Hypogastric Preservation Using a Retrograde Endovascular Bypass in a Patient with Ruptured AAA and Concomitant Bilateral Common Iliac Aneurysms: A Feasible Option in the Acute Setting.

Preservation of the hypogastric circulation is of major clinical importance in cases of endovascular aneurysm repair (EVAR) for ruptured abdominal aortic aneurysm (rAAA). Pelvic ischemia can be detrimental and significantly increase post-operative morbidity and mortality. However, the application of a side branch device or a bell-bottom graft is not possible in ruptured aortoiliac aneurysms (due to off-the-shelf unavailability and/or prolonged operative time) and in most cases pelvic circulation may have to be sacrificed. We report a case of a rAAA with bilateral common iliac artery (CIA) aneurysms that was successfully repaired with an aorto-uni-iliac (AUI) endograft, a cross-femoral bypass, and an inverted-U shaped contralateral EIA to IIA endovascular bypass. The procedure is described in detail and certain technical points are further discussed. The steps in cases where the aneurysm has ruptured are different compared to elective repairs and vascular surgeons need to be aware of certain pitfalls. This strategy may be feasible in the acute setting and permits preservation of the hypogastric circulation with the combination of standard techniques and grafts that are readily available in most institutions.

Abdominal aortic aneurysms and abdominal wall hernias - a systematic review and meta-analysis.

Background: Abdominal wall hernias (AWHs) share common epidemiological characteristics with abdominal aortic aneurysms (AAAs), typically presenting in male population and older ages. Prior reports have associated those two disease entities. Our objective was to perform a systematic review and meta-analysis and examine whether AAA rates are higher among patients with AWH vs controls and whether the incidence of AWH was higher among patients with AAA vs patients without AAA. Methods: We performed a systematic review and meta-analysis according to the PRISMA guidelines. The Medline database was searched up to July 31, 2020. A random effects meta-analysis was performed. Results: In total, 17 articles and 738,972 participants were included in the systematic review, while 107,578 patients were eligible for the meta-analysis. Among four studies investigating the incidence of AAA in patients with hernias, AAA was more common in patients with hernias, compared to patients without hernias. [OR: 2.53, 95% CI: 1.24-5.16, I2=81.6%]. Among thirteen studies that compared patients with known AAA vs no AAA, the incidence of hernias was higher in patients with AAA, compared with patients without AAA [OR: 2.27, 95% CI: 1.66-3.09, I2=84.6%]. Conclusions: Our study findings indicate that a strong association between AWH and AAA exists. AWHs could therefore be used as an additional selection criterion for screening patients for AAA, apart from age, gender, family history and smoking.

An updated systematic review and meta-analysis of results of transcervical carotid artery stenting with flow reversal.

OBJECTIVE: Transcervical carotid artery stenting (CAS) has emerged as an alternative to transfemoral CAS. An earlier systematic review from our group (n = 12 studies; 739 transcervical CAS procedures [489/739 with flow reversal]) demonstrated that transcervical CAS is a safe procedure associated with a low incidence of stroke and complications. Since then, new studies have been published adding nearly 1600 patients to the literature. We aimed to update our early systematic review and also to perform a meta-analysis to investigate outcomes specifically after transcervical CAS with flow reversal. METHODS: An electronic search of PubMed/MEDLINE, Embase, and the Cochrane databases was carried out to identify studies reporting outcomes after transcervical CAS with flow reversal. Crude event rates for outcomes of interest were estimated by simple pooling of data. A proportion meta-analysis was also performed to estimate pooled outcome rates. RESULTS: A total of 18 studies (n = 2110 transcervical CAS procedures with flow reversal) were identified. A high technical success (98.25%) and a low mortality rate (0.48%) were recorded. The crude rates of major stroke, minor stroke, transient ischemic attack, and myocardial infarction (MI) were 0.71%, 0.90%, 0.57%, and 0.57%, respectively; a cranial nerve injury occurred in 0.28% of the procedures. A neck hematoma was reported in 1.04% of the procedures, and a carotid artery dissection occurred in 0.76% of the interventions; in 1.09% of the cases, conversion to carotid endarterectomy was required. After a meta-analysis was undertaken, the pooled technical success rate was 98.69% (95% confidence interval [CI], 97.19-99.70). A pooled mortality rate of 0.04% (95% CI, 0.00-0.29) was recorded. The pooled rate of any type of neurologic complications was 1.88 (95% CI, 1.24-2.61), whereas the pooled rates of major stroke, minor stroke, and transient ischemic attack were 0.12% (95% CI, 0.00-0.46), 0.15% (95% CI, 0.00-0.50), and 0.01% (95% CI, 0.00-0.22), respectively. The pooled rate of bradycardia/hypotension was 10.21% (95% CI, 3.99-18.51), whereas the pooled rate of MI was 0.08% (95% CI, 0.00-0.39). A neck hematoma after transcervical CAS was recorded in 1.51% (95% CI, 0.22-3.54) of the procedures; in 0.74% (95% CI, 0.05-1.95) of the interventions, conversion to CEA was required. Finally, a carotid artery dissection during transcervical CAS occurred in 0.47% (95% CI, 0.00-1.38) of the procedures. CONCLUSIONS: This updated systematic review and meta-analysis demonstrated that transcervical CAS with flow reversal is associated with high technical success, almost zero mortality, and low rates of major stroke, minor stroke, MI, and complications.

The use of iliac branch devices for preservation of flow in internal iliac artery during endovascular aortic aneurysm repair.

OBJECTIVE: Common iliac artery aneurysms are present in more than a third of patients with abdominal aortic aneurysm and may pose a challenge during open and endovascular repair. Although embolization of the internal iliac artery is an established method, it may be complicated with buttock claudication, erectile dysfunction, colon ischemia, and pelvic necrosis. Iliac branch devices (IBDs), which permit preservation of the hypogastric artery, have been used to prevent these complications. We conducted a meta-analysis to assess the safety and outcomes of IBDs and to explore potential differences between the commercially available types of IBDs. METHODS: The meta-analysis was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. After review of the literature, 36 eligible studies with a total of 1502 patients were included in our study. A meta-analysis was performed with investigation of the following outcomes: technical success rate, 30-day mortality, 30-day patency, follow-up patency, endoleak, buttock claudication, and IBD-associated reintervention. Furthermore, we conducted a subgroup meta-analysis by commercial type of endograft among the outcomes of interest. RESULTS: Among all eligible studies, technical success of the method was 97.35% (95% confidence interval [CI], 96.27-98.29). The endoleak rate postoperatively and during the follow-up period was 12.68% (95% CI, 8.80-17.07). The 30-day patency of IBDs was estimated at 97.59% (95% CI, 96.49-98.54), whereas follow-up patency was 94.32% (95% CI, 91.70-96.54). Furthermore, reintervention rate associated with IBDs was 6.96% (95% CI, 5.10-9.03), and buttock claudication during the follow-up period was 2.15% (95% CI, 1.25-3.22). CONCLUSIONS: IBD seems to be a safe, feasible, and effective technique for the treatment of aortoiliac aneurysms in select patients with suitable anatomy. Further results are awaited to explore the long-term efficacy and durability of these devices.

Aortic Banding to Treat Simultaneously a Type Ia Endoleak and Aortic Neck Rupture during Endovascular Abdominal Aortic Aneurysm Repair.

BACKGROUND: Type Ia endoleak due to inadequate seal at the proximal end of the endograft is not infrequent during the initial operation. However, repeated attempts at balloon inflation or over-dilatation of the balloon can produce high axial pressures and can lead to aortic neck rupture with hemodynamic instability. METHODS: The purpose of the paper is to present a useful technique for simultaneously treating a type Ia endoleak and aortic neck rupture during endovascular abdominal aortic aneurysm repair. RESULTS: The technique for treating a type Ia endoleak has been described, but it was used for the first time to treat simultaneously a type Ia endoleak and rupture of the aortic neck with active bleeding during endovascular abdominal aortic aneurysm repair. After laparotomy, the left renal vein was ligated and a proximal control was achieved with placement of a vascular clamp above the renal arteries. Effective external banding of the infrarenal neck was performed with two 10-mm polyester Dacron limbs tied in the same fashion, close to one another, and parallel just below the renal arteries. We describe the steps of the surgical technique in detail and we analyze crucial issues associated with the technique. CONCLUSIONS: In this paper, we presented a useful technique for simultaneously treating a type Ia endoleak and aortic neck rupture during endovascular abdominal aortic aneurysm repair. Effective external banding of the infrarenal neck led to control of the hemorrhage and exclusion of the blood flow in the aneurysm sac.

Angiosarcoma of a Thrombosed Arteriovenous Fistula in a Renal Transplant Recipient.

Angiosarcomas developing in nonfunctioning arteriovenous fistulas in renal transplant recipients are quite rare clinical entities with very poor prognosis. Herein we present a 60-year-old male who developed an angiosarcoma in a thrombosed radiocephalic fistula 6 years after renal transplantation. The patient presented with pain and swelling at the site of a previously asymptomatic fistula. The fistula was excised and diagnosis was made by histology. Despite radical surgery with an above-elbow amputation, the patient died of metastatic disease 6 months later.

Extracranial Internal Carotid Artery Aneurysm in a Patient with Marfan Syndrome.

Extracranial internal carotid artery (ICA) aneurysms are rare and most of them are considered of atherosclerotic etiology. Marfan syndrome (MS) is a systemic connective tissue disorder caused by mutation in the extracellular matrix protein fibrillin 1. Clinical manifestations of the MS include aortic aneurysms, dislocation of the ocular lens, and long bone overgrowth. The presence of extracranial ICA aneurysm in patients with MS is very rare. We report a 62-year-old female patient with MS presented with an extracranial ICA aneurysm. She was treated with aneurysmectomy and end-to-end anastomosis, with good outcomes. Only 10 cases of patients with MS and extracranial ICA aneurysm have been described in the literature. Clinical presentation, treatment, and outcome of these patients are reviewed and discussed.

Spinal Cord Ischemia following Elective Endovascular Repair of Infrarenal Aortic Aneurysms: A Systematic Review.

BACKGROUND: Spinal cord ischemia (SCI) after abdominal aortic aneurysm (AAA) endovascular abdominal aortic aneurysm repair (EVAR) is a rare but devastating complication. The mechanism underlying the occurrence of SCI after EVAR seems to be multifactorial and is underreported and not fully elucidated. The aim of the study was to investigate the clinical outcomes in patients with this serious complication. METHODS: A systematic review of the current literature, as per Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement guidelines, was performed to evaluate the incidence of SCI after elective EVAR. PubMed and Scopus databases were systematically searched. Studies reporting on thoracic endovascular aneurysm repair, open repair of AAAs, and symptomatic or ruptured AAAs were excluded. RESULTS: In total, 18 articles reporting 25 cases were included. The mean age was 74.6 ± 7.6 (range: 60-90) years. The mean diameter of AAAs was 5.96 ± 1.0 cm (range: 4.7-8.3). Six cases also had aneurysms in the common iliac arteries. Seventy-one percent of AAAs had characteristics that made EVAR difficult and technically demanding. The mean operative time was prolonged, 254 ± 104.6 min, and associated with extensive intravascular handling. In 41.6% of cases, additional procedures were performed because of the difficult anatomy. Thirty-two percent of the cases had 1 internal iliac artery (IIA) embolized with coils or covered with the stent graft, and 14% had both IIAs compromised. In most of the cases, SCI symptoms presented immediately after the operation, and in 14.8% of patients, the symptoms had late presentation. Almost all cases had motor loss in the form of paraparesis or paraplegia, 54% of the cases also had diminished sensation, and 29.1% of the cases had urinary and/or fecal incontinence. Heterogeneity was observed regarding the management of the disease; in 6 of the cases, cerebrospinal fluid (CSF) drainage was performed, steroids were administered in 5, and in the other cases, an expectant strategy was selected. In 50% of the cases, only small improvement was seen at follow-up. In 25% of the cases, no improvement was seen, and 25% had almost complete recovery. CONCLUSIONS: Our study identified a common pattern among patients who present SCI after EVAR: difficult anatomy, prolonged operative time, additional procedures, and extensive intravascular handling that may have led to embolization. Patency of pelvic circulation preoperatively is also of importance. Regarding outcomes, only 25% of patients recovered, and in certain cases, CSF drainage may have significantly improved chances for recovery.

Safety and efficacy of polyurethane vascular grafts for early hemodialysis access.

BACKGROUND: Arteriovenous grafts made of polyurethane (PU) have the advantage of early cannulation obviating the placement of a central vein catheter in patients with an acute need for long-term hemodialysis. The aim of the present study was to evaluate the safety, efficacy and complication rate of PU vascular grafts for dialysis access in patients in whom early cannulation was performed. METHODS: Between January 2007 and December 2015, 125 straight brachial-axillary grafts were placed in patients with an acute thrombosis of a previous arteriovenous access. Sixty-four were PU and 61 were polytetrafluoroethylene (PTFE) grafts. Patency and complications rates were compared between the two groups. RESULTS: The median interval from implantation to cannulation was 1 day in the PU group vs 28 days in the PTFE group. Cumulative infection rate at 5 years was 13% and 8% in the PU and the PTFE groups, respectively (P = .6). None of the patients in the PU group developed a pseudoaneurysm necessitating intervention, compared with one patient in the PTFE group. Primary and secondary patency rates did not differ significantly between the two groups. The cumulative median primary patency was 23 months in the PU group vs 26 months in the PTFE group. Median secondary patency was 42 vs 33 months, respectively. Diabetes mellitus was the only factor adversely affecting graft patency in both groups. CONCLUSIONS: PU grafts offer the advantage of early cannulation with infection, pseudoaneurysm formation and patency rates similar to those of the PTFE grafts.

A network meta-analysis of randomized controlled trials comparing treatment modalities for de novo superficial femoral artery occlusive lesions.

BACKGROUND: Treatment of superficial femoral artery (SFA) lesions remains challenging. We conducted a network meta-analysis of randomized controlled trials aiming to explore the efficacy of treatment modalities for SFA "de novo" lesions. METHODS: Eleven treatments for SFA occlusive disease were recognized. We used primary patency and binary restenosis at 12-month follow-up as proxies of efficacy for the treatment of SFA lesions. RESULTS: A total of 33 studies (66 study arms; 4659 patients) were deemed eligible. In terms of primary patency, odds ratios (ORs) with 95% confidence intervals (CIs) were statistically significantly higher in drug-eluting stent (DES; OR, 10.05; 95% CI, 3.22-31.39), femoropopliteal bypass surgery (BPS; OR, 7.15; 95% CI, 2.27-22.51), covered stent (CS; OR, 3.56; 95% CI, 1.33-9.53), and nitinol stent (NS; OR, 2.83; 95% CI, 1.42-5.51) compared with balloon angioplasty (BA). The rank order from higher to lower primary patency in the multidimensional scaling was DES, BPS, NS, CS, drug-coated balloon, percutaneous transluminal angioplasty with brachytherapy, stainless steel stent, cryoplasty (CR), and BA. Combination therapy of NS with CR and drug-coated balloon were the two most effective treatments, followed by NS, CS, percutaneous transluminal angioplasty with brachytherapy, cutting balloon, stainless steel stent, BA, and CR in terms of multidimensional scaling values for binary restenosis. CONCLUSIONS: DES has shown encouraging results in terms of primary patency for SFA lesions, whereas BPS still maintains its role as a principal intervention. On the contrary, BA and CR appear to be less effective treatment options.

Intraoperative Type IIIb Endoleak after Endograft Deployment during EVAR.

Type IIIb endoleak usually occurs years after the initial endograft implantation, and the cause is the chronic fatigue of the endograft. This rare case describes a type IIIb endoleak, appearing immediately after deployment of a new generation low-profile stentgraft and highlights the diagnostic and treatment challenges associated with the type IIIb endoleak. A 74-year-old man underwent elective EVAR for an infrarenal abdominal aortic aneurysm. A type IIIb endoleak near to the flow divider due to a fabric defect was diagnosed. The endoleak was successfully treated by endovascular positioning of a converter stent graft followed by the occlusion of the left limb with an iliac occluder and a femoro-femoral crossover bypass surgery. The ultrasound scan after 4 weeks showed no sign of endoleak. Occurrence of a type IIIb endoleak immediately after deployment is extremely rare. Based on the convenience of the intraoperative procedure and the anatomic characteristics of the aneurysm, we assume that the fabric defect might have occurred during loading of the endograft and subsequent confinement in the delivery catheter. We cannot definitely rule out the possibility of fabric damage induced by low-pressure balloon instrumentation. In case of a suspicion of a type IIIb endoleak, bilateral balloon occlusion of both limbs followed by antergrade aortography will help to identify the leak. In case the defect is near to the flow divider, aortouniliac grafting followed by femoro-femoral crossover bypass surgery represents an alternative option to conversion to open surgical repair.

Management of Patients with Internal Carotid Artery Near-total Occlusion: An Updated Meta-analysis.

BACKGROUND: The decision for revascularization in patients with near-total internal carotid artery (ICA) occlusion still remains controversial. We undertook an extensive review of the literature and conducted a meta-analysis aiming to investigate the appropriate therapeutic approach for patients with near-total ICA occlusion. METHODS: A multiple electronic health database search was performed on all articles published up to December 2014. All available data were analyzed giving emphasis on the applied therapeutic approach (best medical therapy [BMT], carotid endarterectomy [CEA], and carotid artery stenting [CAS]), whereas the main endpoints of the meta-analysis were transient ischemic attack (TIA), stroke, stroke-related death, myocardial infarction (MI), major adverse event (MAE), overall mortality, and restenosis. RESULTS: Five articles on BMT and CEA, 8 articles on CEA, and 11 articles on CAS were deemed eligible. A statistically significant difference was recorded in pooled stroke incidence rates (IRs) per 100 patient-years (p-ys) of BMT (IR = 6.19) compared with CEA (IR = 2.24, P = 0.002) and CAS (IR = 1.64, P < 0.001) studies. No statistically significant differences were recorded in pooled IRs per 100 p-ys between CEA and CAS, concerning TIA (P = 0.96), stroke (P = 0.44), stroke-related death (P = 0.30), and MAE (P = 0.99), whereas a borderline significance was recorded concerning overall mortality (P = 0.08) and restenosis (P = 0.08). No nominally significant effects were demonstrated with respect to almost all the studied potential modifiers in meta-regression analysis among the eligible studies. CONCLUSIONS: An intervention is probably indicated for patients with near-total ICA occlusion. The results of our study underline the need for including patients with near-total ICA occlusion in future randomized controlled trials. Meanwhile, the treatment of these patients should be individualized.

The impact of carotid artery stenting on cognitive function in patients with extracranial carotid artery stenosis.

BACKGROUND: The effect of carotid artery stenting (CAS) on cognitive function in patients with extracranial carotid artery stenosis is equivocal. The aim of this study was to examine the impact of CAS on various domains of cognitive function. METHODS: We performed a meta-analysis of the studies evaluating various domains of cognitive function before and after CAS, namely, (1) global cognition using Mini-Mental State Examination (MMSE) and Rey Auditory Verbal Learning Test (RAVLT), (2) executive function using Trail Making Test (TMT) A or Color Trails Test (CTT) A and TMT B or CTT B, (3) language ability using Boston Naming Test (BNT), (4) memory, (5) attention/psychomotor speed, and (6) functional ability, using various cognitive tests. Pooled weighted mean differences (WMDs) and standardized mean differences (SMDs) with 95% confidence intervals (95% CIs) were appropriately calculated using fixed or random effects models after assessing between-study heterogeneity. Meta-regression analysis was performed with number of patients per study; mean age (years); follow-up (months); proportion of men; proportion of patients with hypertension, diabetes mellitus, hyperlipidemia, smoking, and coronary artery disease; proportion of symptomatic patients; and degree of ipsilateral and degree of contralateral carotid stenosis as covariates. RESULTS: Sixteen studies were eligible, including a total of 626 CAS patients. A statistically significant improvement of global cognition was detected with MMSE (WMD = 0.67, 95% CI = 0.29-1.05, P < 0.001; follow-up = 5.6 months), but not with RAVLT (SMD = 0.45, 95% CI = -0.03 to 0.93, P = 0.07; follow-up = 2.4 months). Significant improvement of memory (SMD = 0.33, 95% CI = 0.11-0.55, P < 0.01; follow-up = 4.1 months) and attention/psychomotor speed (SMD = 0.21, 95% CI = 0.04-0.39, P = 0.02; follow-up = 4 months) was also detected. No statistically significant effect on executive function (TMT A/CTT A and TMT B/CTT B; SMD = 0.08, 95% CI = -0.10 to 0.26, P = 0.39; follow-up = 3.9 months and SMD = -0.02, 95% CI = -0.20 to 0.16, P = 0.82, respectively; follow-up = 3.9 months), language ability (BNT; SMD = 0.24, 95% CI = -0.05 to 0.54, P = 0.10; follow-up = 4 months), and functional ability (SMD = -0.05, 95% CI = -0.25 to 0.15, P = 0.63; follow-up = 3.8 months) was observed. No significant effects of the examined covariates were demonstrated in the meta-regression analyses. CONCLUSIONS: CAS may be associated with improvement in global cognition, memory, and attention/psychomotor speed. There was no positive effect on executive function, language, and functional ability, but CAS was not associated with a decline in any area of cognitive function. Future studies in larger groups of patients are probably needed to fully investigate the long-term effect of CAS on cognition in patients with carotid artery stenosis.

Diagnosis and surgical treatment of extrahepatic portal vein aneurysm: A case report.

Extrahepatic portal vein aneurysm is a relatively uncommon entity. We reported the case of a 51-year-old man, who was incidentally diagnosed with an asymptomatic 52 × 65 mm portal vein aneurysm, which was located at the main trunk of the portal vein, just before its bifurcation. The patient was treated with partial clamping of the portal vein aneurysm and aneurysmorrhaphy. Postoperative course was uneventful. Surgical intervention should be considered for patients with large, symptomatic or expanding portal vein aneurysms.