Gender-related outcomes of chimney EVAR within the PERICLES registry.

OBJECTIVE: Gender-related differences in outcomes in complex endovascular aortic repair have not been profoundly investigated. Use of low profile abdominal devices as in chimney endovascular repair may be beneficial for female patients with pararenal pathologies. With the chimney technique, there is no need for large introduction sheaths. This could be an advantage in case of smaller in diameter iliac access especially in combination with stenosis or elongation. Aim of the present study was to compare the perioperative and mid-term outcomes between males and females patients treated with the chimney/snorkel technique for pararenal aortic pathologies. METHODS: The PERICLES registry collected the world wide experience with the chimney technique. According to the gender, patients were classified in two cohorts. Primary endpoints were freedom from occlusion of the chimney grafts and reintervention. Secondary endpoints included access site complications and need for surgical or interventional revision, Endoleak Type I rate, 30-day overall complications and mortality. Univariate comparison P-values were generated using either the likelihood ratio χ2 test, the Fisher exact test, the Wilcoxon rank sum test, or the log rank test. Kaplan-Meier curves estimated the outcomes in the long run. RESULTS: A total of 412 patients underwent Ch-EVAR, 71 (17%) females and 341 (83%) males with a mean age for both groups being 74 years were included in the present study. After 36 months of mean follow-up, no statistically significant difference was observed between the two cohorts regarding re-interventions ( P= .44). Freedom from occlusion rates at 36 months did not differed between the two groups (females 84% vs. 80% for males ( P= .033). For patients receiving more than one chimney stent, the odds of having a complication did not differ between males and females (M:F OR = 2.0, 95% CI: 0.6-6.4, P = 0.228); 30-day mortality was 0% in the female group, instead five male patients died within one month. ( P = 0.59). The incidence of acute renal failure was low in both groups without statistical difference: 2 (3.1%) vs. 13 (4.6%) 58 ( P = 1.00). Neither patient received an endoconduit to insert the abdominal device. CONCLUSIONS: No statistically significant difference regarding the freedom from reintervention and chimney graft patency was observed between the two genders. The results highlight the beneficial use of the chimney technique in female patients who can have potentially higher risk of access complications.

Significant CT-angiographic evidence of coexisting abdominal aortoiliac aneurysms with simple renal cysts and abdominal wall hernias.

AIM: Aim of the study was to determine and compare the incidence of simple renal cysts (SRCs) and abdominal/inguinal wall hernias (AWHs/IHs) in patients with known abdominal aortoiliac aneurysm (AAA) and aortoiliac occlusive disease (AOD) in order to assess if these comorbidities could be promoted as added high risk factors for AAA development. METHODS: Prospectively collected clinical and radiological data of 236 AAA patients, treated at our institution between June 2009 and June 2012, were retrospectively analyzed regarding the number, location and type of SRCs and AWHs. Two hundred thirty-six randomly chosen patients with aortoiliac occlusive disease (AOD) were recruited as control group. RESULTS: SRCs and AWHs were significantly more frequent in the AAA group than in AOD group (68.6% vs. 37.3%, OR=2.110, 95%-CI 1.325-3.359, P=0.002 and 45.3% vs. 24.2%, OR=1.850, 95%-CI 1.153-2.968, P=0.011). In 30.1% of AAA patients both clinical entities were simultaneously detected (OR=2.441, 95%-CI 1.342-4.437, P=0.003), the comorbidity of SRCs and IHs was related to a 3.6-fold increased risk for a coexisting AAA (OR=3.558, 95%-CI 1.622-7.805, P=0.002). CONCLUSION: The findings of this study contribute to the clinical evidence of a significant coexistence of SRCs and AWH/IHs in AAA patients. However, further clinical screening trials and research are necessary to establish the clinical significance of this observation and to assess a possible common pathogenesis of systemic extracellular matrix degeneration in affected individuals.

Midterm results of the transarterial use of Onyx in the treatment of persisting type II endoleaks after EVAR.

AIM: Type II endoleaks with growing aneurysm sac >5 mm in diameter after EVAR require treatment. Different treatment options have been reported. The aim of this study was to evaluate the use of an ethylene-vinyl alcohol copolymer (Onyx) in an endovascular approach. METHODS: Between January 2010 and December 2011, 10 consecutive patients with persistent type II endoleaks leading to aneurysm growth >5 mm were treated in our center by transarterial Onyx embolization by super selective cannulation of the endoleak with microcatheters. Technical success was defined as transarterial Onyx deployment directly into the aneurysm sac. Clinical success was defined as stable or shrinking axial aneurysmal diameter during follow- up using an angiographic computed tomography. RESULTS: Ten patients with 13 persistent type II endoleaks leading to aneurysm sac growth of >5 mm were identified in the time period. Technical success was 92% (12/13 patients). Two patients underwent a staged procedure because several, unconnected type II endoleaks were present. In one patient a cannulation of the inflow vessel responsible for the endoleak was not possible, continued efforts led to a rupture of the hypogastric artery which was treated by covered stent implantation. In one patient an extravasation of onyx out of the aneurysm sac into the inferior vena cava during the embolization process made a transvenous goose snare maneuver necessary to retrieve the dislocated copolymer. No further complications were observed during the mean follow-up of 19.8 months (range, 3-31 months). In all patients with successful embolization the aneurysm sac remained stable or was decreased within the follow-up period. CONCLUSION: Use of Onyx in the endovascular treatment of type II endoleaks after EVAR is feasible, safe when accurately deployed and efficient. Further studies are necessary to evaluate the value of the different treatment modalities (translumbar vs. transarterial).

Long-term outcome of femoropopliteal stenting. Results of a prospective study.

AIM: Aim of the study was to assess the long-term clinical results of primary stent placement in patients with femoro-popliteal lesions and intermittent claudication (IC) or critical limb ischemia (CLI). METHODS: Prospectively collected data of 517 patients (543 limbs) treated for IC (N.=422; 77.5%) and CLI (N.=121; 22.5%), between September 2006 and December 2010 were evaluated. Survival, limb salvage and patency rates were analyzed and multivariate analysis was performed to evaluate possible risk factors for the development of restenosis. RESULTS: Mean patients' age was 70.6 years (SD ±10); 64.8% of the patients (N.=335) were male. Angiography revealed TASC A or B lesions in 64.5% (N.=350), TASC C or D lesions in 35.5% (N.=193) of the patients. Two hundred thirty-two patients had evidence of occluded femoropopliteal artery (42.7%) and the remaining patients had evidence of high grade (>70%) stenosis. In total, 827 bare metal nitinol stents (1.53±0.9 per limb) were used. No early (<30-day) procedure-related death was recorded. After a mean follow-up period of 60 months (SD ±13.5), 69 patients died (13.4%). Eight (1.5%) patients underwent major amputation. The amputation rate was significantly higher in the CLI group compared to the IC group (P=0.03). Primary patency rates were 86.2%, 79.1%, 75.1% and 62.2% after 1, 2, 3 and 5 years, respectively. No difference in terms of patency rates was found between the results of the treatment of TASC A/B versus TASC C/D lesions and the patient groups with IC versus CLI. CONCLUSION: The endovascular-first line treatment with use of nitinol stents for patients with femoropopliteal artery lesions is associated with acceptable long-term patency rates, even in patients with long lesions.

New EVAR devices: pros and cons.

The first randomized controlled trials comparing the two procedures (EVAR versus open repair) for the treatment of abdominal aortic aneurysms showed considerably better short-term outcomes and on the other side higher rates of device-associated reinterventions and remarkable financial burden in the endovascular arm. In the meantime, specialists experience and expertise have been improved significantly. To solve the reported drawbacks and to prevent endografts-associated complications, safer fixation features, lower profile, more flexible design and new revolutionary release and deployment mechanisms of stent-grafts have been also developed and established over the last years. In this review, we present the new EVAR devices and attempt to provide an overview of their premature performance based on the literature and the clinical practice in our institution.

Complications and reinterventions after EVAR: are they decreasing in incidence?

Endovascular repair of infrarenal abdominal aortic or aortoiliac aneurysms (EVAR) using currently available stent-grafts has proven to be a safe, effective, and durable method with great acceptance among vascular surgeons. Comparison of elective EVAR versus "open" elective abdominal aortic aneurysm (AAA) repair showed significant advantages for EVAR in terms of perioperative complications, postoperative care, and early patient recovery. However, a remarkable incidence of mid- and long-term EVAR-related complications remains. Additionally, several strategies have been investigated to overcome limitations related to very short aortic neck anatomies such as fenestrated or chimney grafts expanding the application of endografts in hostile anatomies. The outcome of these alternative techniques is still under evaluation and any conclusion seems for the moment premature. The aim of the present article was to present an overview about the current status of the durability of EVAR and to attempt to answer the question about the frequency of late interventions.

Performance of thoracic stent grafts.

Anatomically straightforward aneurysms of the descending aorta can be safely treated with the most stent-grafts. Patients with thoracic aneurysm have often thin, tortuous and calcified access vessels and require low profile and flexible delivery systems. The deployment of stent grafts in the aortic arch is challenging requiring perfect conformability and apposition of the device to both greater and lesser curves of the arch. Post-traumatic aortic lesions and aortic dissections need to be treated with dedicated stent grafts.

Successful percutaneous endovascular treatment of symptomatic infrarenal aortic stenosis caused by soft-plaque with the Endurant stent-graft.

Focal stenosis or occlusion of the infrarenal aorta is a relatively rare entity. In particular, soft-plaque of atherothrombotic origin in the aortic segment is linked to high-risk for peripheral embolisation. To our knowledge, the present case report describes for first time in the literature successful percutaneous treatment of a symptomatic soft-plaque infrarenal aortic stenosis with severe calcification of the iliac vessels by stent-graft, in particular by the new Endurant. Endovascular exclusion of the thrombotic lesion by endoprosthesis covers the atherosclerotic wall treating the potential underlying cause of the thrombus formation. The radial force of the endoprosthesis seems to be sufficient achieving complete expansion. However, long-term results are warranted.

[Eccentric infrarenal aortic stenosis. Surgical and endovascular treatment]. / Exzentrische infrarenale Aortenstenose. Chirurgische und endovaskuläre Behandlung.

The management of coral reef lesions reported in this case study demonstrates the complementary and non-competing character of the open and endovascular treatment. The minimally invasive procedure of stent-optimized angioplasty seems to be advantageous as the primary therapy in selected cases. In the case of clinical deterioration the endovascular technique allows surgical reconstruction without significantly diminishing the result. Catheter-based techniques therefore remain an additional instrument for treatment in the hands of vascular surgeons which substantially broadens the range of therapy options for this disease entity.

Endovascular surgery as a bridge solution for selected vascular emergencies.

Vascular emergencies patients present with several problems requiring immediate sufficient evaluation of the situation and intervention in order to save life, limb, or a serious health injury. Endovascular surgery may be very useful as bridging technique in order to obtain immediate bleeding control. Additionally, a remarkable number of patients has poor general health conditions and is unfit for open repair. The surgical solution would be invasive and prohibitive for this high-risk patient's subgroup. Endovascular techniques play an important role in the management of vascular emergencies. They allow treatment to be rapidly coupled with diagnosis, especially beneficial parameter for traumatic injuries. In particular, embolization is a well-established technique for hemostasis and is preferable when intervention for bleeding pelvic fractures is necessary. Additionally, in case of significant tissue destruction and contamination in the vicinity of the injury vascular access by endovascular techniques may be advantageous. Finally, endovascular balloon occlusion for vascular control may be used as an adjunct to surgery when conventional exposure is technically challenging and hazardous. The objectives of this review article are to highlight the utility of endovascular surgery in vascular emergencies and to compare current treatment options of urgent clinical entities, based on the literature.

Endovascular treatment of profunda femoris artery obstructive disease: nonsense or useful tool in selected cases?

BACKGROUND: To evaluate the therapeutic value of endovascular techniques for the treatment of profunda femoris artery obstructive disease (PFAOD) in critical limb ischaemia (CLI) patients, with technically demanding open profunda repair. DESIGN: Retrospective study of prospectively collected data of 15 consecutive CLI patients with technically demanding surgical treatment of PFAOD, that were treated by endovascular means in two European Centers of Vascular Surgery. MATERIALS: All patients had critical limb ischaemia with a history of at least two previous vascular reconstructions in the ipsilateral groin and severe co-morbid conditions. All patients had good common femoral artery flow, long occlusion of the superficial femoral and popliteal arteries and impairment of crural arteries. METHODS: Twelve patients underwent balloon angioplasty alone and, in the other three cases, an additional stent placement was necessary, due to flow-limiting dissection. The follow-up (mean 29.2+/-10 months) included a surveillance protocol with the best medical treatment and duplex scanning at 1, 3, 6, 12 months and yearly thereafter. RESULTS: The endovascular approach was technically successful in all cases and the procedure-related morbidity and mortality rates were 0% for the entire follow-up period. The 3-year primary and secondary patency rates of the treated segment were 80% and 86.7%, respectively. The limb salvage rate was 93.3%. CONCLUSIONS: The outcome of our series underscores the therapeutic value of balloon angioplasty in cases of severe PFAOD, as bailout treatment in critical limb ischaemia patients with technically demanding open profunda repair. This procedure can be repeated easily if significant restenosis occurs and provides a useful tool in selected cases.

Below-knee bare nitinol stent placement in high-risk patients with critical limb ischaemia and unlimited supragenicular inflow as treatment of choice.

PURPOSE: To evaluate the effectiveness of nitinol stent placement in long infrapopliteal lesions in patients with critical limb ischaemia. MATERIALS AND METHODS: Between January 2005 and January 2008, 34 high-risk patients (18 female; mean age: 73.8+/-6.1 years) with critical limb ischaemia underwent infragenicular stenting. They had serious cardiovascular co-morbidities (>3, such as chronic obstructive pulmonary disease (COPD), congestive heart failure and coronary artery occlusive disease), American Society of Anaesthesiologists score of 3 or more, previous myocardial infarction, coronary stent or bypass. The mean stenosis length was 6.5+/-0.9 cm (range: 2.2-8 cm), and the mean occlusion length was 7.5+/-2.9 cm (range: 3-9.6 cm). Primary stent implantation was performed for long stenosis or occlusion based on the TransAtlantic InterSociety Consensus (TASC) C and D classification, secondary stenting for flow-limiting dissections or elastic recoil after balloon dilatation. All patients who returned to the outpatient clinic were assessed for claudication by clinical examination, ankle-brachial index (ABI) measurements, colour flow and duplex Doppler ultrasound (US). Digital subtraction angiography was performed if restenosis or re-occlusion was identified by Doppler US or transcutaneous measurement of partial oxygen pressure (TcpO(2)) measurements, when appropriate. RESULTS: The technical success rate was 97.1% (33 of 34 cases). The crude rate of primary patency rate was 91.1% during a follow-up period of 10.4+/-7.3 months. The mean ankle-brachial index increased significantly following intervention (0.45+/-0.25-0.92+/-0.13, p<0.001). Two patients underwent successful redo angioplasty after tibioperoneal interventions due to in-stent restenosis (>70%) with relevant limitation of pain-free walking distance. In another patient, bypass surgery to the anterior tibial artery 6 months after primary intervention was necessary due to rest pain. Two patients required surgical revision of the femoral artery after antegrade access. No procedure-related death was recorded in the entire follow-up period. CONCLUSIONS: The mid-term outcome underscores infrapopliteal stent placement as a reliable treatment option in patients with critical limb ischaemia. In patients at high risk for crural bypass, with no flow-limiting supragenicular lesions, below-knee stent-supported angioplasty should be considered as a first choice of treatment.

Hybrid open-endovascular repair for thoracoabdominal aortic aneurysms: current status and level of evidence.

PURPOSE: To report the results of a systematic review of the literature and to provide evidence for the hybrid open-endovascular repair (HOER) in patients with thoracoabdominal aortic aneurysms (TAAAs). METHODS: A comprehensive literature review was performed and all studies identified that reported the results of HOER in patients with TAAA and information about primary technical and clinical success in evaluating the immediate and long-term complications such as neurological, renal and respiratory morbidity. All studies were reviewed by two independent observers for the above mentioned parameters. RESULTS: After careful selection according to the given criteria, 13 studies were included in our statistical analysis. The number of reported patients totalled 58. Of those, 37 were men (64.4%) and the mean age of the patients was 68.1 years (range 35-80, 95%CI [72.8, 64.9]). All patients were unfit for open repair with severe comorbidities. The mean follow-up period was 14.5+/-8.7 months (range 4-36, 95%CI [18.7, 9.9]) and the mean aneurysm diameter was 7.15cm (range 5 to 12, 95%CI [7.87, 6.69]). 229 (97.8%) of the 234 visceral vessel grafts remained patent during the follow-up period. Reintervention was necessary in one (1.6%) of the five patients with an occluded graft. The overall long-term endoleak rate was 20.6% (12/58 patients) and the reintervention rate was 13.7% (8/58 patients). No patients developed procedure-related neurological deficits. The overall early and long-term mortality rate for completed procedures was 15.5% (9/58). CONCLUSIONS: HOER shows promising mid-term results for high-risk patients who have TAAA, however, present evidence does not allow robust conclusions.

Combined endovascular stent-graft repair and adjunctive visceral vessel reconstruction for complex thoracoabdominal aortic aneurysms.

AIM: This study demonstrates the therapeutic value of the hybrid open and endovascular procedure in anatomically challenging thoracoabdominal aortic aneurysms (TAAAs) in high-risk patients. METHODS: Between January 2000 and February 2006, 8 patients were treated with open visceral vessel revascularization and endovascular repair for TAAAs. Patient data were available from medical records. Pre- and postoperative physical examination, intra-arterial angiography, and spiral computed tomography scanning was performed in prearranged examinations. RESULTS: A total of 28 visceral bypasses were performed in the 8 patients: 6 patients with complete visceral vessel revascularization and 2 with an aorto-mesenteric-celiac bypass. Aneurysm exclusion was achieved through the deployment of in total 23 stent-grafts. Seven out of the 8 procedures were conducted electively and one under urgent conditions. The mean follow-up period was 21 months. We recorded one procedure-related death due to postoperative hemorrhage resulting from diffuse retroperitoneal bleeding with consecutive multiorgan failure. Moreover, one patient developed acute renal insufficiency, but returned to normal values after temporary hemodialysis. Major adverse events included 2 cases of pneumonia and one myocardial infarction. Two reoperations were performed due to one mesenteric bypass occlusion and one groin hematoma. No neurological complications were observed. CONCLUSION: The combined hybrid endovascular and open surgical approach in the treatment of complex TAAAs remains a feasible and effective operation technique. The less invasive character of the procedure and avoidance of aortic-cross clamping are clear advantages. Nevertheless, further study is mandatory to establish this alternative therapeutic option for complex TAAAs.