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BACKGROUND: Post implantation syndrome (PIS) is a well-defined entity with unclear etiology, complicating a number of patients with abdominal aortic aneurysms treated with endovascular aortic repair (EVAR). The aim of this study was to assess the platelets' role and the influence of aneurysmal sac thrombus volumes in the development of PIS. A retrospective analysis of prospectively collected data was performed, and 76 patients who were treated by EVAR (2011-2013) were studied. Aneurysms with endoleak were not included in the study. Based on the criteria for systemic inflammatory response syndrome (SIRS), 17 patients (22%) developed PIS (which is considered a SIRS analogue), while 59 (78%) did not. METHODS: The 2 groups were compared in relation to the following parameters: baseline platelet count (PLT), decrease of platelet count (PLT drop), volume of the arterial flow before the procedure (V flow), volume of thrombus of the aneurysm (V thromb), ratio of thrombus volume to aneurysm sac volume (V ratio), and the volume of newly formed thrombus (V new). Volume flow measurements were calculated by Osirix software preoperatively and in the first month postoperatively. Parametric and nonparametric techniques (unpaired t-test, Mann-Whitney U test) were used accordingly. RESULTS: Baseline platelets absolute count was greater in the PIS group (239,000 ± 17,000) versus the non-PIS group (194,000 ± 6,900, P = 0.004), and the PLT drop was larger in the PIS group (74,000 ± 15,600 versus 45,000 ± 5,300, P = 0.019). No difference was found regarding the aneurysm volumes (V flow, V thromb, V ratio, and V new) between the 2 groups. CONCLUSIONS: Platelets, in terms of their absolute baseline count and their decrease after the procedure, seem to be an important factor in developing PIS after EVAR. Further, more tailored studies are needed to elucidate the role of platelets and flow or thrombus volumes in the development of PIS.
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PURPOSE: The purpose of this study was to investigate which treatment method for abdominal aortic aneurysm (AAA), endovascular or open repair, has better outcomes in young patients. MATERIALS AND METHODS: A systematic review was conducted to identify observational studies or randomized controlled trials (RCTs) that compared endovascular and open repair of intact AAA in young patients. MEDLINE, EMBASE, and CENTRAL were searched up to March 2022 using the Ovid interface. The risk of bias was assessed with the Newcastle-Ottawa scale (NOS), with a maximum score of 9, or version 2 of the Cochrane risk of bias tool. The certainty of evidence was assessed with the GRADE framework. Primary outcomes were perioperative, overall, and aneurysm-related mortality. Secondary outcomes were reintervention, hospital length of stay, and perioperative complications. Effect measures in syntheses were the odds ratio (OR), risk difference (RD), mean difference (MD), or hazard ratio (HR) and were calculated with the Mantel-Haenszel or inverse variance statistical method and random-effects models. RESULTS: Fifteen observational studies and 1 RCT were included, reporting a total of 48 976 young patients. Definitions of young ranged from 60 to 70 years. The median score on the NOS was 8 (range: 4-9), and the RCT was judged to be high risk of bias. The perioperative mortality was lower after EVAR (RD: -0.01, 95% CI: -0.02 to -0.00), but the overall and aneurysm-related mortality was not significantly different between EVAR and open repair (HR: 1.38, 95% CI: 0.81 to 2.33; HR: 4.68, 95% CI: 0.71 to 31.04, respectively), as was the hazard of reintervention (HR: 1.50, 95% CI: 0.88 to 2.56). The hospital length of stay was shorter after EVAR (MD: -4.44 days, 95% CI: -4.79 to -4.09), and the odds of cardiac (OR: 0.22, 95% CI: 0.13 to 0.35), respiratory (OR: 0.17, 95% CI: 0.11 to 0.26), and bleeding complications were lower after EVAR (OR: 0.26, 95% CI: 0.11 to 0.64). The level of evidence was low or very low. CONCLUSION: Patient preferences and perspectives should be considered during shared decision-making process considering the available evidence. EVAR may be considered in young and fit patients with a suitable anatomy. PROTOCOL REGISTRATION: PROSPERO, CRD42022325051. CLINICAL IMPACT: Uncertainty surrounds the optimal treatment strategy for abdominal aortic aneurysm in young patients. Meta-analysis of some 48,976 young patients showed that endovascular aneurysm repair (EVAR) has a lower perioperative mortality and morbidity and a shorter hospital and intensive care unit stay than open surgical repair, but the overall and aneurysm-related mortality in the short to medium term are not significantly different between EVAR and open repair. EVAR can be considered in young patients.
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OBJECTIVE: The optimal revascularization modality in secondary aortoenteric fistula (SAEF) remains unclear in the literature. The purpose of this investigation was to determine the revascularization approach associated with the lowest morbidity and mortality using real-world data in patients with SAEF. METHODS: A retrospective, multi-institutional study of SAEF from 2002 to 2014 was performed using a standardized database. Baseline demographics, comorbidities, and operative and postoperative variables were recorded. The primary outcome was long-term mortality. Descriptive statistics, Kaplan-Meier survival analysis, and univariate and multivariate analyses were performed. RESULTS: During the study period, 182 patients at 34 institutions from 11 countries presented with SAEF (median age, 72 years; 79% male). The initial aortic procedures that resulted in SAEF were 138 surgical grafts (76%) and 42 endografts (23%), with 2 unknown; 102 of the SAEFs (56%) underwent complete excision of infected aortic graft material, followed by in situ (in-line) bypass (ISB), including antibiotic-soaked prosthetic graft (53), autogenous femoral vein (neoaortoiliac surgery; 17), cryopreserved allograft (28), and untreated prosthetic grafts (4). There were 80 patients (44%) who underwent extra-anatomic bypass (EAB) with infected graft excision. Overall median Kaplan-Meier estimated survival was 319 days (interquartile range, 20-2410 days). Stratified by EAB vs ISB, there was no significant difference in Kaplan-Meier estimated survival (P = .82). In comparing EAB vs ISB, EAB patients were older (74 vs 70 years; P = .01), had less operative hemorrhage (1200 mL vs 2000 mL; P = .04), were more likely to initiate dialysis within 30 days postoperatively (15% vs 5%; P = .02), and were less likely to experience aorta-related hemorrhage within 30 days postoperatively (3% aortic stump dehiscence vs 11% anastomotic rupture; P = .03). There were otherwise no significant differences in presentation, comorbidities, and intraoperative or postoperative variables. Multivariable Cox regression showed that the duration of antibiotic use (hazard ratio, 0.92; 95% confidence interval, 0.86-0.98; P = .01) and rifampin use at time of discharge (hazard ratio, 0.20; 95% confidence interval, 0.05-0.86; P = .03) independently decreased mortality. CONCLUSIONS: These data suggest that ISB does not offer a survival advantage compared with EAB and does not decrease the risk of postoperative aorta-related hemorrhage. After repair, <50% of SAEF patients survive 10 months. Each week of antibiotic use decreases mortality by 8%. Further study with risk modeling is imperative for this population.
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Implante de Prótese Vascular/métodos , Fístula Intestinal/cirurgia , Stents , Fístula Vascular/cirurgia , Idoso , Feminino , Seguimentos , Humanos , Fístula Intestinal/diagnóstico , Fístula Intestinal/mortalidade , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Taxa de Sobrevida/tendências , Estados Unidos/epidemiologia , Fístula Vascular/diagnóstico , Fístula Vascular/mortalidadeRESUMO
Preservation of the hypogastric circulation is of major clinical importance in cases of endovascular aneurysm repair (EVAR) for ruptured abdominal aortic aneurysm (rAAA). Pelvic ischemia can be detrimental and significantly increase post-operative morbidity and mortality. However, the application of a side branch device or a bell-bottom graft is not possible in ruptured aortoiliac aneurysms (due to off-the-shelf unavailability and/or prolonged operative time) and in most cases pelvic circulation may have to be sacrificed. We report a case of a rAAA with bilateral common iliac artery (CIA) aneurysms that was successfully repaired with an aorto-uni-iliac (AUI) endograft, a cross-femoral bypass, and an inverted-U shaped contralateral EIA to IIA endovascular bypass. The procedure is described in detail and certain technical points are further discussed. The steps in cases where the aneurysm has ruptured are different compared to elective repairs and vascular surgeons need to be aware of certain pitfalls. This strategy may be feasible in the acute setting and permits preservation of the hypogastric circulation with the combination of standard techniques and grafts that are readily available in most institutions.
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Aneurisma da Aorta Abdominal/cirurgia , Ruptura Aórtica/cirurgia , Implante de Prótese Vascular/métodos , Procedimentos Endovasculares/métodos , Aneurisma Ilíaco/cirurgia , Enxerto Vascular/métodos , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Ruptura Aórtica/diagnóstico por imagem , Prótese Vascular , Angiografia por Tomografia Computadorizada , Humanos , Aneurisma Ilíaco/diagnóstico por imagem , Masculino , Pessoa de Meia-IdadeRESUMO
INTRODUCTION: Aortic graft infection remains a considerable clinical challenge, and it is unclear which variables are associated with adverse outcomes among patients undergoing partial resection. METHODS: A retrospective, multi-institutional study of patients who underwent partial resection of infected aortic grafts from 2002 to 2014 was performed using a standard database. Baseline demographics, comorbidities, operative, and postoperative variables were recorded. The primary outcome was mortality. Descriptive statistics, Kaplan-Meier (KM) survival analysis, and Cox regression analysis were performed. RESULTS: One hundred fourteen patients at 22 medical centers in 6 countries underwent partial resection of an infected aortic graft. Seventy percent were men with median age 70 years. Ninety-seven percent had a history of open aortic bypass graft: 88 (77%) patients had infected aortobifemoral bypass, 18 (16%) had infected aortobiiliac bypass, and 1 (0.8%) had an infected thoracic graft. Infection was diagnosed at a median 4.3 years post-implant. All patients underwent partial resection followed by either extra-anatomic (47%) or in situ (53%) vascular reconstruction. Median follow-up period was 17 months (IQR 1, 50 months). Thirty-day mortality was 17.5%. The KM-estimated median survival from time of partial resection was 3.6 years. There was no significant survival difference between those undergoing in situ reconstruction or extra-anatomic bypass (Pâ¯=â¯0.6). During follow up, 72% of repairs remained patent and 11% of patients underwent major amputation. On univariate Cox regression analysis, Candida infection was associated with increased risk of mortality (HR 2.4; Pâ¯=â¯0.01) as well as aortoenteric fistula (HR 1.9, Pâ¯=â¯0.03). Resection of a single graft limb only to resection of abdominal (graft main body) infection was associated with decreased risk of mortality (HR 0.57, Pâ¯=â¯0.04), as well as those with American Society of Anesthesiologists classification less than 3 (HR 0.35, Pâ¯=â¯0.04). Multivariate analysis did not reveal any factors significantly associated with mortality. Persistent early infection was noted in 26% of patients within 30 days postoperatively, and 39% of patients were found to have any post-repair infection during the follow-up period. Two patients (1.8%) were found to have a late reinfection without early persistent postoperative infection. Patients with any post-repair infection were older (67 vs. 60 years, Pâ¯=â¯0.01) and less likely to have patent repairs during follow up (59% vs. 32%, Pâ¯=â¯0.01). Patients with aortoenteric fistula had a higher rate of any post-repair infection (63% vs. 29%, P < 0.01) CONCLUSION: This large multi-center study suggests that patients who have undergone partial resection of infected aortic grafts may be at high risk of death or post-repair infection, especially older patients with abdominal infection not isolated to a single graft limb, or with Candida infection or aortoenteric fistula. Late reinfection correlated strongly with early persistent postoperative infection, raising concern for occult retained infected graft material.
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Aorta/cirurgia , Implante de Prótese Vascular/efeitos adversos , Prótese Vascular/efeitos adversos , Remoção de Dispositivo , Procedimentos Endovasculares/efeitos adversos , Infecções Relacionadas à Prótese/cirurgia , Idoso , Implante de Prótese Vascular/instrumentação , Implante de Prótese Vascular/mortalidade , Remoção de Dispositivo/efeitos adversos , Remoção de Dispositivo/mortalidade , Procedimentos Endovasculares/instrumentação , Procedimentos Endovasculares/mortalidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Infecções Relacionadas à Prótese/diagnóstico , Infecções Relacionadas à Prótese/microbiologia , Infecções Relacionadas à Prótese/mortalidade , Reoperação , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de TempoRESUMO
Background: Abdominal wall hernias (AWHs) share common epidemiological characteristics with abdominal aortic aneurysms (AAAs), typically presenting in male population and older ages. Prior reports have associated those two disease entities. Our objective was to perform a systematic review and meta-analysis and examine whether AAA rates are higher among patients with AWH vs controls and whether the incidence of AWH was higher among patients with AAA vs patients without AAA. Methods: We performed a systematic review and meta-analysis according to the PRISMA guidelines. The Medline database was searched up to July 31, 2020. A random effects meta-analysis was performed. Results: In total, 17 articles and 738,972 participants were included in the systematic review, while 107,578 patients were eligible for the meta-analysis. Among four studies investigating the incidence of AAA in patients with hernias, AAA was more common in patients with hernias, compared to patients without hernias. [OR: 2.53, 95% CI: 1.24-5.16, I2=81.6%]. Among thirteen studies that compared patients with known AAA vs no AAA, the incidence of hernias was higher in patients with AAA, compared with patients without AAA [OR: 2.27, 95% CI: 1.66-3.09, I2=84.6%]. Conclusions: Our study findings indicate that a strong association between AWH and AAA exists. AWHs could therefore be used as an additional selection criterion for screening patients for AAA, apart from age, gender, family history and smoking.
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Aneurisma da Aorta Abdominal , Hérnia Abdominal , Idoso , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Fatores de RiscoRESUMO
OBJECTIVE: Transcervical carotid artery stenting (CAS) has emerged as an alternative to transfemoral CAS. An earlier systematic review from our group (n = 12 studies; 739 transcervical CAS procedures [489/739 with flow reversal]) demonstrated that transcervical CAS is a safe procedure associated with a low incidence of stroke and complications. Since then, new studies have been published adding nearly 1600 patients to the literature. We aimed to update our early systematic review and also to perform a meta-analysis to investigate outcomes specifically after transcervical CAS with flow reversal. METHODS: An electronic search of PubMed/MEDLINE, Embase, and the Cochrane databases was carried out to identify studies reporting outcomes after transcervical CAS with flow reversal. Crude event rates for outcomes of interest were estimated by simple pooling of data. A proportion meta-analysis was also performed to estimate pooled outcome rates. RESULTS: A total of 18 studies (n = 2110 transcervical CAS procedures with flow reversal) were identified. A high technical success (98.25%) and a low mortality rate (0.48%) were recorded. The crude rates of major stroke, minor stroke, transient ischemic attack, and myocardial infarction (MI) were 0.71%, 0.90%, 0.57%, and 0.57%, respectively; a cranial nerve injury occurred in 0.28% of the procedures. A neck hematoma was reported in 1.04% of the procedures, and a carotid artery dissection occurred in 0.76% of the interventions; in 1.09% of the cases, conversion to carotid endarterectomy was required. After a meta-analysis was undertaken, the pooled technical success rate was 98.69% (95% confidence interval [CI], 97.19-99.70). A pooled mortality rate of 0.04% (95% CI, 0.00-0.29) was recorded. The pooled rate of any type of neurologic complications was 1.88 (95% CI, 1.24-2.61), whereas the pooled rates of major stroke, minor stroke, and transient ischemic attack were 0.12% (95% CI, 0.00-0.46), 0.15% (95% CI, 0.00-0.50), and 0.01% (95% CI, 0.00-0.22), respectively. The pooled rate of bradycardia/hypotension was 10.21% (95% CI, 3.99-18.51), whereas the pooled rate of MI was 0.08% (95% CI, 0.00-0.39). A neck hematoma after transcervical CAS was recorded in 1.51% (95% CI, 0.22-3.54) of the procedures; in 0.74% (95% CI, 0.05-1.95) of the interventions, conversion to CEA was required. Finally, a carotid artery dissection during transcervical CAS occurred in 0.47% (95% CI, 0.00-1.38) of the procedures. CONCLUSIONS: This updated systematic review and meta-analysis demonstrated that transcervical CAS with flow reversal is associated with high technical success, almost zero mortality, and low rates of major stroke, minor stroke, MI, and complications.
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Derivação Arteriovenosa Cirúrgica/efeitos adversos , Estenose das Carótidas/cirurgia , Complicações Pós-Operatórias/epidemiologia , Derivação Arteriovenosa Cirúrgica/instrumentação , Derivação Arteriovenosa Cirúrgica/métodos , Artéria Carótida Primitiva/cirurgia , Estenose das Carótidas/mortalidade , Veia Femoral/cirurgia , Humanos , Incidência , Ataque Isquêmico Transitório/epidemiologia , Ataque Isquêmico Transitório/etiologia , Veias Jugulares/cirurgia , Infarto do Miocárdio/epidemiologia , Infarto do Miocárdio/etiologia , Complicações Pós-Operatórias/etiologia , Medição de Risco/estatística & dados numéricos , Fatores de Risco , Stents , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/etiologia , Resultado do TratamentoRESUMO
OBJECTIVE: Common iliac artery aneurysms are present in more than a third of patients with abdominal aortic aneurysm and may pose a challenge during open and endovascular repair. Although embolization of the internal iliac artery is an established method, it may be complicated with buttock claudication, erectile dysfunction, colon ischemia, and pelvic necrosis. Iliac branch devices (IBDs), which permit preservation of the hypogastric artery, have been used to prevent these complications. We conducted a meta-analysis to assess the safety and outcomes of IBDs and to explore potential differences between the commercially available types of IBDs. METHODS: The meta-analysis was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. After review of the literature, 36 eligible studies with a total of 1502 patients were included in our study. A meta-analysis was performed with investigation of the following outcomes: technical success rate, 30-day mortality, 30-day patency, follow-up patency, endoleak, buttock claudication, and IBD-associated reintervention. Furthermore, we conducted a subgroup meta-analysis by commercial type of endograft among the outcomes of interest. RESULTS: Among all eligible studies, technical success of the method was 97.35% (95% confidence interval [CI], 96.27-98.29). The endoleak rate postoperatively and during the follow-up period was 12.68% (95% CI, 8.80-17.07). The 30-day patency of IBDs was estimated at 97.59% (95% CI, 96.49-98.54), whereas follow-up patency was 94.32% (95% CI, 91.70-96.54). Furthermore, reintervention rate associated with IBDs was 6.96% (95% CI, 5.10-9.03), and buttock claudication during the follow-up period was 2.15% (95% CI, 1.25-3.22). CONCLUSIONS: IBD seems to be a safe, feasible, and effective technique for the treatment of aortoiliac aneurysms in select patients with suitable anatomy. Further results are awaited to explore the long-term efficacy and durability of these devices.
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Aneurisma da Aorta Abdominal/cirurgia , Implante de Prótese Vascular/instrumentação , Prótese Vascular , Procedimentos Endovasculares/instrumentação , Aneurisma Ilíaco/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Aneurisma da Aorta Abdominal/fisiopatologia , Implante de Prótese Vascular/efeitos adversos , Procedimentos Endovasculares/efeitos adversos , Feminino , Humanos , Aneurisma Ilíaco/diagnóstico por imagem , Aneurisma Ilíaco/fisiopatologia , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Desenho de Prótese , Fluxo Sanguíneo Regional , Fatores de Risco , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND: Type Ia endoleak due to inadequate seal at the proximal end of the endograft is not infrequent during the initial operation. However, repeated attempts at balloon inflation or over-dilatation of the balloon can produce high axial pressures and can lead to aortic neck rupture with hemodynamic instability. METHODS: The purpose of the paper is to present a useful technique for simultaneously treating a type Ia endoleak and aortic neck rupture during endovascular abdominal aortic aneurysm repair. RESULTS: The technique for treating a type Ia endoleak has been described, but it was used for the first time to treat simultaneously a type Ia endoleak and rupture of the aortic neck with active bleeding during endovascular abdominal aortic aneurysm repair. After laparotomy, the left renal vein was ligated and a proximal control was achieved with placement of a vascular clamp above the renal arteries. Effective external banding of the infrarenal neck was performed with two 10-mm polyester Dacron limbs tied in the same fashion, close to one another, and parallel just below the renal arteries. We describe the steps of the surgical technique in detail and we analyze crucial issues associated with the technique. CONCLUSIONS: In this paper, we presented a useful technique for simultaneously treating a type Ia endoleak and aortic neck rupture during endovascular abdominal aortic aneurysm repair. Effective external banding of the infrarenal neck led to control of the hemorrhage and exclusion of the blood flow in the aneurysm sac.
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Angioplastia com Balão/efeitos adversos , Aneurisma da Aorta Abdominal/cirurgia , Ruptura Aórtica/cirurgia , Perda Sanguínea Cirúrgica/prevenção & controle , Implante de Prótese Vascular/efeitos adversos , Endoleak/cirurgia , Hemostasia Cirúrgica , Idoso de 80 Anos ou mais , Angioplastia com Balão/instrumentação , Aneurisma da Aorta Abdominal/complicações , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Ruptura Aórtica/diagnóstico por imagem , Ruptura Aórtica/etiologia , Prótese Vascular , Implante de Prótese Vascular/instrumentação , Conversão para Cirurgia Aberta , Endoleak/diagnóstico por imagem , Endoleak/etiologia , Humanos , Masculino , Stents , Resultado do TratamentoRESUMO
Angiosarcomas developing in nonfunctioning arteriovenous fistulas in renal transplant recipients are quite rare clinical entities with very poor prognosis. Herein we present a 60-year-old male who developed an angiosarcoma in a thrombosed radiocephalic fistula 6 years after renal transplantation. The patient presented with pain and swelling at the site of a previously asymptomatic fistula. The fistula was excised and diagnosis was made by histology. Despite radical surgery with an above-elbow amputation, the patient died of metastatic disease 6 months later.
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Derivação Arteriovenosa Cirúrgica/efeitos adversos , Oclusão de Enxerto Vascular/etiologia , Hemangiossarcoma/etiologia , Transplante de Rim/efeitos adversos , Diálise Renal , Trombose/etiologia , Extremidade Superior/irrigação sanguínea , Neoplasias Vasculares/etiologia , Amputação Cirúrgica , Angiografia Digital , Biópsia , Progressão da Doença , Embolização Terapêutica , Evolução Fatal , Oclusão de Enxerto Vascular/diagnóstico por imagem , Oclusão de Enxerto Vascular/patologia , Oclusão de Enxerto Vascular/cirurgia , Hemangiossarcoma/diagnóstico por imagem , Hemangiossarcoma/secundário , Hemangiossarcoma/cirurgia , Humanos , Imuno-Histoquímica , Imunossupressores/efeitos adversos , Ligadura , Masculino , Pessoa de Meia-Idade , Trombose/diagnóstico por imagem , Trombose/patologia , Trombose/cirurgia , Resultado do Tratamento , Neoplasias Vasculares/diagnóstico por imagem , Neoplasias Vasculares/patologia , Neoplasias Vasculares/cirurgiaRESUMO
Extracranial internal carotid artery (ICA) aneurysms are rare and most of them are considered of atherosclerotic etiology. Marfan syndrome (MS) is a systemic connective tissue disorder caused by mutation in the extracellular matrix protein fibrillin 1. Clinical manifestations of the MS include aortic aneurysms, dislocation of the ocular lens, and long bone overgrowth. The presence of extracranial ICA aneurysm in patients with MS is very rare. We report a 62-year-old female patient with MS presented with an extracranial ICA aneurysm. She was treated with aneurysmectomy and end-to-end anastomosis, with good outcomes. Only 10 cases of patients with MS and extracranial ICA aneurysm have been described in the literature. Clinical presentation, treatment, and outcome of these patients are reviewed and discussed.
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Aneurisma/etiologia , Doenças das Artérias Carótidas/etiologia , Artéria Carótida Interna , Síndrome de Marfan/complicações , Aneurisma/diagnóstico por imagem , Aneurisma/cirurgia , Doenças das Artérias Carótidas/diagnóstico por imagem , Doenças das Artérias Carótidas/cirurgia , Artéria Carótida Interna/diagnóstico por imagem , Artéria Carótida Interna/cirurgia , Angiografia por Tomografia Computadorizada , Feminino , Humanos , Síndrome de Marfan/diagnóstico , Pessoa de Meia-Idade , Resultado do TratamentoRESUMO
OBJECTIVE: We performed a systematic review and meta-analysis aiming to assess the mortality and morbidity of all published case series on thoracoabdominal aortic aneurysms (TAAAs) in experienced centers treated with open repair. METHODS: A systematic search of the literature published until April 2017 was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Separate meta-analyses were conducted for overall in-hospital mortality for TAAA, mortality according to the type of TAAA, spinal cord ischemia, paraplegia and paraparesis, cardiac events, stroke, acute kidney failure, and bowel ischemia. A metaregression analysis was performed with volume of the center, percentage of ruptured cases among the series, length of in-hospital stay, and publication year as covariates. RESULTS: A total of 30 articles were included in the meta-analysis, corresponding to a total of 9963 patients who underwent open repair for TAAAs (543 ruptured). The pooled mortality rate among all studies was 11.26% (95% confidence interval [CI], 9.56-13.09). Mortality was 6.97% (95% CI, 3.75-10.90), 10.32% (95% CI, 7.39-13.63), 8.02% (95% CI, 6.37-9.81), and 7.20% (95% CI, 4.19-10.84) for Crawford types I, II, III, and IV, respectively. Pooled spinal cord ischemia rate was estimated at 8.26% (95% CI, 6.95-9.67), whereas paraparesis and paraplegia rates were 3.61% (95% CI, 2.25-5.25) and 5% (95% CI, 4.36-5.68), respectively. We estimated a pooled cardiac event rate of 4.41% (95% CI, 1.84-7.95) and a stroke rate of 3.11% (95% CI, 2.36-3.94), whereas the need for permanent dialysis rate was 7.92% (95% CI, 5.34-10.92). Respiratory complications after surgery were as high as 23.01% (95% CI, 14.73-32.49). Metaregression analysis evidenced a statistically significant inverse association between mortality and the volume of cases performed in the vascular center (t = -2.00; P = .005). Interestingly, a more recent year of study publication tended to be associated with decreased in-hospital mortality (t = -1.35; P = .19). CONCLUSIONS: Our study showed that despite the advances in open surgical techniques, the morbidity and mortality of the technique continue to remain considerable. Despite the focus on mortality and spinal cord ischemia, respiratory complications, permanent postoperative renal dialysis, stroke rate, and cardiac events also affect the outcome. The estimated trend of lower mortality in high-volume centers suggests that perhaps this type of service should be provided in a few reference centers that have an established record and experience in the management of these patients.
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Aneurisma da Aorta Torácica/cirurgia , Ruptura Aórtica/cirurgia , Implante de Prótese Vascular , Competência Clínica , Hospitais com Alto Volume de Atendimentos , Hospitais com Baixo Volume de Atendimentos , Idoso , Aneurisma da Aorta Torácica/diagnóstico por imagem , Aneurisma da Aorta Torácica/mortalidade , Ruptura Aórtica/diagnóstico por imagem , Ruptura Aórtica/mortalidade , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/mortalidade , Humanos , Tempo de Internação , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Fatores de Risco , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND: Spinal cord ischemia (SCI) after abdominal aortic aneurysm (AAA) endovascular abdominal aortic aneurysm repair (EVAR) is a rare but devastating complication. The mechanism underlying the occurrence of SCI after EVAR seems to be multifactorial and is underreported and not fully elucidated. The aim of the study was to investigate the clinical outcomes in patients with this serious complication. METHODS: A systematic review of the current literature, as per Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement guidelines, was performed to evaluate the incidence of SCI after elective EVAR. PubMed and Scopus databases were systematically searched. Studies reporting on thoracic endovascular aneurysm repair, open repair of AAAs, and symptomatic or ruptured AAAs were excluded. RESULTS: In total, 18 articles reporting 25 cases were included. The mean age was 74.6 ± 7.6 (range: 60-90) years. The mean diameter of AAAs was 5.96 ± 1.0 cm (range: 4.7-8.3). Six cases also had aneurysms in the common iliac arteries. Seventy-one percent of AAAs had characteristics that made EVAR difficult and technically demanding. The mean operative time was prolonged, 254 ± 104.6 min, and associated with extensive intravascular handling. In 41.6% of cases, additional procedures were performed because of the difficult anatomy. Thirty-two percent of the cases had 1 internal iliac artery (IIA) embolized with coils or covered with the stent graft, and 14% had both IIAs compromised. In most of the cases, SCI symptoms presented immediately after the operation, and in 14.8% of patients, the symptoms had late presentation. Almost all cases had motor loss in the form of paraparesis or paraplegia, 54% of the cases also had diminished sensation, and 29.1% of the cases had urinary and/or fecal incontinence. Heterogeneity was observed regarding the management of the disease; in 6 of the cases, cerebrospinal fluid (CSF) drainage was performed, steroids were administered in 5, and in the other cases, an expectant strategy was selected. In 50% of the cases, only small improvement was seen at follow-up. In 25% of the cases, no improvement was seen, and 25% had almost complete recovery. CONCLUSIONS: Our study identified a common pattern among patients who present SCI after EVAR: difficult anatomy, prolonged operative time, additional procedures, and extensive intravascular handling that may have led to embolization. Patency of pelvic circulation preoperatively is also of importance. Regarding outcomes, only 25% of patients recovered, and in certain cases, CSF drainage may have significantly improved chances for recovery.
Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Implante de Prótese Vascular/efeitos adversos , Procedimentos Endovasculares/efeitos adversos , Isquemia do Cordão Espinal/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Aneurisma da Aorta Abdominal/mortalidade , Aneurisma da Aorta Abdominal/fisiopatologia , Implante de Prótese Vascular/mortalidade , Comorbidade , Procedimentos Cirúrgicos Eletivos , Procedimentos Endovasculares/mortalidade , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Fluxo Sanguíneo Regional , Fatores de Risco , Isquemia do Cordão Espinal/mortalidade , Isquemia do Cordão Espinal/fisiopatologia , Isquemia do Cordão Espinal/terapia , Resultado do TratamentoRESUMO
BACKGROUND: Bilateral limb occlusion after endovascular aortic repair (EVAR) is relatively uncommon. The aim of this study was to investigate the incidence of bilateral endograft limb occlusion after EVAR and identify potential anatomical predictive factors of occurrence. METHODS: A total of 579 patients underwent elective EVAR for abdominal aortic aneurysm between January 2010 and December 2015. All patients presenting with unilateral and bilateral occlusions were prospectively analyzed. A group of patients who underwent EVAR but did not present with endograft limb occlusion were matched for sex, age, and commercial type of endograft and were used as controls. RESULTS: Overall, 21 (3.6%) patients were complicated with unilateral endograft limb occlusion, whereas 8 (1.4%) of them presented with sequential (in different time) bilateral limb occlusion. We found that iliac artery angulation ≥60°, iliac perimeter calcification ≥50%, and endograft oversizing in the common iliac artery of more than 15% had the same impact and could equally result in limb occlusion. We coded the variables angle, calcification, and endograft limb oversizing of the common iliac artery with a score from 0 to 2 as follows: (1) 0: angle <60° in both limbs, 1: angle ≥60° in one limb, 2: angle ≥60° in both limbs; (2) 0: calcification <50%: in both limbs, 1: calcification ≥ 50%: in one limb, 2: calcification ≥ 50%: in both limbs; and (3) 0: endograft limb oversizing <15%, 1: endograft limb oversizing ≥15% in one limb, 2: endograft limb oversizing ≥15% in both limbs. A composite variable, consisting of the sum of scoring in variables was analyzed, with a score from 0 to 6. Our study showed that it was the most probable to be in the control group when score in the composite variable was 0-3, it was the most probable to have unilateral limb occlusion when score was 4-5, and finally, it was the most probable to have bilateral limb occlusion when score in the composite variable was equal to 6. CONCLUSIONS: Our study evidenced that the highest probability for bilateral limb occlusion occurred when implantation of a more than 15% oversized endograft in iliac arteries with iliac artery angulation ≥60° and iliac perimeter calcification ≥50% was present in both iliac arteries. It is therefore clear that limb occlusion requires the synergistic effect and interaction of bilateral multiple thrombogenic components in the iliac artery before it is manifested.
Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Implante de Prótese Vascular/efeitos adversos , Procedimentos Endovasculares/efeitos adversos , Oclusão de Enxerto Vascular/epidemiologia , Idoso , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Aneurisma da Aorta Abdominal/epidemiologia , Aneurisma da Aorta Abdominal/fisiopatologia , Aortografia/métodos , Prótese Vascular , Implante de Prótese Vascular/instrumentação , Angiografia por Tomografia Computadorizada , Procedimentos Endovasculares/instrumentação , Feminino , Oclusão de Enxerto Vascular/diagnóstico por imagem , Oclusão de Enxerto Vascular/fisiopatologia , Grécia/epidemiologia , Humanos , Artéria Ilíaca/diagnóstico por imagem , Artéria Ilíaca/cirurgia , Incidência , Masculino , Estudos Prospectivos , Desenho de Prótese , Fatores de Risco , Stents , Fatores de Tempo , Resultado do Tratamento , Calcificação Vascular/diagnóstico por imagem , Calcificação Vascular/epidemiologia , Grau de Desobstrução VascularRESUMO
BACKGROUND: Arteriovenous grafts made of polyurethane (PU) have the advantage of early cannulation obviating the placement of a central vein catheter in patients with an acute need for long-term hemodialysis. The aim of the present study was to evaluate the safety, efficacy and complication rate of PU vascular grafts for dialysis access in patients in whom early cannulation was performed. METHODS: Between January 2007 and December 2015, 125 straight brachial-axillary grafts were placed in patients with an acute thrombosis of a previous arteriovenous access. Sixty-four were PU and 61 were polytetrafluoroethylene (PTFE) grafts. Patency and complications rates were compared between the two groups. RESULTS: The median interval from implantation to cannulation was 1 day in the PU group vs 28 days in the PTFE group. Cumulative infection rate at 5 years was 13% and 8% in the PU and the PTFE groups, respectively (P = .6). None of the patients in the PU group developed a pseudoaneurysm necessitating intervention, compared with one patient in the PTFE group. Primary and secondary patency rates did not differ significantly between the two groups. The cumulative median primary patency was 23 months in the PU group vs 26 months in the PTFE group. Median secondary patency was 42 vs 33 months, respectively. Diabetes mellitus was the only factor adversely affecting graft patency in both groups. CONCLUSIONS: PU grafts offer the advantage of early cannulation with infection, pseudoaneurysm formation and patency rates similar to those of the PTFE grafts.
Assuntos
Derivação Arteriovenosa Cirúrgica/instrumentação , Implante de Prótese Vascular/instrumentação , Prótese Vascular , Oclusão de Enxerto Vascular/cirurgia , Politetrafluoretileno/química , Poliuretanos/química , Diálise Renal , Trombose/cirurgia , Idoso , Derivação Arteriovenosa Cirúrgica/efeitos adversos , Implante de Prótese Vascular/efeitos adversos , Cateterismo , Feminino , Oclusão de Enxerto Vascular/diagnóstico por imagem , Oclusão de Enxerto Vascular/etiologia , Oclusão de Enxerto Vascular/fisiopatologia , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Desenho de Prótese , Estudos Retrospectivos , Fatores de Risco , Trombose/diagnóstico por imagem , Trombose/etiologia , Fatores de Tempo , Resultado do Tratamento , Grau de Desobstrução VascularRESUMO
BACKGROUND: Treatment of superficial femoral artery (SFA) lesions remains challenging. We conducted a network meta-analysis of randomized controlled trials aiming to explore the efficacy of treatment modalities for SFA "de novo" lesions. METHODS: Eleven treatments for SFA occlusive disease were recognized. We used primary patency and binary restenosis at 12-month follow-up as proxies of efficacy for the treatment of SFA lesions. RESULTS: A total of 33 studies (66 study arms; 4659 patients) were deemed eligible. In terms of primary patency, odds ratios (ORs) with 95% confidence intervals (CIs) were statistically significantly higher in drug-eluting stent (DES; OR, 10.05; 95% CI, 3.22-31.39), femoropopliteal bypass surgery (BPS; OR, 7.15; 95% CI, 2.27-22.51), covered stent (CS; OR, 3.56; 95% CI, 1.33-9.53), and nitinol stent (NS; OR, 2.83; 95% CI, 1.42-5.51) compared with balloon angioplasty (BA). The rank order from higher to lower primary patency in the multidimensional scaling was DES, BPS, NS, CS, drug-coated balloon, percutaneous transluminal angioplasty with brachytherapy, stainless steel stent, cryoplasty (CR), and BA. Combination therapy of NS with CR and drug-coated balloon were the two most effective treatments, followed by NS, CS, percutaneous transluminal angioplasty with brachytherapy, cutting balloon, stainless steel stent, BA, and CR in terms of multidimensional scaling values for binary restenosis. CONCLUSIONS: DES has shown encouraging results in terms of primary patency for SFA lesions, whereas BPS still maintains its role as a principal intervention. On the contrary, BA and CR appear to be less effective treatment options.
Assuntos
Arteriopatias Oclusivas/terapia , Procedimentos Endovasculares , Artéria Femoral , Procedimentos Cirúrgicos Vasculares , Ligas , Angioplastia com Balão , Arteriopatias Oclusivas/diagnóstico por imagem , Arteriopatias Oclusivas/fisiopatologia , Braquiterapia , Fármacos Cardiovasculares/administração & dosagem , Materiais Revestidos Biocompatíveis , Constrição Patológica , Crioterapia , Stents Farmacológicos , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/instrumentação , Artéria Femoral/diagnóstico por imagem , Artéria Femoral/fisiopatologia , Humanos , Metanálise em Rede , Razão de Chances , Desenho de Prótese , Ensaios Clínicos Controlados Aleatórios como Assunto , Recidiva , Fatores de Risco , Stents , Fatores de Tempo , Resultado do Tratamento , Dispositivos de Acesso Vascular , Grau de Desobstrução Vascular , Procedimentos Cirúrgicos Vasculares/efeitos adversos , Procedimentos Cirúrgicos Vasculares/instrumentaçãoRESUMO
OBJECTIVE: This study examined the relationship between two new variables, tumor distance to base of skull (DTBOS) and tumor volume, with complications of carotid body tumor (CBT) resection, including bleeding and cranial nerve injury. METHODS: Patients who underwent CBT resection between 2004 and 2014 were studied using a standardized, multi-institutional database. Demographic, perioperative, and outcomes data were collected. CBT measurements were determined from computed tomography, magnetic resonance imaging, and ultrasound examination. RESULTS: There were 356 CBTs resected in 332 patients (mean age, 51 years; 72% female); 32% were classified as Shamblin I, 43% as Shamblin II, and 23% as Shamblin III. The mean DTBOS was 3.3 cm (standard deviation [SD], 2.1; range, 0-10), and the mean tumor volume was 209.7 cm3 (SD, 266.7; range, 1.1-1642.0 cm3). The mean estimated blood loss (EBL) was 257 mL (SD, 426; range, 0-3500 mL). Twenty-four percent of patients had cranial nerve injuries. The most common cranial nerves injured were the hypoglossal (10%), vagus (11%), and superior laryngeal (5%) nerves. Both Shamblin grade and DTBOS were statistically significantly correlated with EBL of surgery and cranial nerve injuries, whereas tumor volume was statistically significantly correlated with EBL. The logistic model for predicting blood loss and cranial nerve injury with all three variables-Shamblin, DTBOS, and volume (R2 = 0.171, 0.221, respectively)-was superior to a model with Shamblin alone (R2 = 0.043, 0.091, respectively). After adjusting for Shamblin grade and volume, every 1-cm decrease in DTBOS was associated with 1.8 times increase in risk of >250 mL of blood loss (95% confidence interval, 1.25-2.55) and 1.5 times increased risk of cranial nerve injury (95% confidence interval, 1.19-1.92). CONCLUSIONS: This large study of CBTs demonstrates the value of preoperatively determining tumor dimensions and how far the tumor is located from the base of the skull. DTBOS and tumor volume, when used in combination with the Shamblin grade, better predict bleeding and cranial nerve injury risk. Furthermore, surgical resection before expansion toward the base of the skull reduces complications as every 1-cm decrease in the distance to the skull base results in 1.8 times increase in >250 mL of blood loss and 1.5 times increased risk of cranial nerve injury.
Assuntos
Perda Sanguínea Cirúrgica , Tumor do Corpo Carotídeo/cirurgia , Traumatismos dos Nervos Cranianos/etiologia , Procedimentos Cirúrgicos Vasculares/efeitos adversos , Adulto , Idoso , Idoso de 80 Anos ou mais , Pontos de Referência Anatômicos , Brasil , Tumor do Corpo Carotídeo/complicações , Tumor do Corpo Carotídeo/diagnóstico por imagem , Tumor do Corpo Carotídeo/patologia , Colômbia , Angiografia por Tomografia Computadorizada , Traumatismos dos Nervos Cranianos/diagnóstico , Bases de Dados Factuais , Europa (Continente) , Feminino , Hong Kong , Humanos , Modelos Logísticos , Angiografia por Ressonância Magnética , Masculino , México , Pessoa de Meia-Idade , Razão de Chances , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Base do Crânio/diagnóstico por imagem , Resultado do Tratamento , Carga Tumoral , Ultrassonografia , Estados Unidos , Adulto JovemRESUMO
Type IIIb endoleak usually occurs years after the initial endograft implantation, and the cause is the chronic fatigue of the endograft. This rare case describes a type IIIb endoleak, appearing immediately after deployment of a new generation low-profile stentgraft and highlights the diagnostic and treatment challenges associated with the type IIIb endoleak. A 74-year-old man underwent elective EVAR for an infrarenal abdominal aortic aneurysm. A type IIIb endoleak near to the flow divider due to a fabric defect was diagnosed. The endoleak was successfully treated by endovascular positioning of a converter stent graft followed by the occlusion of the left limb with an iliac occluder and a femoro-femoral crossover bypass surgery. The ultrasound scan after 4 weeks showed no sign of endoleak. Occurrence of a type IIIb endoleak immediately after deployment is extremely rare. Based on the convenience of the intraoperative procedure and the anatomic characteristics of the aneurysm, we assume that the fabric defect might have occurred during loading of the endograft and subsequent confinement in the delivery catheter. We cannot definitely rule out the possibility of fabric damage induced by low-pressure balloon instrumentation. In case of a suspicion of a type IIIb endoleak, bilateral balloon occlusion of both limbs followed by antergrade aortography will help to identify the leak. In case the defect is near to the flow divider, aortouniliac grafting followed by femoro-femoral crossover bypass surgery represents an alternative option to conversion to open surgical repair.
Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Implante de Prótese Vascular/efeitos adversos , Endoleak/etiologia , Procedimentos Endovasculares/efeitos adversos , Idoso , Angiografia Digital , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Aortografia/métodos , Oclusão com Balão , Prótese Vascular , Implante de Prótese Vascular/instrumentação , Angiografia por Tomografia Computadorizada , Endoleak/diagnóstico por imagem , Endoleak/cirurgia , Procedimentos Endovasculares/instrumentação , Humanos , Período Intraoperatório , Masculino , Falha de Prótese , Reoperação , Stents , Resultado do Tratamento , UltrassonografiaRESUMO
BACKGROUND: Limited data exist concerning the biomechanical and central hemodynamic changes induced by endograft implantation in the descending thoracic aorta. The aim of this prospective ongoing study was to evaluate changes in arterial stiffness, assessed by pulse wave velocity (PWV; m/sec), and N-terminal pro-brain natriuretic peptide (NT-proBNP; pg/mL) levels in patients undergoing endovascular repair of descending thoracic aorta (thoracic endovascular aortic repair [TEVAR]). METHODS: Twenty-seven patients with thoracic aorta pathology who underwent elective TEVAR were included in the study. Blood samples were obtained preoperatively, 24 hr, 48 hr, and 6 months postoperatively, and serum levels of NT-proBNP were measured. PWV was determined before and 6 months after TEVAR. One-way analysis of variance by ranks was used to test the alterations in PWV (from baseline to 6 months) and NT-proBNP (along the 4 phases of evaluation). Post hoc analyses were appropriately performed. RESULTS: We recorded an increase in values of NT-proBNP from baseline (median = 96.1, interquartile range [IQR] = 82.7-117.9) to 24 hr postoperative (median = 201.6, IQR = 82.8-425.9), 48 hr postoperative (median = 317.0, IQR = 102.5-1,479.5), and 6 months postoperative (median = 144, IQR = 82.8-276.4). The Kruskal-Wallis H test showed a statistically significant increase (x2(3) = 11.17, P = 0.01) in NT-proBNP from baseline (rank mean = 22.19) toward the postoperative time points of evaluation (24 hr postoperative: 35.17 [change: +12.9, P = 0.02]; 48 hr postoperative: 42.64 [change: +20.5, P < 0.001]; 6 month postoperative: 34.91 [change: +12.7, P = 0.03]). An increase in PWV values was recorded from baseline (median = 11.9, IQR = 10.0-13.5) to 6 months postoperatively (median = 13.9, IQR = 11.9-16.4). That change achieved statistically significant level [x2(1) = 4.86, P = 0.03], with an increase in mean rank PWV (+7.5). CONCLUSIONS: Implementation of thoracic stent grafts may be associated with considerable increase of both arterial stiffness and NT-proBNP serum levels along time. Those results may indicate an adverse cardiac impact of TEVAR. However, the early and long-term effects of TEVAR on cardiovascular outcomes require further investigation.
Assuntos
Aorta Torácica/cirurgia , Doenças da Aorta/cirurgia , Implante de Prótese Vascular , Procedimentos Endovasculares , Peptídeo Natriurético Encefálico/sangue , Fragmentos de Peptídeos/sangue , Rigidez Vascular , Idoso , Idoso de 80 Anos ou mais , Aorta Torácica/diagnóstico por imagem , Aorta Torácica/fisiopatologia , Doenças da Aorta/sangue , Doenças da Aorta/fisiopatologia , Aortografia/métodos , Biomarcadores/sangue , Prótese Vascular , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/instrumentação , Distribuição de Qui-Quadrado , Angiografia por Tomografia Computadorizada , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/instrumentação , Feminino , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Análise de Onda de Pulso , Fatores de Risco , Stents , Fatores de Tempo , Resultado do Tratamento , Regulação para CimaRESUMO
BACKGROUND: Acute early carotid stent thrombosis (AcuteCST) is a rare complication after carotid artery stenting (CAS). The purpose of this retrospective study was to investigate the incidence, causes, and optimal management of AcuteCST. METHODS: Medical records of all patients undergoing CAS between 2008 and 2016 were retrospectively reviewed. The time of thrombosis, grade of stenosis, lesion side, preprocedural and postprocedural anticoagulants, causes, symptoms, treatment, recanalization, and outcome were reviewed. RESULTS: Overall, 674 patients were treated with CAS. Four cases of AcuteCST were identified (0.59%). In the first patient, the stent thrombosis was attributed to dissection caused by filter deployment within a distal internal carotid artery with 360° coiling. Notably, in 3 of the 4 cases of thrombosis a second overlapping stent had been deployed. In total, 41 patients of the cohort under investigation underwent overlapping stent deployment. The use of a second overlapping stent as a bail-out procedure due to dissection or malposition or due to long lesions was correlated with increased rate of thrombosis (3/41 [7.3%] vs. 1/633 [0.002%]). In 2 patients, carotid stents were thrombosed within 2 hr of the procedure. Endovascular thrombus aspiration and subsequent eversion carotid endarterectomy with stent explantation in the first patient and intrathrombus urokinase administration with thromboaspiration and additional stent placement in the second patient were followed. In the other 2 patients having their carotid stents thrombosed 3 and 4 days after the procedure, treatment with low weight molecular heparin and antiplatelet regimens was followed. CONCLUSIONS: The use of overlapping stents in the carotid artery is a predisposing factor for AcuteCST. Prognostic factors of this potentially devastating complication are the initial clinical presentation expressing the grade of ischemic brain damage, the accurate and timely recognition of the thrombosis, and the prompt restoration of oxygenated blood flow into the viable tissue at risk of infarction.