Endovascular Treatment of Chronic Total Occlusions of the Iliac Arteries: Early and Midterm Results.

BACKGROUND: To examine the effects of endovascular therapy on the treatment of chronic total occlusions (CTOs) of the iliac arteries. METHODS: We analyzed a cohort of 48 patients (56 limbs) who were treated by endovascular means for iliac artery CTOs during a period of 4 years in 2 vascular surgery centers in Greece. The data were collected retrospectively and were statistically analyzed to report on technical success, morbidity, mortality, primary and secondary patency, and limb salvage through different patient and/or lesion stratifications. RESULTS: Recanalization was accomplished without assisting devices, and primary stenting was always performed. The technical success of the endovascular treatment reached 91%. Patients experienced 4.2% major morbidity and 2.1% mortality rate. Mean ankle-brachial pressure index increased from 0.43 ± 0.12 preoperatively to 0.89 ± 0.11 postoperatively. A median improvement by 3 Rutherford clinical categories was recorded at the first-month follow-up. The estimated limb salvage rate for patients suffering from critical limb ischemia (CLI) was 90.9% at 36 months. Kaplan-Meier analysis estimation for overall primary and secondary patency rate of the treated lesions was 91.4% and 95.3%, respectively at 36 months. There were no statistically significant differences in primary and secondary patency rate between patients in different clinical stages (CLI versus intermittent claudication), as well as between CTO lesions of different Trans-Atlantic Inter-Society Consensus (TASC) categories (TASC B versus TASC C versus TASC D). There was not statistical significant difference between the technical success of TASC B, C, and D lesion groups. CONCLUSIONS: The endovascular treatment of iliac CTOs seems to be safe and feasible. The technical success of the procedure could be high, whereas primary and secondary patency rates seem to be optimal, with remarkable limb salvage rate and overall clinical improvement. A potential shift to an endovascular-first approach for such lesions might be currently justified.

Bridging endovascular therapy and subsequent surgical repair for the treatment of infected aneurysms after percutaneous cardiac intervention.

Bridging endovascular therapy, accompanied by a second stage open surgical repair was used to treat a rare case of infected aneurysms alongside external iliac artery after a percutaneous cardiac intervention. Because these aneurysms require early treatment, we suggest this approach, in order to avoid immediate, major surgery in a recently symptomatic cardiac and bacteremic patient receiving dual antiplatelet therapy. The approach seems to be safe and durable.

Use of the vascu-guard bovine pericardium patch for arteriotomy closure in carotid endarterectomy. Early and long-term results.

BACKGROUND: To report the early and long-term results of Vascu-Guard bovine pericardium (BP) for patch angioplasty in carotid endarterectomy (CEA). METHODS: We retrospectively analyzed the data of 256 CEAs with BP patch closure performed in 238 patients during the past 12 years in our department. Patch-related complications (restenosis, infection, and aneurysm formation) and early and late (12 to 144 months follow-up) clinical outcomes were recorded and statistically analyzed. RESULTS: Thirty-day postoperative stroke rate was 1.2% (3/256) with zero mortality. Major complications occurred in 3.5% (9 of 256) of the procedures and cranial nerve injury in 4.3% (11 of 256). At 12 years, cumulative estimates of freedom from any stroke, stroke-free survival, and freedom from restenosis were 88.4% (standard error [SE]: 3.3%), 60% (SE: 7.8%), and 98.3% (SE: 0.8%), respectively. No patient experienced patch infection or aneurysm formation. CONCLUSIONS: This series shows the efficacy, safety, and durability of CEA with BP patch closure, in both the short and long term. BP combines the advantages of vein and synthetic patches, representing a suitable option when performing CEA.

Spinal cord early ischemic preconditioning activates the stabilized fraction of ß-catenin after thoracoabdominal aortic occlusion in pigs.

BACKGROUND: Paraplegia after thoracoabdominal aortic surgery is a devastating complication attributed to motor neurons loss and dysfunction, due to spinal cord ischemia. ß-Catenin is a protein that has been associated with cell survival and healing and many studies have correlated this protein with late ischemic preconditioning (IPC). Herein we investigate the potential contribution of ß-catenin in an early IPC animal model, and its relationship with heat shock protein 70 (Hsp70), suggesting a possible role of this protein as a first window of protection. METHODS: A total of 42 pigs were used in an experimental thoracoabdominal aortic occlusion model. Twelve animals were used for neurologic evaluation and were randomly assigned to 2 groups (A and B). The remaining 30 animals were used in experiments for biologic measurements and innunohistochemical studies, and were randomly assigned to 5 groups (1-5). Western blotting analysis and immunoprecipitations were performed to study the levels of ß-catenin and its binding relationship with Hsp70. The cellular distribution of ß-catenin at various time-points was investigated by immunohistochemical studies. RESULTS: According to neurologic evaluation, the animals in the IPC+ischemia group had significantly better neurologic scores compared with those in the ischemia group, indicating a protective role for IPC. The biologic measurements demonstrated a significant (P=0.03) increase in ß-catenin levels and translocation of the protein in the nucleus at the end of ischemic preconditioning. CONCLUSIONS: Our results suggest a significant role of ß-catenin in early IPC protection of spinal cord after thoracoabdominal occlusion, as IPC seems to trigger the activation of the ß-catenin stabilized fraction and, thus, its survival pathway.

Contained rupture of a celiac artery aneurysm treated with aortic endograft deployment and assisting percutaneous coil and thrombin infusion.

In this report we present a case of a ruptured celiac artery aneurysm (CAA) with a thrombosed distal neck, which was treated as an emergently with a deployment of a tube thoracic endograft to the descending thoracic and upper abdominal aorta. The initial treatment was assisted with a second stage percutaneous, transhepatic, ultrasound guided needle infusion of coil and thrombin to the aneurysmal sac due to type Ib endoleak, with immediate thrombosis of the aneurysm. This technique, although not standard,could also be considered as a useful choice for the treatment of CAAs with wide proximal and patent distal neck.

Stenting of the descending thoracic aorta: a six-year single-center experience.

OBJECTIVES: The aim of this study was to review the six-year results of the endovascular repair of descending thoracic aortic pathologies, reporting the early perioperative outcomes as well as the mid-term follow-up of the treated patients. METHODS: Fifty-five consecutive patients who underwent endovascular repair for thoracic aortic pathology (32 aneurysms, 17 acute thoracic aortic syndromes, and six traumatic aortic ruptures) during a six-year period were retrospectively reviewed. From these patients, 30 (54.5%) were treated electively and 25 (45.5%) on an emergency basis. In eight cases (14.5%) there was a need for left subclavian artery orifice overstenting. In seven patients (12.7%) an abdominal aortic lesion was simultaneously treated, while three more patients (5.5%) had previously had their abdominal aortic aneurysm repaired. RESULTS: The primary technical success was 92.7%. Seven patients (12.7%) underwent some operation related complication, while postoperative complications occurred in five patients (9.1%), namely four myocardial infarctions, one acute respiratory distress syndrome and two delayed parapareses resulting in an overall incidence of neurological complications of 3.6%. The combined 30-day and in-hospital mortality was 9.1%, exclusively related to patients treated emergently (P = 0.01). In a mean follow-up period of 34 months there were six deaths, and the overall cumulative survival at four years was estimated at 72.6%. Only one type II endoleak was observed one month after the procedure and it spontaneously disappeared 18 months later. CONCLUSIONS: The endovascular repair of descending thoracic aortic pathologies seems to be a well-established method, with favorable morbidity and mortality rates, at least for 30 days and in the mid-term. Taking into account the potential of a wide application of the endovascular technique in many vascular centers, stenting of the thoracic aorta might offer an overall better solution for patients suffering from these devastating pathologies.

Abdominal aortic endograft proximal collapse: Successful repair by endovascular means.

Infolding of an aortic endograft, usually characterized as endograft collapse, is a quite rare complication reported to occur mainly in thoracic aortic grafts. This report presents a case of an early proximal collapse of an endoprosthesis in an abdominal aortic aneurysm. The complication was diagnosed during the first month of follow-up and was not associated with any endoleak. It was treated with the deployment of a proximal endograft cuff with suprarenal fixation. Endograft collapse may complicate endovascular repair of the abdominal aorta in rare situations. Upon diagnosis of the problem, endovascular repair of graft collapse seems to be feasible.

Modified staged surgical approach to coexisting severe coronary artery disease and large abdominal aortic aneurysm.

Surgical management of coexisting severe coronary artery disease and large or symptomatic abdominal aortic aneurysm may be required in patients who are unsuitable candidates for minimally invasive interventions. Although several options have been proposed, the optimal timing to deal with both entities, in order to achieve the best outcome, is still debatable. This report presents a modified approach based on a two-stage treatment in a single anesthetic session.

Antirestenotic effects of a novel polymer-coated d-24851 eluting stent. Experimental data in a rabbit iliac artery model.

Experimental and clinical data suggest that stents eluting antiproliferative agents can be used for the prevention of in-stent restenosis. Here we investigate in vitro the antiproliferative and apoptotic effect of D-24851 and evaluate the safety and efficacy of D-24851-eluting polymer-coated stents in a rabbit restenosis model (n = 53). Uncoated stents (n = 6), poly (DL: -lactide-co-glycolide) (PLGA)-coated stents (n = 7), and PLGA-coated stents loaded with 0.08 +/- 0.0025 microM (31 +/- 1 mug; low dose; n = 7), 0.55 +/- 0.02 microM (216 +/- 8 mug; high dose; n = 6), and 4.55 +/- 0.1 microM (1774 +/- 39 mug; extreme dose; n = 5) of D-24851 were randomly implanted in New Zealand rabbit right iliac arteries and the animals were sacrificed after 28 days for histomorphometric analysis. For the assessment of endothelial regrowth in 90 days, 12 rabbits were subjected to PLGA-coated (n = 3), low-dose (n = 3), high-dose (n = 3), and extreme-dose (n = 3) stent implantation. In vitro studies revealed that D-24851 exerts its growth inhibitory effects via inhibition of proliferation and induction of apoptosis without increasing the expression of heat shock protein-70, a cytoprotective and antiapoptotic protein. Treatment with low-dose D-24851 stents was associated with a significant reduction in neointimal area and percentage stenosis only compared with bare metal stents (38% [P = 0.029] and 35% [P = 0.003] reduction, respectively). Suboptimal healing, however, was observed in all groups of D-24851-loaded stents in 90 days in comparison with PLGA-coated stents. We conclude that low-dose D-24851-eluting polymer-coated stents significantly inhibit neointimal hyperplasia at 28 days through inhibition of proliferation and enhancement of apoptosis. In view of the suboptimal re-endothelialization, longer-term studies are needed in order to establish whether the inhibition of intimal growth is maintained.

Pancreatic injury after thoracoabdominal aortic occlusion in a porcine model.

BACKGROUND: The aim of this study was to investigate pancreatic injury after 45 min of thoracoabdominal aortic occlusion in a porcine model. METHODS: Twenty-four pigs were used. Six pigs underwent sham operation and 18 intravascular balloon thoracoabdominal aortic occlusions for 45 min. The animals were randomly killed at 12, 48 and 120 h after reperfusion. After killing, all pancreata were examined macroscopically for any signs of acute pancreatitis, whereas gland specimens were harvested for histological study to evaluate pancreatic injury (haematoxylin and eosin staining) and acinar cell apoptosis (Terminal deoxynucleotidyl transferase mediated dUTP Nick-End Labelling staining). RESULTS: Pancreatic injury severity score was mildly increased in terms of oedematous features at 12 h after reperfusion, but normalized to sham levels by the second day and thereafter. Necrotic injury was not statistically significant at any time point. Acinar cell apoptotic index was mildly increased at 12 and 48 h, but showed a tendency to decrease towards sham levels by the fifth day. One animal developed acute pancreatitis. CONCLUSION: Acute pancreatitis is unlikely to occur after 45 min of thoracoabdominal aortic occlusion. However, an early, mild oedematous and apoptotic injury that occurs subclinically seems to be a constant event. This injury might have clinical significance when combined with pre-existent pancreatic pathologies.

Endovascular repair for thoracic aortic disease: tertiary single-center experience in northwestern Greece.

The purpose of this article is to report the initial experience with endovascular repair of thoracic aortic disease in a single tertiary vascular unit in northwestern Greece. Between 2003 and 2005, 16 patients were treated with endovascular techniques for various pathologies of the descending thoracic aorta. Twelve patients were treated electively and four emergently. Operative and follow-up data for a mean time of 18.4 months were retrospectively collected and analyzed. Primary technical success was obtained in 14 (87.5%) cases. No early or late deaths occurred, and there was no major operation-related complication. No paraplegia was observed in our patients. Stent graft-related complications occurred in 18.75% (one type 2 and two type 3 endoleaks), but they all had a favorable outcome. No further problems have been reported in any of our patients. Endovascular stent graft repair for diseases of the thoracic aorta seems to be a promising alternative to open surgery, especially for high-risk patients. Long-term results are needed to confirm the early benefit of this treatment option with regard to morbidity and mortality rates. The potential of this technique to be applicable even in relatively small, tertiary vascular centers might be of great benefit to patients.

Carotid endarterectomy with bovine pericardium patch angioplasty: mid-term results.

The objective of this study was to assess the efficacy of bovine pericardium (BP) as a patch material in carotid endarterectomy (CEA) in terms of peri- and postoperative complications and the incidence of recurrent stenosis. During a 4-year period, 148 CEAs were performed in 138 consecutive patients. The study group included elective, emergency, and combined with cardiac operation CEAs in both symptomatic and asymptomatic carotid artery disease patients. Patch angioplasty using the BP followed the standard CEA in all patients. Postoperative follow-up included clinical examination and periodical color duplex scans at 3, 6, and 12 months and yearly thereafter. Surgical outcome was evaluated by the operation-related parameters, early and late mortality and morbidity rates, and the incidence of recurrent stenosis. All CEAs were performed without any unfavorable event. In the early postoperative period, there were no deaths and the morbidity consisted of transient cranial nerve paresis (4.7%) in seven patients and two ipsilateral strokes (1.4%). During the follow-up period, three patients (2%) developed significant carotid restenosis, though they remain asymptomatic, while there were no deaths related to the CEA. Patch angioplasty of the carotid artery using BP showed unwittingly early and mid-term surgical outcome. Our results demonstrate the BP to be a suitable patch material for routine use in carotid surgery.

Endovascular stent-graft repair as a late secondary procedure after previous aortic grafts.

Thoracic and abdominal aortic endovascular procedures as alternatives to aortic reoperations were studied in three different cases. An anastomotic aneurysm after previous thoracic aortic graft for coarctation, a second-stage elephant trunk repair (descending thoracic aortic aneurysm), and a secondary aneurysm proximal to a previous abdominal aortic graft were successfully treated with endovascular stent-grafts. During the follow-up period no lethal events or major aortic or graft-related complications were observed, except a type II endoleak in the anastomotic aortic aneurysm case. An endovascular stent-graft can be safely deployed into a previously implanted vascular graft, avoiding repeat surgery.

Evolution of spinal cord injury in a porcine model of prolonged aortic occlusion.

BACKGROUND: Spinal cord injury and subsequent paraplegia remains an unpredictable and devastating complication of thoracoabdominal aortic surgery. The aim of this study was to investigate spinal cord injury due to prolonged thoracoabdominal aortic occlusion. MATERIALS AND METHODS: We used a highly reproducible porcine model of 45-min thoracoabdominal aortic occlusion, which was accomplished by two balloon occlusion catheters. Neurological evaluation after the end of experiment was performed by an independent observer according to the Tarlov scale. The lower thoracic and lumbar spinal cords were harvested at 10, 48, and 120 h (n = 6 animals per time point) and examined histologically with hematoxylin and eosin (H&E) stain and TUNEL method. Tarlov scores, number of neurons, and the grade of inflammation were analyzed. RESULTS: H&E staining revealed reduction in the number of motor neurons which occurred in two phases (between 0 and 10 h and between 48 and 120 h of reperfusion), as well as development of inflammation in spinal cord sections during the reperfusion period, reaching a peak at 48 h. TUNEL reaction was negative for apoptotic neurons at any time point. CONCLUSIONS: In this porcine model, we demonstrated that, after 45 min of thoracoabdominal aortic occlusion, motor neuron death seems to occur in two phases (immediate and delayed). Inflammation was a subsequent event of transient prolonged spinal cord ischemia and possibly a major contributor of delayed neuronal death. Using TUNEL straining we found no evidence of neuronal apoptosis at any time point of reperfusion.

Superiority of early relative to late ischemic preconditioning in spinal cord protection after descending thoracic aortic occlusion.

OBJECTIVE: We previously showed that ischemic preconditioning significantly reduced spinal cord injury caused by 35-minute aortic occlusion. In this study we investigated the effect of ischemic preconditioning on spinal cord injury after 45-minute aortic occlusion. METHODS: Thirty-two pigs were divided as follows: group 1 (n = 6) underwent sham operation, group 2 (n = 6) underwent 20 minutes of aortic occlusion, group 3 (n = 6) underwent 45 minutes of occlusion, group 4 (n = 6) underwent 20 minutes of occlusion and 48 hours later underwent an additional 45 minutes, and group 5 (n = 8) underwent 20 minutes of occlusion and 80 minutes later underwent an additional 45 minutes. Aortic occlusion was accomplished with two balloon occlusion catheters placed fluoroscopically after the origin of the left subclavian artery and at the aortic bifurcation. Neurologic evaluation was by Tarlov score. The lower thoracic and lumbar spinal cords were harvested at 120 hours and examined histologically with hematoxylin-eosin staining. The number of neurons was counted, and the inflammation was scored (0-4). Statistical analysis was by Kruskal-Wallis and 1-way analysis of variance tests. RESULTS: Group 5 (early ischemic preconditioning) had better Tarlov scores than group 3 ( P < .001) and group 4 (late ischemic preconditioning, P < .001). The histologic changes were proportional to the Tarlov scores, with the least histologic damage in the animals of group 5 relative to group 3 (number of neurons P < .001, inflammation P = .004) and group 4 (number of neurons P < .001, inflammation P = .006). CONCLUSION: Early ischemic preconditioning is superior to late ischemic preconditioning in reducing spinal cord injury caused by the extreme ischemia of 45 minutes of descending thoracic aortic occlusion.