Self-Made Bovine Pericardial Tube Grafts for the Treatment of Abdominal Aortic Infections.

BACKGROUND: Aortic infections are uncommon but life-threatening diseases. The material of choice for aortic reconstruction is still a matter of debate. The aim of this study is to examine the short- and mid-term outcomes in the treatment of abdominal aortic infections using self-made bovine pericardium tube grafts. METHODS: This retrospective, single-center study collected all patients who underwent in situ abdominal aortic reconstruction using self-made bovine pericardial tube grafts between February 2020 and December 2021 in a tertiary care center. Patient comorbidities, symptoms, radiological, bacteriological, and perioperative findings, as well as postoperative outcomes, were analyzed. RESULTS: Bovine pericardial aortic tube grafts were used in 11 patients (10 males, median age 68.7 years). Two patients presented with a native aortic infection, and 9 had graft infections (4 bypass grafts, 4 endografts, and a plurioperated patient who had undergone both endovascular and open procedures). There were 2 emergent surgeries due to infectious aneurysm ruptures. All patients were symptomatic, and the most frequent clinical finding was lumbar or abdominal pain (36%), followed by wound infection (27%), and fever (18%). Seven bifurcated and 4 straight pericardial tube grafts were needed. Purulent drainage was obtained around the previous graft or in the aneurysmal sac in 7 cases; intraoperative cultures were positive in 6 cases (gram + bacteria). Two patients died in the immediate postoperative period (perioperative mortality 18%; urgent procedures 50%; scheduled procedures 11%). One patient had a major complication due to bilateral severe acute respiratory syndrome coronavirus 2 pneumonia. There was 1 single reintervention to control hemostasis due to bleeding nongraft-related. The median follow-up was 14.1 months (3-24 months). CONCLUSIONS: Our preliminary experience in the treatment of abdominal aortic infections by in situ reconstruction with self-made bovine pericardial tube grafts shows promising results. These should be confirmed in the long term.

Endovascular Treatment of a Traumatic Axillary Artery Rupture Using the Dual Bull's-Eye Technique.

BACKGROUND: Our purpose is to report a case of an axillary artery rupture treated by endovascular means using the dual bull's-eye technique. An 83-year-old woman with multiple comorbidities was diagnosed with axillary artery rupture after the reduction of a shoulder dislocation. METHODS: An endovascular repair attempt was made, but, despite the use of a double approach (antegrade and retrograde), reconnecting both ends of the severed artery was deemed not possible. 5-mm Amplatz GooseNeck snares were advanced from each access and superposed in a perpendicular plane. A percutaneous infraclavicular puncture with a lumbar needle was made through both snares, and a V14 guidewire was subsequently introduced. The guidewire was recovered through femoral and brachial accesses, and a 7 × 100 mm covered self-expandable stent was deployed. RESULTS: The final angiographic control did not show further hemorrhage, and the patient recovered radial pulse. Follow-up showed complete patency and no complications at 9 months after the procedure. CONCLUSIONS: The dual bull's-eye technique can be used as a resource tool in cases of arterial rupture, when the arterial continuity cannot be re-established by conventional approaches.

Midterm Results of Endovascular Treatment for Complete Iliac Axis Occlusions Using Covered Stents.

BACKGROUND: Endovascular treatment of complex aortoiliac disease is seeing a growing popularity despite the Trans-Atlantic Inter-Society Consensus (TASC) II recommendations for open surgery in this cases. However, the available evidence does not focus particularly on patients with complete unilateral iliac axis obstruction (CIAO) (TASC II D4 group). This study reports mid-term results of endovascular therapy with covered stents for CIAO. METHODS: This is single-center retrospective review of patients with CIAO endovascular treatment from January 2015 to December 2017 (3 years). Two types of covered stents were used, alone or combined: the Viabahn self-expandable stent (W. L. Gore, Flagstaff, AZ) and the Advanta V12 balloon-expandable stent (Atrium-Maquet, Hudson, NH). Thirty-day outcomes, long-term patency (assessed with Kaplan-Meier estimates), in-hospital stay, and limb salvage were analyzed. RESULTS: Thirty-nine patients with CIAO were treated in the period (87.2% male, mean age 64.3 ± 9 years). A majority presented with critical limb ischemia (56.4%, n = 22). Recanalization could be accomplished from an ipsilateral or contralateral femoral access in 82.1% of patients (1 case needed the use of a re-entry device), and from a left brachial access in 17.9%. Technical success was 100%. About 66.7% of cases received an aortic kissing stent technique. Common femoral artery/profundoplasty with prosthetic or bovine patch was associated with 74.3% of cases. Thirty-day mortality was 2.6% (1/39). Primary, assisted, and secondary patency rates at 24 months were all 96.8%. Mean in-hospital stay was 5 days; no limb loss was registered during follow-up. CONCLUSIONS: Endovascular treatment of complete iliac axis occlusions can offer comparable midterm patency rates to open surgery aortoiliac femoral bypass, when an adequate combination of balloon and self-expandable covered stents is used and an appropriate outflow through the common femoral artery is warranted.

Hybrid Repair of an Innominate Artery Mycotic Aneurysm with an "On-The-Table" Customized Endograft.

BACKGROUND: The objective of this report is to present a challenging case of a mycotic aneurysm of the innominate artery (IA) in a patient with a bovine aortic arch. MATERIALS AND METHODS: An 85-year-old woman presented with intermittent fever and positive blood cultures for Staphylococcus aureus. An echocardiogram and a positron emission tomography-computed tomography were performed, showing a hypermetabolic dilation of the IA compatible with a mycotic aneurysm with a type one bovine aortic arch. Conventional open arch repair and total endovascular repair with a custom-made aortic endograft were rejected given the elderly age and need for urgent repair. Treatment was achieved with a hybrid procedure, including a left carotid transposition and exclusion of the aneurysm with a modified Endurant II® iliac limb (two stents were cut off and it was resheathed in an inverted fashion) released through a prosthetic graft sutured onto the right axillary artery, followed by coil embolization of the sac. One year after the repair, the patient is well with complete exclusion of the aneurysm. CONCLUSIONS: Under the need for urgent repair, "on-the-table" modification of standard endograft components can be an effective solution for aneurysm exclusion when off-the-shelf endovascular stent grafts do not meet the anatomical requirements.

Use of aortic extension cuffs for preserving hypogastric blood flow in endovascular aneurysm repair with aneurysmal involvement of common iliac arteries.

BACKGROUND: Intentional hypogastric artery covering during endovascular repair of abdominal aortic aneurysms (EVAR) can carry a non-negligible rate of complications; to preserve pelvic blood flow, several approaches are in use, such as sandwich techniques, branched iliac devices, or the use of aortic extender cuffs in a bell-bottom configuration. We assess the performance of the latter for treatment of common iliac artery aneurysms during EVAR. METHODS: Prospective gathering of data in 21 dilated common iliac arteries (18-25 mm) with coexisting abdominal aorta aneurysm, which were treated from 2005 to 2010 and received a GORE(®) Excluder endograft and one (n = 14) or several aortic extenders in a bell-bottom configuration. Control group consisted of 136 EVARs performed with the same device in the same time frame. Median follow-up was of 47 months, with contrast-enhanced computed tomography assessment 1 month after the procedure and yearly thereafter. RESULTS: Age and comorbidities were homogeneously distributed among groups, although the aortic aneurysm diameter was lower in the bell-bottom group (50 mm vs. 58.2 mm, P < 0.001). There was no 30-day mortality registered in this group, and only one patient died during follow-up (5.3%), without relation with the aneurysmal disease. No significant differences were found in reintervention (15.8% vs. 14.7%, P = 0.707) or endoleak rates (36.8% vs. 38.9%, Fisher P = 1). There were no type I and four type II endoleaks, two of which precised treatment for sac growth. Endoleak-free survival (P = 0.994) and reintervention-free survival (P = 0.563) did not show differences either. CONCLUSION: Bell-bottom technique is a feasible and safe alternative for preserving hypogastric blood flow, and does not imply a higher risk of reintervention or endoleak at 3-year follow-up.

Outcomes of Self-Expanding Covered Stents for the Treatment of External ILIAC Artery Obstructive Disease.

PURPOSE: To describe the early results and mid-term patency rates of external iliac artery (EIA) stenting using self-expanding covered stents. METHODS: We conducted a multicenter retrospective study (2015-2021), including patients receiving primary endovascular treatment of external iliac artery occlusive disease with self-expanding covered stents. All patients were treated with the Viabahn (W.L Gore & Associates, Inc., Flagstaff, AZ-USA) stent. Patency and limb salvage rates were estimated with Kaplan-Meier curves. RESULTS: Ninety-three patients (mean age, 69 ± 9 years; 81% males) were treated for disabling claudication in 44%, rest pain in 28%, and tissue loss in 28%. TASC C/D lesions were present in 72% and iliac complete occlusion in 30%. Mean lesion length was 6.9 ± 2.4 cm; 30% had moderate/severe EIA calcifications; and the mean iliac tortuosity index was 1.17 ± 0.13. Technical success was 100%. There was one perioperative death (1.4%) and procedural complication rate was 6.5%. At 42 months (mean, 25 months), primary patency was 89.8% (95%CI 83-98); the presence of EIA tortuosity (tortuosity index > 1.25, 87.7 ± 11% vs 89.9 ± 8%; P = .6) or severe calcifications (87.6 ± 9% vs 96.0 ± 8%; P = .400) had no significant impact. After univariate analysis, the use of a stent with diameter < 8 mm (HR 8.5, 95%CI 3.24-14.22; P < .001) was negatively associated with primary patency. CONCLUSIONS: The use of self-expanding covered stents provided excellent early and mid-term results in the treatment of obstructive disease of the EIA, also in cases of high EIA tortuosity and high grade of calcifications. The use of a < 8 mm-diameter stent was associated with a reduced primary patency.

The Use Of The Gore® Hybrid Vascular Graft For Treatment Of Complex Iliofemoral Revascularization Procedures.

PURPOSE: To describe the uses and advantages of hybrid vascular grafts (HVGs) for complex iliofemoral revascularization procedures. CASE REPORT: We report 3 cases of iliofemoral occlusions repaired with the Gore HVG, used as an alternative technique to standardized common femoral artery (CFA) endarterectomy associated with iliac stenting or open repair. The indication in each of the 3 cases was different: In the first case, there was an absent CFA secondary to a mycotic pseudoaneurysm, in the second case, an iatrogenic lesion of the posterior wall of the CFA during the intervention was performed, and in the third case, the indication was because of thrombosis of a previous iliofemoral revascularization procedure. CONCLUSION: Although we only present 3 cases, the Gore HVG can be useful for complex iliofemoral revascularizations, serving as an alternative to standardized CFA endarterectomy plus iliac stenting in cases where there is a damaged or absent CFA, especially in high-surgical risk patients.

Pseudooclusión carotídea sintomática: tratamiento quirúrgico y resultados / Symptomatic pseudo-occlusion of the carotid artery: surgical treatment and outcomes

Introducción. Estudios multicéntricos recientes sugieren un dudoso beneficio de la endarterectomía carotídea (EC) en pacientes con pseudooclusión carotídea (POC). Objetivo. Evaluar el resultado clínico y hemodinámico de la EC en las POC sintomáticas. Pacientes y métodos. Entre 1999 y 2005 se intervinieron 13 pacientes con POC interna (3,96% de la cirugía carotídea) sintomáticas: siete con infarto cerebral (53,8%), tres con accidente isquémico transitorio (23,1%), dos con amaurosis fugaz (15,4%) y uno con síncopes de repetición (7,7%). En todos se realizó eco-Doppler y angiografía. Criterios diagnósticos del eco-Doppler: oclusión origen carótida interna, flujo en goteo o señal distal amortiguada. Criterios diagnósticos de la angiografía: obstrucción origen carótida interna con relleno filiforme distal. Se indicó la revascularización quirúrgica en todos ellos. Resultados. En 12 pacientes se pudo revascularizar la carótida interna (92,3%) y en uno se hizo su ligadura (7,7%). Técnica de revascularización: 11 EC y un bypass a carótida interna distal. Morbimortalidad quirúrgica del 0%. Control clínico: 3-69 meses (media: 31,6 meses) mediante eco-Doppler de troncos supraaórticos y transcraneal, encontrándose todos vivos, asintomáticos y con permeabilidad de la carótida interna. La reserva hemodinámica homolateral postoperatoria se ha encontrado normalizada en la mayoría de los pacientes. Conclusiones. Se considera indicada la intervención quirúrgica en casos sintomáticos de POC, ya que logra la repermeabilización de la carótida y la normalización de la reserva hemodinámica en un alto porcentaje, previniendo además la aparición de nueva sintomatología a largo plazo

Introduction. Recent multicentre studies suggest dubious benefits for carotid endarterectomy (CE) in patients with pseudo-occlusion of the carotid artery (POC). Aim. To evaluate the clinical and haemodynamic outcomes of CE in cases of symptomatic POC. Patients and methods. Between 1999 and 2005 interventions were carried out on 13 patients with symptomatic pseudo-occlusion of the internal carotid artery (3.96% of the carotid surgery conducted): seven with cerebral infarction (53.8%), three with transient ischemic attack (23.1%), two with amaurosis fugax (15.4%) and one with recurring syncopes (7.7%). Doppler ultrasonography and angiography recordings were performed in all cases. Diagnostic criteria for Doppler ultrasonography were occlusion with its origin in the internal carotid artery, a drip flow or attenuated distal signals. Diagnostic criteria for angiography were occlusion with its origin in the internal carotid artery with filiform distal filling. Surgical revascularisation was indicated in all cases. Results. The internal carotid artery was revascularised in 12 patients (92.3%) and ligation was performed in one of them (7.7%). Revascularisation technique: 11 CE and one distal internal carotid artery bypass. Surgical morbidity and mortality rates of 0%. Clinical monitoring: 3-69 months (mean: 31.6 months) using transcranial and supra-aortic trunk Doppler ultrasonography; all patients were alive, asymptomatic and with patency of the internal carotid artery. The post-operative homolateral haemodynamic reserve was found to be at normal levels in most of the patients. Conclusions. Surgical intervention is considered to be indicated in symptomatic cases of POC, as it achieves repatency of the carotid artery and normalises the haemodynamic reserve in a high percentage of cases; it also prevents the appearance of new symptoms in the long term

Historia natural de los aneurismas de la aorta torácica / The natural history of thoracic aortic aneurysms

Introducción. La historia natural de los aneurismas de la aorta torácica (AAT) está escasamente documentada debido a la dificultad en el diagnóstico de pacientes asintomáticos con AAT y la falta de estudios de cribado en la población. Su evolución natural es el crecimiento progresivo que concluye en la ruptura, con elevada mortalidad. Desarrollo. Revisión sistemática de la bibliografía publicada en las bases de datos Medline y PubMed mediante las palabras clave indicadas al pie y en especial con la evaluación de los registros informatizados con bases de datos amplias de universidades o sociedades europeas y americanas de cirugía vascular, cardiovascular y torácica. Conclusiones. La supervivencia a cinco años de los pacientes con AAT no tratados es menor del 19%; la causa principal de muerte es la ruptura aneurismática. El tamaño es el factor fundamental de riesgo de ruptura. El riesgo de ruptura aumenta exponencialmente cuando el diámetro de la aorta ascendente supera los 6 cm y el de la aorta descendente los 7 cm, e igualmente cuando se producen crecimientos rápidos. La cirugía mejora la evolución natural de la enfermedad. La historia natural de los AAT está determinada por su tamaño y tasa de crecimiento. El principio de toma de decisiones en el tratamiento de estos enfermos ha de basarse en determinar el riesgo individualizado de complicaciones en su evolución natural (ruptura, disección) frente al riesgo de la corrección quirúrgica en la experiencia del grupo quirúrgico concreto. La cirugía endovascular ha supuesto ya un impacto positivo en la historia natural al permitir la corrección de AAT en pacientes de alto riesgo, sin otras posibilidades previas de tratamiento

Introduction. The literature on the natural history of thoracic aortic aneurysms (TAA) is scarce due to the difficulty involved in diagnosing asymptomatic patients with TAA and the lack of screening studies conducted in the population. Its natural history comprises a progressive growth that ends in rupture, with a high mortality rate. Development. We carried out a systematic search of the literature published in the Medline and PubMed databases using the key words indicated in the footnote below. Additionally and perhaps more important, we also evaluated the computer records in extensive databases from universities and European or American vascular, cardiovascular and thoracic surgery societies. Conclusions. The survival rate of untreated TAA patients at five years is lower than 19%, the main cause of death being aneurysmal rupture. Size is a fundamental factor associated to the risk of rupture. The risk of rupture increases exponentially when the diameter of the ascending aorta exceeds 6 cm and that of the descending aorta goes beyond 7 cm; this is also the true when rapid growth takes place. Surgery improves the natural history of the disease. The natural history of TAAs is determined by their size and growth rate. The principle guiding decision-making in the treatment of these patients must be based on determining the individual risk of complications in their natural history (rupture, dissection) versus the risk involved in surgical correction, according to the experience of each particular surgical group. Endovascular surgery has had a positive effect on the natural history by allowing TAA to be corrected in high-risk patients who previously had no other chances of treatment open to them