Comparison of surgical versus percutaneously created arteriovenous hemodialysis fistulas.

OBJECTIVE: The aim of the present study was to compare the results between percutaneous arteriovenous fistulas (p-AVFs) created with the Ellipsys device (Ellipsys Vascular Access System; Avenu Medical, San Juan Capistrano, Calif) and surgical arteriovenous fistulas (s-AVFs). METHODS: A single-center retrospective comparative study of the first 107 patients who had undergone p-AVF creation with the Ellipsys system from May 2017 to May 2018 with an equal number of consecutive patients who had undergone s-AVF creation in our center during the same period. The primary endpoints included the maturation and patency rates. The secondary endpoints were reintervention, risk of infection, and the incidence of steal syndrome and aneurysm formation. RESULTS: The demographic, hypertension, and diabetes data were similar for both groups. The only difference between the two groups was that more p-AVF patients had already been receiving hemodialysis (61% vs 47%; P < .05). The p-AVFs showed superior maturation rates at 6 weeks (65% vs 50%; P = .01). The primary patency rates were greater for the s-AVFs at 12 months (86% vs 61%; P < .01). However, primary patency was comparable between the two groups at 24 months (52% vs 55%; P = .48). No significant difference was found in the secondary patency rates at 12 (90% vs 91%) and 24 (88% vs 91%) months. At the 2-year follow-up point, the rate of percutaneous reintervention was similar; however, the s-AVFs had required more frequent surgical revision (36% vs 17%; P = .01). Issues with wound healing and infection were also more frequent with s-AVFs (9% vs 0.9%; P < .01). CONCLUSIONS: Fistulas created percutaneously with the Ellipsys system showed superior maturation rates and similar patency with s-AVFs created in an experienced high-volume vascular surgery practice. p-AVFs had a lower risk of wound healing issues, infection, and surgical revision. Larger, prospective, randomized multicenter studies are needed to confirm these findings.

Midterm results of percutaneous arteriovenous fistula creation with the Ellipsys Vascular Access System, technical recommendations, and an algorithm for maintenance.

OBJECTIVE: The aim of this study was to report our midterm results of percutaneous arteriovenous fistula (pAVF) creation using the Ellipsys (Avenu Medical, San Juan Capistrano, Calif) device and to present technical recommendations and our algorithm of pAVF maintenance. METHODS: A single-center comprehensive database of all consecutive predialysis and end-stage renal disease patients who had a pAVF creation with the Ellipsys device was reviewed retrospectively. Study end points included technical success, maturation, functional patency, and required interventions. RESULTS: Between May 2017 and July 2019, there were 234 patients (mean age, 64 years; 148 male [63%]) who had a pAVF created. Technical success was achieved in 232 individuals (99%), and average duration of the procedure was 15 minutes (7-35 minutes). Average follow-up was 252 days (range, 83-696 days). The 1-year primary, primary assisted, and secondary patency rates were 54%, 85%, and 96%, respectively. Average pAVF flow was 923 mL/min (range, 425-1440 mL/min). There were no significant adverse events related to the procedure. Only three patients (1%) required a later conversion of the pAVF anastomosis to a surgical fistula. Twenty-four (10%) patients required superficialization of deep outflow veins because of difficult cannulation. Average maturation time was 4 weeks (range, 1-12 weeks). Fourteen patients (6%) had early (<2 weeks after creation) cannulation of the pAVF. CONCLUSIONS: The Ellipsys pAVF device allows the rapid and safe creation of a reliable autogenous access. Rates of technical success, patency, and maturation were excellent. For patients unsuited for a distal radiocephalic arteriovenous fistula, it should be considered the next preferred access option.

Optimising Aortic Endovascular Repair in Patients with Marfan Syndrome.

OBJECTIVE: In Marfan syndrome (MFS) patients, endovascular repair carries a risk of aortic wall injury, which may result in retrograde aortic dissection, dilatation, or false aneurysm at the landing zones. It was hypothesised that potentially these complications may be avoided using modified practices. This study aimed to describe experience of a specific protocol for endovascular aortic repair in patients with MFS. METHODS: All MFS patients treated by aortic endovascular repair between February 2015 and August 2018 were included prospectively. The following rules were applied: (i) excluding stent grafts with bare stents and barbs, (ii) proximal landing in a pre-existing graft, or (iii) minimising proximal oversizing when landing in the proximal native aorta (<10%), and (iv) distal undersizing for chronic dissection cases. RESULTS: In eighteen patients (55% men, mean age: 47 ± 17 years), the index procedures were initial endovascular aortic repair (n = 10), elephant trunk completion (n = 6), and anastomotic pseudo-aneurysm after thoracic open repair (n = 2). The technical success rate was 100%. Proximal landing was in the native aorta in 11 patients (61%), with a mean proximal oversizing of 2.4 mm (8% oversized). Distal landing in the native aorta was performed in 16 cases (89%), with a mean distal undersizing of 8.9 mm (- 23%). No mortality, spinal cord ischaemia, stroke, or retrograde aortic dissection occurred post-operatively. One type 1b endoleak was observed. The mean follow up was 21.4 months. Aortic aneurysm related mortality was 5% (n = 1) and occurred after distal thoraco-abdominal surgery planned from the outset (prior to endovascular repair). Another patient presented a proximal landing zone complication with aortic enlargement. The mean maximum aortic diameter decreased significantly from 59 mm to 45 mm (p = .0005) after treatment. CONCLUSION: The specific protocol described in this study seems to optimise the results of endovascular aortic repair in MFS patients with significant aortic remodelling.

False lumen embolization in chronic aortic dissection promotes thoracic aortic remodeling at midterm follow-up.

OBJECTIVE: Failure of thoracic endovascular aortic repair (TEVAR) in chronic aortic dissections can be partially explained by retrograde false lumen (FL) flow through distal re-entry tears. After implantation of a thoracic stent graft, FL thrombosis occurs in less than 50% of the cases. The objectives of this study were to describe the feasibility and outcomes of FL embolization in patients with chronic aortic dissections. METHODS: Between June 2015 and January 2018, 27 patients (mean age, 61 ± 14 years) with chronic aortic dissection underwent FL embolization as an adjunct during or after TEVAR placement procedure. Indications for embolization were (1) symptomatic chronic aortic dissections with pain or rapid growth of aortic diameter (≥5 mm/y) requiring rapid exclusion of the aneurysm, (2) aneurysmal dilatation with persistent FL retrograde flow after TEVAR, and (3) large FL aneurysms (≥55 mm) that might lead to persistent retrograde flow. Twenty patients presented with type B chronic aortic dissections (74.1%) and seven presented a residual type A chronic aortic dissections (25.9%). Eight patients had a previous aortic arch replacement (29.6%). Six patients had previous repair with TEVAR (22.2%). The delay between the onset of dissection and the first endovascular repair was 47 months (range, 3-144). Spinal fluid drainage was used in 74.1% of cases (20/27 patients). Embolization devices included coils and vascular plugs. RESULTS: The technical success rate was 100% (27/27). Complete spinal cord ischemia was observed in one patient (3.7%). There was one hospital death from pneumonia after zone 1 supra-aortic trunk debranching with TEVAR and embolization. After the index procedure, FL thrombosis was observed in 81.5% of patients (22/27) on late phase computed tomography angiography. Five patients required two or more embolization procedures, leading to a high rate of complete FL thrombosis (92.6%). One patient presented a type IB endoleak and one patient presented a type II endoleak. Radiologic follow-up was 20 ± 10 months. The maximum thoracic aortic diameter significantly decreased from 63 mm to 54 ± 10 mm (P < .001). CONCLUSIONS: Embolization of the FL of chronic aortic dissections is technically feasible with a low morbidity rate. The FL thrombosis is observed in the majority of case and promotes favorable thoracic aortic remodeling. Longer follow-up is needed to confirm these good results on the thoracic aorta and this technique may, therefore, improve the results of TEVAR in chronic aortic dissections.

Impact of Stent-Graft Oversizing on Gutter Areas after Chimney Graft Repair for Complex Abdominal Aortic Aneurysms.

BACKGROUND: The aim of this retrospective study was to examine the impact of graft oversizing on gutter area and stent compression in chimney graft (CG) for complex abdominal aortic aneurysm (CAAA) repair. The influence of stent-graft oversizing on type Ia endoleaks and bridging stent occlusion rates was also examined. METHODS: Preoperative and postoperative computed tomographic angiography scans of patients requiring CGs for CAAA between June 2009 and April 2013 in our institution were analyzed. Two groups were identified: proximal oversizing of the stent-graft component < 25% (group 1) and >25% (group 2). Relative gutter areas were calculated and compared between both groups. Incidence of target vessel stent compression, target vessel occlusions, and type Ia endoleaks was also analyzed. RESULTS: Of 39 patients treated with CG during the study period, 23 fulfilled the selection criteria for analysis. Group 1 included 10 patients and group 2 included 13 patients (mean oversizing: 18.4 ± 4.9% and 34.5 ± 6% respectively). Relative gutter areas were significantly higher in group 1 when compared with group 2 (6.1 ± 2.1% vs. 4.2 ± 3.2%, P = 0.03). No stent compression and no target vessel occlusion occurred in either groups. There was no statistical difference in type Ia endoleak in both groups (group 1 n = 0, group 2 n = 2; P = 0.48). CONCLUSIONS: In our study, a >25% stent-graft oversizing reduced the gutter area without modifying the bridging stent patency. However, no benefit in terms of type Ia endoleak was observed.

Percutaneous radial access for peripheral transluminal angioplasty.

OBJECTIVE: The radial approach is currently gaining popularity in the setting of coronary percutaneous transluminal angioplasty (PTA) because it decreases the incidence of vascular complications. This study reports our initial results with radial access for peripheral PTA. METHODS: Between November 2011 and January 2014, we performed peripheral PTA in 526 patients. PTA was performed through left radial access in 24 ambulatory patients (4.6%) presenting with TransAtlantic Inter-Society Consensus A or B lesions on preoperative computed tomography angiography. Materials included a 110-cm-long introducer, a 0.018-inch 400-cm-long wire, 150-cm-long angiography catheters, 180-cm-long shaft balloons and stents. Data were prospectively collected. RESULTS: There were 22 men (92%), median age was 65 years (range, 45-88 years), and 38 target lesions were treated. Indication for revascularization was disabling claudication in 22 patients (92%) and critical ischemia in two (8%). Indication for choosing the radial approach was bilateral hostile groins in 12 patients (50%), bilateral infrainguinal lesions in 4 (17%), need for a contralateral femoral approach in the setting of kissing iliac stents or bifurcated surgical aortic grafts in 3 (13%), and elective in 5 (21%). Radial puncture failed in one patient (4%), and PTA was performed through brachial access. Technical success was 91% (20 of 22 patients). Thirty-seven stents were implanted. Total procedure duration was 45 minutes (range, 30-120 minutes). Fluoroscopy time was 9 minutes (range, 5-35 minutes), and 40 mL (range, 20-90 mL) of contrast was necessary. Radial artery rupture secondary to spasm was noted at the end of the procedure in two patients (8%). All patients could ambulate 2 hours after the procedure. No patient died. Median follow-up was 8 months (range, 1-23 months). Three radial arteries (13%) were occluded at the last follow-up. At 6 months, freedom from target lesion revascularization and target vessel revascularization were 91% and 91%, respectively, for iliac lesions and 93% and 86%, respectively, for infrainguinal lesions. CONCLUSIONS: This study demonstrates the feasibility of radial access for peripheral PTA. Radial access could represent an alternative to brachial access for peripheral and visceral interventions. Although complication rates of the present series are concerning, larger studies are needed to determine the role of transradial PTA once the learning curve is overcome. A wider diffusion of the technique mandates (1) smaller-diameter sheaths, (2) longer shaft devices, and (3) the development of specifically designed rescue devices such as covered stents and thromboaspiration catheters.

Initial Experience with Percutaneous Angioplasty of the Common Femoral Artery in De Novo Stenotic Lesions.

BACKGROUND: The aim of this study was to report an initial experience with percutaneous transluminal angioplasty (PTA) in de novo stenotic lesions of the common femoral artery (CFA). METHODS: A retrospective analysis for 34 consecutive patients was conducted. The follow-up consisted of clinical evaluation and color duplex ultrasound scan (CDU) 1, 6, and 12 months after the procedure. RESULTS: The symptoms were claudication in 16 patients (47%), critical limb ischemia in 17 (50%), and preservation of an infrainguinal bypass in 1 (3%). PTA was performed in CFA alone in 45.7%, associated to iliac and/or profunda/superficial femoral artery PTA in 54.3%. Stenting was performed in 23 patients (65.7%). All procedures were successful. Two patients required surgery for a local complication. Median hospital stay was 2 days. Mean follow-up was 11 months (range 1-56). Primary and secondary sustained clinical improvement rates were 77% and 85%, and primary, CDU-controlled patency rate was 88%. Four reinterventions were required for symptomatic CFA restenosis. At the end of follow-up, no major amputation had been performed, all patients with claudication remained improved with no restenosis, and the secondary sustained improvement rate was 85%. CONCLUSIONS: PTA for primary CFA lesions is feasible and safe, with acceptable short-term results in claudicants. In patients with tissue loss, frequent reinterventions raise questions about PTA benefit. This approach needs to be compared with open surgery in a randomized trial.

De novo periaortic fibrosis after endovascular aortic repair.

We report a case of a 63-year-old man presenting with abdominal pain and hydronephrosis secondary to periaortic fibrosis (PAF) 8 months after an endovascular aortic repair (EVAR) using a woven polyester bifurcated graft. De novo delayed PAF after open repair is rare and even more infrequent after EVAR. All 3 previously reported cases occurred after woven polyester grafts and no reported cases after polytetrafluorethylene grafts. Management included steroidal anti-inflammatory treatment and bilateral double J tube placement. Satisfactory results were obtained.

Chimney stent graft for endovascular sealing of a pararenal aortic aneurysm.

Chimney endovascular aneurysm repair is still a controversial treatment of complex aortic aneurysms. Stent-graft patency and type-I endoleaks are the main challenges that temper this bailout technique. Endovascular aneurysm sealing (EVAS) consists of anchoring and sealing the device within the aneurysm sac. The first results are promising, even for adverse anatomy. We describe a case of EVAS for a pararenal aortic aneurysm associated with a chimney stent graft for the right renal artery. Wrapping the chimney stent graft inside endobags filled with polymer is expected to prevent gutters and stent compressions.

Long-term preservation of native arteriovenous dialysis fistulas.

Preservation of native arteriovenous fistulas (AVFs) in the long term can be technically challenging. Various anatomic or functional problems can occur and multiple open and/or endovascular interventions may be required for extended preservation of native accesses. In this report, we review vascular access maintenance in a 72-year-old woman during a 5-year period. Multiple complications of her native radiocephalic AVF included recurrent occlusions, a central venous stent fracture and symptomatic venous outflow stenosis. We present this case to illustrate the various techniques and combination of approaches used in the long-term preservation of a native AVF.

Elective treatment of abdominal aortic aneurysm is reasonable in patients >85 years of age.

BACKGROUND: The numbers of patients >85 years of age referred for abdominal aortic aneurysm (AAA) repair have increased in recent decades. With the population aging, increased screening of AAA, and introduction of less invasive surgical techniques, vascular surgeons will be treating more elderly patients. Few data are available for estimating the risks and benefits of prophylactic repair among those with such an advanced age. The aim of this single-center study was to evaluate the short-term to midterm results after AAA repair in patients >85 years of age. METHODS: Between 2004 and 2012, data of patients >85 years old who required an elective AAA repair at our institution were collected prospectively. According to the current guidelines, patients underwent endovascular aneurysm repair (EVAR) each time the aortic anatomy was suitable. Open repair (OR) was performed in those patients with hostile proximal neck anatomy and/or severe iliac tortuosity. Type of repair (EVAR or OR) and perioperative and midterm outcomes were analyzed. Primary end points were 30-day mortality and midterm survival. RESULTS: Among 1016 patients undergoing elective AAA repair during the study period, 59 (5.8%) were ≥85 years of age (54 men, mean age 87 ± 2 years), with a mean aneurysm diameter of 61.5 ± 20.3 mm. Thirty-three patients (56%) underwent EVAR and 26 (44%) had an OR. Thirty-day mortality was 6.7% (6% with EVAR and 7.6% with OR, P <0.05). Mean follow-up was 24.7 ± 18 months. Kaplan‒Meier analyses for survival were 85.5%, 64.5%, and 50% at 1, 3, and 5 years, respectively. No aneurysm-related death was observed during follow-up. CONCLUSION: Elective repair may be proposed in patients >85 years of age in cases of threatening AAA, showing acceptable perioperative mortality and reasonable midterm survival results. Even if EVAR did not seem to offer significant benefits in perioperative mortality in our study, it appears reasonable to suggest this less invasive technique as first-line treatment in cases of suitable anatomy in such an advanced-age population.

Tagliatelle technique for arteriovenous fistula creation using a great saphenous vein semipanel graft.

Lower limb arteriovenous (AV) access creation can be attempted in patients where upper limb options are exhausted. Utilization of the great saphenous vein as a conduit for AV access has been limited due to its small diameter and resistance to dilatation. Lower limb AV fistulas today are mostly either prosthetic grafts with high rates of infection and thrombosis or transposition of the femoral vein that can lead to limb-threatening venous hypertension. In this report, we describe an optimized technique for reconstruction of the great saphenous vein to serve as a dialysis conduit. This semipanel graft reconstruction effectively doubles the diameter of the conduit without disruption of the deep venous circulation and also mitigates the requirement for a venovenous anastomosis.

Customizable modification of banding with external stenting for arteriovenous fistula flow reduction.

We performed a single-center retrospective study of prospectively collected data for all patients who had flow reduction surgery with FRAME FR between November 2020 and January 2021. Ten patients had arteriovenous fistula flow reduction surgery with this technique. One patient had a distal fistula, whereas nine were within the cubital fossa. In nine patients the device was applied over the postanastomotic arteriovenous fistula outflow vein and in one in the preanastomotic radial artery. Technical success was achieved in all patients with a median flow reduction from 2150 to 825 mL/min. There were no wound or device-specific complications.

Percutaneous arteriovenous fistulae: Technique, feasibility and results

Patients with end-stage renal disease that require chronic haemodialysis need a reliable vascular access. Unanimously, native arteriovenous fistulae are considered to be the most reliable access for patients with reasonable life expectancy. For the last 60 years arteriovenous fistulae have been created surgically at the wrist or the elbow with variable rates of success, maturation problems, reinterventions and complications, making this field of surgery particularly challenging and full of scientific controversies. The recent addition of the technical ability to create arteriovenous fistulae percutaneously comes to add one more option for the patients and one more source of controversy for the experts.

Surgical revascularization of the celiac artery for persistent intestinal ischemia in short bowel syndrome.

BACKGROUND AND OBJECTIVES: Without prompt superior mesenteric artery (SMA) revascularization, acute mesenteric ischemia (AMI) frequently leads to death or short bowel syndrome (SBS). In SBS patients, persistent or chronic intestinal ischemia (PII) of the remnant bowel can lead to recurrences of AMI. Since SMA revascularization is sometimes unfeasible, celiac artery (CA) revascularization may improve blood supply to the remnant bowel. The aim of this study was to describe and to assess our experience of the CA revascularization in case of SMA occlusion unsuitable for revascularization in the setting of PII in SBS patients. METHODS: All consecutive patients with i) SBS consecutive to AMI, ii) persistent intestinal ischemia (PII), iii) irreversible SMA occlusion, i.e unsuitable for radiological or surgical revascularization and iv) occlusion or severe stenosis of the CA were included. RESULTS: Thirteen patients (7 males/6 females, mean age = 47.2 ±â€¯12.1 years) were included. The mean length of remnant small bowel was 47 ±â€¯39 cm and 77% of patients had a stoma. The types of revascularization included anterograde aorto-hepatic bypass n = 11 (84%), ilio-hepatic bypass n = 1 (8%) and endarterectomy n = 1 (8%). Major adverse events were observed in 5 cases: bypass graft infection (n = 2), hemorrhagic pericarditis (n = 2), hemorrhagic shock (n = 2) and aortic false aneurysm (n = 1). After a mean follow-up of 27.0 ±â€¯25.2 months, symptoms of PII relieved in 12 cases (92%) allowing for digestive surgical rehabilitation with continuity restoration in 7 patients (54%). PN was weaned for 2 patients. One-year and 3-year survival rates were 73.8% and 73.8% respectively. No recurrence of AMI or further need for bowel resection was noticed. CONCLUSION: For patients with SBS suffering from PII with CA occlusion or stenosis without possibility of SMA revascularization, the surgical revascularization of the CA allowed digestive rehabilitation with acceptable morbidity and mortality rates.