Carotid endarterectomy with saphenous vein patch angioplasty: a single-center experience.

BACKGROUND: When performing a conventional CEA it is recommended the use of patch angioplasty (PA), since previous meta-analyses have shown PA to be superior to primary closure (PRC) in terms of stroke and restenosis rates. Different materials patches can be employed although none of them has been proved to be superior. Although autologous veins are potentially more resistant to immediate thrombosis as well as infection, cons may be represented by patch rupture and late dilatation. Aim of this study is to evaluate immediate and long-term results of CEA with saphenous vein patch angioplasty (SVPA) in a single-center experience. METHODS: A retrospective study was performed analyzing all patients undergoing CEA with SVPA at our institution from January 2012 to March 2020. CEA was performed in symptomatic patients with 50-99% carotid stenosis degree or asymptomatic patients with 70-99% stenosis degree. Exclusion criteria were critical limb ischemia, varicose disease, unavailability of saphenous veins, vein diameter <3.5 mm. All CEAs were performed under general anesthesia with routine shunting. Primary endpoints were perioperative stroke, death, carotid thrombosis and hematoma requiring surgery rates. Secondary endpoints included the rate of recurrent stenosis >70%, patch aneurysm/rupture/infection at follow-up. RESULTS: Overall, 488 interventions were performed on 461 patients. Most patients were male (77.8%) with a mean age of 71.2±8.3 years. Thirty-day mortality and stroke rates were 0.4% and 1.2% respectively. Carotid thrombosis occurred in five patients (1%). Five patients (1%) developed a surgical site hematoma requiring surgical drainage. At a mean follow-up of 34.4±25.8 months 12 restenoses (2.5%) were detected. Five-year freedom from restenosis rate was 96.7%. Restenosis at follow-up was more frequent in patients who had contralateral carotid stenosis (P=0.019). Two patients (0.4%) developed carotid patch aneurysmal degeneration at a mean follow-up of 78.7 months. No infection nor patch disruption were detected. CONCLUSIONS: CEA with SVPA resulted safe and effective in terms of early and late results. The perioperative complications rates we recorded were quite similar to those reported by other larger reviews and meta-analyses.

Long term efficacy and safety of rivaroxaban plus cilostazol in the treatment of critical ischemia of the lower limbs in a frail, elderly patient with non valvular atrial fibrillation.

BACKGROUND: Many patients with critical lower limb ischemia are not eligible for revascularization procedures. Still, given the emerging role of both platelet and coagulation activation in the formation of arterial thrombi, they may benefit from the novel anticoagulant and antiplatelet drugs. CASE PRESENTATION: We describe the case of a male with critical lower limb ischemia complicated by older age, frailty, polymorbidity and non valvular atrial fibrillation, who was deemed as non eligible for surgery. The patient was successfully treated with the combination of rivaroxaban and cilostazol, and the clinical benefit was maintained throughout 32 months, with no occurrence of major or minor hemorrhagic or thrombotic events. CONCLUSIONS: To our knowledge, this is the first report on the efficacy and safety of such a combination therapy in critical lower limb ischemia. In a clinical setting in which alternative pharmacological approaches are urgently needed, the association of rivaroxaban and cilostazol warrants further investigations.

Eversion Endarterectomy of the Femoral Bifurcation: Technique, Results and Potential Advantages.

BACKGROUND: Despite recent advances in endovascular techniques, surgical endarterectomy remains the "gold standard" for treatment of atherosclerotic lesions of the femoral bifurcation. Eversion endarterectomy (EE) of the femoral bifurcation is a well-known technique that ensures an extensive plaque removal; furthermore, EE can be performed to avoid the use of prosthetic material. The aim of this study is to evaluate the efficacy and safety of the EE of the femoral bifurcation in a contemporary prospective series from a single-center experience. MATERIALS AND METHODS: All patients undergoing EE at our institution between January 2014 and December 2016 were retrospectively reviewed. EE was performed as an isolated procedure or in a hybrid fashion. Clinical presentation was defined according to Rutherford's classification. End points included major complications and patency rates. RESULTS: Thirty-three EEs were performed on 31 patients during the study period. Thirteen procedures (39%) were performed in a hybrid fashion with concurrent endovascular interventions. Technical success was achieved in 100%. Thirty-day mortality was null, whereas 5 overall complications (15%) were recorded; among those, 2 (6%) were major. In both cases, an early thrombosis of the femoral bifurcation occurred, successfully treated by a short Dacron replacement of the common femoral artery. During follow-up, no femoral pseudoaneurysm or groin infections were observed. Two restenosis occurred at 7 and 10 months after EE, respectively. Two-year primary patency and assisted primary patency rates were 87% and 100%, respectively. During follow-up, two patients underwent percutaneous revascularization of the contralateral femoropopliteal axis at 5 and 8 months after EE, respectively. In both of them, the procedure was successfully performed through direct puncture of the endoarterectomized common femoral artery, without any access-site complications. CONCLUSIONS: Endarterectomy remains the gold standard in the treatment of atherosclerotic lesions of the femoral bifurcation with excellent long-term patency rates. Furthermore, EE adds the advantages of avoiding the use of prosthetic materials in the groin and the possibility to use the treated vessels as access for further percutaneous procedures.

First Case of 2 Synchronous Gluteal Arteries Aneurysms Treated by Endovascular Plug Embolization: Case Report and Literature Review.

INTRODUCTION: Gluteal artery aneurysms (GAAs) are rare, accounting for less than 1% of all arterial aneurysms. Most of them are post-traumatic in nature and involve the superior gluteal artery (SGA), while injuries of the inferior gluteal artery (IGA) have been reported less frequently. We report an unusual case of a patient with double saccular GAA of unknown etiology, involving both the SGA and IGA, successfully treated by endovascular embolization. CASE REPORT: A 80-year-old man referred to our hospital complaining of the progressive onset of left buttock pain and swelling exacerbated by sitting position in the last 4 months. His past medical history was positive for hypertension, prostatic adenocarcinoma treated by brachytherapy, and endocarditis diagnosed about 30 years before and treated by cardiac surgical valve replacement; no history of trauma was reported. After ultrasonography was carried out, an enhanced computed tomography (CT) scan confirmed the presence of 2 large GAAs involving both the SGA and IGA, with maximum transverse diameter of 38 and 84 mm, respectively. The patient was referred for endovascular treatment after informed consent was provided. After sequential selective catheterization of SGA and IGA, 3 Amplatzer Plugs II (St. Jude Medical, Zaventem, Belgium) were deployed inside the aneurysms. Postoperative course was uneventful as buttock pain completely disappeared on the second postoperative day. The patient was discharged to home on the third postoperative day. One-month CT scan confirmed the complete thrombosis of the aneurysms without any endoleak. CONCLUSIONS: GAAs represent a rare pathology, and for that reason, the correct timing and choice of treatment are not clearly defined. Endovascular techniques are the first step in the approach to GAAs. In case of complex anatomy, GAAs embolization by the use of vascular plugs can be successfully performed.