Association of Neutrophil-Lymphocyte and Platelet-Lymphocyte Ratio with Adverse Events in Endovascular Repair for Abdominal Aortic Aneurysm.

The association of chronic inflammatory markers with the clinical outcome after endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA) was investigated. We included 230 patients, treated electively with EVAR. The values of neutrophil-lymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR) were measured pre- and postoperatively. Any major adverse cardiovascular event (MACE) and acute kidney injury (AKI) were recorded. Adverse events occurred in 12 patients (5.2%). Seven patients suffered from MACE and five from AKI. Median NLR and PLR values were significantly increased after the procedure (NLR: from 3.34 to 8.64, p < 0.001 and PLR: from 11.37 to 17.21, p < 0.001). None of the patients or procedure characteristics were associated with the occurrence of either a MACE or AKI. Receiver operating characteristic curve analysis showed that postoperative NLR and PLR were strongly associated with AKI. A threshold postoperative NLR value of 9.9 was associated with the occurrence of AKI, with a sensitivity of 80% and specificity of 81%. A threshold postoperative PLR value of 22.8 was associated with the occurrence of AKI, with a sensitivity of 80% and specificity of 83%. Postoperative NLR and PLR have been associated with the occurrence of AKI after EVAR for AAA.

Transesophageal echocardiography during endovascular procedures for thoracic aorta diseases: sensitivity and specificity analysis.

INTRODUCTION: The widespread use of endovascular repair in thoracic aorta (TEVAR) pathologies has ameliorated postoperative outcomes. This meta-analysis was designed to investigate the intra-operative use of transesophageal echocardiography (TEE) compared to angiography in patients undergoing TEVAR. EVIDENCE ACQUISITION: The meta-analysis was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement (PRISMA) guidelines. A data search of the English literature was conducted, using PubMed, EMBASE and CENTRAL databases, until November 30, 2019. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach was used to evaluate the quality of evidence and the summary of findings for each of the included outcomes. EVIDENCE SYNTHESIS: The final analysis included 7 articles (183 patients). All patients underwent TEVAR using intra-operative TEE and angiography. The sensitivity and specificity rates of entry points were 0.624 (95% CI: 0.145-0.97) and 0.377 (95% CI: 0.029-0.856), respectively. Regarding the detection of adequate guidewire advancement, the sensitivity was 0.778 (95% CI: 0.288-939) and specifity 0.346 (95% CI: 0.019-0.844). TEE could detect endograft incomplete deployment within acceptable rates of sensitivity and specifity, estimated at 0.616 (95% CI: 0.141-0.971) and 0.365 (95% CI: 0.028-0.845), respectively. The intra-operative detection of endoleaks presented a sensitivity estimated at 0.875 (0.51-0.998) and specificity at 0.698 (95% CI: 0.284-0.904). CONCLUSIONS: Despite the limitations of this analysis, TEE may be evaluated in the current endovascular era, as a useful tool, providing adequate information, on graft deployment and early endoleaks.

A systematic review and meta-analysis of carotid artery stenting using the transcervical approach.

INTRODUCTION: Carotid artery stenting (CAS) via a transcarotid revascularization (TCAR) approach has emerged as an alternative when carotid endarterectomy or conventional CAS is contraindicated. The present study was conducted to assess the feasibility and safety of TCAR in patients with carotid artery stenosis. EVIDENCE ACQUISITION: A systematic review of the literature was performed, according to PRISMA guidelines (Preferred Reporting Items for Systematic reviews and Meta-Analyses), using PubMed, EMBASE and CENTRAL databases. The primary outcomes included technical success, perioperative neurological event, myocardial ischemic events, death and their composite. Operational duration, flow reversal time and any local procedure related complication (carotid dissection and cranial nerve injury) were also recorded. EVIDENCE SYNTHESIS: Twenty-three studies were included, reporting on 3130 patients, undergoing TCAR. Thirty-five per cent of them were symptomatic. Technical success was 98% (95% CI: 0.97-0.99; P=0.11, I2=32%). Early (30-day) new neurological event rate was estimated at 2% (95% CI: 0.01-0.02; P=1.0, I2=0%, respectively) while early death rate was 1% (95% CI: 0.00-0.01; P=1.0, I2=0%). Myocardial ischemic (MI) event rate was 1% (95% CI, 0.00-0.01, P=0.97, I2=6.6%). The composite outcome of neurological event/MI/death at 30-day follow-up was 2% (95% CI: 0.01-0.02, P=0.79, I2=14%). Carotid dissection rate during the intervention was 2% (95% CI: 0.01-0.03, P=0.58, I2=2.9%) while the post-operatively detected cranial nerve injury rate was 1% (95% CI, 0.00-0.01, P=1.0, I2=0%). Regarding the technical aspects of the procedures, operational and flow reversal time were at 73.8 min and 13.7 min, respectively (95% CI: 68.2-79.3, P=0.18, I2=37.6% and 95% CI: 11.3-16.1, P=0.48, I2=0%, respectively). CONCLUSIONS: TCAR is feasible with high technical success rate. The procedure presents low incidence of local complications, neurological events, myocardial complications and mortality during the early postoperative period and should be considered an acceptable alternative for patients treated for carotid artery stenosis.

Large Diameter (≥29 mm) Proximal Aortic Necks Are Associated with Increased Complication Rates after Endovascular Repair for Abdominal Aortic Aneurysm.

BACKGROUND: The aim of this study is to investigate the impact of proximal aortic diameter on outcome after endovascular aneurysm repair (EVAR) of infrarenal abdominal aortic aneurysms (AAAs). METHODS: This is a case-control (1:1) retrospective analysis of prospectively collected data on 732 AAA patients treated with EVAR in 2 university centers. Patients with an infrarenal neck diameter of 29-32 mm (wide neck, WN group) were compared with patients with a neck diameter of 26-28.9 mm (control group) matched for age, gender, and maximum aneurysmal sac diameter. Any patients treated outside the instructions for use of each endograft or with no adequate follow-up were excluded. The primary end point was any neck-related adverse event (a composite of type Ia endoleak, neck-related secondary intervention, and endograft migration) during follow-up. RESULTS: Sixty-four patients with a proximal neck diameter of 29-32 mm (WN group) were compared with a matched control group of 64 patients with a neck diameter of 26-28.9 mm (control group). Oversizing was significantly higher in the study group (17.9% vs. 15.5%, P = 0.001). Overall median available follow-up was 24 months (range 12-84) (WN group 24 months vs. control group 18.5 months, P = 0.943). Primary end point was recorded in 8 patients (12.5%) of the WN group and in 1 patient (1.6%) of the control group. Freedom from the primary end point at 36 months (standard error <10%) was 87.3% for the study versus 98.4% for the control group (log rank = 4.66, P = 0.03). On multiple regression analysis, the presence of a proximal aortic neck >29 mm was the only independent risk factor for neck-related adverse events (odds ratio 7.4, 95% confidence interval 1.2-47.1). CONCLUSIONS: EVAR in the presence of a wide proximal aortic neck is likely to be associated with higher adverse neck-related event rates and thus, in such cases closer follow-up may be required.

Endovascular aneurysm repair in patients with a wide proximal aortic neck: a systematic review and meta-analysis of comparative studies.

INTRODUCTION: The aim was to investigate the impact of wide proximal aortic diameter on outcome after standard endovascular repair (sEVAR) of infrarenal abdominal aortic aneurysms. EVIDENCE ACQUISITION: A systematic search of the literature was undertaken using the PUBMED, EMBASE, and Cochrane databases for articles comparing outcome after sEVAR in patients with large versus small diameter aortic neck. The prognostic factor of interest was large diameter proximal aortic neck and the results were reported as odds ratio (OR) or mean difference (MD) and 95% confidence interval (CI). A time-to-event data meta-analysis for late outcomes was performed using the inverse-variance method and reported the results as summary hazard ratio (HR) and 95% CI. EVIDENCE SYNTHESIS: We identified 6 observational studies reporting on a total of 6602 patients (1616 with large and 4986 with small diameter neck). Patients with large proximal aortic neck were older (MD 0.87, 95% CI: 0.35-1.39; P=0.001). The prevalence of male gender (OR=1.63, 95% CI: 1.34-1.98; P<0.001), coronary artery disease (OR=1.20, 95% CI: 1.06-1.36; P=0.004), chronic obstructive pulmonary disease (OR=1.18, 95% CI: 1.03-1.36; P=0.02) and chronic kidney disease (OR=1.43, 95% CI: 1.23-1.66; P<0.001) was higher in the wide neck group. Patients with large diameter proximal neck had shorter proximal neck (MD=-1.91, 95% CI: -2.04 to -1.77; P<0.001) and a larger aneurysm diameter compared to those with small diameter neck (MD=3.40, 95% CI: 2.71-4.10; P<0.001). Patients with small diameter proximal neck had significantly higher freedom from aneurysm-related reintervention (HR=2.06, 95% CI: 1.23-3.45; P=0.006), freedom from type Ia endoleak (HR=6.69, 95% CI: 4.39-10.20; P<0.001), freedom from sac expansion (HR=10.07, 95% CI: 1.80-56.53; P=0.009), freedom from aneurysm rupture (HR 5.10, 95% CI: 1.40-18.58; P=0.01), and survival (HR=1.55, 95% CI: 1.08-2.24; P=0.02). CONCLUSIONS: Patients with a wide proximal aortic neck undergoing standard EVAR were found to have worse outcome, as indicated by a lower freedom from aneurysm-related reintervention, type Ia endoleak, sac expansion and aneurysm rupture, and a higher overall survival. This anatomic characteristic should be considered in decision making. In such patients, closer imaging surveillance after EVAR in the long term may be required to identify early and treat timely the complications.

Comparison of the Effects of Ezetimibe-Statin Combination Therapy on Major Adverse Cardiovascular Events in Patients with and without Diabetes: A Meta-Analysis.

BACKGROUND: Ezetimibe-statin combination therapy has been found to reduce low density lipoprotein cholesterol levels and the risk of major adverse cardiovascular events (MACEs) in large trials. We sought to examine the differential effect of ezetimibe on MACEs when added to statins according to the presence of diabetes. METHODS: Randomized clinical trials with a sample size of at least 50 participants and at least 24 weeks of follow-up that compared ezetimibe-statin combination therapy with a statin- or placebo-controlled arm and reported at least one MACE, stratified by diabetes status, were included in the meta-analysis and meta-regression. RESULTS: A total of seven trials with 28,191 enrolled patients (mean age, 63.6 years; 75.1% men; 7,298 with diabetes [25.9%]; mean follow-up, 5 years) were analysed. MACEs stratified by diabetes were obtained from the published data (two trials) or through direct contact (five trials). No significant heterogeneity was observed among studies (I²=14.7%, P=0.293). Ezetimibe was associated with a greater reduction of MACE risk in subjects with diabetes than in those without diabetes (pooled relative risk, 0.84 vs. 0.93; P(heterogeneity)=0.012). In the meta-regression analysis, the presence of diabetes was associated with a greater reduction of MACE risk when ezetimibe was added to statins (ß=0.87, P=0.038). CONCLUSION: Ezetimibe-statin combination therapy was associated with greater cardiovascular benefits in patients with diabetes than in those without diabetes. Our findings suggest that ezetimibe-statin combination therapy might be a useful strategy in patients with diabetes at a residual risk of MACEs.

Balloon Angioplasty Versus Stenting for the Treatment of Failing Arteriovenous Grafts: A Meta-Analysis.

PURPOSE: To assess the outcomes of plain balloon angioplasty versus stenting for the treatment of failed or malfunctioning chronic haemodialysis arteriovenous grafts (AVGs). METHODS: A systematic search of the literature was undertaken using the PUBMED, EMBASE, and Cochrane databases from January 2000 to September 2016 for articles comparing balloon angioplasty versus stenting in the management of failed or malfunctioning chronic haemodialysis AVGs. Results are reported as OR and 95% CI. RESULTS: The search identified eight studies (1051 patients). Balloon angioplasty alone was used in 521 patients (49.6%) and stenting in 530 patients (50.4%). At the time of the endovascular re-intervention, the mean life of AVGs was 807.7±115.4 days for the balloon angioplasty and 714.2±96.3 days for the stenting group (p=.92). All AVGs were located in the arm. Most procedures (98.1%) were performed across the venous anastomosis, while 88% of the patients in the stenting group received a stent graft. The technical success rate was significantly higher in the stenting group (OR 0.16, 95% CI 0.08-0.31, p<.001). At 12 months, loss of primary and secondary patency was significantly higher in patients undergoing plain balloon angioplasty compared with stenting (OR 3.54, 95% CI 2.18-5.74, p<.001, and OR 1.82, 95% 1.17-2.82, p=.008, respectively). CONCLUSION: Stenting is associated with better technical success and patency rates compared with plain angioplasty in treating failed or malfunctioning chronic haemodialysis AVGs, and thus it should be considered as the first line therapeutic option.

Initial Clinical Experience with the Endologix AFX Unibody Stent Graft System for Treating Patients with Abdominal Aortic Aneurysms: A Case Controlled Comparative Study.

PURPOSE: The newly designed unibody AFX endograft system for endovascular aortic aneurysm repair is the only graft with anatomical fixation to the aortic bifurcation in comparison to most other grafts that use the infrarenal neck as the main fixation point. The aim of this study was to assess the preliminary results of the AFX stent-graft system used with infrarenal aortic component and compare them with those obtained in patients treated with a well established endograft of the same material and pure infrarenal fixation as the Gore Excluder. MATERIALS AND METHODS: A retrospective analysis of prospectively collected data from March 2014 to December 2014 identified 10 elective abdominal aortic aneurysm patients treated with the AFX endograft, in comparison to a matched group of 20 patients treated with the Excluder stent-graft. Endpoints included technical and clinical success, freedom from any secondary intervention, any type of endoleak and aneurysm related death. RESULTS: Primary technical success was achieved in all patients and no 30-day device related complications or deaths were occurred. The two groups were similar in terms of radiation burden, contrast media, duration of the procedure, post implantation syndrome and in-hospital stay. During a median follow-up period of 23 months (range, 18-26 months) there were no differences in clinical success, freedom from reintervention and aneurysm related death. No type I endoleak was observed in either group. Five of the 6 type II endoleaks (1 in the AFX and 4 in the Excluder group) spontaneously resolved, while in only one patient (Excluder) the endoleak remained without however any change in aneurysm sac diameter (log rank=0.34). CONCLUSION: The initial experience with the AFX stent graft system is promising, with successful aneurysm exclusion and good short-term results. Further and larger studies are needed to fully evaluate the sort as well as the long-term results.

A Systematic Review of Proximal Neck Dilatation After Endovascular Repair for Abdominal Aortic Aneurysm.

PURPOSE: To provide an updated systematic literature review and summarize current evidence on proximal aortic neck dilatation (AND) after endovascular aneurysm repair (EVAR). METHODS: A review of the English-language medical literature from 1991 to 2015 was conducted using MEDLINE and EMBASE to identify studies reporting AND after EVAR. Studies considered for inclusion and full-text review fulfilled the following criteria: (1) reported AND after EVAR, (2) included at least 5 patients, and (3) provided data on AND quantification. The search identified 26 articles published between 1998 and 2015 that encompassed 9721 patients (median age 71.8 years; 9439 men). RESULTS: AND occurred in 24.6% of patients (95% CI 18.6% to 31.8%) over a period ranging from 15 months to 9 years after EVAR. No significant dilatation of the suprarenal part of the aorta was reported by most studies. The incidence of combined clinical events (endoleak type I, migration, reintervention during follow-up) was higher in the AND group (26%) when compared with 2% in the group without AND (OR 28.7, 95% CI 5.43 to 151.67, p<0.001). CONCLUSION: AND affects a considerable proportion of EVAR patients and was related to worse clinical outcome, as indicated by increased rates of type I endoleak, migration, and reinterventions. Future studies should focus on a better understanding of the pathophysiology, predictors, and risk factors of AND, which could identify patients who may warrant a different EVAR strategy and/or a closer post-EVAR surveillance strategy.

An update on predictive biomarkers for major adverse cardiovascular events in patients undergoing vascular surgery.

Cardiovascular complications signify a major cause of morbidity and mortality in patients undergoing vascular surgery adversely affecting both short- and long-term prognosis. During the last decade, unmet needs for a distinct cardiovascular risk assessment have led to an intensive research for establishment of biomarkers with sufficient predictive value. This literature review aims in examining the value of several biomarkers in predicting the incidence of major adverse cardiac events in vascular surgery patients. We reviewed the English language literature and analyzed the biomarkers as independent predictors or in correlation with other factors. We found several biomarkers showing a significant predictive value for a major adverse cardiovascular event in patients undergoing vascular surgery. These biomarkers can be used in clinical practice as outcome predictors, although sensitivity and specificity varies. Detection of subclinical cardiovascular damage may improve total risk estimation and facilitate clinical assessment of patients at risk for future cardiovascular events. The wide variety of sensitivity and specificity in predicting a MACE of these biomarkers exert the need for future trials in which these markers will be tested as adjunctive tools of cardiovascular risk estimation scoring systems.

Management of concomitant abdominal aortic aneurysm and colorectal cancer.

OBJECTIVE: To conduct a systematic review of the literature and perform an analysis of outcomes of treatment of concomitant colorectal cancer (CRC) and abdominal aortic aneurysm (AAA) with a focus on the different treatment options and the related therapeutic outcomes. METHODS: A review of the English-language medical literature from 1980 to 2015 was undertaken using the PubMed and EMBASE databases to identify studies reporting surgical treatment of patients with concomitant CRC and AAA. The search identified 24 articles encompassing 254 patients (81% male; mean age 73.5 ± 6.1 years). RESULTS: In 96 patients (37.9%) cancer resection was performed first, followed by AAA repair at a later stage (open aortic repair [OAR], 79.2%; endovascular abdominal aortic repair [EVAR], 20.8%). Eighty-two patients (32.3%) underwent AAA repair (OAR, 47.5%; EVAR, 52.5%) before CRC resection. Seventy-one patients (27.9%) underwent combined OAR and CRC resection, and just five (1.9%) were treated with EVAR and cancer surgery in a single stage. There were eight of 96 interval AAA ruptures (8.3%), mostly in the early postoperative period concerning aneurysms >6 cm in diameter. The mean interval between the two procedures was much shorter in patients treated with EVAR than OAR (11.5 ± 1.8 days vs 103.9 ± 42.3 days). The overall 30-day mortality rate was 10.9%. Data from observational studies showed no significant differences in 30-day mortality between patients treated in one or two stages (P = .89). No mortality was recorded in any of the EVAR-treated patients. There was only one graft infection recorded (0.4%). CONCLUSIONS: Among different approaches, no significant differences in 30-day outcomes among patients treated in either two or one stage were evident. EVAR showed the lowest mortality and also diminished the delay between the two procedures in <2 weeks for a two-stage approach, although it has been associated with a significant risk for thrombotic events. The coexistence of AAA and CRC seems to favor the use of EVAR in treating those patients.

Oxidative Stress and Total Antioxidant Status During Internal Carotid Artery Clamping with or without Shunting: An Experimental Pilot Study.

BACKGROUND The exact role of shunting during carotid endarterectomy remains controversial and unclear. The aim of this experimental study was to investigate to what degree carotid clamping may induce changes in the cerebral oxidative status and to focus on the relation of these changes with shunt insertion. MATERIAL AND METHODS Forty New-Zealand rabbits were randomized into 4 groups: group 1 classifying animals with carotid shunt and patent contralateral carotid artery; group 2 shunt and occlusion of the contralateral carotid artery; group 3 no-shunt and patent contralateral carotid artery; and group 4 no-shunt and occlusion of the contralateral carotid artery. Blood samples were collected from the ipsilateral internal jugular vein, immediately after carotid clamping (time 0), and then at 5, 10, 15, 30, and 60 minutes afterwards. Evaluation of oxidative stress was accomplished by measuring the lag-time, representing the initial phase of oxidation, rate of accumulation (RA), showing concentration of free oxygen radical and total antioxidant status (TAS) representing antioxidant composition of serum. RESULTS Lag-time was significantly different in time points 0, 30 and 60 minutes within each different group. TAS was significantly different in time points 0, 15 and 60 min and RA in time points 0, 5, 10 and 60 min within each different group. 60 minutes after carotid clamping, the rate of accumulation as well as lag-time and TAS were increased in all groups, independently of using or not shunting or the presence of contralateral occlusion. After comparing groups 1, 2 and 3 regarding lag-time, TAS and RA, we did not find statistical difference among the groups at any time point. On the contrary, groups 1, 2 and 3 did show significantly different values comparing to group 4 after 60 min of occlusion. CONCLUSIONS Our experimental work based on cerebral metabolism found a significantly higher oxidative stress in models with contralateral carotid occlusion. The use of shunt in all other models did not have any influence on oxidative response. Future human studies should focus on the relation of oxidative status and shunt insertion to determine the benefit of selective or routine shunting during CEA.

Meta-analysis of the Effect of Stent Design on 30-Day Outcome After Carotid Artery Stenting.

PURPOSE: To review the contemporary literature and analyze whether stent cell design plays a role in 30-day outcomes after carotid artery stenting (CAS). METHODS: A systematic review of the literature was undertaken that identified 9 studies comparing the effect of different cell design on 30-day outcome in patients undergoing CAS. Random-effects models were applied to calculate pooled outcome data for mortality and cerebrovascular morbidity. Results are reported as the odds ratio (OR) and 95% confidence interval (CI). RESULTS: The 9 studies included 8018 patients who underwent 8028 CAS procedures (4018 open-cell stents, 4010 closed-cell stents). Six studies were retrospective in design, one was a registry, and only two studies prospectively compared the effect of different cell designs. Nearly half of the patients (3452, 43.1%) were symptomatic, with no significant difference between the closed- and open-cell stent groups (p=0.93). During the first month after the procedure, there were no significant differences in mortality (OR 0.69, 95% CI 0.39 to 1.24, p=0.21), transient ischemic attacks (OR 0.95, 95% CI 0.69 to 1.30, p=0.74), or strokes (OR 1.17, 95% CI 0.83 to 1.66, p=0.37). CONCLUSION: This meta-analysis showed that 30-day cerebrovascular complications after CAS were not significantly different for the open-cell group in comparison to the closed-cell group. Future prospective clinical trials comparing different free cell areas and other stent design properties are still needed to further investigate whether stent design plays a significant role in the results of carotid stenting.

The effect of adding ezetimibe to rosuvastatin on renal function in patients undergoing elective vascular surgery.

We compared the effects of lipid lowering with rosuvastatin (RSV) monotherapy versus intensified treatment by combining RSV with ezetimibe (EZT) on kidney function in patients undergoing vascular surgery. Patients were randomly assigned to either 10 mg/d RSV (n = 136) or RSV 10 mg/d plus EZT 10 mg/d (RSV/EZT, n = 126). At 12 months, a similar decrease in estimated glomerular filtration rate (eGFR) was noted. Patients who achieved a low-density lipoprotein cholesterol (LDL-C) of <100 mg/dL had less eGFR decrease than those patients having an LDL-C limit of more than 100 mg/dL. There were no significant changes in the urinary total protein to creatinine ratio in either group. Significant microalbuminuria was evident in both the groups. Patients undergoing vascular surgery show deterioration in their renal function during the first year, despite statin therapy. Intensified lipid-lowering therapy by adding EZT does not appear to have any renoprotective effect.

Bridging endovascular therapy and subsequent surgical repair for the treatment of infected aneurysms after percutaneous cardiac intervention.

Bridging endovascular therapy, accompanied by a second stage open surgical repair was used to treat a rare case of infected aneurysms alongside external iliac artery after a percutaneous cardiac intervention. Because these aneurysms require early treatment, we suggest this approach, in order to avoid immediate, major surgery in a recently symptomatic cardiac and bacteremic patient receiving dual antiplatelet therapy. The approach seems to be safe and durable.