Multicenter Comparative Analysis of Late Open Conversion in Patients With Adherence and Nonadherence to Instructions for Use Endovascular Aneurysm Repair.

PURPOSE: The widespread adoption of endovascular aneurysm repair (EVAR) as preferred treatment modality for abdominal aortic aneurysm (AAA) has enlarged the number of patients needing open surgical conversion (OSC). The relationship between adherence to Instructions For Use (IFU) and EVAR long-term outcomes remains controversial. The aim of this study is to compare preoperative differences and postoperative outcomes between EVAR patients not adjusted to IFU and adjusted to IFU who underwent OSC. METHODS: This multicenter retrospective study reviewed 33 explanted EVARs between January 2003 and December 2019 at 14 Vascular Units. Patients were included if OSC occurred >30 days after implantation and excluded if explantation was performed to treat an endograft infection, aortic dissection, or traumatic transections. Variables analyzed included baseline characteristics, adherence to IFU, implant and explant procedural details, secondary reinterventions, and postoperative outcomes. RESULTS: Fifteen explanted patients (15/33, 45.5%) were identified not accomplished to IFU (out-IFU) at initial EVAR vs 18 explanted patients adjusted (in-IFU). During follow-up, a mean of 1.73±1.2 secondary reinterventions were performed, with more type I endoleaks treated in the subgroup out-IFU: 16.7% vs 6.3% in-IFU patients and more type III endoleaks (8.3% vs 0%). Patients out-IFU had shorter mean interval from implant to explant: 47.60±28.8 months vs 71.17±48. Type II endoleak was the most frequent indication for explantation. Low-flow endoleaks (types II, IV, V) account for 44% of indications for OSC in subgroup of patients in-IFU, compared with 13.3% in patients out-IFU and high-flow endoleaks (types I and III) were the main indication for patients out-IFU (33.3% vs 16.7% in-IFU). Total endograft explantation was performed in 57.5% of cases (19/33) and more suprarenal clamping was required in the subgroup out-IFU. Overall, 30-day mortality rate was 12.1% (4/33): 20% for patients out-IFU and 5.6% in-IFU. CONCLUSIONS: In our experience, type II endoleak is the most common indication for conversion and differences have been found between patients treated outside IFU with explantation taking place earlier during follow-up, mainly due to high-flow endoleaks and with higher mortality in comparison with patients adjusted to IFU. Ongoing research is required to delve into these differences.

Aortic Rupture by an Acute Dissection of the Thoracoabdominal Aorta in a 12-Year-Old Boy.

Aortic dissection is exceptional in children. When they are affected, many clinical conditions as Marfan syndrome or Ehlers-Danlos syndrome are usually involved, but up to 22% have no associated background. Its high morbidity and low incidence in this age group require a high level of suspicion in children without predisposing factors when the presentation is atypical, to avoid the severe consequences of the delay of their diagnosis. In this article we describe the dissection and aortic rupture in a 12-year-old child without relevant medical history, and the open repair that was performed as treatment.

Prognostic Value of Initial Aneurysmal Sac Regression after EVAR.

BACKGROUND: The objective of the study was to evaluate the impact of initial aneurysmal sac reduction after endovascular aneurysm repair on the evolution of aneurysmal sac over follow-up. METHODS: A retrospective cohort study was made of patients subjected to elective treatment between January 2005 and December 2014, with a minimum follow-up of 18 months. An analysis was made of the evolution of the aneurysmal sac according to its condition one year after surgery, defining of two groups: A (sac reduction) and B (stable sac). Follow-up by computed tomography (CT) angiography was made after one month and then every 6 months or annually, depending on the presence of endoleak. RESULTS: A total of 128 patients were included. Fifty-one patients (39.8%) showed a significant decrease in diameter during the first year (group A), whereas 77 patients (60.2%) showed no initial decrease (group B). Preoperative CT angiography showed the patients in group A to have larger aneurysms (63.5 mm vs. 59.25; P = 0.048), a greater presence of posterior thrombus (68.6% vs. 30.7%; P < 0.001), and fewer patent lumbar vessels (56.9% vs. 83.1%; P = 0.001). The prevalence of endoleak at some point during follow-up was lower in group A (31.4% vs. 74% in group B; P < 0.001), and 100% of all aneurysmal growths were associated to the presence of endoleak. After 5 years, significant differences were observed in the growth-free rate (96.9% in group A vs. 85.2% in group B; hazard ratio [HR] 4.8 [1.1-21.4; P = 0.036]) and in the reintervention-free rate (95,7% vs. 84.6%; HR 6.6 [0.8-52.4; P = 0.07]). No reoperation in group A was due to type II endoleak. CONCLUSIONS: The aneurysmal sac can be expected to take a favorable course in those cases characterized by initial aneurysmal sac reduction. These findings may imply a change in the follow-up protocol, even in cases with type II endoleak.

Outcomes of the Repair of 1000 Abdominal Aortic Aneurysms in the Endovascular Era.

BACKGROUND: To analyze the outcome of abdominal aortic aneurysm (AAA) repair with elective open surgery (OS) versus endovascular aneurysm repair (EVAR) and assess the predictors of survival. METHODS: A retrospective cohort study was made of 1000 AAA treated between January 1998 and November 2014 (68.1% OS and 31.9% EVAR), with the comparison of comorbidity and complications, and survival analysis (Kaplan-Meier and Breslow). Multivariate logistic regression and Cox regression analyses were performed. RESULTS: The EVAR group had a higher prevalence of smokers (33.2% vs. 21%; P < 0.001), hypercholesterolemia (56.4% vs. 41.1%; P < 0.001), type 1 diabetes (11.3% vs. 2.8%; P < 0.001), ischemic heart disease (36.4% vs. 25.0%; P = 0.013), chronic renal failure (25.4% vs. 16.2%; P < 0.001), and an older age [74.6 ± 7.1 vs. 68.3 ± 7.2 (years); P < 0.001]. The OS group showed a greater prevalence of chronic ischemia of the lower extremities (22.8% vs. 9.4%; P < 0.001), a greater AAA diameter [61.2 ± 13.6 vs. 58.5 ± 13.8 (mm); P < 0.001], a greater aneurysm neck diameter [24.1 ± 3.9 vs. 23.3 ± 3.0 (mm); P = 0.002], and a shorter aneurysm neck length [15.1 ± 11.1 vs. 24.0 ± 11.1 (mm); P < 0.001]. Early mortality was low in both groups but higher with OS (1.9% vs. 0.3%; P = 0.046). OS [OR 16.98 (95% CI: 1.97-146.29) (P < 0.001)] and age [OR 1.22 (95% CI: 1.09-1.36) (P < 0.001)] were independent predictors of higher early mortality. However, there was no increase in mortality in the OS group in patients under 73.5 years (P = 0.996), and the differences increased over 73.5 years of age (P = 0.005). There were also more postoperative complications (23.9% vs. 9.7%; P < 0.001) and early reinterventions in the OS group (4.4% vs. 1.6%; P = 0.026). Only the prevalence of renal function impairment was greater in the EVAR group (6.6% vs. 3.5%; P = 0.034), but this complication resulted not significative in the multivariate analysis [OR 0.84 (95% CI: 0.41-1.69) (P = 0.618)]. The median duration of follow-up was 33 (range 0-175) and 59 months (range 0-190) for the EVAR and OS groups, respectively. The survival rate after 24 and 48 months was 92.9% and 83.9% (EVAR) versus 94.6% and 90.6% (OS) (P < 0.001). This difference was not significative in the multivariable analysis: hazard ratio (HR) 1.46 (95% CI 0.99 to 2.12); P = 0.060. OS also resulted in better freedom from reintervention rates for the same periods: 92.1% and 90.4% versus 92.9% and 88.1%, including multivariate analysis [HR 1.93 (95% CI 1.27 to 2.93) P = 0.002]. The factors independently associated to poorer survival were age [HR 1.09 (1.06-1.11); P < 0.001], chronic obstructive pulmonary disease [HR 1.39 (1.04-1.86); P = 0.026], and chronic renal failure [HR 2.08 (1.51-2.87); P < 0.001]. CONCLUSIONS: Elective AAA repair offers excellent middle-term outcomes with both OS and EVAR. EVAR reduces early mortality in the subgroup of patients older than 73.5 years. In patients younger than 73.5 years with a low to moderate surgical risk, EVAR offers no advantage over OS and therefore should not be regarded as the treatment of choice.

Free skin micrografts with cyanoacrylate as outpatient treatment for venous leg ulcers.

OBJECTIVE: The present study describes an ambulatory, free skin micrograft technique with cyanoacrylate as a coadjuvant venous leg ulcer (VLU) healing strategy and its outcomes after one month. METHODS: This prospective study involved Comprehensive Classification System for Chronic Venous Disorders (CEAP) stage C6 patients with good granulation tissue and negative culture results, consecutively recruited in January 2017 in the Hospital Clinico San Carlos. A skin micrograft was harvested from the anterior surface of the patient's thigh with a 0.4cm punch (0.12cm2). The graft was adhered to the ulcer bed with cyanoacrylate. Anti-adherent dressing and double-layer bandaging was applied, with weekly replacements. Measurements were obtained of the surface of the VLU and graft progression (in cm2) using a photographic grid. RESULTS: A total of 12 VLUs in 12 patients were included, with a mean treated surface of 20.32±13.9cm2. A total of 18 grafts were placed and all were found to be viable after one week. Average graft growth was not noticeable after one week but was found to be 0.25±0.08cm2 after week two, 0.41±0.98cm2 after week three, and 0.70±0.15cm2 after week four (p<0.001). There were no complications in the donor zone. CONCLUSION: The findings of this study show that free skin micrografting with cyanoacrylate as outpatient treatment for VLUs was simple, rapid and without complication in this study, and may contribute to its wider application in clinical use.

Endovascular treatment of abdominal aortic aneurysms with narrow aortic bifurcation using Excluder bifurcated stent grafts.

OBJECTIVE: This study investigated the influence of the aortic bifurcation anatomy on the endovascular treatment of abdominal aortic aneurysms using Excluder (W. L. Gore & Associates, Flagstaff, Ariz) bifurcated stent grafts. METHODS: This was a retrospective single-center study of patients treated with the Excluder stent graft. Analysis included anatomical factors of the aortic bifurcation (aortic bifurcation diameter [ABD], calcification, thrombus), characteristics of the stent graft limbs (sum of stent graft limbs diameters [SLD]), and the SLD/ABD ratio. Narrow bifurcation was defined as ABD <20 mm. Primary outcomes were intraoperative stenosis, need for additional intraoperative measures, limb stenosis, and occlusion during follow-up. RESULTS: The study included 232 patients. Mean ABD was 24.6 ± 6 mm, with 53 patients (23%) presenting with narrow bifurcation (range, 12.5-19.5 mm). Median SLD in these patients was 28 mm, and the SLD/ABD ratio was 1.64. Calcification involving >50% of the bifurcation circumference was present in 32% of the patients, with 17% presenting thrombus in this area. Of 53 patients with narrow bifurcation, intraoperative stenosis >50% occurred in three (5.7%), which required adjunctive treatment. Computed tomography at 1 month showed limb stenosis >50% in nine patients (17%). No limb occlusions were recorded with a median follow-up of 34 months. Multivariate analysis of the overall series showed a higher risk of limb stenosis on the computed tomography at 1 month in patients with peripheral artery disease (hazard ratio [HR], 5.3; 95% confidence interval [CI], 1.2-24.4; P = .032), narrow bifurcation (HR, 5.7; 95% CI, 2-15.8; P = .001), higher SLD/ABD ratio (HR, 29.3; 95% CI, 4-215.2; P = .001), and calcium >50% (HR, 3; 95% CI, 1.1-8; P = .03), and lower in bifurcations with thrombus (HR, 0.3; 95% CI, 0.1-0.8; P = .017). CONCLUSIONS: Abdominal aortic aneurysms with narrow bifurcation can be treated with the bifurcated Excluder device without additional adjunctive measures. The presence of limb stenosis during follow-up is not associated with occlusion. Long-term follow-up studies are needed to confirm these results.

Outcomes of the Endovascular Treatment of Stenotic Lesions versus Chronic Total Occlusions in the Iliac Sector.

BACKGROUND: This study compares outcomes of the endovascular treatment (EVT) of iliac artery occlusive disease according to whether the treated lesion is a stenosis or a chronic total occlusion (CTO). METHODS: Patients undergoing EVT from 2003 to 2013 for iliac artery occlusive disease were identified and the lesions treated stratified into stenotic (Group 1, n = 375) or CTO (Group 2, n = 87). Patients were followed clinically and hemodynamically (thigh-brachial index, TBI). Comorbidities, procedural factors, and outcomes were compared between the 2 groups using Kaplan-Meier, Breslow, and Cox models. RESULTS: Four hundred sixty-two iliac endovascular procedures in 378 patients were included in a retrospective study. The 2 groups only differed in preprocedural TBI [0.77 (Group 1) vs. 0.67 (Group 2), P < 0.001], lesion length [39.7 mm (Group 1) vs. 49.9 mm (Group 2), P < 0.001], and the use of a covered stent [11.6% (Group 1) vs. 46.2% (Group 2), P < 0.001]. The technical success rate was higher in Group 1 (99.2% vs. 89.7%, P < 0.001). Five early occlusions were recorded in Group 1 and 3 in Group 2 (1.3% vs. 3.8%, P = 0.146). Median follow-up was 34 months (1-113). At 12 and 36 months, stenotic lesions showed better primary (P1) and secondary (P2) patency rates [P1 93.0% and 85.8% vs. 83.1% and 74.7%, hazard ratio (HR) 1.90 (1.15-3.14), P = 0.018; P2 97.8% and 96.8% vs. 93.0% and 87.4%, HR 2.86 (1.39-5.90), P = 0.007] and freedom from reintervention (FFR) rates [91.6% and 83.5% vs. 84.1% and 78.9%, HR 1.51 (0.90-2.53), P = 0.132]. In a multivariate analysis, CTO showed a worse P2 than stenotic lesions [HR 2.81 (1.17-6.76), P = 0.021], yet no differences emerged in P1 [HR 1.41 (0.76-2.63), P = 0.277] or FFR [HR 1.43 (0.79-2.57), P = 0.237]. A lower preprocedural TBI was correlated with a greater risk of EVT failure in terms of patency and FFR (P < 0.05). The use of a stent shorter than 40 mm emerged as a protective factor with an HR for P1 of 3.68 (1.53-8.87) (P = 0.004). CONCLUSIONS: EVT for iliac artery disease offers good outcomes in terms of long-term patency, although improved results were observed here for the treatment of stenotic lesions over CTO. Procedures performed in patients with a lower TBI and the use of a stent >40 mm were related to a worse stent patency.

Open Versus Endovascular Treatment for Patients with Post-Carotid Endarterectomy Restenosis: Early and Long-term Results.

BACKGROUND: The aim of this study is to assess and compare the short- and long-term results of carotid artery stenting (CAS) and redo surgery in patients with restenosis after carotid endarterectomy (CEA). METHODS: From January 1988 to December 2014, 44 consecutive patients were treated for carotid restenosis (CR): 23 redo-CEA (52.3%) and 21 CAS (47.7%). Data from these patients were prospectively collected in a dedicated database. Early results and 3-year end points were analyzed and compared between groups with χ2 test, Kaplan-Meier curves, and Breslow test. RESULTS: Demographic characteristics and comorbidity were similar in both groups, except for arterial hypertension and chronic renal insufficiency which were higher in the CAS group. CR was symptomatic in 7 patients in the redo-CEA group (30.4%) and 1 (4.8%) in CAS (P = 0.04). No differences were found in the time period between primary CEA and reintervention, critical carotid stenosis, or contralateral carotid occlusion. Median follow-up was 61.5 months. In the redo-CEA group, 1 patient (4.3%) had a perioperative transient ischemic attack and 3 (13%) experienced cranial nerve injury with complete regression at 30 days. No differences were found between groups in terms of early and long-term mortality, neurologic morbidity, and overall morbidity. The rate of secondary restenosis and freedom from reintervention was similar in both groups during follow-up. CONCLUSIONS: Both CAS and redo-CEA are suitable options for patients with CR. CAS might be the treatment of choice due to the risk of cranial nerve injuries in redo-CEA. When CAS is contraindicated, redo-CEA remains a safe and effective treatment option.

Comparison of popliteal artery aneurysm therapies.

OBJECTIVE: Surgical treatment of popliteal artery aneurysms (PAAs) has advanced over time. Constant development of new endovascular techniques has converted these into the most attractive methods available today. However, results for each endovascular procedure are still limited, and available data have emerged from studies examining only a small number of cases. The present retrospective review was designed to examine early and late results for PAA treatment and to identify possible factors associated with graft patency. METHODS: This was a retrospective review of all PAAs treated from January 1993 to December 2013. Symptomatic and asymptomatic PAAs >2 cm treated using open surgery or an endovascular procedure were included. Kaplan-Meier curves and the Breslow test were used to analyze data. RESULTS: A total of 171 aneurysms were treated in 142 men (mean age, 69.3 years); of these, 53.3% were asymptomatic and 18.7% presented as acute ischemia. Saphenous vein was used for bypass in 57.9% of the patients, expanded polytetrafluoroethylene (ePTFE) in 23.4%, and a stent graft in 18.7%. In the open surgical group, a popliteal-popliteal bypass was performed in 37.4% and a distal anastomosis to a tibial vessel was required in 14.4%. Good runoff (two to three vessels) was present in 69%. Perioperative mortality (30 days) was 1.8%. Of eight early occlusions recorded, five (2.9%) underwent reoperations. Major amputations were needed in five patients (all with previous acute ischemia). Median follow-up for the entire cohort was 49 months (range, 1-228 months). Primary and secondary patency rates at 24, 36, and 60 months were 76.3% and 89.5%, 73.4% and 87.4%, and 68.3% and 80.9%, respectively. Popliteal-popliteal bypasses showed better primary patency at 24 months when saphenous vein was used vs ePTFE (94.9% vs 79%; P = .04); however, similar patency rates were recorded for short ePTFE bypasses and stent grafts (79% vs 79.7%). On multivariate analysis, only poor runoff emerged as an independent factor for worse primary patency (hazard ratio, 3.5; 95% confidence interval, 1.7-7.2; P = .001). CONCLUSIONS: The open repair of PAA offers good long-term results, especially in asymptomatic patients, those undergoing elective surgery, and those showing good runoff. Given the also good midterm outcomes of endovascular treatment, this may be a feasible option in selected patients.

Endovascular treatment of external iliac artery occlusive disease: midterm results.

PURPOSE: To report midterm outcomes for endovascular treatment of external iliac artery (EIA) occlusive disease and assess possible factors affecting patency. METHODS: A retrospective analysis was conducted of 99 consecutive patients (91 men; mean age 67.3 years) with claudication (n=70) or critical limb ischemia (n=29) owing to occlusive EIA disease treated at our center from January 2005 to June 2012. The majority of lesions (79/108) were TASC A/B. Lesions were a mean 42.2 mm long (range 10-125); 43/108 affected the distal third of the EIA. Balloon angioplasty alone was performed in 7 limbs, while the remaining 101 lesions were stented (65 self-expanding, 24 balloon-expandable, and 12 covered). Clinical and hemodynamic follow-up was performed at 1, 3, 6, and 12 months after therapy and yearly thereafter. The factors examined were procedure characteristics and patency rates. RESULTS: Over a median follow-up of 27.5 months (range 1-89), there were 2 (1.9%) early occlusions followed by a successful reintervention, 4 late occlusions, and 5 hemodynamic failures followed by 7 reinterventions. These events led to primary and secondary patency rates at 30 months of 89.7% and 94.1%, respectively. No differences in patency rates were detected according to age, clinical state, or comorbidity. Use of covered stents (p=0.006) was the only variable associated with lower primary patency rates. CONCLUSION: Endovascular therapy to treat TASC A/B lesions of the EIA yielded good short and midterm patency and low early morbidity and mortality. Lesions involving the distal third of the EIA treated by simple angioplasty ± stenting fared worse. No clinical factors could be correlated with patency.

Results of endovascular treatment of venous anastomotic stenosis in prosthetic arteriovenous for hemodialysis PTFE grafts. Comparative analysis between patent and occluded grafts.

OBJECTIVE: To analyze the results of endovascular treatment of venous anastomotic stenosis (VAS) in humero-axillary arteriovenous grafts (HAG), comparing outcomes between patent and thrombosed HAG. MATERIAL AND METHODS: A retrospective cohort study was made of endovascular treated patients because of a VAS in a HAG between January 2009 and December 2019. Group A: Thrombosed HAG secondary to a VAS. Group B: Patent HAG with a VAS detected during follow-up. Technical success was defined as residual stenosis after treatment <30%, and clinical success as satisfactory immediate dialysis after surgery. After ET a biannual clinical and ultrasound follow-up was performed. STATISTICAL ANALYSIS: Survival analysis was performed for time-to-event data to assess patency. RESULTS: Group A: 55 patients. Group B: 22. There were no significative differences in demographic and anatomical factors between groups. Technical and clinical success were 100% in group B and 94.5% and 91% respectively in group A. Primary patency at 1, 6 and 12 months was: Group A: 81.8%, 22.4% y 15.7% respectively. Group B: 100%, 85.9%, 76,4% (p < 0.001). Secondary patency at 1, 6 and 12 months was: Group A: 85.2%, 45.8% y 31.3% respectively. Group B 100%, 95.3%, 95.2% (p < 0.001). Use of non-covered stents was associated with an increased risk of occlusion (HR 2.669 IC 95% 1.146-6.216, p = 0.010). CONCLUSION: A higher patency of EV performed on a patent HAG is expected. It is therefore advisable to develop surveillance programs that are capable to detect VAS before its occlusion.

Results of endovascular treatment of venous anastomotic stenosis in prosthetic arteriovenous for hemodialysis PTFE grafts. Comparative analysis between patent and occluded grafts. / Resultados del tratamiento endovascular de la estenosis de la anastomosis venosa en las fístulas arteriovenosas protésicas para hemodiálisis de PTFE. Análisis comparativo entre fístulas permeables y trombosadas.

OBJECTIVE: To analyze the results of endovascular treatment of venous anastomotic stenosis (VAS) in humero-axillary arteriovenous grafts (HAG), comparing outcomes between patent and thrombosed HAG. MATERIAL AND METHODS: A retrospective cohort study was made of endovascular treated patients because of a VAS in a HAG between January 2009 and December 2019. Group A: Thrombosed HAG secondary to a VAS. Group B: Patent HAG with a VAS detected during follow-up. Technical success was defined as residual stenosis after treatment <30%, and clinical success as satisfactory immediate dialysis after surgery. After ET a biannual clinical and ultrasound follow-up was performed. STATISTICAL ANALYSIS: Survival analysis was performed for time-to-event data to assess patency. RESULTS: Group A: 55 patients. Group B: 22. There were no significative differences in demographic and anatomical factors between groups. Technical and clinical success were 100% in Group B and 94.5% and 91% respectively in Group A. Primary patency at 1, 6 and 12 months was: Group A: 81.8%, 22.4% and 15.7% respectively. Group B: 100%, 85.9%, 76.4% (p<0.001). Secondary patency at 1, 6 and 12 months was: Group A: 85.2%, 45.8% and 31.3% respectively. Group B 100%, 95.3%, 95.2% (p<0.001). Use of non-covered stents was associated with an increased risk of occlusion (HR 2.669 95% CI 1.146-6.216, p=0.010). CONCLUSION: A higher patency of EV performed on a patent HAG is expected. It is therefore advisable to develop surveillance programs that are capable to detect VAS before its occlusion.

Preoperative Squid embolization of carotid paragangliomas with direct puncture.

BACKGROUND AND PURPOSE: Preoperative embolization of carotid paragangliomas is a common procedure in interventional neuroradiology. Direct puncture embolization has shown less morbidity and mortality than endovascular embolization and a higher percentage of devascularization. We describe our experience using Squid® as the only embolic agent in direct puncture glomus embolization. METHODS: We retrospectively reviewed pre-embolization imaging tests, emphasizing the volume of the lesion, clinical history data, technical aspects of the procedure, as well as the approximate amount of blood lost during the surgical procedure in all patients with preoperative embolization of carotid paragangliomas performed at our tertiary care hospital. RESULTS: Six patients met our criteria from May 2017 to August 2018. The volume of the mass ranged from 1.4-18.5 mL and the quantity of Squid® injected varied from 1.1-15 mL. Total devascularization was achieved in almost all cases (>90%), with one puncture needed in all but one patient, who was punctured two times. No hemorrhagic complications were described in surgery, no blood transfusions were needed, and the mean decrease of hemoglobin after surgery was 1.04 g/dL. CONCLUSIONS: Direct puncture embolization of carotid paragangliomas only using Squid® is a safe and relatively simple procedure that facilitates the subsequent surgery with minimal blood loss.

Prospective study of safety and effectiveness in the use of radiofrequency ablation for incompetent great saphenous vein ≥12 mm.

OBJECTIVE: The objective of this study was to assess the outcomes of radiofrequency ablation (RFA) in incompetent great saphenous vein (GSV) according to its diameter. METHODS: This was a prospective single-center study including all patients treated with RFA from September 2014 to December 2015. The sample was divided according to the maximum GSV diameter measured on duplex ultrasound scan (A, <12 mm; B, ≥12 mm). Second-generation catheters (ClosureFast; Covidien, Mansfield, Mass) and tumescent anesthesia were used. Clinical stage (according to Clinical, Etiology, Anatomy, and Pathophysiology [CEAP] classification), quality of life (measured by the 14-item Chronic Venous Insufficiency Questionnaire), and pain on visual analog scale were recorded before the procedure and during follow-up. Technical success was defined as GSV occlusion on duplex ultrasound scan. Safety was defined as incidence and type of adverse events at 10 days, 1 month, 6 months, and 12 months. RESULTS: There were 257 patients included, 183 (71%) with GSV diameter <12 mm and 74 (29%) with GSV diameter ≥12 mm. Mean GSV diameter was 8 ± 2 mm (4-11 mm) and 14 ± 2 mm (12-21 mm), respectively. Before the procedure, although a tendency toward greater clinical severity was observed in group B, no significant differences were found in the percentage of patients in C4 and C5 categories (A, 10%; B, 22%), median pain perception (A, 40; B, 39), or median quality of life value on the 14-item Chronic Venous Insufficiency Questionnaire scale (A, 27; B, 27). The rate of GSV occlusion at 1 month (n = 221) was 97% in group A and 100% in group B (P = .325); at 6 months (n = 158), it was 97% and 98%, respectively (P > .999); and at 12 months (n = 90), it was 99% and 96% (P = .481). There was a significant improvement in pain and quality of life in both groups, without differences between them. Finally, no differences between groups were found in terms of adverse events. Paresthesias were the most frequent event (A, 4%; B, 5%; P = NS), which disappeared during follow-up in half of the cases. Regarding major adverse events, there was only one case of deep venous thrombosis in group B. CONCLUSIONS: RFA is safe and effective for the treatment of GSV ≥12 mm at midterm.

Resultados del tratamiento endovascular de la estenosis de la anastomosis venosa en las fístulas arteriovenosas protésicas para hemodiálisis de PTFE. Análisis comparativo entre fístulas permeables y trombosadas / Results of endovascular treatment of venous anastomotic stenosis in prosthetic arteriovenous for hemodialysis PTFE grafts. Comparative analysis between patent and occluded grafts

Objetivo: Analizar los resultados del tratamiento endovascular (TEV) de las estenosis en las anastomosis venosas (EAV) de las fístulas arteriovenosas protésicas (FAVp), comparando su utilidad al realizarse sobre FAVp permeables frente a trombosadas.Material y métodosEstudio retrospectivo de pacientes intervenidos mediante TEV por EAV de fístulas humeroaxilares realizadas entre enero de 2009 y diciembre de 2019 en nuestro centro. Grupo A: FAVp trombosada secundaria a EAV; Grupo B: FAVp permeable con EAV detectada en seguimiento. Se definió éxito técnico como estenosis residual ≤ 30% y éxito clínico como diálisis efectiva inmediata. Tras el TEV se realizó un seguimiento clínico y con eco-Doppler semestral. Estudio estadístico: se realizó un análisis de supervivencia mediante el método Kaplan Meier para el estudio de permeabilidades.ResultadosGrupo A: 55 pacientes. Grupo B: 22 pacientes. No existieron diferencias significativas en las características demográficas ni anatómicas entre grupos.El éxito técnico y clínico fueron del 100% en el grupo B frente a un 94,5% y 91%, respectivamente, en el grupo A.La permeabilidad primaria a 1, 6 y 12 meses en el Grupo A fue: 81,8%, 22,4% y 15,7%, respectivamente, frente al Grupo B: 100%, 85,9%, 76,4% (p<0,001). Permeabilidad secundaria a 1, 6 y 12 meses en el Grupo A fue 85,2%, 45,8% y 31,3%, respectivamente, frente al Grupo B 100%, 95,3%, 95,2% (p<0,001). El uso de stents no cubierto se asoció a un mayor riesgo de oclusión (HR 2,669 IC 95% 1,146-6,216, p=0,010).ConclusiónEs esperable una mayor permeabilidad del TEV realizado sobre una FAVp permeable, por lo que es recomendable elaborar programas de seguimiento que sean capaces de detectar la EAV previo a su trombosis. (AU)

Objective: To analyze the results of endovascular treatment of venous anastomotic stenosis (VAS) in humero-axillary arteriovenous grafts (HAG), comparing outcomes between patent and thrombosed HAG.Material and methodsA retrospective cohort study was made of endovascular treated patients because of a VAS in a HAG between January 2009 and December 2019. Group A: Thrombosed HAG secondary to a VAS. Group B: Patent HAG with a VAS detected during follow-up. Technical success was defined as residual stenosis after treatment <30%, and clinical success as satisfactory immediate dialysis after surgery. After ET a biannual clinical and ultrasound follow-up was performed. Statistical analysis: Survival analysis was performed for time-to-event data to assess patency.ResultsGroup A: 55 patients. Group B: 22. There were no significative differences in demographic and anatomical factors between groups.Technical and clinical success were 100% in Group B and 94.5% and 91% respectively in Group A.Primary patency at 1, 6 and 12 months was: Group A: 81.8%, 22.4% and 15.7% respectively. Group B: 100%, 85.9%, 76.4% (p<0.001). Secondary patency at 1, 6 and 12 months was: Group A: 85.2%, 45.8% and 31.3% respectively. Group B 100%, 95.3%, 95.2% (p<0.001). Use of non-covered stents was associated with an increased risk of occlusion (HR 2.669 95% CI 1.146–6.216, p=0.010).ConclusionA higher patency of EV performed on a patent HAG is expected. It is therefore advisable to develop surveillance programs that are capable to detect VAS before its occlusion. (AU)

Evolution and prognosis of intramural aortic hematoma. Insights from a midterm cohort study.

BACKGROUND: Although several hypotheses have been proposed, the true origin and pathogenesis of aortic intramural hematoma (IMH) remain unclear. Evolution of patients with aortic IMH is highly variable. Progression to classic aortic dissection, aneurysm or to complete resolution have been described. Our purpose was to assess in-hospital and mid-term evolution of patients with aortic IMH. METHODS: From 2000 to 2015, 40 patients with aortic IMH were prospectively and consecutively recruited in a tertiary care referral center. Aortic IMH was defined as the presence of a circular or crescent-shaped thickening of the aortic wall (≥5mm) in the absence of detectable blood flow inside, within the context of acute aortic syndrome. RESULTS: Twenty three patients (57.5%) had type A, and 17 (42.5%) type B IMH. Up to 34.7% of patients with type A and 47.1% with type B IMH showed intimal tears in the imaging test at admission. In-hospital mortality was higher in the type A IMH group. All-cause mortality after discharge was 20%, without significant differences among groups. Out of hospital death was related to the aortic pathology in just one patient. At follow-up, radiological persistence of IMH was observed in 35.7% of patients with type A and 60% of those with type B IMH. CONCLUSIONS: IMH related mortality takes place primarily during the acute phase of the disease. Clinical evolution after discharge is favorable, either in cases of reabsorption or persistence of the IMH. Imaging test findings rekindle the debate on the true training mechanism of the aortic IMH.

Reparación del arco aórtico mediante prótesis híbrida y su combinación con TEVAR / Aortic arch repair with elephant trunk and TEVAR combination

Introducción y objetivos: la reparación del arco y aorta torácica descendente (ATD) se asocia a una elevada morbi-mortalidad. Las prótesis híbridas del arco y las endoprótesis torácicas (TEVAR) pueden disminuir sus complicaciones.El objetivo es describir resultados a corto y medio plazo del abordaje híbrido de esta patología.Material y métodos: análisis retrospectivo de pacientes intervenidos entre agosto de 2016 y febrero de 2020 porpatología aneurismática del arco aórtico y ATD mediante una prótesis híbrida y TEVAR en dos tiempos.Resultados: trece pacientes intervenidos, todos por aneurisma sin disección. Inicialmente se empleó una prótesishíbrida con diámetro mediano de 30 mm (29-33) y una longitud de 130 mm en 12 de ellos. Se conservaron los3 TSA en todos los pacientes, con pastilla para tronco braquiocefálico y carótida izquierda y bypass a subclaviaizquierda en el 69 % de ellos.El tiempo mediano hasta el TEVAR fue de 13,5 semanas (6-20), con un éxito técnico del 100 %. Se implantó un solomódulo en 9 casos con una sobredimensión media del 10 % respecto a la trompa de elefante. No hubo ningúncaso de paraplejia, ictus o muerte perioperatoria. El tiempo mediano de ingreso hospitalario fue de 4 días (2-6) y elseguimiento mediano tras el TEVAR de 17 meses (9-25), con una supervivencia del 100 % a 24 meses. Se comprobóuna correcta exclusión del aneurisma en el angio-TC de control en todos los casos y sin objetivarse fugas de altofl ujo durante el seguimiento.Conclusiones: en nuestra experiencia, el TEVAR es una opción segura como segundo tiempo, y ofrece unos exce-lentes resultados a medio plazo en tasa de exclusión del aneurisma.(AU)

Introduction and objectives: aortic arch and descending thoracic aorta repair are associated with a high mor-bidity and mortality. The frozen elephant trunk combined with TEVAR could improve outcomes. The objective isto describe short and midterm results of the hybrid approach in this pathology.Material and methods: retrospective analysis of patients who underwent two-staged intervention with hybridprosthesis and TEVAR for aortic arch and thoracic descending aneurysm between August 2009 and February 2020.Results: thirteen patients were included, all of them secondary to non-dissecting aneurysm. First-stage interventionwith frozen elephant trunk (average prosthesis diameter: 30 mm [29-33] average length: 130 mm). Supraaorticvessel reimplantation was performed most frequently (69 %) with an island technique for innominate artery andleft common carotid artery and a left subclavian artery bypass to the aortic graft.The average time to TEVAR implantation was 13.5 weeks (6-20), with technical success of 100 %. A single devicewas implanted in 9 cases, with 10 % oversizing relative to the hybrid prosthesis. No cases of paraplegia, stroke orperioperative death were observed. The average hospital stay length was 4 days (2-6) and the average follow-upafter TEVAR was 17 months (9-25), survival at 24 months was 100 %. Correct aneurysm exclusion was documentedin all CT controls, with no high-flow endoleaks during follow-up.Conclusions: based on our experience, TEVAR is a safe option as a second-stage intervention for complex thoracicaortic aneurysm pathology, offering excellent mid-term results for aneurysm exclusion.(AU)

Development of a Telemetric System for Postoperative Follow-up of Vascular Surgery Procedures: In Vitro Model.

BACKGROUND: Because of the unique electromagnetic characteristics of the magnetoelastic microwire, the changes in the pressure of a fluid will provoke a variation of the mechanical pressure on the sensor, which will cause a variation of its magnetization that will be detectable wirelessly. Thus, a wireless system can be developed for following up vascular surgery procedures. METHODS AND RESULTS: The sensor consists of a magnetoelastic microwire ring, which was integrated into an in vitro model with pulsatile flow. Different degrees of stenosis were simulated in different locations both in bovine artery as well as in a polytetrafluoroethylene anastomosis. A Fourier analysis of the registered signals and a statistical analysis using Pearson test and receiver operating characteristic (ROC) curves were made. A Pearson index of 0.945 (P<0.001) was obtained between the invasive pressure of the fluid and the power of the signal transmitted by the sensor in bovine artery. The sensor obtained very good ROC curves upon analyzing the signals registered, both in the case of preanastomotic stenosis (area under the curve [AUC], 0.98; 95% CI, 0.97-1.00), of anastomosis (AUC, 0.93; 95% CI, 0.86-0.99), as well as distal (AUC, 0.88; 95% CI, 0.79-0.98), compared to the control group. CONCLUSIONS: The magnetoelastic microwire has shown that it is capable of detecting, locating, and quantifying the degree of stenosis in bovine artery, as well as in a latero-terminal anastomosis, with a high statistical potency. For the first time, a wireless in vitro sensor has been developed for the postoperative follow-up of vascular surgery procedures.