Sex-Related Outcomes in Asymptomatic Patients Undergoing Carotid Artery Stenting.

PURPOSE: Aim of the study was to evaluate the influence of sex in asymptomatic patients undergoing carotid artery stenting (CAS). MATERIALS AND METHODS: A retrospective observational study was conducted from January 2006 to December 2020. A total of 438 consecutive patients with asymptomatic carotid artery stenosis >70% underwent transfemoral CAS and were stratified in males (M) and females (F). Periprocedural 30-day outcomes were: stroke, death, and myocardial infarction (MI). Follow-up outcomes were: death and stroke rates (primary) and freedom from restenosis (FFR) and reintervention rates (secondary). Follow-up data were analyzed at 1, 5, and 10 years. Data were analyzed with χ2 test and Fisher's exact test and follow-up outcomes with Kaplan-Meier curves. The log-rank test was used to determine differences between the groups and univariate analysis to identify the association between risk factors and intraoperative details with mortality and restenosis rates. RESULTS: A total of 462 procedures were performed (M: n=321, 69.4%), in which 24 CAS were bilateral (5.5%). Mean age was 71.9±7.6 years (M: 72.1±7.8; F: 71.7±7.3). Periprocedural outcomes were: stroke rate 2.2% (n=10; M: n=5, 1.6%; F: n=5, 3.5%; p=0.176), mortality rate 0.6% (M: n=3, p=0.334), and stroke/death rate 2.8% (n=13; M: n=8, 2.5%; F: n=5, 3.5%; p=0.528); no cardiac events (MI) were recorded. A not-disabling (minor) stroke was detected in 3 males (0.9%), while a disabling (major) stroke was reported in 7 patients (1.7%) of whom 5 were ischemic events (M: n=2, 0.6%; F: n=3, 2.2%) and 2 were cerebral hemorrhages (F: 1.3%, p=0.046). Mean follow-up was 73.66±40.83 months (M: 72.66; F: 76.01; p=0.246). Overall survival rate was 96.1% (95% confidence interval [CI]: 93-98), 81.8% (95% CI: 77-86), and 45.5% (95% CI: 38-53) at 1, 5, and 10 years, respectively (p=0.236). The overall stroke rate was 0.3% (freedom from stroke [FFS]: 99.7%; 95% CI: 98-100), 0.9% (FFS: 99%; 95% CI: 98-100), and 4.3% (FFS: 95.7%; 95% CI: 89-98; M: n=6; F: n=2; p=0.774). Stroke-related mortality rate was 0.7% (FFS: 99.3%; 95% CI: 97-100) and 2.9% (FFS: 97.1%; 95% CI: 91-99) at 5 and 10 years, respectively, without differences between the groups (M: n=4; F: n=2; p=0.763). Overall FFR rate was 97.4% (95% CI: 95-99), 93.4% (95% CI: 90-96), and 89.5% (95% CI: 84-93; p=0.322). Two severe symptomatic restenosis (>70%, M) required a new endovascular revascularization. CONCLUSION: The sex variable does not influence outcomes of CAS in asymptomatic patients at short- and long-term follow-up, although females show a worst incidence of periprocedural major strokes. Carotid artery stenting may be safely proposed when a careful patient selection is applied. CLINICAL IMPACT: The sex variable has been advocated as a considerable factor that could influence the outcomes of transfemoral carotid artery stenting (CAS). Literature data are contrasting, even if different papers mainly reported that CAS is associated to worst outcomes in female patients. Our study shows that the sex-variable does not influence outcomes of CAS in asymptomatic patients at short and long-term follow-up, although females had a worst incidence of periprocedural major strokes. CAS may be safely proposed when a careful patient selection is applied.

Preliminary results from a multicenter Italian registry on the use of a new branched device for the treatment of thoracoabdominal aortic aneurysms.

OBJECTIVE: The study purpose was to present early outcomes of patients treated for thoracoabdominal aortic aneurysms or complex abdominal aortic diseases using endovascular repair with a new branched endograft. METHODS: This multicenter, retrospective, observational cohort study included all patients treated with a new branched endograft. All elective patients were treated with a staged operative strategy and spinal drainage Primary outcomes of interest were technical success, early (≤30 days) mortality, and late (≥30 days) survival, and freedom from adverse aortic events. RESULTS: A total of 16 consecutive patients were treated for Crawford's extent type I (n = 1), type II (n = 7), type III (n = 1), and type IV (n = 5) endoleaks, with an additional two complex pararenal abdominal aortic lesions (enlarging type Ia endoleak, n = 1; anastomotic pseudoaneurysm, n = 1). There were 13 male (81%) and 3 female (19%) patients with a median age of 72.5 years (interquartile range [IQR], 69-78 years). The median diameter of the aortic aneurysm was 65 mm (IQR, 58-81 mm) and the median EuroSCORE prediction for mortality was 18% (IQR, 12%-36%). Thoracoabdominal aortic aneurysm was secondary to a previous dissection in four patients. A total of 62 of the 64 visceral vessels (96.9%) were stented. Technical success was achieved in 14 (87.5 %) and the cumulative aorta-related mortality rate was 19%. Spinal cord ischemia did not occur. The mean follow-up was 8 ± 4 months (range, 2-15 months). No type I or type III endoleaks were detected. Primary bridging stent patency was 98% (one asymptomatic thrombotic occlusion of a celiac trunk branch). No aortic reintervention was required. CONCLUSIONS: Endovascular repair of complex aortic aneurysms with this new branched endograft can be performed with high technical success and acceptable morbidity. A 19% mortality is quite high; however, it is tolerable in such a high-risk cohort. The survival rate was acceptable, and graft-related outcomes at early follow-up included an absence of threatening endoleaks and a high target visceral vessel patency.

Acute Distress Respiratory Syndrome and Cardiac Shock after AngioJet Thrombectomy for Acute Occlusion of an Aortic Endograft.

Partial thrombosis or total occlusion of aortic or limb graft are possible complications after endovascular aneurysm repair. Different strategies for therapeutic management are available; these include open surgical techniques or endovascular treatments. The choice of the treatment depends on the patient's clinical conditions and on the timing of the thrombosis. Bypass still remains the first choice in case of chronic occlusion but in the last 10 years, the use of percutaneous mechanical/rheolytic thrombectomy systems is increasing. These devices can be used in case of acute or subacute onset of native arterial and venous thrombosis or embolism and in case of graft occlusion. AngioJet is a percutaneous rheolytic mechanical thrombectomy system. Through a pressurized saline solution jet, a low-pressure zone is made up and the thrombus is fragmented and aspirated by the device. Different transient adverse effects caused by lysis of the thrombus are described such as hemoglobinuria but in some cases the release of high doses of the thrombus degradation products such as heme and adenosine diphosphate can lead to fatal consequences for the patient. We reported a case of an acute onset of acute distress respiratory syndrome, pulmonary edema, cardiac shock, and renal failure following AngioJet thrombectomy in an 81-year-old man with an acute occlusion of an aortic endograft.

Hypogastric Artery Salvage Using an Unibody Bifurcated Aorto-Iliac Graft Associated to Double-Barrel Technique in Spontaneous Isolated Abdominal Aortic Dissection.

A 54-year-old male patient was admitted with acute left lower limb ischemia (ALI). Computed tomography (CT) angiogram showed an isolated abdominal aortic dissection (IAAD) with a single entry tear just proximal to the aortic bifurcation and an intramural hematoma (IMH) extending to the descending thoracic aorta. The IAAD involved the left iliac bifurcation, with a flow limiting dissection flap into the internal iliac artery (IIA) and external iliac artery (EIA) thrombosis with femoro-popliteal embolization. A surgical thrombectomy of the femoral arteries was performed. An unibody bifurcated endograft was deployed into the true lumen to cover the entry tear, and a double-barrel technique was employed to restore the flow into the EIA and to preserve the IIA patency. The postoperative period was complicated by a compartment syndrome of the calf, requiring a fasciotomy. Follow-up imaging after 12 months showed complete resolution of the IAAD and patency of the stented vessels.

Endovascular Treatment of Multiple Ruptures of Postdissecting Thoraco Abdominal Aortic Aneurysm with a Custom Branched Device Used as an Off-the-shelf Device.

Endovascular treatment of postdissection aortic aneurysms (PDAAs) is fascinating and challenging. The Colt branched graft (Jotec/Cryolife, Kennesaw, Georgia), because of its characteristics, can be used as an off-the-shelf device especially in urgent/emergency settings. In this report, we describe the first case of a PDAA successfully treated with a Colt device.

Endovascular and Hybrid Management of Patients Affected by Abdominal Aortic Aneurysm and Occlusion of the Iliac Arteries.

The presence of a concomitant aortoiliac occlusive disease and abdominal aortic aneurysm (AAA) is rare and limits the implant of a bifurcated endograft. BACKGROUND: The objective of the study was to evaluate early and midterm results of an endovascular or a hybrid approach in patients undergoing iliac revascularization and AAA exclusion. METHODS: We reviewed our clinical series of patients from January 2016 to February 2018. Inclusion criterion was an iliac occlusion with concomitant aortic aneurysm. RESULTS: We treated 8 male patients: 8 common iliac arteries (CIAs) and 5 external iliac arteries (EIAs). We implanted 8 bifurcated devices and 13 covered stents, 8 in CIA and 5 in EIA. In 5 cases, when the EIA was involved, we also performed a common femoral artery endarterectomy with a patch. During a mean follow-up of 10 months, the primary patency of the recanalized iliac arteries was 100%, no endoleaks, sac growth, or rupture were also recorded. CONCLUSIONS: Endovascular or hybrid treatment of the iliac occlusion combined with infrarenal aortic aneurysm is feasible with favorable early and midterm results.

Endovascular treatment of multiple aneurysms complicating Cogan syndrome.

To report the use of endografts to manage multiple aneurysms due to Cogan syndrome (CS). A 38-year-old woman with descending thoracic aorta and right common carotid artery aneurysms due to CS was treated with endovascular grafts. After 4 years, angio computed tomography scan demonstrated complete exclusion of the aneurysms with no signs of endoleak, whereas echo color Doppler showed patency of the carotid graft, no signs of restenosis, no progression of the disease in the landing zones, and complete aneurysm exclusion. Endovascular repair seems to have favorable long-term outcomes and should be considered a viable alternative to surgery in unfit for open surgery patients, even if they are young, and when the aneurysm size and location would pose a higher risk of perioperative and postoperative complications after an open surgical procedure.

Endovascular management of type Ib endoleak complicating a juxtarenal aortic aneurysm previously treated with a multilayer stent.

BACKGROUND: To report the use of an endograft to manage a type Ib endoleak in a patient with a juxtarenal aortic aneurysm previously treated with a multilayer stent. METHODS: Under compassionate use, a 68-year-old patient with a juxtarenal aortic aneurysm and multiple comorbidities was treated with a multilayer flow modulating stent. Twelve months later a new computed tomography (CT) scan identified a type Ib endoleak with an increase in the aortic aneurysm size because of the extension of the aneurysmal disease to the aortic carrefour. A new endovascular procedure was then performed, deploying an aorto-biiliac endoprosthesis. After 18 months, serial echocolor duplex and CT scans have shown normal visceral arteries patency, no signs of endoleak, and sac shrinkage of 5 mm. DISCUSSION AND CONCLUSION: In this case, the Multilayer Aneurysm Repair System failed to treat the abdominal aortic aneurysm and required a reoperation with conventional-covered stent graft for distal sealing, which may be considered a feasible solution to manage potential endoleaks.