Solitary iliac branch endoprosthesis placement for iliac artery aneurysms.

BACKGROUND: Isolated iliac artery aneurysms (IAAs), accounting for 2% to 7% of all abdominal aneurysms, are often treated with the use of iliac branched endografts. Although outside the manufacturer's instructions for use, iliac branched devices can be used solely, without the adjunctive placement of an endovascular aneurysm repair device, for the treatment of an isolated IAA. In the present study, we have described the outcomes of the use of the Gore iliac branched endoprosthesis (IBE; W.L. Gore & Associates, Flagstaff, Ariz), without the support of an infrarenal endovascular aneurysm repair device, for the exclusion of an isolated IAA. The present study was an international multicenter retrospective cohort analysis. METHODS: All the patients who had undergone treatment with a solitary IBE for IAA exclusion from January 11, 2013 to December 31, 2018 were retrospectively reviewed. The primary outcome was technical success. The secondary outcomes included mortality, intraoperative and postoperative complications, and reintervention. RESULTS: A total of 18 European and American centers participated, with a total of 51 patients in whom 54 IAAs were excluded. The technical success rate was 94.1%, with an assisted technical success rate of 96.1%. No 30-day mortality occurred, with 98.1% patency of the internal and external iliac artery found at 24 months of follow-up. At 24 months of follow-up, 81.5% of the patients were free of complications and 90% were free of a secondary intervention. CONCLUSIONS: Treatment with a solitary IBE is a safe and, at midterm, an effective treatment strategy for selected patients with a solitary IAA.

Thoracic Endovascular Aortic Repair for Type B Acute Aortic Dissection Complicated by Descending Thoracic Aneurysm.

OBJECTIVES: To analyse the results and review the literature about thoracic aortic endovascular repair (TEVAR) for type B acute aortic dissection (TBAAD) complicated by descending thoracic aortic aneurysm (DTA) in the hyperacute or acute phases. METHODS: This was a multicentre, observational descriptive study. Inclusion criteria were TBAAD with a DTA of ≥50 mm, TBAAD on an already known aneurysmal descending thoracic aorta, and TBAAD presenting with an enlarged aorta with a total diameter <50 mm, but with >50% diameter increase compared with a previous computed tomography angiography (CTA) showing a non-dissected aorta with normal sizing. Primary endpoints were early and long-term survival, freedom from TEVAR and aortic related mortality (ARM), and freedom from re-intervention. RESULTS: Twenty-two patients were included in the analysis. The mean aortic diameter was 66 ± 26 mm (range 42-130; IQR 51-64). The in hospital TEVAR related mortality was 14% (n = 3). The mean radiological follow-up was 56 ± 45 months (range 6-149; IQR 12-82), and the follow-up index 0.97 ± 0.1. All surviving patients were available for follow-up. During follow-up the cumulative mortality was 26% (n = 5) and TEVAR related mortality was 5% (n = 1). Overall the estimate of survival was 82% (95%CI: 61.5-93) at 1 year, and 64% at 5 years. Ongoing primary clinical success was 79% (re-intervention n = 4). Freedom from aortic related mortality was 86% (95%CI: 66-95) at 1 and 5 year, while freedom from re-intervention was 95% (95%CI: 75.5-95) at 1 year, and 77% (95%CI: 50-92) at 5 years. CONCLUSIONS: In our experience, DTA is a frequent complication from the very beginning of the clinical onset of TBAAD. In this high-risk cohort, TEVAR showed satisfactory results, better than those predicted by the risk score for open repair, with favourable stability of the aortic diameter and no aortic related adverse events during follow-up.

Extensibility and Distensibility of the Thoracic Aorta in Patients with Aneurysm.

OBJECTIVES: Reference values of aortic deformation during the cardiac cycle can be valuable for the pre-operative planning of thoracic endovascular aortic repair (TEVAR) and for facilitating computational fluid dynamics. This study aimed to quantify normal aortic extensibility (longitudinal extension) and distensibility (radial expansion), as well as pulsatile strain, in a group of 10 (>60 years) individuals with abdominal or thoracic aortic aneurysms. METHODS: ECG gated CT images of the thoracic aorta were reconstructed into virtual 3D models of aortic geometry. The centre lumen line length of the thoracic aorta and three longitudinal segments, and the aortic diameter and luminal areas of four radial intersections were extracted with a dedicated software script to calculate extensibility, longitudinal strain, distensibility, and circumferential area strain. RESULTS: Mean extensibility and longitudinal strain of the entire thoracic aorta were 3.5 [1.3-6.8] × 10-3 N-1, and 2.7 [1.0-4.5]%, respectively. Extensibility and longitudinal strain were most pronounced in the ascending aorta (20.6 [5.7-36.2] × 10-3 N-1 and 15.9 [6.6-31.9]%) and smallest in the descending aorta (4.4 [1.6-12.3] × 10-3 N-1 and 2.2 [0.7-4.7]%). Mean distensibility and circumferential area strain were most pronounced at the sinotubular junction (1.7 [0.5-2.9] × 10-3 mmHg-1 and 11.3 [3.3-18.5]%, respectively). Distensibility varied between 0.9 [0.3-2.5] × 10-3 mmHg-1 and 1.2 [0.3-3.3] × 10-3 mmHg-1 at the intersections in the aortic arch and descending aorta. CONCLUSIONS: Pulsatile deformations in both longitudinal and circumferential directions are considerable throughout the thoracic aorta. These findings may have implications for pre-operative TEVAR planning and highlight the need for devices that can mimic the significant aortic longitudinal and circumferential strains.

A pilot observational study on magnesium and calcium imbalance in elderly patients with acute aortic dissection.

BACKGROUND: Magnesium (Mg) and calcium (Ca) are the principal essential elements involved in endothelial cell homeostasis. Extracellular changes in the levels of either alter endothelial contraction and dilatation. Consequently Mg and Ca imbalance is associated with a high risk of endothelial dysfunction, the main process observed during acute aortic dissection (AAD); in this clinical condition, which mainly affects elderly men, smooth muscle cell alterations lead to intimal tears, creating a false new lumen in the media of the aorta. AAD patients have a high risk of mortality as a result of late diagnosis because often it is not distinguished from other cardiovascular diseases. We investigated Mg and Ca total circulating levels and the associated pro-inflammatory mediators in elderly AAD patients, to gain further information on the pathophysiology of this disorder, with a view to suggesting newer and earlier potential biomarkers of AAD. RESULTS: Total circulating Mg and Ca levels were both lower in AAD patients than controls (p < 0.0001). Using Ca as cut-off, 90% of AAD patients with low Ca (<8.4 mg/dL) came into the type A classification of AAD. Stratifying AAD according to this cut-off, Mg was lower in patients with lower total Ca. Compared to controls, both type A and B AAD patients had higher levels of all the pro-coagulant and pro-inflammatory mediators analyzed, including sP-sel, D-dimer, TNF-α, IL-6, and CRP (p < 0.05). Dividing types A and B using the Stanford classification, no significant differences were found (p > 0.05) The levels of both ICAM-1 and EN-1 were lower in AAD than in a control group (p < 0.0001 and p < 0.05 respectively). CONCLUSIONS: These findings suggest that low Mg and Ca in AAD elderly patients may contribute to altering normal endothelial physiology and also concur in changing the normal concentrations of different mediators involved in vasodilatation and constriction, associated with AAD onset and severity.

Acute phase of aortic dissection: a pilot study on CD40L, MPO, and MMP-1, -2, 9 and TIMP-1 circulating levels in elderly patients.

BACKGROUND: Acute aortic dissection (AAD) is an event which may be rapidly fatal without early diagnosis and treatment. Aging is one of the main risk factors that could leading to AAD. To date, no specific biomarkers are available to increase the speed of diagnosis. CD40 ligand (CD40L), myeloperoxidase (MPO), matrix metalloproteinase (MMP)-1, -2, -9 and metallopeptidase tissue inhibitor 1 (TIMP-1) are biologically related molecules which integrate inflammation, tissue injury and remodeling, all events associated to AAD. Our is a pilot study to evaluate whether circulating levels of these molecules may be used as potential biomarkers in timely diagnosis of AAD. RESULTS: Within 24 h of symptom onset, circulating CD40L, MPO, MMP-1,-2,-9 and TIMP-1 were quantified by enzyme-linked immunosorbent assays in 22 patients (40-86 years of age) with AAD of ascending aorta (type A according to Stanford classification) and 11 patients with AAD of descending aorta (type B). 30 healthy individuals age matched were used as control group compared to controls, both type A and B AAD patients had higher CD40L (p < 0.001) and MPO (p < 0.01) levels. MMP-1 was higher in the overall AAD group (p < 0.01). After Stanford classification, type A group had increased level compared to both control and type B (p < 0.01 and p < 0.05, respectively). TIMP-1 was higher in both A and B groups compared to controls (p < 0.001). No differences were observed in MMP-2 and MMP-9 levels. CONCLUSIONS: The simultaneous evaluation of CD40L, MPO and MMP-1 and TIMP-1, which may contribute to structural changes in aortic tissue in AAD patients, seems to be a novel promising diagnostic panel.

Endovascular repair of acute uncomplicated aortic type B dissection promotes aortic remodelling: 1 year results of the ADSORB trial.

OBJECTIVES: Uncomplicated acute type B aortic dissection (AD) treated conservatively has a 10% 30-day mortality and up to 25% need intervention within 4 years. In complicated AD, stent grafts have been encouraging. The aim of the present prospective randomised trial was to compare best medical treatment (BMT) with BMT and Gore TAG stent graft in patients with uncomplicated AD. The primary endpoint was a combination of incomplete/no false lumen thrombosis, aortic dilatation, or aortic rupture at 1 year. METHODS: The AD history had to be less than 14 days, and exclusion criteria were rupture, impending rupture, malperfusion. Of the 61 patients randomised, 80% were DeBakey type IIIB. RESULTS: Thirty-one patients were randomised to the BMT group and 30 to the BMT+TAG group. Mean age was 63 years for both groups. The left subclavian artery was completely covered in 47% and in part in 17% of the cases. During the first 30 days, no deaths occurred in either group, but there were three crossovers from the BMT to the BMT+TAG group, all due to progression of disease within 1 week. There were two withdrawals from the BMT+TAG group. At the 1-year follow up there had been another two failures in the BMT group: one malperfusion and one aneurysm formation (p = .056 for all). One death occurred in the BMT+TAG group. For the overall endpoint BMT+TAG was significantly different from BMT only (p < .001). Incomplete false lumen thrombosis, was found in 13 (43%) of the TAG+BMT group and 30 (97%) of the BMT group (p < .001). The false lumen reduced in size in the BMT+TAG group (p < .001) whereas in the BMT group it increased. The true lumen increased in the BMT+TAG (p < .001) whereas in the BMT group it remained unchanged. The overall transverse diameter was the same at the beginning and after 1 year in the BMT group (42.1 mm), but in the BMT+TAG it decreased (38.8 mm; p = .062). CONCLUSIONS: Uncomplicated AD can be safely treated with the Gore TAG device. Remodelling with thrombosis of the false lumen and reduction of its diameter is induced by the stent graft, but long term results are needed.

Endovascular stenting of the ascending aorta for type A aortic dissections in patients at high risk for open surgery.

BACKGROUND: Open repair is the gold standard for type A aortic dissection (TAAD). Endovascular option has been proposed in very limited and selected TAAD patients. We report our experience with endovascular TAAD repair. METHODS: Inclusion criteria were: (1) entry tear in the ascending aorta; (2) proximal landing zone of at least 2 cm; (3) distance between entry tear and brachio-cephalic trunk of at least 0.5 cm; (4) no signs of cardiac tamponade or severe aortic regurgitation and (5) no signs of aortic branches ischaemia. Patients with cardiac revascularisation from ascending aorta were excluded. RESULTS: From April 2009 to June 2012, 37 patients with TAAD were admitted to our hospital. As many as 28 underwent surgical repair and 9 were considered at high surgical risk in a multidisciplinary meeting. Four met our inclusion criteria for an endovascular approach. Two of them had previous ascending aortic repair for TAAD and one had aortic valve replacement. Technical success was achieved in 100% of the patients. No mortality was registered during a median follow-up of 15 months (range 4-39 months), no migration of the graft and complete false lumen thrombosis of the ascending aorta in three patients. CONCLUSION: Endovascular treatment of TAAD is challenging but feasible in a selected subset of patients. Further research remains mandatory.

Endovascular treatment of ruptured thoracic aortic aneurysm in patients older than 75 years.

OBJECTIVES: To investigate the outcomes of thoracic endovascular aortic repair (TEVAR) for ruptured descending thoracic aortic aneurysm (rDTAA) in patients older than 75 years. METHODS: We retrospectively identified all patients treated with TEVAR for rDTAA at seven referral centres between 2002 and 2009. The cohort was stratified according to age ≤75 and >75 years, and the outcomes after TEVAR were compared between both groups. RESULTS: Ninety-two patients were identified of which 73% (n = 67) were ≤75 years, and 27% (n = 25) were older than 75 years. The 30-day mortality was 32.0% in patients older than 75 years, and 13.4% in the remaining patients (p = 0.041). Patients older than 75 years suffered more frequently from postoperative stroke (24.0% vs. 1.5%, p = 0.001) and pulmonary complications (40.0% vs. 9.0%, p = 0.001). The aneurysm-related survival after 2 years was 52.1% for patients >75 years, and 83.9% for patients ≤75 years (p = 0.006). CONCLUSIONS: Endovascular treatment of rDTAA in patients older than 75 years is associated with an inferior outcome compared with patients younger than 75 years. However, the mortality and morbidity rates in patients above 75 years are still acceptable. These results may indicate that endovascular treatment for patients older than 75 years with rDTAA is worthwhile.

Acute aortic dissection: perspectives from the International Registry of Acute Aortic Dissection (IRAD).

Acute aortic dissection is a rare but deadly disease first described over 200 years ago by the physician to the late King George II on necropsy. Over the ensuing 2 centuries, the understanding of the pathophysiology, presentation, diagnosis, treatment and follow-up has matured. In an effort to understand the contemporary treatment of this disease, the International Registry of Acute Aortic Dissection (IRAD) has enrolled over 2000 patients over the past 12 years. In this article we summarize the key lessons learned from this multi-national registry of patients presenting with acute aortic dissection.

Bifurcated endovascular graft for spontaneous acute aortic dissections: report of a case using a simple technique to help safe deployment.

This paper presents the description of the author's experience with bifurcated endovascular stent graft in a patient affected by spontaneous infrarenal acute aortic dissection (SIAAD). The authors report a case of SIAAD occurring in the normal aorta of a patient who presented with severe lower back pain radiated to the abdomen, not responding to common pain-killers. A complete exclusion of the dissected aorta was accomplished with a bifurcated endovascular graft using a simple technique. SIAAD is a rare event. Endovascular therapy is a safe option and can be considered the treatment of choice even for dissection extending into one or both iliac.

Computational simulation of TEVAR in the ascending aorta for optimal endograft selection: A patient-specific case study.

Thoracic endovascular aortic repair of the ascending aorta is becoming an option for patients considered unfit for open surgery. Such an endovascular procedure requires careful pre-operative planning and the customization of prosthesis design. The patient-specific tailoring of the procedure may call for dedicated tools to investigate virtual treatment scenarios. Given such considerations, the present study shows a computational framework for choosing and deploying stent-grafts via Finite Element Analysis, by supporting the device sizing and selection in a real case dealing with the endovascular treatment of a pseudoaneurysm. In particular, three devices with various lengths and materials were examined. Two off-the-shelf devices were computationally tested: one composed of Stainless Steel rings with a nominal length of 60 mm and another one with Nitinol rings and a distal free flow extension, with a nominal length of 70 mm. In third place, a custom-made stent-graft, also with Nitinol rings and containing both proximal and distal bare extensions with a nominal length of 75 mm, was deployed. The latter solution based on patient morphology and virtually benchmarked in this simulation framework, enhanced the apposition to the wall by reducing the distance between the skirt and the vessel from more than 6 mm to less than 2 mm in the distal sealing zone. Our experience shows that in-silico simulations can help choosing the right endograft for the ascending aorta as well as the right deployment sequence. This process may also encourage vendors to develop new devices for cases where open repair is unfeasible.

Plasma levels of metalloproteinases-3 and -9 as markers of successful abdominal aortic aneurysm exclusion after endovascular graft treatment.

BACKGROUND: Structural alterations of aortic wall resulting from degradation of matrix proteins by matrix metalloproteinases (MMPs) characterize abdominal aortic aneurysms (AAAs). No studies have compared circulating levels of MMPs after endovascular graft (EVG) exclusion in comparison with open surgical repair (OSR) in patients affected by AAA. METHODS AND RESULTS: An abdominal angiography and CT scan were performed in all patients at the time of enrollment. A spiral CT scan was performed at 6 months to detect presence of endoleaks. MMP-3 and MMP-9 levels were measured before EVG (n=30) and OSR (n=15) treatments and at 1, 3, and 6 months of follow-up by a sandwich ELISA technique. Healthy volunteers (n=10) were used as control subjects. Immunohistochemical staining for MMP-9 and MMP-3 was performed on tissue samples from surgical cases. Both MMP-9 and MMP-3 mean basal levels were significantly higher in patients affected by AAA than in control subjects (32.3+/-20.7 ng/mL for EVG and 28+/-9.9 ng/mL for OSR versus 8.9+/-2.5 ng/mL, 2P<0.05; 18.3+/-9.7 ng/mL and 26.7+/-10.8 ng/mL versus 8.2+/-5.3 ng/mL, 2P<0.001). In the OSR group, both MMP-9 and MMP-3 mean levels decreased after surgery (28+/-9.9 ng/mL at basal versus 14.7+/-6.6 ng/mL at 6 months, 2P<0.001; 26.7+/-10.8 versus 12+/-5.3 ng/mL; 2P<0.001). In the EVG group, a statistically significant difference at 6-month follow-up in MMP-9 and MMP-3 mean plasma values was detected in patients who had endoleakage in comparison with patients without endoleakage (44.3+/-20.7 versus 14.6+/-7.0 ng/mL, 2P<0.005; 25+/-11.5 versus 10.3+/-5.4 ng/mL, 2P<0.005). CONCLUSIONS: After EVG exclusion, MMP-9 and MMP-3 levels decreased to a level similar to that of patients undergoing OSR. In addition, a lack of decrease in MMP levels after EVG exclusion may help in identifying patients who will have endoleakage and consequent aneurysm expansion caused by continuous sac pressurization during follow-up.

Ruptured aneurysm of the internal iliac artery.

The aneurysms of the internal iliac artery are rare and very often asymptomatic. Because of the anatomic location of this artery, it can be difficult to diagnose this kind of aneurysm, when isolated. Frequently it is diagnosed in consequence of aneurysmatic complication, such as rupture and/or impending rupture. In this work we report our experience concerning 6 cases of ruptured aneurysm of the internal iliac artery, observed in 5 patients. In three of these cases the lesion was isolated. In two cases the patients had already been operated on for abdominal aortic aneurysm, 4 and 6 years before. All the five patients were operated on. In 5 cases we ligated the aneurysm, without using any vascular graft. In one case where the external iliac artery was involved, we used a vascular graft between the common iliac and common femoral artery, in order to repair the vascular axis. One case of mortality was observed and a rare complication occurred in one case. An 83-year-old man treated in emergency for ruptured aneurysm of the left internal iliac artery, with regular post-operative course, was hospitalized again 24 days later with sepsis and pain in the left lower abdomen. A CT scan and a following urography showed a urinary fistula probably due to an ischemic necrosis of a segment of the ureter. A percutaneous nephrostomy has been performed and the patient successfully discharged.

Ruptured aneurysms of the thoracoabdominal aorta: a case series.

Fifteen cases of ruptured thoracoabdominal aneurysm (-TAA) were encountered in 1987-July 1994. These patients included 13 males (86.6%), 2 females (13.4%) with a mean age of 66.3 years (range 58-78). Surgery was performed on 13 patients of whom 6 (46.1%) died within 30 days. The two other patients had died of heart failure prior to surgery. In 8 of these patients (53.4%) the condition was not diagnosed until clear symptoms had appeared. The ruptured aneurysms were thoracic in 9 cases (60%), abdominal in 6 (40%). The maximum aneurysm diameter in the most frequently ruptured group was 6.1-8 cm (in 9 patients-60%)./ For 5 cases (33.4%) the maximum diameter of ruptured aneurysms included dorsolumbar pain. In one patient a concomitant aortobronchial fistula had produced rupture. Low blood pressure was found in 9 cases (60%). In 5 cases (38.4%) curative surgery was performed within 24 hours of the onset of symptoms. In this group, the mortality rate was 40% (2 patients). In the remaining 8 cases, on whom surgery could not be performed within 24 hours (range 25 hours-4 months) the mortality rate was 50% (4 cases). All four cases of paraplegia (30.7%) were encountered among patients in the second group, 2 of whom died. Follow-up revealed a 5-year mortality rate of 71.4%.

Proximal pseudoaneurysm of ascending-abdominal aortic bypass.

Proximal pseudoaneurysm of ascending-abdominal aortic bypass is an uncommon surgical disease. We report a repair of complete detachment of proximal anastomosis of the ascending-abdominal aortic bypass in a 68-year-old man that underwent surgery in 1988 for chronic descending thoracic aortic aneurysm treated with thromboesclusion technique. The clinical, diagnostic, and operative aspects are discussed.

Acute type A aortic dissection and coarctation of aortic isthmus.

Acute type A aortic dissection and coarctation of the aorta is a rare associated disease. A case of two-stage repair is presented. Firstly the ascending aorta and the right hemi-arch was replaced using deep hypo-thermic circulatory arrest. Cardiopulmonary bypass was proximally instituted, in a patient with total aortic isthmus occlusion, using right axillary artery cannulation. Distally arterial perfusion was obtained cannulating the bilateral hypoplasic femoral arteries. Ten months later a left subclavian artery-descending thoracic aorta bypass was performed.

Single stage repair of symptomatic type IV thoracoabdominal aortic and iliac aneurysm in Behçet's disease. Case report.

A 50-year-old man with Behçet's disease (BD) diagnosed ten years previously, was submitted to emergency operation of two symptomatic type IV thoracoabdominal aortic and left common iliac aneurysms repair. Despite the rarity of vascular lesions in the course of BD, the uncommon clinical situation of double symptomatic aneurysms was successfully treated with surgical management that appears more difficult because of the inflammatory process associated with obliterative endoarteritis involving all periaortic tissues.

[Inflammatory aneurysms of the subrenal aorta. Histopathological, diagnostic and therapeutic aspects]. / Gli aneurismi infiammatori dell'aorta sottorenale. Aspetti istopatologici, diagnostici e terapeutici.

Inflammatory abdominal aneurysms (AIAA) represent a clearly defined clinical entity with an incidence ranging between 1.2% and 15%. In spite of the increasing number of observations reported in recent years, the etiopatholgenesis and natural history have not been defined. The lesion can present in an acute, subacute or chronic manner and the histopathological studies reveal prevalently two components: an inflammatory infiltrate and a diffuse fibrosis, in varying degree. This study aimed to analyze the more recent imaging procedures in order to correctly diagnose this lesion. In our experience the incidence of AIAA is about 2.5%. On the basis of macro microscopic pictures the authors divided patients into two groups: one constituted by the acute or subacute inflammatory forms, the other by chronic clear inflammatory aneurysms. All patients underwent on operative treatment. The surgical adopted techniques and the obtained results are reported.

[Prevalence of carotid kinking in a resident population. Partial results of the OPI (Objective Prevention of Ictus)]. / Prevalenza del kinking carotideo in una popolazione residente. Risultati parziali del programma OPI (Obiettivo Prevenzione Ictus).

This paper reports partial results on carotid kinking prevalence from the ongoing program Obiettivo Prevenzione Ictus, whose main target is to detect atherosclerotic carotid lesions in a resident population. Over a period of 23 months, 13.936 subjects, aged 45 to 75, were screened by physical vascular and carotid CW Doppler ultrasound examinations; 1.386 (9.9%) subjects underwent color coded echoflow imaging, according to the design of the screening program (suspected carotid atherosclerotic lesion at first level screening): 185 among this subgroup, 40 males and 145 females, were affected with 266 carotid kinkings. In 81 cases (43.8%) the lesions were bilateral. Sensibility and specificity of carotid bruit (25% and 73%, respectively) and CW Doppler ultrasound (48.5% and 55.8%, respectively) proved inadequate for routine diagnosis of carotid kinking. Hypertension was recorded in 146 cases (78.9%). No cerebral ischemic attack was recorded in these 185 subjects over the period considered.