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BACKGROUND: Endovascular repair of complex abdominal (CAAA) and thoracoabdominal aortic aneurysms (TAAA) with fenestrated and branched devices (F/BEVAR) represents the first-line treatment in old or unfit patients. Currently, the widespread diffusion of these techniques has led to a progressive increase of complex endovascular procedures also in younger and fitter patients, but the related results have been only minimally reported without long-term data. We investigated the long-term results of F/BEVAR for CAAA and TAAA repair in young and fit patients. METHODS: All consecutive patients, aged 70 or younger, undergone F/BEVAR for CAAA and TAAA over the last 13 years at two tertiary Institutions were included in the study. All subjects presented a low to intermediate risk according to the Society for Vascular Surgery (SVS) clinical comorbidity grading system. The primary endpoints were technical and clinical success, late overall and aortic-related survival. Major complications and specific target vessel-related outcomes were investigated as secondary endpoints. RESULTS: A total of 183 patients (155 males, 84.7%; mean age 64.5 + 5.7 years, range 33-70) underwent F/BEVAR during the study period, for a total of 167 (91.3%) degenerative and 16 (8.7%) post-dissection aneurysms including 44 (24%) juxtarenal, 33 (18%) pararenal and 106 (58%) thoraco-abdominal aortic aneurysms. Technical and clinical success were achieved in 176 (96.2%) and 171 patients (93.4%), respectively. Four patients (2.2%) died perioperatively, of which 2 (1.1%) operated in emergency. Postoperatively, 5 patients (2.7%) presented permanent grade 3 spinal cord injury, and 3 (1.6%) renal failure needing permanent dialysis. The mean follow-up was 65.7 + 39.6 months (range 1-158). Estimated overall and aortic-related survival at 12, 60, and 120 months was 94.0%, 85.1%, 72.2%, and 97.8%, 97.8%, 96.2%, respectively, while reintervention and branch instability-free survival at the same time spam was 84.4%, 71.8%, 71.8%, and 93.2%, 86.3%, 72.2%, respectively. An aneurysm growth > 5 mm was detected in 6 patients (3.3%) while a sac shrinkage > 5 mm was achieved in 118 cases (64.5%). The Cox regression analysis demonstrated the need for unplanned procedure as the only risk factor for overall mortality [OR=3.331 (1.397-7.940), p < 0.01]. CONCLUSION: F/BEVAR in young and fit patients led to a low perioperative mortality and major morbidity, and favorable overall survival rate in the long-term making this technique particularly appealing in such a subgroup of patients. The availability of long-term data derived from the results of young patients, may additionally provide helpful information to re-define indication for treatment and allow future targeted device and technique improvements.
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INTRODUCTION: The complexity of the peripheral recanalization comes from the difficulty to cross the lesion or get into the subintimal space and its re-entry afterward, with a high risk of complications like artery dissection and/or rupture, which are life-threatening complications. To our knowledge, we report the first case of the use of a homemade steerable sheath for the successful revascularization of a heavy chronic total occlusion in a patient with unsuitable upper vascular access. TECHNIQUE: By contralateral vascular access and the use of a 6Fr 55-cm Cook Flexor sheath and a pre-looped 0.014" choice guidewire, a steerable homemade sheath was used to achieve the support, pushability, and steer needed to access the subintimal space at the origin of a heavy occluded common iliac artery, thus giving us the ability to cross the lesion. CONCLUSIONS: The homemade steerable sheath is feasible, quick, cheap, and easy to use, sparing the use of re-entry systems and catheters for the attempts of subintimal navigation. In addition, this technique gives the advantage to steer the catheters and wires as needed, avoiding non-desired re-entry points with secondary collaterals lumen compromise or extensive dissections.
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Angioplastia de Balón , Arteriopatías Oclusivas , Humanos , Arteria Ilíaca , Resultado del Tratamiento , Arteriopatías Oclusivas/terapia , Catéteres , Enfermedad Crónica , Arteria FemoralRESUMEN
OBJECTIVE: To assess the complex management of arterial anomalies in Vascular Ehlers-Danlos Syndrome (vEDS). METHODS: We report the case of a 34-year-old male, diagnosed with vEDS, who presented with acute intraperitoneal hemorrhage caused by the rupture of a splenic artery aneurysm, treated in emergency with coil embolization and splenectomy. Computed Tomography (CT) scan showed the concomitant presence of right renal artery (RRA) and common hepatic artery (CHA) aneurysms. RESULTS: Both aneurysms were conservatively managed and the patient went through serial CT imaging. After 3 months, rapid regression of the vascular abnormalities led to complete disappearing of RRA and CHA aneurysms, confirmed at 24-month imaging follow-up. In the same time span, two pseudoaneurysms developed in other sites used for transarterial access, requiring two secondary interventions. The present case emphasizes the unpredictability of disease's evolution and arterial complications in vEDS. Conservative management of complex lesions such as visceral artery aneurysms, which in this case resulted to be the best strategy, avoided the risks associated with surgical intervention in such fragile tissues. The reported complications underline that operative indications should be carefully weighed in these patients.
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OBJECTIVES: To assess the outcomes of Cook t-Branch off-the-shelf multibranched stent graft in the treatment of complex aortic aneurysms with narrow internal aortic lumen. METHODS: Between 2016 and 2020, 48 patients (mean age, 73 years) underwent elective or urgent or emergent Cook t-Branch implantation for thoracoabdominal or para/juxtarenal aortic aneurysms in two Italian vascular centers. Among these, 20 patients presented a paravisceral or pararenal luminal diameter of less than 25 mm. Major clinical and radiologic outcomes of patients with narrow aortic lumen were compared with patients with a larger lumen in a multicenter, nonrandomized, retrospective fashion. RESULTS: The in-hospital mortality was 10% (5% in the elective setting). Spinal cord ischemia occurred in 6% of the cases. During a mean follow-up of 18 months (range, 1-63 months), late t-Branch procedure-related mortality and the need for reintervention was 0% and 12%, respectively. Comparing the outcomes of patients with large internal aortic lumen (group 1) with patients with small lumen (group 2), no significant difference was found regarding fluoroscopy time (P = .3); technical success (P = 1); early (P = .4) and late (P = 1) mortality; spinal cord ischemia (P = .2); bowel ischemia (P = .5); renal (P = .7), cardiac (P = 1), and respiratory complications (P = 1); reintervention rate (P = 1); and primary patency rate of stented target vessels (P = 1). CONCLUSIONS: The use of the Cook t-Branch in our experience was safe and effective in the treatment of complex aortic aneurysms regardless the caliber of the aortic lumen. With all the limitations of a small sample size, this approach has demonstrated to be feasible when maneuverability is decreased, with low mortality and morbidity, and acceptable reintervention rates. Perioperative mortality remains closely related to clinical presentation. Large-scale studies are needed to confirm these results.
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Aneurisma de la Aorta Torácica , Implantación de Prótesis Vascular , Procedimientos Endovasculares , Isquemia de la Médula Espinal , Anciano , Aneurisma de la Aorta Torácica/diagnóstico por imagen , Aneurisma de la Aorta Torácica/cirugía , Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/efectos adversos , Procedimientos Endovasculares/efectos adversos , Humanos , Complicaciones Posoperatorias , Diseño de Prótesis , Estudios Retrospectivos , Factores de Riesgo , Isquemia de la Médula Espinal/etiología , Stents/efectos adversos , Factores de Tiempo , Resultado del TratamientoRESUMEN
The aim of this paper is to describe a case of complete transfemoral approach for endovascular treatment of a large intercostal patch aneurysm with custom-made stent-graft in a patient with Loeys-Dietz syndrome and previous multiple aortic operations. Three aortic components were used to exclude a 65-mm intercostal patch aneurysm. Because of the reimplantation site of supra-aortic trunks in a previous open arch repair, we used a complete transfemoral approach with a homemade steerable sheath to deliver all the renovisceral bridging stents through the downward side-branches. No major complications were registered. A 6-month follow-up resulted uneventfully, and an initial shrinkage of the aneurysmal lesion was found. The use of a homemade steerable sheath was safe and effective for catheterization and stenting of all the target vessels through the downward side branches.
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Aneurisma , Aneurisma de la Aorta Torácica , Implantación de Prótesis Vascular , Procedimientos Endovasculares , Aneurisma/cirugía , Aneurisma de la Aorta Torácica/diagnóstico por imagen , Aneurisma de la Aorta Torácica/etiología , Aneurisma de la Aorta Torácica/cirugía , Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/efectos adversos , Procedimientos Endovasculares/efectos adversos , Humanos , Diseño de Prótesis , Stents/efectos adversos , Resultado del TratamientoRESUMEN
OBJECTIVE: To report the results of a single-centre in the treatment of extensive aorto-iliac occlusive disease (AIOD) by the covered endovascular reconstruction of aortic bifurcation (CERAB) technique. METHODS: A retrospective analysis was conducted on data obtained from the review of medical charts of all consecutive patients treated with CERAB technique for AIOD between January 2016 and December 2019 in San Giovanni-Addolorata Hospital (Rome, Italy). Clinical examination, duplex ultrasound with ankle-brachial index measurement and contrast-enhanced computed tomography angiography were performed preoperatively. A clinical and ultrasound follow-up was carried out at one month and then half yearly after the intervention to evaluate patients' clinical status, limb salvage, target lesion revascularization rate, primary and secondary patency rate. RESULTS: During the study period, 24 patients (14 men, 58.3%; 10 women, 41.7%; median age 59 years, range 37-79 years) underwent CERAB for AIOD (TASC II C 29.2%, TASC II D 70.8%). Indications for treatment were: intermittent claudication in 18 patients (75%) and critical limb ischemia in 6 (25%). Technical success was achieved in all cases. Perioperative minor complications occurred in three cases (12.5%). One patient reported an intraoperative iliac rupture requiring adjunctive covered stenting. Median hospital length of stay was two days (range 1-9). No patient died perioperatively nor at the last follow-up. At a median follow-up of 18 months (range 6-48 months), mean ankle-brachial index increased significantly (from 0.62 ± 0.15 before the procedure to 0.84 ± 0.18) (P < 0.001) and target lesion revascularization rate was 12.5%. At two years, the limb salvage rate was 100%, and primary and secondary patency rates were 87.5% and 100%, respectively. CONCLUSION: CERAB technique demonstrated to be effective at the mid-term follow-up with low rate of complications and short length of stay. Long-term results and more robust data are needed to affirm this technique as the first-line treatment for extensive AIOD. However, it could become the preferred option especially in fragile patients and during contemporary COVID-19 pandemic due to the current limitations in vascular and critical care bed capacity.
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Enfermedades de la Aorta , Arteriopatías Oclusivas , COVID-19 , Procedimientos Endovasculares , Síndrome de Leriche , Adulto , Anciano , Enfermedades de la Aorta/diagnóstico por imagen , Enfermedades de la Aorta/etiología , Enfermedades de la Aorta/cirugía , Arteriopatías Oclusivas/diagnóstico por imagen , Arteriopatías Oclusivas/etiología , Arteriopatías Oclusivas/cirugía , Procedimientos Endovasculares/efectos adversos , Femenino , Humanos , Arteria Ilíaca/diagnóstico por imagen , Arteria Ilíaca/cirugía , Masculino , Persona de Mediana Edad , Pandemias , Estudios Retrospectivos , Stents , Resultado del Tratamiento , Grado de Desobstrucción VascularRESUMEN
OBJECTIVE: The aim of this study was to evaluate early and late results of hybrid repair techniques for Kommerell's diverticulum (KD). METHODS: All patients who underwent hybrid repair (thoracic endovascular aortic repair + supra-aortic debranching) for KD between 2009 and 2018 were included in this retrospective multicenter study (three Italian centers). A proximal landing zone (PLZ) of at least 2 cm of healthy aorta was considered adequate for the deployment of a standard thoracic stent graft. The early end points were technical success, in-hospital mortality, and cerebrovascular events. Late outcomes included survival, reintervention, and patency of supra-aortic debranching. We used an embryogenetic anomaly based aortic arch classification for PLZ evaluation to identify the most appropriate hybrid adjunct. RESULTS: Sixteen patients with KD were included. According to the aforementioned classification, stent graft deployment was required in six patients (37.5%) in PLZ 0, nine patients (56.3%) in PLZ 1, and one patient (6.3%) in PLZ 2. Technical success was achieved in all patients. One patient (6.3%) died in the hospital because of posterior cerebral hemorrhage after total debranching (PLZ 0). No further cerebrovascular events were observed. One patient (6.3%) had an asymptomatic left subclavian artery-right left subclavian artery bypass occlusion and required early reintervention. The 30-day secondary patency of supra-aortic debranching was 100%. Two type II endoleaks (12.5%) were detected at 1 month through computed tomography angiography. Further transient complications were found in three cases: hemidiaphragm paralysis in one patient and recurrent laryngeal nerve paralysis in two patients. At a mean follow-up of 48 months, four patients had died because of nonaortic reasons, and one RCCA-right subclavian artery bypass had lost its patency. None of the patients reported any growth of KD after hybrid repair. Ten patients (62.5%) showed aneurysmal sac shrinkage of at least 5 mm. CONCLUSIONS: Hybrid repair is confirmed to be a safe and effective approach for KD. Operative risk is associated primarily with the invasiveness of the hybrid adjunct.
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Aneurisma de la Aorta Torácica/cirugía , Implantación de Prótesis Vascular/métodos , Divertículo/cirugía , Endofuga/epidemiología , Procedimientos Endovasculares/métodos , Anciano , Aorta Torácica/anomalías , Aorta Torácica/diagnóstico por imagen , Aorta Torácica/cirugía , Aneurisma de la Aorta Torácica/mortalidad , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/instrumentación , Angiografía por Tomografía Computarizada , Divertículo/mortalidad , Endofuga/diagnóstico , Endofuga/etiología , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/instrumentación , Femenino , Estudios de Seguimiento , Mortalidad Hospitalaria , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Reoperación/estadística & datos numéricos , Estudios Retrospectivos , Stents/efectos adversos , Resultado del Tratamiento , Grado de Desobstrucción VascularRESUMEN
Several surgical sealant devices are commercially available after their rigorous clinical testing with no apparent complications reported so far in the current literature. Cyanoacrylate glue can be used to stabilize the anastomoses and permit a better tensile strength in cardiovascular surgery. We first report the case of a 71-year-old male patient presenting with symptoms of progressive limitation of walking distance, 13 months after a successful femoroinfrapopliteal bypass surgery, because of a calcified tissue extrinsically stenosizing the first segment of the previous bypass graft, caused by the use of cyanoacrylate glue.
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Cianoacrilatos/efectos adversos , Oclusión de Injerto Vascular/etiología , Claudicación Intermitente/etiología , Vena Safena/trasplante , Injerto Vascular/efectos adversos , Anciano , Oclusión de Injerto Vascular/diagnóstico por imagen , Oclusión de Injerto Vascular/fisiopatología , Oclusión de Injerto Vascular/cirugía , Humanos , Claudicación Intermitente/diagnóstico por imagen , Claudicación Intermitente/fisiopatología , Claudicación Intermitente/cirugía , Masculino , Reoperación , Vena Safena/diagnóstico por imagen , Vena Safena/fisiopatología , Factores de Tiempo , Resultado del Tratamiento , Grado de Desobstrucción VascularRESUMEN
OBJECTIVE: The objective of this study was to assess early and midterm results after endovascular aortic arch repair using a double inner branch stent graft (DIBSG) in patients with aortic arch aneurysm or dissection unfit for open surgery. METHODS: Between 2012 and 2018, there were 24 patients with aortic arch disease who were treated with a single model of a DIBSG (Terumo Aortic, Glasgow, United Kingdom) in nine Italian cardiovascular centers. We investigated technical success, mortality, occurrence of major complications, and need for reintervention in a multicenter, nonrandomized, retrospective fashion. RESULTS: The in-hospital mortality rate was 16.7%. Cerebrovascular events occurred in 25% of patients and major strokes in 12.5%. Two patients experienced a retrograde dissection (8.3%), whereas none reported any type I or type III endoleak. During a mean follow-up of 18 months (range, 1-60 months), one patient died of a nonaortic cause and one reported a nonarch-related major stroke. No late secondary intervention was needed during the follow-up. Excluding from the analysis the first six patients treated until 2014 as part of the learning curve, in-hospital mortality, major stroke, and retrograde dissection rates were 11.1%, 11.1%, and 5.6%, respectively. CONCLUSIONS: Endovascular aortic arch repair using this model of DIBSG is feasible, and results are acceptable for a new technique in a high-risk subset of patients. Operative mortality suffers the effect of a learning curve, whereas midterm aorta-related survival is promising. Endovascular repair of aortic arch disease with a DIBSG should always be considered to give high-risk patients a chance of repair. Large-scale studies are needed to assess the long-term durability of this technique.
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Aorta Torácica/cirugía , Enfermedades de la Aorta/cirugía , Implantación de Prótesis Vascular/instrumentación , Prótesis Vascular , Procedimientos Endovasculares/instrumentación , Stents , Anciano , Anciano de 80 o más Años , Enfermedades de la Aorta/diagnóstico por imagen , Enfermedades de la Aorta/mortalidad , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/mortalidad , Competencia Clínica , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/mortalidad , Femenino , Mortalidad Hospitalaria , Humanos , Italia , Curva de Aprendizaje , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/mortalidad , Complicaciones Posoperatorias/terapia , Diseño de Prótesis , Sistema de Registros , Estudios Retrospectivos , Factores de Riesgo , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND: An endovascular-first approach to limb salvage and relief from lifestyle-limiting claudication is widely accepted. Stenosis or short occlusion of common, superficial femoral, and popliteal arteries can be corrected with percutaneous transluminal angioplasty (PTA) with stent positioning. Patency rates of these procedures are limited. We report our experience with external iliac artery to the infrapopliteal vessels vein grafts when the endovascular treatment fails. METHODS: Between January 2013 and January 2019, 16 patients (16 limbs) were operated on for limb-threatening ischemia after the occlusion of PTA with stent positioning of the common, superficial femoral, and popliteal arteries. Three patients were treated at our hospital by interventional radiologists; the remaining were operated on elsewhere. An external iliac artery to the infrapopliteal vessels vein bypass graft was anatomically interposed to restore blood flow. End points of the study were death-related events, vein graft failure, and major (above- or below-knee amputation) or minor (foot or toe amputation) limb loss. RESULTS: There were 12 men and 4 women. Mean age of patients was 68 years. Indication for the initial PTA with stent positioning of the common and superficial femoral artery was according to the Rutherford classification Grade I: Category 1, 11 patients (69%) and Category 2, 5 (31%) patients (Stage IIa and IIb according to Fontaine classification, respectively). Great saphenous vein was used in 14 (87%) cases and in 2 (13%) cases a composite graft with a segment of cephalic vein was required. The distal anastomoses were performed on the posterior tibial artery in 6 (37%) cases, anterior tibial artery in 4 (26%), and peroneal artery in 6 (37%). Four-year survival and primary patency rates were 71% (standard error [SE] = 0.15) and 73% (SE = 0.14), respectively. One graft occlusion required an above-knee amputation. Four-year limb salvage rate was 86% (SE = 0.13). DISCUSSION: We recommend the external iliac artery as source of inflow in patients in whom the vein bypass cannot originate from the common femoral or from a more distal inflow source because of previous PTA with stent positioning or it is deemed hazardous.
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Arteria Femoral , Arteria Ilíaca/cirugía , Isquemia/cirugía , Intervención Coronaria Percutánea/efectos adversos , Enfermedad Arterial Periférica/terapia , Arterias Tibiales/cirugía , Injerto Vascular/métodos , Anciano , Anciano de 80 o más Años , Amputación Quirúrgica , Femenino , Arteria Femoral/diagnóstico por imagen , Arteria Femoral/fisiopatología , Oclusión de Injerto Vascular/diagnóstico por imagen , Oclusión de Injerto Vascular/fisiopatología , Oclusión de Injerto Vascular/cirugía , Humanos , Arteria Ilíaca/diagnóstico por imagen , Arteria Ilíaca/fisiopatología , Isquemia/diagnóstico por imagen , Isquemia/etiología , Isquemia/fisiopatología , Recuperación del Miembro , Masculino , Persona de Mediana Edad , Intervención Coronaria Percutánea/instrumentación , Enfermedad Arterial Periférica/diagnóstico por imagen , Enfermedad Arterial Periférica/fisiopatología , Estudios Retrospectivos , Factores de Riesgo , Stents , Arterias Tibiales/diagnóstico por imagen , Arterias Tibiales/fisiopatología , Factores de Tiempo , Insuficiencia del Tratamiento , Injerto Vascular/efectos adversos , Grado de Desobstrucción VascularRESUMEN
Prodromal signs of a non-healing wound after revascularisation, which might be strictly linked with impending failure of vascular reconstructions, are associated with an inflammatory response mediated by several circulating adhesion molecules, extracellular endopeptidases, and cytokines. The aim of our study was to investigate the role of selected plasma biomarkers in the prediction of both wound healing and failure of infrapopliteal vein graft or percutaneous trans-luminal angioplasty (PTA) with selective stent positioning of the superficial femoral artery (SFA) in a population affected with critical limb ischaemia. A total of 68 patients who underwent either surgical or endovascular revascularisation of the inferior limb with autologous saphenous vein infrapopliteal bypass or PTA and selective stenting of the SFA were enrolled in our study. Patients were divided into two groups according to treatment: 41 patients were included in Group 1 (open surgery) and 27 in Group 2 (endovascular procedure). Plasma and blood samples were collected on the morning of surgery and every 6 months thereafter for up to 2 years of follow-up or until an occlusion occurred of either the vein bypass graft or the vessel treated endovascularly. Fifteen age-matched healthy male volunteers were considered a reference for biological parameters. Vascular cell adhesion molecule 1 [VCAM-1]/CD106, inter-cellular adhesion molecule-1 [ICAM-1]/CD54), interleukin-1 (IL-1), interleukin-6 (IL-6), tumour necrosis factor alpha (TNF-α), and metalloproteinases (MMP)-2 and -9 plasma levels were measured with enzyme-linked immunosorbent assay (ELISA) kits. The mean observed time to heal of 54 wounds was 13 ± 4 months, with no statistically significant differences among the groups. The healing failure of the remaining wounds was strictly related to an unsuccessful open (n = 12) or endovascular (n = 8) treatment. The 2-year primary patency rate was 65% (SE = .09) in Group 1 and 52% (SE = .1) in Group 2. When compared with mean concentration values of Group 1, VCAM-1 and ICAM-1 were always significantly higher during follow-up in patients of Group 2 (P < .05). Furthermore, in the same group, IL-6 and tumour necrosis factor alpha (TNF-α) were found to be significantly higher at 6- and 12-month (P < .05) when compared with surgically treated patients. Cox regression analysis showed that elevated plasma levels of VCAM-1, ICAM-1, IL-6, and TNF-α during follow up were strongly related to impaired wound healing and/or revascularisation failure (P < .05). Elevated plasma levels of inflammatory markers VCAM-1, ICAM-1, IL-6, and TNF-α may be related to the failure of wound healing and revascularisation procedures. Interestingly, we have observed that endovascular treatments cause a higher level of these inflammation biomarkers when compared with a vein graft, although wound-healing and patency and limb salvage rates are not influenced.
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Citocinas/uso terapéutico , Procedimientos Endovasculares/métodos , Arteria Femoral/cirugía , Complicaciones Posoperatorias/tratamiento farmacológico , Cicatrización de Heridas/efectos de los fármacos , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana Edad , Resultado del TratamientoRESUMEN
BACKGROUND: Off-the-shelf devices for branched endovascular aortic repair of thoracoabdominal aortic aneurysm (TAAA) have been developed to overcome the manufacturing- and logistics-related delays characteristic of device customization. Nonetheless, the structural requirements of branched endovascular aortic repair, together with the need for additional thoracic components to suit different anatomies, might lead to a large sacrifice of healthy aorta. METHODS: We enrolled 18 consecutive TAAA patients treated between 2010 and 2016 in two centers employing the off-the-shelf t-Branch (Cook Medical, Bloomington, Ind) device (TB group). We matched these 18 patients one-to-one with another 18 patients of the 464 consecutive TAAAs treated in the same period by means of open repair (O group) in one of the two centers. The patients were matched on the basis of t-Branch feasibility, distance from the left subclavian artery to the beginning of the aneurysm, and diameter of proximal landing zone evaluated at preoperative computed tomography angiography. We compared the overall length of sacrificed healthy native aorta (the sealing zone in the TB group) in the two groups according to postoperative computed tomography angiography, and we investigated the number of intercostal arteries lost from that healthy aortic segment. We calculated also the real unnecessary sacrificed aorta by subtracting the compulsory minimum neck coverage requested to obtain the proximal sealing (25 mm). RESULTS: We matched one-to-one six extent II, seven extent III, and five extent IV TAAAs. Overall, the length of sacrificed healthy aorta was longer (P < .001) in the TB group (median length: TB group, 49 mm [interquartile range (IQR), 31-60 mm]; O group, 14 mm [IQR, 10-20 mm]), and consequently the number of intercostal arteries lost (median number of pairs lost: TB group, four [IQR, three-four]; O group, two [IQR, one-three]) was higher (P = .004). Stratifying the results according to TAAA extent and after having subtracted from the TB group the length of aorta required for proximal sealing (25 mm), the length of sacrificed healthy aorta was longer (P = .008) only in the extent IV TAAA, 125 mm (IQR, 56-155 mm). The number of intercostal artery pairs sacrificed was longer only in extent III TAAA (P = .043) and extent IV TAAA (P = .024). No significant 30-day clinical outcomes difference was observed between the matched groups. CONCLUSIONS: The use of the t-Branch device compared with open repair is associated with a greater sacrifice of healthy aorta in extent IV TAAA and with an increased loss of intercostal arteries arising from healthy aortic proximal neck. The theoretical possible increased risk of spinal cord ischemia secondary to the routine use of this off-the-shelf device should thus be analyzed further.
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Aorta Torácica/cirugía , Aneurisma de la Aorta Torácica/cirugía , Implantación de Prótesis Vascular/instrumentación , Prótesis Vascular , Procedimientos Endovasculares/instrumentación , Stents , Anciano , Aorta Torácica/diagnóstico por imagen , Aneurisma de la Aorta Torácica/diagnóstico por imagen , Aortografía/métodos , Implantación de Prótesis Vascular/efectos adversos , Angiografía por Tomografía Computarizada , Procedimientos Endovasculares/efectos adversos , Femenino , Humanos , Italia , Masculino , Diseño de Prótesis , Estudios Retrospectivos , Factores de Riesgo , Isquemia de la Médula Espinal/etiología , Factores de Tiempo , Resultado del TratamientoRESUMEN
PURPOSE: To assess early and midterm outcomes of iliac branch device (IBD) implantation without an aortic stent-graft for the treatment of isolated common iliac artery aneurysm (CIAA). METHODS: From December 2006 to June 2016, 49 isolated CIAAs in 46 patients were treated solely with an IBD at 7 vascular centers. Five patients were lost to follow-up, leaving 41 male patients (mean age 72.5±7.8 years) for analysis. Mean CIAA diameter was 39.1±10.5 mm (range 25-65). Thirty-two patients (2 with bilateral CIAAs) were treated with a Cook Zenith iliac branch device; 9 patients (1 bilateral) received a Gore Excluder iliac branch endoprosthesis. Primary endpoints were technical success, survival, aneurysm exclusion, device patency, and freedom from reintervention at 1 and 5 years. Freedom from major adverse events and aneurysm shrinkage at 1 year were also assessed. RESULTS: Thirty-day mortality and the IBD occlusion rate were 2.4% and 2.3%, respectively. At a mean follow-up of 40.2±33.9 months, no patient presented buttock claudication, erectile dysfunction, or bowel or spinal cord ischemia. Three patients died within 6 months after the procedure. Estimates of cumulative survival, device patency, and freedom from reintervention were 90.2%, 95.2%, and 95.7%, respectively, at 1 and 5 years. At 1 year, CIAA shrinkage ≥5 mm was recorded in 21 of 38 survivors. No evidence of endoleak, device migration, or disconnection was found on imaging follow-up. CONCLUSION: The use of IBDs without an aortic stent-graft for isolated CIAAs resulted in excellent patency, with low morbidity and mortality. This, in conjunction with no endoleak or migration and a low reintervention rate, supports the use of isolated IBDs as a stable and durable means of endovascular reconstruction in cases with suitable anatomy. Longer follow-up and a larger cohort are needed to validate these results.
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Implantación de Prótesis Vascular/instrumentación , Prótesis Vascular , Procedimientos Endovasculares/instrumentación , Aneurisma Ilíaco/cirugía , Stents , Anciano , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/mortalidad , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/mortalidad , Femenino , Humanos , Aneurisma Ilíaco/diagnóstico por imagen , Aneurisma Ilíaco/mortalidad , Aneurisma Ilíaco/fisiopatología , Italia , Masculino , Complicaciones Posoperatorias/mortalidad , Complicaciones Posoperatorias/terapia , Supervivencia sin Progresión , Diseño de Prótesis , Sistema de Registros , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Grado de Desobstrucción VascularRESUMEN
A 70-year-old woman presented to our attention with a painless pulsating mass at the level of the upper left thigh without any previous history of trauma, arterial surgery, or puncture of the femoral artery. Duplex ultrasound showed a nodular angiomatous-like formation with deep venous compression; computed tomographic angiography and magnetic resonance imaging reported the presence of capsulated lesion vascularized by muscular branch of deep femoral artery (DFA). The patient underwent surgical excision of a very rare thrombized DFA branch false aneurysm. Spontaneous DFA false aneurysm, although rare, will be considered in absence of trauma or vascular catheterization or previous aneurysmal rupture.
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Aneurisma Falso/diagnóstico por imagen , Arteria Femoral/diagnóstico por imagen , Neoplasias de los Tejidos Blandos/diagnóstico por imagen , Anciano , Aneurisma Falso/patología , Aneurisma Falso/cirugía , Angiografía por Tomografía Computarizada , Diagnóstico Diferencial , Femenino , Arteria Femoral/patología , Arteria Femoral/cirugía , Humanos , Angiografía por Resonancia Magnética , Valor Predictivo de las Pruebas , Neoplasias de los Tejidos Blandos/patología , Ultrasonografía Doppler DúplexRESUMEN
PURPOSE: To evaluate the incidence and reasons for secondary procedures in patients treated with iliac branch devices (IBDs) for isolated iliac aneurysm or aortoiliac aneurysms involving the iliac bifurcation. METHODS: Between January 2005 and December 2015, 575 surgical-high-risk patients (mean age 72.0±8.4 years; 558 men) with isolated iliac aneurysms (n=79) or aortoiliac aneurysms involving the iliac bifurcation (n=496) were treated with placement of 650 ZBIS or Gore IBDs (75 bilateral) in 6 European centers. The primary outcome was procedure-related reinterventions for occlusion or high-grade (>70%) stenosis of the bridging device, occlusion of the ipsilateral common or external iliac artery (EIA), type I/III endoleak, rupture, or infection following IBD implantation. Clinical and radiological data were analyzed based on preset definitions of comorbidities, aneurysm morphology, intraoperative variables, and follow-up strategies. RESULTS: Nine (1.6%) reinterventions were performed within 30 days for occlusion or endoleak. Among 10 (1.5%) occluded EIAs ipsilateral to a deployed IBD, 6 underwent a reintervention with additional stent placement after thrombolysis (n=4) or a femorofemoral or iliofemoral crossover bypass (n=2). Three of 14 patients with early type I endoleak had a reintervention for an insufficient proximal sealing zone (stent-grafts in 2 common iliac arteries and 1 bifurcated endograft). Mean clinical and radiological follow-up were 32.6±9.9 and 29.8±21.1 months, respectively. Forty-two (7.3%) patients underwent reinterventions in the follow-up period. The overall postoperative reintervention rate was 8.9%. Both external and common iliac segments occluded in 30 (4.6%) IBDs; 2 patients had a crossover bypass and 14 were treated with endovascular techniques. In the other 14 patients, no specific treatment was performed. Seven (1.2%) patients with isolated EIA occlusion were treated during follow-up. Nineteen of the overall 28 patients with type I endoleak underwent endovascular repair. The other 9 were under radiological surveillance due to less significant (<5 mm) sac increase. No reintervention was performed to recanalize 11 (1.6%) occluded internal iliac arteries. CONCLUSION: Midterm experience with placement of IBDs is associated with a low incidence of secondary procedures due to type I endoleaks and occlusions. The main reasons for reinterventions seem to be short proximal sealing zone and poor conformability of the ZBIS device in elongated EIAs.
Asunto(s)
Aneurisma de la Aorta/cirugía , Implantación de Prótesis Vascular/instrumentación , Prótesis Vascular , Endofuga/cirugía , Procedimientos Endovasculares/instrumentación , Oclusión de Injerto Vascular/cirugía , Aneurisma Ilíaco/cirugía , Infecciones Relacionadas con Prótesis/cirugía , Stents , Anciano , Anciano de 80 o más Años , Aneurisma de la Aorta/diagnóstico por imagen , Aortografía , Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/efectos adversos , Endofuga/diagnóstico por imagen , Endofuga/etiología , Procedimientos Endovasculares/efectos adversos , Europa (Continente) , Femenino , Oclusión de Injerto Vascular/diagnóstico por imagen , Oclusión de Injerto Vascular/etiología , Humanos , Aneurisma Ilíaco/diagnóstico por imagen , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Diseño de Prótesis , Falla de Prótesis , Infecciones Relacionadas con Prótesis/diagnóstico por imagen , Infecciones Relacionadas con Prótesis/etiología , Sistema de Registros , Reoperación , Estudios Retrospectivos , Factores de Riesgo , Stents/efectos adversos , Factores de Tiempo , Resultado del TratamientoRESUMEN
The purpose of this report was to describe the exclusion of the false lumen in a residual type A aortic dissection (TAAD) by the deployment of 2 covered stents: one in the right common carotid artery (RCCA) and one in the left subclavian artery (LSA). A 77-year-old female, already treated with ascending aorta replacement for acute TAAD, was referred to our center for a 97-mm post-dissection arch aneurysm. A computed tomography angiography (CTA) showed false lumen patency by reperfusion from secondary tears located at the level of RCCA and LSA. No primary aortic tear was noted. Under local anesthesia and by transfemoral percutaneous approach, the tears at the level of RCCA and LSA were covered by a 9-mm Viabahn stent graft (Gore, Flagstaff, AZ), and a 10-mm V-12 stent graft (Maquet, Rastatt, Germany), respectively. The false lumen was finally occluded by the deployment of a 6-mm vascular plug at the level of LSA re-entry tear, by left transbrachial puncture. The procedure was completed uneventfully. Twelve-month CTA showed exclusion of the false lumen, patency of all supra aortic trunks, and initial shrinkage of the aneurysm. Spot stenting of secondary re-entry tears, already described for visceral branches, seems to be safe and effective also for supra-aortic trunks in selected patients.
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Aneurisma de la Aorta Torácica/cirugía , Aneurisma de la Aorta/cirugía , Disección Aórtica/cirugía , Implantación de Prótesis Vascular/instrumentación , Prótesis Vascular , Arteria Carótida Común/cirugía , Procedimientos Endovasculares/instrumentación , Stents , Arteria Subclavia/cirugía , Anciano , Disección Aórtica/diagnóstico por imagen , Aneurisma de la Aorta/diagnóstico por imagen , Aneurisma de la Aorta Torácica/diagnóstico por imagen , Aneurisma de la Aorta Torácica/etiología , Aortografía/métodos , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/métodos , Arteria Carótida Común/diagnóstico por imagen , Angiografía por Tomografía Computarizada , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/métodos , Femenino , Humanos , Diseño de Prótesis , Arteria Subclavia/diagnóstico por imagen , Resultado del TratamientoRESUMEN
Aneurysmal degeneration of distal landing zones after endovascular aneurysm repair (EVAR) can be a potential cause of late failure of this technique. Aneurysmal degeneration of common iliac arteries increases the risk of rupture of the iliac aneurysm itself as well as of the abdominal aortic aneurysm owing to aneurysm's reperfusion as a type Ib endoleak. Reoperation consists in plugging and covering the internal iliac artery (IIA), by extension into the external iliac artery, or preservation of antegrade flow in IIA by iliac branch devices (IBDs) or sandwich technique. The management of common iliac aneurysms after EVAR with the purpose of preserving antegrade flow into IIA generally requires a brachial or axillary access. However, this approach may be theoretically associated with local or systemic complications. We report a case of IBD implantation after EVAR, using a steerable sheath for IIA bridging stent deployment via contralateral femoral approach.
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Aneurisma de la Aorta/cirugía , Implantación de Prótesis Vascular/instrumentación , Prótesis Vascular , Cateterismo Periférico/métodos , Procedimientos Endovasculares/instrumentación , Arteria Femoral , Aneurisma Ilíaco/cirugía , Stents , Dispositivos de Acceso Vascular , Anciano , Aortografía/métodos , Implantación de Prótesis Vascular/efectos adversos , Angiografía por Tomografía Computarizada , Procedimientos Endovasculares/efectos adversos , Arteria Femoral/diagnóstico por imagen , Humanos , Aneurisma Ilíaco/diagnóstico por imagen , Aneurisma Ilíaco/etiología , Masculino , Diseño de Prótesis , Punciones , Recurrencia , Reoperación , Resultado del TratamientoRESUMEN
OBJECTIVE: The aim of this study was to investigate outcomes of patients treated with endovascular repair (ER) with the use of fenestrated and branched stent grafts or open surgery (OS) for thoracoabdominal aortic aneurysm (TAAA) in a current series of patients. METHODS: All TAAA patients undergoing repair at three centers between January 2007 and December 2014 were included in a prospective database. Patients were stratified according to treatment by ER or OS, and outcomes were compared using propensity score matching (1:1). Covariates included age, sex, aneurysm extent, hypertension, coronary disease, chronic pulmonary disease, diabetes, and renal function. The primary end points were mortality and paraplegia. Secondary end points included any spinal cord ischemia (SCI), renal and respiratory insufficiency, and a composite of these complications or death at 30 days. All-cause survival and freedom from reintervention were compared in the two groups. RESULTS: Of 341 patients, 84 (25%) underwent ER and 257 underwent OS (75%). After propensity score matching (65 patients per group), no significant differences were observed in rates of 30-day mortality (7.7% in ER and 6.2% in OS; P = 1) and paraplegia (9.2% and 10.8%; P = 1). Any SCI, renal insufficiency, and respiratory insufficiency were 12.3% and 20% (P = .34), 9.2% and 12.3% (P = .78), and 0% and 12.3% (P = .006) in ER and OS, respectively. The incidence of the composite end point was significantly lower in ER patients (18.5% in ER vs 36.0% in OS; P =.03). According to Kaplan-Meier estimates, all-cause survival at 24 months was 82.8% in ER and 84.9% in OS, with rates unchanged at 42 months (P = .9). Rates of freedom from reintervention were 91.0% vs 89.7% at 24 months and 80.0% vs 79.9% at 42 months in ER vs OS, respectively (P = .3). CONCLUSIONS: A propensity score analysis in patients with TAAA undergoing repair suggests an early benefit from ER compared with OS with regard to the composite end point because of reduced 30-day respiratory complications. No significant differences were found in SCI and renal insufficiency at 30 days and in survival and reintervention rates at midterm.
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Aneurisma de la Aorta Torácica/cirugía , Implantación de Prótesis Vascular , Procedimientos Endovasculares , Anciano , Aneurisma de la Aorta Torácica/diagnóstico por imagen , Aneurisma de la Aorta Torácica/mortalidad , Prótesis Vascular , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/instrumentación , Implantación de Prótesis Vascular/mortalidad , Supervivencia sin Enfermedad , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/instrumentación , Procedimientos Endovasculares/mortalidad , Femenino , Humanos , Italia , Estimación de Kaplan-Meier , Modelos Logísticos , Masculino , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/mortalidad , Complicaciones Posoperatorias/terapia , Puntaje de Propensión , Diseño de Prótesis , Retratamiento , Estudios Retrospectivos , Medición de Riesgo , Stents , Factores de Tiempo , Resultado del TratamientoRESUMEN
OBJECTIVE: This study analyzed total aortic arch reconstruction in a contemporary comparison of current open and endovascular repair. METHODS: Endovascular (group 1) and open arch procedures (group 2) performed during 2007 to 2013 were entered in a prospective database and retrospectively analyzed. Endovascular repair (proximal landing zones 0-1), with or without a hybrid adjunct, was selected for patients with a high comorbidity profile and fit anatomy. Operations involving coverage of left subclavian artery only (zone 2 proximal landing: n = 41) and open hemiarch replacement (n = 434) were excluded. Early and midterm mortality and major complications were assessed. RESULTS: Overall, 100 (78 men; mean age, 68 years) consecutive procedures were analyzed: 29 patients in group 2 and 71 in group 1. Seven group 1 patients were treated with branched or chimney stent graft, and 64 with partial or total debranching and straight stent graft. The 29 patients in group 2 were younger (mean age, 61.9 vs 70.3; P = .005), more frequently females (48.2% vs 11.3; P < .001) with less cardiac (6.9% vs 38.2%; P = .001), hypertensive (58.5% vs 88.4%; P = .002), and peripheral artery (0% vs 16.2%; P = .031) disease. At 30 days, there were six deaths in group 1 and four in group 2 (8.5% vs 13.8%; odds ratio, 1.7; 95% confidence interval, 0.45-6.66; P = .47), and four strokes in group 1 and one in group 2 (odds ratio, 0.59; 95% confidence interval, 0.06-5.59; P = 1). Spinal cord ischemia occurred in two group 1 patients and in no group 2 patients. Three retrograde dissections (1 fatal) were detected in group 1. During a mean follow-up of 26.2 months, two type I endoleaks and three reinterventions were recorded in group 1 (all for persistent endoleak), and one reintervention was performed in group 2. According to Kaplan Meier estimates, survival at 4 years was 79.8% in group 1 and 69.8% in group 2 (P = .62), and freedom from late reintervention was 94.6% and 95.5%, respectively (P = .82). CONCLUSIONS: Despite the older age and a higher comorbidity profile in patients with challenging aortic arch disease suitable and selected for endovascular arch repair, no significant differences were detected in perioperative and 4-year outcomes compared with the younger patients undergoing open arch total repair. An endovascular approach might also be a valid alternative to open surgery in average-risk patients with aortic arch diseases requiring 0 to 1 landing zones, when morphologically feasible. However, larger concurrent comparison and longer follow-up are needed to confirm this hypothesis.
Asunto(s)
Aorta Torácica/cirugía , Enfermedades de la Aorta/cirugía , Implantación de Prótesis Vascular/métodos , Procedimientos Endovasculares , Procedimientos de Cirugía Plástica/métodos , Adulto , Factores de Edad , Anciano , Anciano de 80 o más Años , Enfermedades de la Aorta/diagnóstico , Enfermedades de la Aorta/mortalidad , Prótesis Vascular , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/instrumentación , Implantación de Prótesis Vascular/mortalidad , Distribución de Chi-Cuadrado , Comorbilidad , Bases de Datos Factuales , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/instrumentación , Procedimientos Endovasculares/mortalidad , Femenino , Humanos , Estimación de Kaplan-Meier , Modelos Logísticos , Masculino , Persona de Mediana Edad , Oportunidad Relativa , Complicaciones Posoperatorias/mortalidad , Complicaciones Posoperatorias/terapia , Diseño de Prótesis , Procedimientos de Cirugía Plástica/efectos adversos , Procedimientos de Cirugía Plástica/instrumentación , Procedimientos de Cirugía Plástica/mortalidad , Estudios Retrospectivos , Factores de Riesgo , Stents , Factores de Tiempo , Resultado del TratamientoRESUMEN
OBJECTIVE: Currently, the best approach to the aortic arch remains unsupported by robust evidence. Most of the available data rely on small sample numbers, heterogeneous settings, and limited follow-up. The objective of this study was to evaluate early and midterm results of arch debranching and endovascular procedures. METHODS: From 2005 through 2013, 104 consecutive patients underwent elective arch treatment with debranching and thoracic endovascular aortic repair. Rates of perioperative (30-day) mortality and neurological complications, and mortality, endoleak, supra-aortic vessel patency, and arch diameter changes at 5 years were analyzed. RESULTS: Patients' mean age was 69.8 years, and 90 were males. Twenty arches were repaired for dissection. Nineteen patients required total debranching for diseases extended to zone 0. In 59, debranching and thoracic endovascular aortic repair procedures were staged. At 30 days, death, stroke, and spinal cord ischemia occurred in six, four, and three patients, respectively. Extension to ascending aorta (zone 0 landing) was the only multivariate independent predictor for perioperative mortality (odds ratio, 9.6; 95% confidence interval, 1.54-59.90; P = .015), but not for stroke. Four retrograde dissections, two fatal, occurred during the perioperative period. At 1, 3, and 5 years, Kaplan-Meier survival rates were 89.0%, 82.8%, and 70.9%, and freedom from persistent endoleak rates were 96.1%, 92.5%, and 88.3%, respectively. Over 5-year follow-up, 34 aneurysms shrank ≥ 5 mm, and four grew. Five reinterventions were required. Two supra-aortic vessel occlusions and no late aorta-related mortalities were recorded. CONCLUSIONS: Despite the perioperative mortality risk, the late outcome of endovascular arch repair presents a low rate of aorta-related deaths and reinterventions and acceptable midterm survival. Furthermore, more than one-third of the aneurysms' diameters decrease over 5 years as a measure of the long-term efficacy of treatment. Retrograde type A dissection remains a major concern in the perioperative period and careful arch approach is required.