Carotid Artery Stenting versus Carotid Endarterectomy in Terms of Neuroprotection DW-MRI Detected and Neuropsychological Assessment Impairment.

BACKGROUND: Carotid artery stenting (CAS) versus carotid endarterectomy (CEA) is well issue known, but the purpose of this study is to compare CAS versus CEA in terms of asymptomatic Diffusion-weighted magnetic resonance imaging (DW-MRI) demonstrated microembolic scattering of infarction and neuropsychological assessment impairment. METHODS: We performed a prospective, observational, cohort study on 211 consecutive carotid revascularizations at our institution. Patients were divided into 2 different cohorts: CEA was performed in n = 116 patients (Group A); CAS was performed in n = 95 (Group B). Adverse events were collected at 30 days and 6 months postoperative. Differences in terms of DW-MRI demonstrated microembolic scattering of infarction were analyzed and considered significative for P ≤ 0.05. Secondary objectives were: major and minor stroke, neuropsychological assessment impairment, death, myocardial infarction (MI). RESULTS: CEA was associated with a significative decreased rate of asymptomatic DW-MRI demonstrated microembolic scattering of infarction (13.8% vs. 51%; P = 0.0001) and of 6 months neuropsychological assessments impairment (0.8 vs. 7.4) (P = 0.04) in asymptomatic patients. There was no significant difference between 2 groups in terms of comorbidities. Stroke rates were similar at 30 days (1.7% CEA vs. 4.1% CAS) and 6 months (2.6% CEA vs. 5.3% CAS P = 0.32). There were no differences in terms of central neurological events, death, transient ischemic attack, MI between the groups. The composite end point of stroke/death/MI at 6 months postoperatively was 2.6% vs. 6.3% (P = 0.19). CONCLUSIONS: According to these results, CEA achieved better outcomes compared to patients treated by CAS with distal filter in terms of asymptomatic microembolic event and impairment National Institutes of Health Stroke Scale scale and neuropsychological assessments. Limitations of the study lead to limited conclusions only in the specific population and not generalized. Further, comparative randomized studies are warranted.

Simultaneous aortoiliac kissing Endovascular stenting for management of isolated monolateral common iliac artery aneurysm with no proximal landing zone.

BACKGROUND: Isolated iliac artery aneurysm (IIAA) is an uncommon finding. It, accounts for 0.03% of all patients and 2% of all abdominal aneurysm. Endovascular approach represents the treatment of choice for most patients with IIAA. We reported our experience on iliac aneurysm with no proximal landing zone by simultaneous aortoiliac kissing endovascular (S.A.K.E.) covered stenting. METHODS: This is a retrospective analysis of nine consecutive patients with IIAA with no proximal landing zone, who underwent endovascular kissing covered stenting (Gore®Viabahn®VBX) The median aneurysm diameter was 4.1 cm, with a median 3-mm proximal neck length. In 3/9 aneurysms involving the internal iliac arteries the origin of the internal iliac artery was covered after its embolization and a stent graft extending to the external iliac artery (EIA) was placed. All stents were flared with semi-compliant balloon. RESULTS: Iliac aneurysm exclusion was obtained in all cases (100%), no graft migration or endo-leak were recorded. The median operative time was 28 min; the median fluoroscopy time was 9 min and a median 70 mL of contrast was used. At a median 24-month follow-up, all patients are alive, and no endo-leak or migration, infection, distal embolization, limb loss were observed. Moderate buttock claudication was experienced in 1/9 patients with internal iliac artery embolization. In 6/9 patients a shrinkage of the aneurysmal sac was recorded after 1 year. DISCUSSION: Endovascular management of IIAAs cases has been reported in literature and it was confirmed to be safe and successful. The IAA usually progresses into expansion which eventually leads into rupture. Adequate long proximal and distal landing zones were the most important feature related to better outcomes. Short proximal neck (˂10 mm) represents a real challenge for iliac aneurysm treatment and, nowadays, a classical bifurcated aortoiliac endograft deployment represents the treatment of choice. Endovascular repair of isolated CIA aneurysms with no proximal neck is safe and successful using the SAKE stenting technique with VBX adequately flared and it represents effective and minimally invasive alternative to aortobiliac endograft implantation in the treatment of these aneurysms. To the best of our knowledge, this is the first report which describes this approach in the treatment of IIAA with no adequate proximal landing zone. Our approach overcomes the need to aortic bifurcation graft implantation and reduces procedure time, contrast dose and radiation exposure. It also preserves relevant collaterals vessels thanks to inferior mesenteric artery and lumbar arteries sparing. A proximal aortic bifurcation endograft allows proximal sealing to be regained. Large population study with longer follow-up are needed to establish this approach as a new standard.

Are Small Popliteal Aneurysm so Innocent?

BACKGROUND: We recently recorded 5 lower limb ischemia related to a small (diameter≤20 mm) popliteal artery aneurysm (PAA) thrombosis hence we performed a retrospective data analysis on small symptomatic PAA management from our database. METHODS: We performed a retrospective cohort study on 48 acute leg ischemia from aneurysm's thrombosis. All of them underwent surgical distal thrombectomy and bypass creation. Patients were divided into 2 different cohorts: GROUP A (diameter ≥20 mm) and GROUP B (diameter ≤20 mm). Differences in terms of the limb salvage (end-point: the amputation rate) was analyzed and considered significative for P ≤ 0.05. Secondary objectives were: vessel runoff recovery and patency rate. Adverse events were collected at 12 and 24 months postoperative. RESULTS: Two-year overall amputation rate was: 22.9% (11/48); 21.8% (7/32) in GROUP A and 25% (4/16) in GROUP B (RR:0.87, CI:0.29-2.55, p.80). The mean age was 68 ± 13 years, No statistically significant differences were identified in term of primary and secondary patency (RR:0.95, CI:0.55-1.6, p.85 and (RR:0.95, CI:0.53-1.7, p.88 respectively) no differences were found in terms of comorbidities. Patients' follow-up ranged from 8 to 36 months. In 90% of those amputated patients, the length of ischemia exceeded 4 days. Amputation rate was correlated with one runoff vessel recovery, only. CONCLUSION: s According these results small PAA are not as innocent as it is often presumed and was associated with not negligible incidence of limb loss due to thrombosis or distal embolizations also if compared to larger aneurysm. The immediate surgery is mandatory also when the ischemia exceeds 2 days.

Isolated popliteal artery lesion due to giant cell vasculitis post COVID-19 mRNA vaccine and COVID-19 asymptomatic infection.

OBJECTIVE: Giant cell arteritis (GCA) is a rare granulomatous vasculitis, affecting medium and large vessels, usually in old patients. The incidence of GCA has been higher during current COVID-19 pandemia and COVID-19 is recognized for its immune dysregulation. Lower limbs involvement is uncommon but can be limb threatening, resulting in limb loss. METHOD: A 43-year-old man presented with a sudden pain in his right calf and foot associated with pallor and hypothermia, and there was objective evidence of ischemia. Symptoms began few days after he received the first dose of a COVID-19 mRNA vaccine and COVID-19 asymptomatic infection 20 days after vaccination. He had no history of any signs of claudication pre-COVID or limb trauma and was very fit.Enhanced computed tomography and magnetic resonance imaging (MRI)suggest diagnosis of popliteal artery cystic adventitial disease. We resected the affected popliteal artery with interposition using a right great saphenous vein graft, through a posterior approach. On the fourth postoperative day, he was discharged.Histopathological examination revealed patchy intramural inflammatory infiltrates composed of lymphocytes and rare multinucleated giant cells at the internal lamina and adventitia consistent with a diagnosis of GCA. CONCLUSION AND RESULT: Our case represents the first reported case of isolated popliteal GCA following vaccination with a COVID-19 mRNA vaccine and COVID-19 infection. We propose that the upregulated immune response to the vaccine acted as a trigger for GCA in this patient with predisposing risk factors and recurrent and repetitive microtrauma in popliteal fossa (the patient is a professional runner). Our case suggests the need for further studies about real world incidence of GCA associated vaccination and COVID-19 infection. Currently, data is limited regarding this relationship. We continue to encourage COVID-19 vaccination, even in elderly patients because the benefits of vaccination far outweigh any theoretical risk of immune dysregulation following administration.

Common carotid artery endovascular clamping for neuroprotection during carotid stenting: Flow-gate system as an innovative treatment approach.

OBJECTIVES: We here report our clinical experience in CAS management through common carotid artery endovascular clamping with FlowGate2 system. METHODS: Forty-five patients were enrolled with de novo asymptomatic internal carotid artery stenosis ≥70%. Cerebral protection during the stenting procedure was achieved using a unique endovascular clamping technique developed in our Institution which includes: (a) the occlusion of the common carotid artery only, through inflatable balloons integrated in the FlowGate2 Balloon Guide Catheter system; (b) flow inversion connecting catheter to 16 G blood cannula previously placed in arm vein; (c) after the placement of the stent, the flow inversion is maintained for 30 s to allow debris washout. The related primary end-point was the rate of Diffusion-weighted imaging magnetic resonance (DWI) micro-embolic scattering of infarction. The patient's clinical and the neurological status were assessed prior, during and after intervention, at discharge. RESULTS: Transient clamping intolerance was observed in two patients (2/45; 4%). One minor stroke (1/45; 2%) occurred 8 hr the procedure with DWI ipsilateral micro-embolic lesions. No major strokes or deaths were observed at 3 months follow-up. DWI demonstrated ipsilateral micro-embolic scattering of infarction, in one asymptomatic patient. In all patients, no worst changes in NIHSS scale assessment were recorded at 1, 3, and 6 months. CONCLUSIONS: Our data confirmed the efficacy of FlowGate2 in terms of neuroprotection during CAS. To our knowledge, these are the first published data on this innovative approach developed in our institution. A large controlled trial is ongoing to confirm preliminary evidences.

Retroperitoneal Hematoma Caused by Suprarenal Stent Perforation Two Years after Ovation Abdominal Stent-Graft Implantation.

Retroperitoneal hematoma due to late perforation of aortic wall endograft deployment is a rare but, potentially, fatal event. We report a case of symptomatic retroperitoneal hematoma due to aortic perforation by free flow barbs of Ovation Prime stent graft. The patient was successfully treated by celiac trunk embolization and aortic cuff placement. The patient was discharged with no further treatment. At 3-month follow-up, no complications were detected.

Endovascular Treatment with Two Overlapping Micromesh-Covered Stents and Balloon Guide Catheter for Symptomatic Carotid Pseudoaneurysm Ten Years after Eversion Endarterectomy.

Pseudoaneurysm is a rare complication after carotid endarterectomy. Herein, we report a successful endovascular exclusion of a symptomatic carotid pseudoaneurysm occurred ten years after an eversion carotid endarterectomy by means of 2 overlapping micromesh stents (InspireMD C-Guard™) and balloon guide catheter (FlowGate2 Balloon Guide Catheter) used as a proximal protection device.

Type 2 Endoleak Incidence and Fate After Endovascular Aneurysms Repair in a Multicentric Series: Different Results with Different Devices?

BACKGROUND: The aim of this work is describing incidence and fate of type 2 endoleaks (T2ELs) in a multicentric cohort of patients treated by endovascular aneurysms repair using the Ovation device (Endologix) and comparing them with a group treated using the Excluder (W. L. Gore & Associates). METHODS: This is a retrospective study conducted on 261 patients treated using the Ovation device and 203 using the Excluder. Outcomes were intraprocedural, 30-day, 12-month, and mean time follow-up T2EL incidence and related reinterventions. Patent inferior mesenteric artery (IMA), ≥3 lumbar arteries (LAs), intrasac thrombus volume, the mean diameter of common and external iliac arteries, external iliac artery stenosis (>70%), diameter ≤5 mm, iliac tortuosity ratio ≤0.5, thrombosis, and calcification were noted and considered as potentially influencing outcomes. RESULTS: Patients of the Ovation group presented significantly more thrombosed, calcified, and tortuous iliac vessels than those in the Excluder group. No significant differences were noted in sac thrombosis, IMA, and LA patency. At completion angiography, T2EL was evident in 57 Ovation and 46 Excluder patients (P = 0.832). At 1 month, it was evident in 33 Ovation group and 28 Excluder group patients (P = 0.726). At 12-month and mean time (30.14 months) follow-up, no differences were evident between the 2 groups (P = 0.940 and 0.951, respectively). The log-rank test showed that the rate of T2EL-related reintervention was not different between the 2 groups (P = 0.46). Regarding anatomical characteristics, a statistically significant difference was not observed between patients presenting or not with T2EL (P > 0.05). CONCLUSIONS: Data showed no significant differences in terms of T2EL incidence between the 2 study groups. None of preoperative anatomical features were found to be significantly associated with the appearance of T2EL.

Anaphylactic Reaction during Implantation of Ovation Abdominal Stent Graft in Patients with Abdominal Aortic Aneurysm.

The Ovation Abdominal Stent Graft System is a trimodular endoprosthesis planned to overcome the limitations of currently available stent grafts, allowing complex iliac and femoral access and providing a proximal seal in challenge infrarenal neck morphology. The proximal sealing is achieved by means of a network of inflatable rings filled with low-viscosity radiopaque polyethylene glycol-based polymer during stent-graft deployment. The leakage of polymer outside the channel to fill the rings into the vascular system may induce an hypersensitivity reaction and anaphylactic shock. We report a case of anaphylactic reaction during Ovation Abdominal Stent Graft System implantation. The endovascular procedure was successfully concluded.

Real-Life Experience with Ovation Stent Graft: Lesson Learned from the First One Hundred Fifty Treated Patients.

BACKGROUND: The objective of the study was to report immediate and midterm results of an unselected population of patients treated for abdominal aortic aneurysms (AAAs) by endovascular aneurysm repair (EVAR) using the Ovation stent graft. METHODS: A double-center retrospective study was conducted on a prospectively collected database between 2012 and 2015. One hundred fifty-six elective patients were included. The outcome measures considered for analysis were primary technical success, 30-day and midterm reinterventions, and all-cause and AAA-related mortality rates. The presence of an aortic neck ≤10 mm, and of a noncylindrical aortic neck, as well as a narrowed aortic bifurcation was defined as an aortic bifurcation average diameter (ABaverage) ≤ 18 mm or an ABarea ≤ 20 mm2, and an external iliac artery diameter ≤5 mm was considered as independent factors potentially influencing the outcome. RESULTS: Male patients totaled 128 (82.1%), and mean age was 74.83 ± 6.76 years (range: 56-91). Mean aortic diameter was 57.15 ± 8.77 mm, mean diameter at inferior renal artery level + 13 was 24.44 ± 3.31 mm, and mean aortic neck length was 18.77 ± 8.45 mm. Fifty-four patients (34.6%) had an aortic neck ≤10 mm, and cylindrical aortic neck shape was present in 34 patients (21.8%). Regarding the aortic bifurcation (AB), 31 patients (19.9%) presented ABaverage ≤ 18 mm, and 35 (22.4%) an ABarea ≤ 20 mm2. Technical success was achieved in all cases. At 30-day follow-up, 2 type I endoleaks (1.3%) were detected. One patient was successfully treated endovascularly by proximal aortic cuff implantation, while the other patient refused further treatment. Three-month unscheduled computed tomographic angiography shows endoleak resolution and complete aneurysm seal. One patient suffered from a limb graft occlusion, managed by medical treatment. At a mean follow-up time of 20.4 ± 8.8 (1-60) months, 6 reinterventions were reported, including 2 embolizations for type II endoleak and 4 for iliac and femoral vessel occlusive disease. Log-rank test on preoperative anatomical features showed no significant differences in terms of freedom from reinterventions, and P values were 0.653 for aortic neck length ≤10 mm, 0.309 for noncylindrical aortic neck length shape, 0.520 for ABaverage ≤ 18 mm, 0.604 for ABarea ≤ 20 mm2, and 0.421 for external iliac artery diameter ≤5 mm. CONCLUSIONS: Our initial experience suggests that in an unselected patient population undergoing AAA repair, EVAR by Ovation stent graft can be performed safely with satisfactory immediate and midterm outcomes.

Endovascular Treatment of Symptomatic Thrombus of the Descending Thoracic Aorta.

Thoracic aorta mural thrombosis (TAMT) is uncommon pathology with potentially catastrophic complications due to recurrent spontaneous distal embolization. Best treatment, medical or surgical, is still under debate especially in high-risk patients. Endovascular approach by means of thoracic endoprosthesis seems to be a feasible and minimally invasive treatment option. We report a successful treatment of symptomatic TAMT using a thoracic aortic stent graft in a high-risk patient for open repair and contraindication to systemic anticoagulation.

Role of mini access during carotid endarterectomy: a prospective observational study.

BACKGROUND: Data from literature confirmed the non-trivial risk associated with carotid revascularization. The purpose of this study is to evaluate carotid endarterectomy (CEA) via a mini-invasive access (3-6 cm longitudinal) incision as a viable alternative to the traditional access via a cutaneous incision (˃6 cm) in terms of nerve sparing and neck pain/disability for patients. METHODS: We performed a prospective, observational, cohort study on 796 consecutive patients who underwent CEAs. A number of 730 patients was included in the final analysis. Patients entered in two different cohorts: CEA with 3-6 cm incision was performed in N.=398 (Group A); CEA with>6 cm incision was performed in N.=398 (Group B). Entire data set is available from 382 in group A and 348 in group B. Adverse events were recorded at 30 days, 3 and 6 months after surgery. The primary purpose of this study was to identify the incidence of cranial nerve injuries and related pain (by Northwick Park Neck Pain Questionnaire [NPq]) in both groups. Differences between groups were exploratory, only, and considered significative for P≤0.05. Secondary objectives were: death, major and minor stroke, transient ischemic attack (TIA), myocardial infarction (MI) and main duration of operation. RESULTS: The cumulative incidence of transient deficit of peripheral nerve in group A was 1.7% at 30 days and 19.4% in group B (RR: 0.10, 95% CI 0.07-0.1, P=0.0001) suggesting a possible benefit from mini-skin incision on nerve injuries reduction. Cranial nerve permanent injuries were identified in 0.17% of mini-incision group and 0.23% of standard group. Exploratory comparison did not demonstrate significative differences between the groups (RR: 0.72, 95% CI 0.19-2.71, P=0.63). The median NPq postoperative score was 40% in GROUP A and 79% in GROUP B (exploratory difference 39%, 95% CI 32.22-45.20%, P=0.0001, χ2: 114.007). At 6 months, NPq was 20% and 42%, respectively; exploratory differences were still present. The need to prolong the mini-incision in GROUP A to preserve the surgical outcome was 1.3%, only. CONCLUSIONS: According to these results the mini skin incision allows a sufficient vessels exposure for dissection, endarterectomy, reconstruction of carotid artery and shunt positioning, minimizing surgical invasiveness, decreasing the incidence of temporary cervical nerve dysfunction and improving the aesthetic result with significative less pain suffered by the patients. Transverse cervical and great auricular nerves sparing decreased postoperative hypo-paresthesia in the neck, improving patient's satisfaction. These data suggest that this procedure can be considered safe. Exploratory analysis suggested that it could possibly be considered a safety alternative to standard carotid endarterectomy. A randomized controlled trial is ongoing for definitive conclusions.

SIADH after carotid endarterectomy.

The syndrome of inappropriate secretion of antidiuretic hormone after carotid endarterectomy is very rare; only two cases have been reported in medical literature. We describe the case of an 82-year-old woman presenting with lethargy and drowsiness due to severe hyponatremia with urine hyperosmolarity and plasma hypo-osmolarity after carotid endarterectomy.

Endovascular central venous stenosis treatment ended with superior vena cava perforation, pericardial tamponade, and exitus.

Venous hypertension and outflow stenosis of arteriovenous hemodialysis access managed using endovascular procedures usually present a high technical success rate, with few complications. We reported a rare and fatal complication of superior vena cava perforation with pericardial tamponade 3 months after subclavian vein stenting. Interventional recanalization with stenting for the management of superior vena cava syndrome or central vein stenosis is a safe procedure with a low complication rate. Stent misplacement, reocclusion, migration, or access-related complications appear to occur most frequently.

Heparin-induced thrombocytopenia type II because of heparin-coated polytetrafluoroethylene graft used to bypass.

Heparin-induced thrombocytopenia type II is an immune-mediated syndrome that may arise in a time-dependent manner after heparin therapy. Thrombocytopenia and thrombosis in patients exposed to heparin are suggestive of this syndrome.

Thirty-day results from prospective multi-specialty evaluation of carotid artery stenting using the CGuard MicroNet-covered Embolic Prevention System in real-world multicentre clinical practice: the IRON-Guard study.

AIMS: The aim of the present study was to evaluate periprocedural and 30-day outcomes in a prospective series of patients treated with the CGuard Embolic Prevention System (EPS). METHODS AND RESULTS: From April 2015 to June 2016, a physician-initiated prospective multicentre study was performed in 200 consecutive patients admitted for protected carotid artery stenting (CAS) and treated using the CGuard EPS in twelve vascular centres. Outcome measures were: technical success, periprocedural (0-24 hours) and post-procedural (24 hours-30 days) major and minor strokes, death, acute myocardial infarction (AMI), transient ischaemic attack (TIA), and external carotid occlusion. In three centres, consecutive diffusion-weighted magnetic resonance cerebral imaging (DW-MRI) was performed ≤72 hours prior to and within 72 hours after the intervention. A distal embolic protection device was employed in 182 patients (91%). Technical success was 100%. No death, AMI or major stroke occurred periprocedurally. There were two TIAs and five periprocedural minor strokes (2.5%), including one thrombosis solved by surgery. In the remaining patients (199/200; 99.5%) one-month follow-up duplex ultrasound revealed optimal technical results. Post-procedural clinical follow-up was uneventful. No external carotid artery occlusion occurred. New post-procedural DW-MRI lesions were detected in 12 patients out of 61 (19.6%), including bilateral in five (8.2%) and isolated ipsilateral in six (9.8%), whereas one patient (1.6%) had contralateral only lesions. CONCLUSIONS: Multicentre multi-specialty use of the CGuard EPS in routine clinical practice was associated with no major periprocedural neurologic complications and a total elimination of post-procedural neurologic complications by 30 days.

Successful covered stent-graft repair in symptomatic renal artery aneurysm early after childbirth.

Renal artery aneurysm (RAA) rupture during pregnancy is a rare but life-threatening event and few cases have been reported in literature. Currently the best approach, endovascular or surgical, seems to be under discussion. A case of a 31-year-old woman with a symptomatic right RAA detected three days after childbirth is reported. A successful endovascular repair by a covered stent-graft was performed.

Suprarenal fixation resulting in intestinal malperfusion after endovascular aortic aneurysm repair.

Superior mesenteric artery (SMA) and coeliac axis (CA) occlusion after endovascular abdominal aneurysm aortic repair (EVAR-AAA), using endograft with suprarenal fixation, are uncommon. However, we are reporting a case of visceral malperfusion, which occurred 7 days after successful EVAR with suprarenal fixation for symptomatic AAA. Endograft metal stent barbs caused severe stenosis of SMA and CA. A successful recovery of SMA was carried out by means of a balloon-expandable stent released through bare metal stent barbs. We believe that an unfavourable anatomy of a proximal aortic neck and visceral aorta may have caused a wrong stent strut deployment with the coverage of CA and SMA.

Combined brachial embolectomy and stent graft endovascular exclusion in the treatment of acute arm ischemia due to subclavian artery aneurysms thrombosis or distal embolization.

AIM: Purpose of this study is to report our results after simultaneous transbrachial embolectomy and endovascular aneurysm exclusion with stentgraft in the treatment of upper limb acute ischemia due to subclavian artery aneurysm thrombosis and embolization . METHODS: From January 2010 to December 2015, seven consecutive patients (6 men; mean age 71.5, range 44-85) underwent to emergent revascularization for upper limb ischemia due to thrombosis/embolization of SAA by means of brachial embolectomy and endovascular exclusion. Demographics, clinical, surgical data, complications and survival were recorded. Univariate analysis by chi-square was carried out to evaluate the role of demographics data and risk factors variables on reconstruction patency rate. Primary, primary assisted and secondary patency and limb salvage were calculated using the Kaplan Meyer's life table method. RESULTS: Successful treatment was achieved in all cases. No postoperative death or complications occurred. Primary and assisted primary patency rates at 1 and 3 years were respectively 85.7%, 71.4% and 100%.Secondary patency and limb salvage at 1 and 3 years was 100%. A fatal ischemic stroke occurred in 1 case at 6 months (14.2%). A redo PTA was carried out at 24 months. Univariate analysis showed as demographics data and risk factor variables did not influence the primary, assisted primary, secondary patency rate and limb salvage. CONCLUSION: Endovascular repair is a less invasive alternative to open repair especially in high risk patients. long term results must still be confirmed in further studies. KEY WORDS: Arm ischemia, Endovascular treatment, Subclavian aneurysm.