Endovascular Aneurysm Repair Assisted by CO2 Digital Subtraction Angiography and Intraoperative Contrast-Enhanced Ultrasonography: Single-Center Experience.

BACKGROUND: Allergy to iodinated contrast (IC) agent and advanced chronic kidney disease are major limitations to endovascular repair (EVAR) of abdominal aortic aneurysms (AAAs). We describe our experience combining CO2-assisted EVAR with intraoperative contrast-enhanced ultrasound (CEUS) in an attempt to avoid contrast-induced allergy or nephropathy. METHODS: Observational cohort study using prospectively acquired data on patients undergoing CO2-assisted EVAR in single institution. EVAR planning was performed using computed tomographic angiography or magnetic resonance aortography in patients contraindicated for IC. Patients were considered if their estimated glomerular filtration rate was <40 mL/min and anatomically suitable for conventional infrarenal EVAR. Outcomes of interest included technical success rate and reintervention rates, total radiation dose, length of hospital stay, and graft kinking or migration. RESULTS: Fifteen patients (10 male) were treated across a 5-year period. Technical success was achieved in all cases. Completely IC-free EVAR was performed in 9 cases, whereas the remaining 6 required IC administration for adjunct procedures. CO2 completion angiography detected all type I endoleaks (2 Ia and 1 Ib) but was less sensitive to type II. Intraoperative CEUS confirmed all type I and 2 cases of type II endoleaks. Median hospital stay was 4 days. No significant deterioration in renal function was seen postoperatively. CONCLUSIONS: In patients with abdominal aortic aneurysms and with contraindication for IC, a combined approach of using CO2 digital subtraction angiography and CEUS can be used safely and efficiently to minimize or obviate the need for IC agents with satisfactory mid-term results.

Outcomes of Endovascular Aneurysm Repair using the Ovation Stent Graft System in Adverse Anatomy.

OBJECTIVE: The aim was the evaluation of mid-term efficacy and safety outcome measures for the Ovation (Endologix, Santa Rosa, CA, USA) stent graft system in the management of infrarenal abdominal aortic aneurysms (iAAA) with adverse anatomy. METHODS: A retrospective observational study of all patients undergoing elective iAAA repair was carried out from 2012 to 2017 using Ovation Prime or iX stent grafts with a minimum of 3 months follow-up at a single UK vascular centre. Post-operative surveillance involved computed tomography scans at 3 months and 1 year, with duplex ultrasound yearly thereafter. Outcome measures were established with retrospective analysis of pre- and post-operative imaging, and included peri-operative mortality, major adverse events, limb complications, aneurysm diameter change, and endoleak rates. All patients were within Ovation instructions for use (IFU), and assessment was made to determine whether aneurysms had anatomical features considered adverse for other commonly used stent graft platforms. RESULTS: Ovation stent grafts were implanted in 52 patients (79% male, mean age 75.7 years) with a mean aneurysm diameter of 62.5 mm (range 55-107 mm). There was 100% technical deployment success. The 30 day mortality was 0% and there was no aneurysm related mortality during follow-up (median 24 months, range 3-48 months). There were no type I or III endoleaks, but 19% developed type II endoleaks with one patient requiring re-intervention. No iliac limb occlusions were identified but one case required relining for limb kinking. All 52 cases were within the IFU for Ovation but only 12% met the IFU criteria for the Cook and Medtronic devices. CONCLUSIONS: The mid-term experience with Ovation demonstrates safe, durable treatment of iAAAs, including those with unfavourable anatomy, frequently off IFU for other commonly used devices.

The role of the community clinician in early detection, referral and treatment of critical limb ischaemia.

Critical limb ischaemia (CLI) is a significant public health issue worldwide, with an ever-growing incidence among people over 65. Awareness of CLI is low, particularly among non-vascular clinicians, leading to underdiagnosis and undertreatment. A diagnosis of CLI is known to have a grave effect on a person's quality of life, with devastating outcomes for both their life and limb, often resulting in uncontrolled pain, amputation or early death from a cardiovascular event. Community nurses and podiatrists are key clinicians who can play a crucial and active role in earlier identification, rapid referral and ongoing non-surgical care for this overlooked population.

Neurovascular complications post bronchial artery embolisation in patients with cystic fibrosis. A 7-year single centre retrospective review.

Bronchial artery embolisation (BAE) is a treatment used to manage haemoptysis. We performed a 7-year review of BAE procedures for haemoptysis at our CF centre aiming to evaluate the incidence and outcomes of patients with neurovascular complications post-BAE. Our review suggests that whilst BAE is an effective method for controlling life-threatening haemoptysis, patients are at risk of developing neurovascular complications with long term residual symptoms, and therefore careful consideration should be given in offering BAE, especially to otherwise well patients with chronic small volume haemoptysis and managing teams should have a low threshold to image symptomatic patients.

Acute mesenteric haematoma and hematoperitoneum following a coughing episode induced by COVID-19.

Acute mesenteric haematoma (AMH) is a rare condition and established causes include blunt trauma, aneurysmal rupture, acute pancreatitis and anticoagulant use. A male patient in his 50s presented with abdominal pain and loss of consciousness that was immediately preceded by a prolonged coughing episode. A computed tomography (CT) abdomen-pelvis revealed two acute mesenteric haematomas and haematoperitoneum and admission swabs diagnosed coronavirus disease 2019 (COVID-19). The patient had no other acute clinical issues and was not taking anticoagulants. The haematomas were managed conservatively and a follow up computed tomography (CT) 4 weeks post-discharge revealed significant improvement. No clear vessel was identified as the source of the bleed in any of the investigations. This case represents a rare instance of AMH and haematoperitoneum with no established cause. We theorize that the combination of the patient's systemic response to COVID-19 and raised intra-abdominal pressure caused by coughing contributed to the bleeding.

Radiological initial treatment of vascular catastrophes in pancreas transplantation: Review of current literature.

BACKGROUND: Arterio-enteric fistula (AEF) is a rare but potentially devastating complication of solid organ pancreatic transplantation. Traditional management has been to remove the pancreas-duodenum allograft and control the vascular defect. Interventional radiological (IR) techniques present a new method of managing AEF related haemorrhage without re-operation and the potential to preserve graft function. This paper examines the available literature to assess efficacy and safety of this novel approach. METHODS: Aggregate results tables were constructed from 28 cases identified in the English language literature where IR was used in the management of AEF following pancreas transplantation. Outcomes recorded were death, re-bleeding, surgical intervention required and post intervention graft function. These were analysed with respect to technical factors and graft function at time of presentation. RESULTS: 28 cases of AEF managed by IR methods were identified. Mortality was high at 17.9%. 78.6% of all AEFs were present in failed pancreas allografts. Median time from transplant to bleeding event was 29 months. There was a trend of bleeding event occurring within 12 months of allograft failure or rejection. Of the AEFs present in functioning grafts, graft salvage rate was 33% from available data. Coil embolization or use of haemostatic compressed sponge as primary intervention was associated with a higher rate of re-bleeding and death versus arterial stenting. Arterial stenting resulted in a higher rate of distal ischaemia requiring surgical re-vascularisation. All deaths occurred in patients who did not have a transplant pancreatectomy as part of their definitive treatment. CONCLUSION: IR can be an effective way to manage bleeding in the context of AEF associated with pancreas transplantation. If patient condition allows, it should be the first-choice intervention to manage AEF associated bleeding. Use of arterial stenting is more effective in controlling and preventing further bleeding. In a non-functioning graft, transplant pancreatectomy should be strongly considered, possibly in conjunction with or following arterial stenting.

Endovascular Hepatic Artery Stents in the Modern Management of Postpancreatectomy Hemorrhage.

Background: Postoperative hemorrhage is a potentially lethal complication of pancreatoduodenectomy. This study reports on the use of endovascular hepatic artery stents in the management of postpancreatectomy hemorrhage. Methods: This is a retrospective analysis of a prospectively maintained, consecutive dataset of 440 patients undergoing pancreatoduodenectomy over 68 months. Data are presented on bleeding events and outcomes, and contextualized by the clinical course of the denominator population. International Study Group of Pancreatic Surgery terminology was used to define postpancreatectomy hemorrhage. Results: Sixty-seven (15%) had postoperative hemorrhage. Fifty (75%) were male and this gender difference was significant (P = 0.001; 2 proportions test). Postoperative pancreatic fistulas were more frequent in the postoperative hemorrhage group (P = 0.029; 2 proportions test). The median (interquartile range [IQR]) delay between surgery and postoperative hemorrhage was 5 days (2-14 days). Twenty-six (39%) required intervention comprising reoperation alone in 12, embolization alone in 5, and endovascular hepatic artery stent deployment in 5. Four further patients underwent more than 1 intervention with 2 of these having stents. Endovascular stent placement achieved initial hemostasis in 5 of 7 (72%). Follow-up was for a median (IQR) of 199 days (145-400 days) poststent placement. In 2 patients, the stent remained patent at last follow-up. The remaining 5 stents occluded with a median (IQR) period of proven patency of 10 days (8-22 days). Conclusions: This study shows that in the specific setting of postpancreatoduodenectomy hemorrhage with either a short remnant gastroduodenal artery bleed or a direct bleed from the hepatic artery, where embolization risks occlusion with compromise of liver arterial inflow, endovascular hepatic artery stent is an important hemostatic option but is associated with a high risk of subsequent graft occlusion.

Midaortic syndrome in neurofibromatosis type 1 resulting in bilateral renal artery stenosis.

We describe the case of a 23-year-old white woman with a long history of hypertension. She was referred to us 7 years after her initial diagnosis of hypertension when her blood pressure control worsened during pregnancy. Clinical examination showed an abdominal bruit and weak femoral pulses. Imaging showed midaortic syndrome with bilateral renal artery stenosis as the cause of her hypertension, and further investigations showed neurofibromatosis type 1 as the underlying disorder. Midaortic syndrome, a rare disorder of the abdominal aorta that is different from classic coarctation, typically is associated with neurofibromatosis. Renal artery stenosis is common, as are weak femoral pulses and impaired development of the lower limbs. Because of the rarity of this syndrome, only anectodal evidence exists with regard to treatment. Surgery and interventional treatment with stent placement in the abdominal aorta have been reported, as well as good outcomes with long-term medical management. Our patient continues to be healthy without intervention, with reasonable blood pressure control and normal kidney function on a 4-drug antihypertensive regimen. We discuss midaortic syndrome with a focus on diagnosis, differential diagnosis, associated conditions, and management. Nephrologists, radiologists, and ultrasonographers should be aware of this rare cause of renovascular hypertension.

Midterm follow-up of a single-center experience of endovascular repair of abdominal aortic aneurysms with use of the Talent stent-graft.

PURPOSE: To review the midterm results of endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms (AAAs) with the Talent stent-graft. MATERIALS AND METHODS: All patients who underwent EVAR of AAAs with Talent stent-grafts from February 1998 to April 2002 at a single institution were monitored for a minimum of 2 years or until an endpoint of death or rupture was reached. RESULTS: There were 68 eligible patients, who were monitored for a mean period of 39 months (range, 24-72 months). Forty-nine (72.9%) were alive at 2 years; among the 19 deaths, two resulted from aneurysm rupture and the other 17 were unrelated to EVAR. There was one immediate conversion to open repair and five primary proximal endoleaks; the remaining 62 patients (91.2%) all had a technically successful procedure. There were 33 endoleaks during follow-up: 23 (69.7%) were treated conservatively and 10 (30.3%) underwent secondary intervention in the form of embolization (n=2), attempted embolization (n=2), endovascular stent-graft placement (n=3), combined stent-graft placement and embolization (n=1), or surgical conversion (n=2). Overall, there were five persistent endoleaks, and the remaining patients were free of endoleak at their last review or endpoint. Three stent-grafts migrated and required further endovascular intervention. Wire fracture was seen in two stents but presented no clinical sequelae. There was one case of graft limb thrombosis that required surgical thrombectomy. CONCLUSIONS: EVAR of AAAs with use of the Talent stent-graft is a promising and acceptable alternative to open surgery. Our 30-day mortality rate of zero compares extremely well with historical data from open surgery and the findings of more recently published trials. The risk of endoleak and uncertainty over durability require long-term surveillance.