A Greek Multicentre Study Assessing the Outcome of Late Rupture After Endovascular Abdominal Aortic Aneurysm Repair.

OBJECTIVE: Late rupture after endovascular aortic aneurysm repair (EVAR) for an abdominal aortic aneurysm (AAA) is an increasing complication associated with a high mortality rate. This study aimed to analyse the causes and outcomes in patients with AAA rupture after EVAR. METHODS: A multi-institutional Greek study of late ruptures after EVAR between 2008 - 2022 was performed. Primary outcomes were intra-operative and in hospital death. RESULTS: A total of 70 patients presented with late rupture after EVAR (proportion of ruptured EVARs among all EVARs, 0.6%; 69 males; mean age 77.2 ± 6.7 years). The mean time interval between EVAR and late rupture was 72.3 months (range 6 - 180 months). In all cases the cause of rupture was the presence of an endoleak (type I, 73%) with sac enlargement. Moreover, 34% of subjects with rupture after EVAR had been lost to follow up and 32% underwent a secondary intervention. Additionally, 57 patients (81%) were treated by conversion to open surgical repair (COSR) and the remainder by endovascular correction of endoleak (ECE). Eleven intra-operative deaths (16%) were recorded. The overall in hospital mortality rate was 41% (23% ECE vs. 46% COSR; p = .21). Of the patients who presented as initially haemodynamically stable, 23% died during hospitalisation, while the respective mortality rate for patients who presented as unstable was 78% (odds ratio [OR] 11.8, 95% confidence interval [CI] 3.6 - 39.1; p < .001). Multivariable logistic regression analysis revealed that severity of haemodynamic shock was the most significant risk factor for intra-operative (OR 7.15, 95% CI 1.58 - 32.40; p = .010) and in hospital death (OR 9.53, 95% CI 2.79 - 32.58; p < .001). CONCLUSION: These data underline the devastating prognosis of late rupture after EVAR. Haemodynamic status at presentation was an important predictive factor for death both in the ECE and COSR groups. Rigorous follow up and prompt evaluation of an unstable patient in case of rupture after EVAR is recommended.

Editor's Choice - Infective Native Aortic Aneurysms: A Delphi Consensus Document on Terminology, Definition, Classification, Diagnosis, and Reporting Standards.

OBJECTIVE: There is no consensus regarding the terminology, definition, classification, diagnostic criteria, and algorithm, or reporting standards for the disease of infective native aortic aneurysm (INAA), previously known as mycotic aneurysm. The aim of this study was to establish this by performing a consensus study. METHODS: The Delphi methodology was used. Thirty-seven international experts were invited via mail to participate. Four two week Delphi rounds were performed, using an online questionnaire, initially with 22 statements and nine reporting items. The panellists rated the statements on a five point Likert scale. Comments on statements were analysed, statements revised, and results presented in iterative rounds. Consensus was defined as ≥ 75% of the panel selecting "strongly agree" or "agree" on the Likert scale, and consensus on the final assessment was defined as Cronbach's alpha coefficient > .80. RESULTS: All 38 panellists completed all four rounds, resulting in 100% participation and agreement that this study was necessary, and the term INAA was agreed to be optimal. Three more statements were added based on the results and comments of the panel, resulting in a final 25 statements and nine reporting items. All 25 statements reached an agreement of ≥ 87%, and all nine reporting items reached an agreement of 100%. The Cronbach's alpha increased for each consecutive round (round 1 = .84, round 2 = .87, round 3 = .90, and round 4 = .92). Thus, consensus was reached for all statements and reporting items. CONCLUSION: This Delphi study established the first consensus document on INAA regarding terminology, definition, classification, diagnostic criteria, and algorithm, as well as reporting standards. The results of this study create essential conditions for scientific research on this disease. The presented consensus will need future amendments in accordance with newly acquired knowledge.

Individual Patient Data Meta-Analysis of 10-Year Follow-Up after Endovascular and Open Repair for Ruptured Abdominal AorticAneurysms.

BACKGROUND: Endovascular aortic repair (EVAR) has conferred an early survival advantage compared to an open surgical repair (OSR) in patients with ruptured abdominal aortic aneurysms (rAAA). However, the long-term survival benefit after EVAR was not displayed among randomized controlled trials (RCTs), whereas many non-RCTs have provided conflicting results. We conducted a time-to-event individual patient data (IPD) meta-analysis on long-term rAAA data. METHODS: All studies comparing mortality after EVAR versus OSR for rAAA were included. We used restricted mean survival times (RMSTs) as a measure of life expectancy for EVAR and OSR. RESULTS: A total of 21 studies, including 12,187 patients (4952 EVAR and 7235 OSR) were finally deemed eligible. A secondary IPD analysis included 725 (372 EVAR and 353 OSR) patients only from the 3 RCTs (Immediate Management of the Patient With Rupture : Open Versus Endovascular Repair, Endovasculaire ou Chirurgie dans les Anévrysmes aorto-iliaques Rompus and Amsterdam Acute Aneurysm Trial trials). Among all studies, the median survival was 4.20 (95% confidence interval [CI]: 3.70-4.58) years for EVAR and 1.91 (95% CI: 1.57-2.39) years for OSR. Although EVAR presented with increased hazard risk from 4 to 7 years, which peaked at 6 years after the operation, the RMST difference was 0.54 (95% CI: 0.35-0.73; P < 0.001) years gained with EVAR at the end of the 10-year follow-up. IPD meta-analysis of RCTs did not demonstrate significant differences. CONCLUSIONS: At 10-years follow-up, EVAR was associated with a 6.5 month increase in life expectancy when compared to OSR after analyzing all eligible studies. Evidence from our study suggests that a strict follow-up program would be desirable, especially for patients with long-life expectancy.

Antegrade Endograft Deployment with Supra-Aortic Debranching to Treat Arch and Descending Thoracic Aortic Lesions. A Single-Center Experience.

BACKGROUND: Thoracic endovascular aortic repair (TEVAR) is a widely used procedure that has drastically changed the management of thoracic aortic diseases. We assess the effectiveness of supra-aortic debranching during antegrade TEVAR procedures with a retrospective analysis of our clinical experience. METHODS: Between December 2005 and April 2017, 55 patients underwent 64 TEVAR procedures. Among them, there were 8 male patients, mean age 72, who underwent hybrid antegrade stent-graft deployment. Particularly, for degenerative aneurysms of the aortic arch, 3 patients for aneurysm of descending thoracic aorta 3, for post-traumatic pseudoaneurysm 1, and for penetrating aortic ulcer 1 which had resulted in an aortoesophageal fistula. Proximal landing zones were Z0:1, Z1:3 and Z2:4. Type I hybrid aortic arch repair was performed in 1 case, carotid-carotid bypass in 2, carotid-subclavian in 5 and aorto-carotid in 1. RESULTS: The 30-day postoperative mortality was 12.5%. One patient suffered a temporary right hemiplegia which resolved after left aorto-carotid bypass. No endoleaks were observed postoperatively and in follow-up period. In the long term and a mean follow-up of 4.9 years, there were no deaths related to the stent-graft implantation or to revascularization procedures. Regarding the aortic arch rerouting procedure, there were no pseudoaneurysm or other anastomotic events. CONCLUSIONS: Antegrade delivery of the endograft, combined with hybrid and revascularization procedures of the supra-aortic vessels is a safe treatment modality, in complex hostile anatomies. However, further improvements are recommended due to the presence of neurologic complications and reinterventions.

In situ bypass and extra-anatomic bypass procedures result in similar survival in patients with secondary aortoenteric fistulas.

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.

Snare Entrapment During EVAR Limb Cannulation Resulting in Open Conversion. A Rare Complication.

We present an unreported complication that occurred during an accidental loss of the ipsilateral limb's wire during EVAR. During an endovascular repair of an abdominal aortic aneurysm (EVAR), unintentional loss of the ipsilateral limb's wire during deployment and withdrawal of the endogaft's main body occurred. The snare's loops were entrapped while attempting to catch the wire through the limb. Multiple maneuvers were performed to detach the snare, but all were unsuccessful. We then performed a conversion to open repair. In conclusion, commercially available endografts should include standard radiopaque markers in the ipsilateral limb to facilitate retrograde cannulation. Retrieval via the snare should not be performed proximal to the gate of the limb.

Contemporary Outcomes After Partial Resection of Infected Aortic Grafts.

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 (P = 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; P = 0.01) as well as aortoenteric fistula (HR 1.9, P = 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, P = 0.04), as well as those with American Society of Anesthesiologists classification less than 3 (HR 0.35, P = 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, P = 0.01) and less likely to have patent repairs during follow up (59% vs. 32%, P = 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.

The use of iliac branch devices for preservation of flow in internal iliac artery during endovascular aortic aneurysm repair.

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.

A Technical Tip of Aortic Stump Reinforcement with Plication of the Falciform Ligament of the Liver.

BACKGROUND: The residual stump after excision of an infected aortic graft may be subject to acute disruption-blowout-because of recurrence of infection or fatigue due to the mechanical stress. We present an innovative technique in which we used the falciform ligament of the liver to reinforce the aortic stump. METHODS: We excised the falciform ligament by giving attention to avoid any bleeding from the liver. The aortic stump was reinforced with synthetic, monofilament, nonabsorbable polypropylene sutures and the falciform ligament of the liver was plicated inside the stump and further sutured with polypropylene sutures. RESULTS: After 5 months, he is in excellent condition. His laboratory examination is normal, he has stopped taking antibiotics, gained his initial weight, and recovered full activity. CONCLUSIONS: We presented an innovative technique in which we used the falciform ligament of the liver to reinforce the aortic stump after excision of an infected aortobiiliac synthetic graft. This technique can be an alternative option in patients with weak arterial wall or extended bacterial local infection in the retroperitoneal area which renders the aortic wall tissue extremely stiff to be folded and sutured. This technique may enhance the mechanical integrity of the stump.

Aortic Banding to Treat Simultaneously a Type Ia Endoleak and Aortic Neck Rupture during Endovascular Abdominal Aortic Aneurysm Repair.

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.

Long-Term Outcomes of Percutaneous Stenting of Aortic Endograft Limb Occlusion.

INTRODUCTION: To investigate the safety and efficacy of percutaneous stenting for the management of chronic ischemia caused by endograft limb occlusion following endovascular aortic aneurysm repair (EVAR). METHODS: This is a retrospective, single-center study investigating all patients who underwent percutaneous endovascular covered or bare metal stent placement for the management of intermittent claudication (IC) or critical limb ischemia following EVAR limb occlusion, between January 2010 and October 2017. Cases suffering from acute limb ischemia were treated surgically and were excluded from the analysis. Primary outcome measures were technical success and symptoms-free interval. Secondary outcome measures included clinically driven target-lesion reintervention (TLR)-free survival, primary patency, and complication rates. RESULTS: Of 29 limb occlusions, 11 limbs (11 patients; 100% male; mean age: 71.6 ± 6.9 years) were treated percutaneously and were included in the study. The majority suffered from IC (10/11; 90.9%) with a single case of rest pain. Technical success was obtained in 10 patients (90%). No major complications occurred. Mean follow-up time was 37.6 ± 25.7 months. Stent grafts were mainly used, while and in 2 cases (18.18%), only nitinol bare stents were deployed. According to Kaplan-Meier analysis, both symptoms-free interval and primary patency were 83.33% in up to 5 years follow-up. TLR-free survival was 100% at 5 years, as 2 cases of claudication relapse were managed conservatively. CONCLUSIONS: Percutaneous stenting for the management chronic ischemia due to EVAR limb occlusion is feasible and safe, with satisfactory long-term outcomes. Careful patient selection warrants clinical success.

Angiosarcoma of a Thrombosed Arteriovenous Fistula in a Renal Transplant Recipient.

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.

Extracranial Internal Carotid Artery Aneurysm in a Patient with Marfan Syndrome.

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.

Spontaneous isolated superior mesenteric artery dissection: Systematic review and meta-analysis.

OBJECTIVES: Spontaneous isolated superior mesenteric artery dissection (SISMAD) is a rare disease with an incidence of 0.06%. The purpose of the meta-analysis was to identify the outcomes associated with the various treatment options in the management of asymptomatic and symptomatic patients with SISMAD. METHODS: Eligible studies were selected by searching PubMed, EMBASE, and Cochrane Library. Endpoints were outcome of asymptomatic patients treated conservatively, resolution of symptoms according to the treatment approach, rate of symptomatic patients switched from conservative to the endovascular and/or open repair, characteristics of the dissected lesion, and findings regarding the remodeling of superior mesenteric artery. RESULTS: We identified 30 studies including 729 patients. Among them, 608 (83.4%) were symptomatic and were managed with conservative (438/72%), and/or endovascular (139/22.8%) and/or open treatment (31/5%). The remaining were asymptomatic and they were treated solely conservatively. A high rate of resolution of symptoms (92.8%) was noted for patients treated conservatively. Conversion from conservative treatment to either endovascular or open procedure was required in 12.3% and 4.4%, respectively. Resolution of symptoms was observed in 100% for those treated with open procedure and 88.8% for those treated endovascularly. The pooled rate of bowel ischemia in patients treated conservatively was 3.75% (95% confidence interval = 1.15-7.27). Complete remodeling was achieved in 32% and partial in 26% of those who were treated conservatively. CONCLUSIONS: The majority of symptomatic patients with SISAMD were treated conservatively and showed an uncomplicated course and only a small percentage required conversion to endovascular or open repair. This might highlight the benign course of the disease.

Open repair of thoracoabdominal aortic aneurysms in experienced centers.

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.

Emergent Carotid Stent Removal after Carotid Stent Thrombosis.

BACKGROUND: Acute carotid stent thrombosis in patients undergoing CAS is a relatively rare and potentially devastating complication influencing significantly the quality of life. With the increasing use of stenting in clinical practice, it is expected to represent a more often encountered complication for physicians performing CAS. Emergent removal of the thrombosed stent and endarterectomy is indicated when the intrastent thrombosis is not associated with intracranial carotid branch thrombosis. METHODS: The technique and its peculiarities and tip and tricks of this carotid operation have not been described meticulously. We describe the steps of the surgical technique in detail, and we analyze crucial issues associated with the technique. RESULTS: We have performed this emergency operation in 2 patients with acute early stroke after CAS. Both patients presented recovery of their previous neurologic deficits and had uneventful postoperative course. CONCLUSIONS: We illustrate the technique of emergent removal of the thrombosed stent after CAS. If carotid stent thrombosis with no distal extension is documented post procedurally, emergency stent removal and endarterectomy is the preferred strategy. Special care should be taken to avoid risk of clot dislocation and consequent cerebral embolization during the surgical exposure of the carotid bifurcation and placement of the vascular clamps.

Hepatorenal Revascularization Enables Endovascular Aneurysm Repair on a Patient with Abdominal Aortic Aneurysm and an Ectopic Right Renal Artery.

In last 30 years, the endovascular aneurysm repair (EVAR) has become the standard method of treatment of abdominal aortic aneurysms (AAAs). Nevertheless, the method has limitations mainly based on the anatomic characteristics of the specific aneurysm. In these cases, a combination of endovascular and open techniques can be used. We describe a case of a patient with an infrarenal AAA and an ectopic right renal artery emerging from within the aneurysm sac. The patient was treated with a combination of endovascular and open techniques. In particular, he underwent a hepatorenal revascularization followed by a standard EVAR procedure, with a successful final outcome. For the treatment of AAA disease, the combination of open and endovascular procedures can overcome difficulties, where a standard EVAR cannot be an option.

Remote Ischemic Preconditioning Decreases the Magnitude of Hepatic Ischemia-Reperfusion Injury on a Swine Model of Supraceliac Aortic Cross-Clamping.

BACKGROUND: Temporary hepatic ischemia is inevitable during open aortic surgery when supraceliac clamping is necessary, as in thoracoabdominal or pararenal aneurysms. Remote ischemic preconditioning (RIPC) has been described as a potential protective means against ischemia-reperfusion injury (IRI) in various tissues including the liver. The aim of this experimental study was to detect the effect of RIPC on liver IRI in a model of supraceliac aortic cross-clamping. METHODS: An animal study was performed. Four groups of 6 swines each were examined: the control (sham) group, the ischemia-reperfusion (IR) group, and 2 remote ischemic preconditioning groups (RIPC I and RIPC II group). In the IR group, the animals underwent a complete cessation of the splanchnic arterial circulation for 30 min by a concomitant occlusion of the supraceliac and the infrarenal aorta. In the RIPC groups, a remote preconditioning was applied before the splanchnic ischemia. This consisted of a temporary occlusion of the infrarenal aorta for 15 min followed by 15 min of reperfusion (RIPC I group), and 3 cycles of 5 min similar ischemia, followed by 5 min of reperfusion each (RIPC II group). All animals were followed for 24 hr after the ischemia (reperfusion period). The liver ischemia-reperfusion injury was assessed by examining specific serum biomarkers indicating the magnitude of metabolic injury from selective blood samples of the hepatic circulation. In particular, the following parameters were examined: C-reactive protein, interleukin 6, tumor necrosis factor a, ferritin, and L-arginine. RESULTS: All parameters were affected in the IR group as compared to the sham group. Both RIPC groups developed a less serious change as compared to the IR group, in all examined parameters. CONCLUSIONS: In an animal study of splanchnic ischemia produced in a way to this produced during a supraceliac aortic aneurysm open repair, the remote ischemic preconditioning seemed to attenuate the effect of hepatic ischemia-reperfusion injury. CLINICAL RELEVANCE: Remote ischemic preconditioning produced with short bouts of ischemia of the lower body by temporary clamping of the infrarenal aorta might be used as a means of decreasing the detrimental effects of hepatic ischemia-reperfusion injury after supraceliac aortic cross-clamping. This was found in a swine model of suprarenal AAA open repair by studying the variance of certain biological biomarkers in selective blood samples retrieved from the hepatic vein.

Bilateral Endograft Limb Occlusion after Endovascular Aortic Repair: Predictive Factors of Occurrence.

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.

Spinal Cord Ischemia following Elective Endovascular Repair of Infrarenal Aortic Aneurysms: A Systematic Review.

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.