) may be misdiagnosed at completion angiography. Intraoperative contrast-enhanced ultrasound (CEUS) may play a role in early detection and immediate treatment of type Ia EL. Methods From January 2017 to April 2018, patients treated with EVAR underwent intraoperative CEUS. After endograft deployment and ballooning, digital subtraction angiography (DSA) and intraoperative CEUS were performed in a blinded fashion. All cases of type Ia EL at DSA or CEUS were considered. Results Type Ia EL detected at intraoperative CEUS and undetected at DSA was defined in 2 patients. The former was solved with intraoperative re-ballooning; in the latter case, a Palmaz stent deployment was required. The resolution of type Ia EL was detected at intraoperative CEUS control and post-operative computed tomography angiography (CTA). In another patient, the DSA detected a type Ia EL, but intraoperative CEUS reveal a type II EL from lumbar arteries. Post-operative CTA confirm the type II EL. Conclusions The reported cases prove the clinical utility of the intraoperative CEUS, permitting the early identification of 2 type Ia EL. In addition, the intraoperative CEUS is useful in case of dubious type Ia EL at DSA, avoiding unnecessary intraoperative adjunctive procedure or post-operative CTA.

Endovascular treatment for restenosis of carotid venous bypass graft: a clinical case report.

BACKGROUND AND AIM: Restenosis after open carotid surgery (OCS) represents an issue that experts are very often facing nowadays, both after carotid endoarterectomy(CEA) and carotid bypass(CB). Yet, even if from one side carotid artery stenting (CAS) is currently recommended by most guidelines as treatment of choice for carotid restenosis after CEA, on the other side little is known regarding the best treatment of restenosis after CB. This clinical case report is aimed to empathize the endovascular treatment as an effective therapeutic option for restenosis after OCS. METHODS: A 75-year-old woman with severe comorbidities was admitted to our Unit for left carotid bypass graft restenosis. One year earlier, the patient had been treated with left carotid bypass grafting in saphenous vein for infectious complications occurred after CEA for symptomatic left carotid stenosis. The patient underwent a carotid Duplex ultrasonography scan (DUS) which showed a hemodynamically significant left carotid venous graft stenosis with peak systolic velocity of 315 cm/sec; in order to assess the grade of the stenosis a computed tomography angiography confirmed the presence of a significant narrowing of left carotid graft. A carotid artery angiography was performed after 20days, reconfirming the presence of a significant left carotid graft stenosis and was successfully treated with 7x40mm self-expanding stent. RESULTS: The patient had an uneventful post-procedural course and was discharged the day after. After six months, the patient underwent a carotid DUS in our outpatient clinic which confirmed the overall graft and stent patency. CONCLUSION: CAS represents a feasible therapeutic option for carotid restenosis in patients treated after CB. This clinical case demonstrates that CAS can be performed with acceptable risks and good early results.

Endovascular Treatment of Persistent Sciatic Artery Occlusion: Case Report and Literature Review.

Persistent sciatic artery (PSA) is a rare congenital anatomic variant of the lower limb vascular system with highly variable presentations. The management of lower limb ischemia due to PSA disease is not specifically recommended in guidelines, and surgical by-pass is usually the most described treatment. We reported a case of a 46-year-old patient with bilateral PSA and right chronic limb-threatening ischemia due to PSA occlusion at the PSA-popliteal junction which was successfully treated with percutaneous transluminal balloon angioplasty. In addition to this case report, a systematic review of the literature regarding the endovascular management of PSA stenosis and occlusion was conducted.

Surgical and Endovascular Management of Isolated Internal Iliac Artery Aneurysms: A Systematic Review and Meta-Analysis.

OBJECTIVES: The purpose of this paper is to report the different modalities for the treatment of isolated internal iliac artery aneurysms (IIIAA), as well as their outcomes. METHODS: We performed a systematic review of the literature (database searched: PubMed, Web of Science, Scopus, Cochrane Library; last search: April 2020). We included articles reporting on the outcomes for IIIAA interventions comprising at least 5 patients. Studies were included when presenting extractable outcome data regarding intraoperative and/or early results. We performed meta-analyses of proportions for different outcomes, using random effects model. RESULTS: Thirteen non-randomized studies were included (192 patients with 202 IIIAA). IIIAA were symptomatic in the 18.1% (95%CI 9.3-26.9; I2 54.46%, P = .019). Estimated mean IIIAA diameter was 46.28 mm (95%CI 39.72-52.85; I2 88.85%, P < .001). Open repair was performed in 21/202 cases. Endovascular treatments were: embolization (81/181), embolization and hypogastric artery coverage (79/181), hypogastric artery coverage by stent-grafting (15/181), stent-grafting in the hypogastric artery (6/181). Overall estimated technical success (TS) rate was 91.6% (95% CI 86.8-95.5; I2 45.82%, P = .031). TS rate was 94.5% for open surgery (95%CI 85.3-100; I2 0%, P = .907), and 89.7% for endovascular repair (95%CI 83.8-95.6; I2 55.43%, P = .006). Estimated overall 30-day mortality was 3.1% (95%CI 0.8-5.4; I2 0%, P = .969). Mortality rates after open surgery and endovascular repair were 8.2% (95%CI 3.4-19.8; I2 0%, P = .545) and 2.8% (95%CI 0.5-5.1; I2 0%, P = .994), respectively. Estimated mean follow-up was 32.63 months (95%CI 21.74-43.53; I2 94.45%, P < .001). During this timeframe, IIIAA exclusion was preserved in 92.8% of the patients (95%CI 89.3-96.2; I2 0%, P = .797). Buttock claudication occurred in 13.9% of the patients (95%CI 8.7-19.2; I2 0%, P = .622). CONCLUSIONS: IIIAA are frequently large, and symptomatic at presentation. Several treatments are proposed in literature, open and endovascular, both with good results. The endovascular treatment is the preferred method of treatment in literature, since it offers good short- to mid-term results and low early mortality. Buttock claudication after hypogastric artery exclusion is a common complication.

A Novel Scoring System for Small Artery Disease and Medial Arterial Calcification Is Strongly Associated With Major Adverse Limb Events in Patients With Chronic Limb-Threatening Ischemia.

PURPOSE: To evaluate the roles of small artery disease (SAD) and medial arterial calcification (MAC) in patients with chronic limb-threatening ischemia (CLTI) and to identify any correlation between these factors and peripheral artery disease (PAD) or outcomes after treatment. MATERIALS AND METHODS: A retrospective review was conducted of 259 limbs with tissue loss among 223 CLTI patients (mean age 72.2±11.4 years; 194 men) having an angiographic foot vessel study, foot radiography, and at least 6 months of follow-up after intervention. SAD and MAC were quantified using a 3-level score (0=absent, 1=moderate, 2=severe) based on angiography for SAD and foot radiographs for MAC. The MAC score was validated and compared with the SAD score, evaluating their associations with PAD distribution and clinical outcomes. RESULTS: Based on the MAC score, the 259 limbs were classified as 55 group 0 (21.2%), 89 group 1 (34.4%), and 115 group 2 (44.4%). The SAD score stratified the 259 limbs as 67 group 0 (25.9%), 76 group 1 (29.3%), and 116 group 2 (44.8%). Interobserver reproducibility of the MAC score was high (correlation coefficient 0.96). Sensitivity and specificity of the MAC score in detecting SAD was 100% and 98.1%, respectively, in SAD groups 0 and 2 vs 99.1% and 92.7%, respectively, for SAD group 1. PAD was more proximal in MAC and SAD groups 0 and more distal in groups 1 and 2. Both MAC and SAD scores were able to predict clinical endpoints. Multivariable analysis demonstrated that the MAC score represents an independent risk factor for adverse limb events. CONCLUSION: SAD and MAC must be considered expressions of the same obstructing disease, able to adversely impact the fate of CLTI patients. SAD and MAC scores are powerful prognostic indicators of major adverse limb events in CLTI patients.

Association of infrapopliteal medial arterial calcification with lower-limb amputations in high-risk patients: A systematic review and meta-analysis.

Medial arterial calcification (MAC) is a known risk factor for cardiovascular morbidity. The association between vascular calcifications and poor outcome in several vascular districts suggest that infrapopliteal MAC could be a risk factor for lower-limb amputation (LLA). This study's objective is to review the available literature focusing on the association between infrapopliteal MAC and LLA in high-risk patients. The PubMed and Embase databases were systematically searched. We selected original studies reporting the association between infrapopliteal MAC and LLAs in patients with diabetes and/or peripheral artery disease (PAD). Estimates were pooled using either a fixed-effects or a random-effects model meta-analysis. Heterogeneity was evaluated using the Q and I2 statistics. Publication bias was investigated with a funnel plot and Egger test. The trim-and-fill method was designed to estimate the possibly missing studies. Influence analysis was conducted to search studies influencing the final result. Test of moderators was used to compare estimates in good versus non-good-quality studies. Fifteen articles satisfied the selection criteria (n = 6489; median follow-up: 36 months). MAC was significantly associated with LLAs (pooled adjusted risk ratio (RR): 2.27; 95% CI: 1.89-2.74; I2 = 25.3%, Q-test: p = 0.17). This association was kept in the subgroup of patients with diabetes (RR: 2.37; 95% CI: 1.76-3.20) and patients with PAD (RR: 2.48; 95% CI: 1.72-3.58). The association was maintained if considering as outcome only major amputations (RR: 2.11; 95% CI: 1.46-3.06). Our results show that infrapopliteal MAC is associated with LLAs, thus suggesting MAC as a possible new marker of the at-risk limb.

GLASS (Global Limb Anatomic Staging System): a critical appraisal.

BACKGROUND: THE Global Vascular Guidelines (GVGs) propose a new Global Anatomic Staging System (GLASS) resulting in three stages of complexity for intervention. The aim of this study was to retrospectively classify a large cohort of CLTI patients according to the GLASS, evaluating its distribution in a real-world setting. METHODS: Retrospective, single center, observational study enrolling all consecutive CLTI patients submitted to infra-inguinal endovascular revascularization in our institution, between June 2014 and September 2019. Patients were categorized according to the GLASS for femoro-popliteal (FP), infra-popliteal (IP) and infra-malleolar grading. FP and IP grades were merged to get the final GLASS stage for each limb. RESULTS: The study included 1995 CLTI patients who underwent 2850 endovascular procedures in which 6009 arterial lesions were successfully treated. The FP segment was classified as: 1292 (45.3%) grade 0, 475 (16.6%) grade 1, 159 (5.6%) grade 2, 209 (7.4%) grade 3, and 715 (25.1%) grade 4. The IP segment was classified as: 1529 (53.6%) grade 0, 183 (6.4%) grade 1, 80 (2.8%) grade 2, 207 (7.3%) grade 3, and 851 (29.9%) grade 4. The combination of FP and IP grading led to GLASS stages: 922 (32.3%) stage 1, 375 (13.2%) stage 2, 1472 (51.6%) stage 3. CONCLUSIONS: The distribution of the FP, IP and final GLASS grading was mainly grouped at the two extremes, letting the intermediate grades rather scarce. The majority of patients present with an absent or severely diseased pedal arch, stressing the need to incorporate infra-malleolar disease into the GLASS.

Foot Angiosomes: Instructions for Use.

In the last 15 years an abundance of literature has demonstrated that angiosome-targeted revascularization, either endovascular or open, can lead to better clinical results in patients with chronic limb-threatening ischemia. According to this literature, the angiosome concept should guide our treatment strategy in every chronic limb-threatening ischemia patient. However, in our daily practice, its application is often difficult or impossible. Most foot wounds spread over multiple angiosomes and, moreover, the value of an angiosome-guided revascularization approach can vary according to vascular anatomy, collateral vessel network, type of revascularization, and wound. The aim of this article is to explore values and limits of the angiosome concept, and to propose some "instructions for use" regarding its application in our daily practice.

Prevalence, risk factors and clinical impact of intraprosthetic thrombus deposits after EVAR.

BACKGROUND: The aim was to define the prevalence, the evolution and the clinical relevance of the intraprosthetic thrombus deposit (IPT) after endovascular abdominal aortic repair (EVAR). METHODS: Patients treated with EVAR from 2009 to 2017 for abdominal aortic aneurysm were retrospectively considered. Patients with at least one postoperative computed tomography angiography (CTA) performed after a 3-month follow-up were included. Postoperative medical therapy (antiplatelet and/or oral anticoagulant) were recorded. Aorto-iliac anatomical characteristics were measured on pre-operative CTA, while structural and dimensional endograft features were extracted from instructions for use. IPT was defined as intra-endograft thrombus with minimum thickness of 2mm and longitudinally extended for minimum 4 mm, and was assessed in all postoperative CTA. Primary endpoints were freedom from IPT occurrence, risk factors for IPT and evolution of IPT. Secondary endpoints were the prevalence of overall and IPT-related tromboembolic events (TEE: main-body or limb occlusion, distal embolization) during follow-up and its correlation with IPT. RESULTS: Two-hundred twenty-one patients (mean age 76±7 years; male 94%) were included. Deployed endografts were: aorto-biiliac 96%, aorto-uniiliac 3%, aortic tube 1%; dacron 90%, ePTFE 10%. Mean follow-up was 30±25 months. Overall IPT prevalence was 36% (80/221). At 6, 12, 24 and 48 months, overall estimated freedom from IPT occurrence was 86%, 80%, 60% and 52%, respectively (Kaplan-Meier analysis). At Cox uni-variate analysis, postoperative medical therapy has no influence on IPT; aorto-iliac anatomical risk factors for IPT were larger neck diameter (P<0.001), severe neck thrombus (P=0.043), higher percentage of sac thrombus (P<0.001), hypogastric occlusion/coverage (P=0.040); endograft risk factors were proximal diameter ≥30mm (P<0.001), longer main body (P=0.002), dacron fabric (P=0.025), higher ratio between main body area/gate areas and main body area/distal iliac areas (P<0.001 and P<0.001, respectively). At Cox multi-variate analysis, independent risk factors for IPT were larger neck diameter (P=0.003), higher percentage of sac thrombus (P=0.005) and longer main body (P=0.028). During follow-up, IPT disappeared in 14 cases (18%). Overall TEE prevalence was 4% (8/221) and overall estimated freedom from TEE occurrence at 6, 12, 24 and 48 months was 99%, 99%, 95.3%, 94.1%, respectively (Kaplan-Meier analysis). TEE was IPT-related in 5/8 cases (63%). No statistical correlation were found between IPT and TEE. CONCLUSIONS: The development of intraprosthetic graft thrombus (IPT) is a frequent event after EVAR. The risk of IPT is closely correlated with the proximal aortic neck size, the presence of intra-aneurysmal sac thrombus, and the length of the endograft main body. However, there was no statistical correlation between the presence of IPT and TEE.

Twelve years of experience in carotid endarterectomy with general anesthesia and preserved consciousness.

BACKGROUND: Carotid endarterectomy (CEA) can be performed both under general anesthesia (GA) or local anesthesia (LA) with good results. General anesthesia with preserved consciousness (GAPC) using remifentanil infusion has been already reported in literature and could potentially merge the advantages of GA and LA overcoming the disadvantages of this last technique. Although the good results of GAPC reported in literature, this technique is not widespread in clinical practice. The aim of this study was to report the perioperative results of CEA under GAPC in a large series of consecutive patients. METHODS: This is a retrospective, single center, observational study including all patients treated for CEA under GAPC in our institution between January 2008 and October 2019. Primary endpoints were neurological complications rate, mortality rate in the perioperative period, need to GAPC conversion to GA during surgery and evaluation of the technique with a specific questionnaire regarding patients' satisfaction. Secondary endpoints were myocardial infarction (MI) rate, other perioperative complications rate, rate of intraoperative shunting and need of reintervention in the perioperative period. RESULTS: In the considered period 1290 CEA under GAPC were performed and included in this study. Neurological complications rate was 2.01%, mortality rate in the perioperative period was 0.07%, need of GAPC conversion to GA rate during surgery was 0.46% and patients satisfaction regarding the technique were high with a mean vote of 9.1 in a 0 to 10 scale. In the perioperative period MI rate was 0.23%, other perioperative complications rate was 1.39%, intraoperative shunting rate was 7.1% and reintervention rate after surgery was 2.4%. CONCLUSIONS: CEA under GAPC may combine the advantages of LA and GA, with a very low rate of conversion to GA during surgery and good patients' satisfaction. Moreover, it does not increase neurological, cardiologic and systemic complications. For these reasons CEA under GAPC could represents a valid alternative to GA or LA.

Systematic Review and Meta-Analysis of the Outcome of Different Treatments for Type 1a Endoleak After EVAR.

BACKGROUND: Insufficient evidence is available to recommend a particular strategy for the treatment of type 1a endoleaks (T1aELs) after endovascular abdominal aneurysm repair (EVAR). The aim of this study was to report outcomes of the different treatment modalities proposed for persistent and late-occurring T1aEL after EVAR. METHODS: A systematic review of the literature (database searched: PubMed, Web of Science, Scopus, Cochrane Library) was undertaken until August 2018. Studies about treatment of T1aEL after EVAR (excluding intraoperative treatments during the first EVAR) presenting a series of 5 or more patients with extractable outcome data (at least intraoperative and/or early results) were included. Meta-analyses of proportions were performed using a random-effects model. RESULTS: A total of 39 nonrandomized studies were included (714 patients; 88.1% males, 95% confidence interval [CI] 84.5-91.7; weighted mean age 75.76 years, 95% CI 74.11-77.4). Overall estimated technical success (TS) and clinical success (CS) rates were 93.2% (95% CI 90.5-95.8) and 88.2% (95% CI 84.5-91.9), respectively. Two hundred eighteen patients underwent proximal extension (98.1% TS, 95% CI 96.3-99.8), 131 chimney EVAR (93.9% TS, 95% CI 89.9-97.9), 97 fenestrated EVAR (86.2% TS, 95% CI 77.3-95.1), 90 open conversion (96.5% TS, 95% CI 93-100), 71 embolization (95.2% TS, 95% CI 90.4-100), 35 endostapling (57.2% TS, 95% CI 14.1-100), and 72 conservative treatment (75.4% CS, 95% CI 56.4-94.5). Estimated overall 30-day mortality was 3.2% (95% CI 1.7-4.7), and it was higher for patients undergoing open surgery (6.6%, 95% CI 1.7-11.5). Overall, endoleak resolution during the mean follow-up of 19.4 months (95% CI 15.45-23.36) was maintained in 91% of the patients (95% CI 87.7-94.3). CONCLUSIONS: T1aEL repair appeared generally feasible, with good early to midterm outcomes. Different treatments are available, and the choice should be based on endoleak characteristics, aortic anatomy, and the patient's surgical risk. Conservative treatment and endoleak embolization should be considered only in selected cases, such as low-flow endoleaks and unfit patients.

Intraoperative contrast-enhanced ultrasound for early diagnosis of endoleaks during endovascular abdominal aortic aneurysm repair.

BACKGROUND: The aim of this study was to evaluate the feasibility and utility of intraoperative contrast-enhanced ultrasound (CEUS) for early detection of endoleaks (ELs) during endovascular abdominal aortic aneurysm repair (EVAR) compared with completion digital subtraction angiography. METHODS: Patients undergoing elective EVAR from January 2017 to April 2018 were consecutively enrolled in this prospective study. After endograft deployment, two-digital subtraction angiography (2DSA) with orthogonal C-arm angulations (anteroposterior and sagittal view) were routinely performed. After the endovascular treatment of clear, high-flow type I/III ELs detected by 2DSA, intraoperative CEUS was carried out in sterile conditions on the surgical field before guidewire removal. Presence and type of EL were evaluated with 2DSA and CEUS. CEUS was performed with the vascular surgeon blinded to the 2DSA findings. The primary end point was the level of agreement between 2DSA and CEUS to detect any type of EL and type II EL. Agreement between two diagnostic methods was calculated using Cohen's kappa. The secondary end point was utility of CEUS for intraoperative adjunctive procedure guidance. RESULTS: Sixty patients were enrolled (mean age, 78 ± 6 years; 90% male). 2DSA revealed 11 ELs (18%; 1 type IA, 10 type II), and CEUS 25 ELs (42%; 2 type IA, 23 type II). 2DSA and CEUS were in agreement in 39 cases (65%; 32 no ELs, 7 type II ELs). CEUS detected 17 ELs not identified by 2DSA (28%; 2 type IA, 15 type II); 2DSA detected three ELs not identified by CEUS (5%; 3 type II). In one case, 2DSA and CEUS detected type II and type IA ELs, respectively. For EL and type II EL detection, Cohen's kappa was 0.255 and 0.250, respectively (both "fair agreement"). Intraoperative adjunctive sac embolization was performed under CEUS control in 4 cases and technical success was 100%. CONCLUSIONS: Intraoperative CEUS during EVAR is feasible and can detect a greater number of ELs than 2DSA, in particular type II ELs. Further studies are necessary to assess the reliability of this intraoperative diagnostic examination. In type II ELs, CEUS may represent an additional, useful tool for intraoperative sac embolization guidance.

Endovascular repair of an abdominal aortic aneurysm using bifurcated stent-graft in a patient with bilateral external iliac artery occlusion.

Abdominal aortic aneurysm (AAA) in association with external iliac artery (EIA) occlusion is a rare entity which may limit endovascular aortic aneurysm repair (EVAR) feasibility. We describe the case of an 84-year-old man affected by a 64mm infrarenal inflammatory abdominal aortic aneurysm with complete bilateral occlusion of EIA and patency of both common and internal iliac arteries. The common femoral arteries (CFA) were patent, and the patient was asymptomatic for lower limb claudication. The treatment was performed by EVAR using a bifurcated stent-graft after the recanalization of the left EIA, achieving technical success.

Hybrid Foot Vein Arterialization in No-Option Patients With Critical Limb Ischemia: A Preliminary Report.

PURPOSE: To describe a preliminary experience in treating no-option critical limb ischemia (CLI) patients with a hybrid foot vein arterialization (HFVA) technique combining open plus endovascular approaches. MATERIALS AND METHODS: Between May 2016 and January 2018, 35 consecutive patients (mean age 68±12 years; 28 men) with 36 no-option CLI limbs underwent HFVA in our center. All limbs had grade 3 WIfI (Wound, Ischemia, and foot Infection) ischemia, and the wound classification was grade 1 in 4 (11%) limbs, grade 2 in 4 (11%), and grade 3 in 28 (78%). Surgical bypass was done on the medial marginal vein or a posterior tibial vein, followed by endovascular removal of foot vein valves and embolization of foot vein collaterals. A "tension-free" surgical approach was used to treat foot lesions. RESULTS: At a mean follow-up of 10.8±2 months, limb salvage was achieved in 25 (69%) limbs and wound healing in 16 (44%); 9 patients presented an unhealed wound. Eleven (31%) patients underwent a major amputation (2 below the knee and 9 thigh). One patient with an unhealed wound and open bypass died of myocardial infarction. CONCLUSION: HFVA is a promising technique able to achieve acceptable rates of limb salvage and wound healing in no-option patients generally considered candidates for an impending major amputation. Further studies are needed to standardize the technique and better identify patients who can benefit from this approach.

Significance and Risk Factors for Intraprosthetic Mural Thrombus in Abdominal Aortic Endografts: A Systematic Review and Meta-analysis.

BACKGROUND: The detection of intraprosthetic thrombus (IPT) deposits is a common finding during follow-up for endovascular abdominal aneurysm repair (EVAR); however, its clinical significance is still debated. The aim of this study was to determine if IPT represents a risk factor for thromboembolic events (TEs; endograft or limb thrombosis, or distal embolization) after EVAR. METHODS: A systematic review of English literature was undertaken until November 2017. Studies providing 2-group comparison (patients with IPT development on postoperative computed tomography angiography versus patients without IPT) with extractable outcome data (TE related to IPT and/or risk factors for IPT development) were included. Meta-analysis was performed when comparative data were given in 2 or more articles. RESULTS: Five single-center studies (808 patients) were analyzed. IPT detection at any time during follow-up occurred in 20.8% (168/808) of patients. Extractable data for postoperative TE were available in 4 studies (613 patients): on comparative meta-analysis, IPT was not significantly associated with TE occurrence during follow-up (odds ratio 2.25, 95% confidence interval [CI] 0.50-10.1; P = 0.29). IPT is generally detected during the first year after EVAR (maximum reported median: 12 months, range: 1.2-23). Polyester graft material (odds ratio 2.34, 95% CI 1.53-3.58; P < 0.001) and aorto-uni-iliac configuration of the endograft (odds ratio 3.27, 95% CI 1.66-6.44; P = 0.001) were confirmed as risk factors for IPT formation on meta-analysis. The literature systematic review suggests that IPT formation may be also associated with long main bodies and large necks. CONCLUSIONS: IPT detection on postoperative computed tomography angiography was not significantly associated with the occurrence of TE over time. The aorto-uni-iliac configuration and the use of polyester fabric for endografts were confirmed as risk factors for IPT development.

Surgical Treatment of a High-Flow Femoro-Femoral Arteriovenous Fistula in an Intravenous Drug Abuser.

BACKGROUND: We report the surgical treatment of a high-flow femoro-femoral arteriovenous fistula (AVF), a rare complication of intravenous drug abuse. METHODS: A 36-year-old woman with history of intravenous heroin and cocaine abuse presented with right lower limb edema, inguinal bruit, and heart failure. Duplex ultrasound examination (DUS) and computed tomography angiography showed a large, high-flow AVF involving the common femoral vein and the superficial femoral artery, which is associated with thrombosis of the great saphenous vein and an important inflammation in the right groin, without active bleeding. Under general anesthesia, the patient underwent open surgical repair of the AVF through a right-groin cutdown. The 3-cm-long AVF was repaired with the interposition of a bovine pericardium patch that is sewn from inside the femoral vein through a longitudinal venotomy with a continuous 5-0 polypropylene suture. RESULTS: The venotomy was repaired with a 5-0 polypropylene running suture. No perioperative or postoperative complications were recorded. The inguinal bruit resolved, the arteries recovered good pulsatility, and the lower limb edema promptly reduced. A 6-month DUS confirmed the patency of the femoral arteries and veins and the absence of AVF or infection signs in the right groin. CONCLUSIONS: Surgical repair of femoro-femoral AVF in drug abusers by biologic patch interposition is a challenging, but feasible, and effective technique with encouraging midterm results in terms of patency and resistance to infections.