[Open surgical treatment for carotid stenoses]. / Operative Versorgung von Karotisstenosen.

BACKGROUND: Globally, stroke is considered the second most common cause of death. According to the German Federal Statistical Office, 33.6% of mortality was due to cardiovascular diseases, making them the most prevalent cause of death. PROBLEM: Specifically, cerebral infarctions were recorded as the cause in over 16,000 cases. These figures underscore the significant role that cerebrovascular diseases play in Germany's mortality statistics. Notably, about 80% of strokes are ischemic. Moreover, one-fifth of all strokes result from extracranial carotid stenosis. The increase in stroke risk with advancing age, especially among men, is particularly striking. This trend highlights the growing importance of efficient stroke prevention and treatment in an aging society. CONCLUSION: Open surgical therapy, as a crucial treatment method, is increasingly important, especially as an emergency intervention. Its role in modern medicine emphasizes the urgency of prioritizing this life-saving procedure in healthcare and making it widely available.

Sex disparities in popliteal artery aneurysms.

OBJECTIVE: Only 5% of patients with popliteal artery aneurysms (PAAs) are female. Evidence on PAA treatment and outcomes in women is therefore scarce. The POPART Registry provides one of Europe's largest data collections regarding PAA treatment. Data on clinical presentation, aneurysm morphology, and perioperative outcomes after open surgical PAA repair in women will be presented. METHODS: POPART is a multicenter, noninterventional registry for open and endovascular PAA repair, with 42 participating centers in Germany and Luxembourg. All patients aged >18 years who have been treated for PAA since 2010 are eligible for study inclusion. Data collection is based on an online electronic case report form. RESULTS: Of the 1236 PAAs, 58 (4.8%) were in women. There were no significant differences in age or cardiopulmonary comorbidities. However, female patients had a lower prevalence of contralateral PAAs and abdominal aortic aneurysms (P < .05). PAAs in women were more likely to be symptomatic before surgery (65.5% vs 49.4%; P = .017), with 19% of women presenting with acute limb ischemia (vs 11%; P = .067). Women had smaller aneurysm diameters than men (22.5 mm vs 27 mm; P = .004) and became symptomatic at smaller diameters (20 mm vs 26 mm; P = .002). Only 8.6% of women and 11.6% of men underwent endovascular aneurysm repair (P > .05); therefore, the perioperative outcome analysis focused on open surgical repair. In total, 23.5% of women and 16.9% of men developed perioperative complications (P > .05). There were no differences in major cardiovascular events (P > .05), but women showed a higher incidence of impaired wound healing (15.7% vs 7.2%; P = .05) and major amputation (5.9% vs 1.1%; P = .027). Female sex was significantly associated with the need for nonvascular reinterventions within 30 days after surgery (odds ratio: 2.48, 95% confidence interval: 1.26-4.88), whereas no significant differences in the odds for vascular reinterventions were observed (odds ratio: 1.98, 95% confidence interval: 0.68-5.77). In the multiple logistic regression model, female sex, symptomatic PAAs, poor quality of outflow vessels, and graft material other than vein graft were independently associated with perioperative reinterventions. CONCLUSIONS: Women have smaller PAAs, are more likely to be symptomatic before treatment, and are more often affected by nonvascular reinterventions in the perioperative course. As our understanding of aneurysmatic diseases in women continues to expand, sex-specific treatment strategies and screening options for women in well-selected cohorts with modified screening protocols should be continuously re-evaluated.

Feasibility of aortic aneurysm sac embolization using a novel shape memory polymer embolic device.

BACKGROUND: We investigated the feasibility of aneurysm sac embolization using a novel self-expanding porous shape memory polymer (SMP) device during endovascular aortic abdominal or thoracic aneurysm repair (EVAR). METHODS: Retrospective analysis of consecutive patients treated at 2 centers in Germany. Patients were treated from January 2019 to July 2021 with follow-up at 7 days and 3, 6, and 12 months. Aneurysm sacs were implanted with SMP devices immediately following endograft placement during the same procedure. Primary endpoint was technically successful SMP-device deployment into the aneurysm sac outside the endograft. Secondary endpoints were changes in aneurysm volume and associated complications (e.g., endoleaks). RESULTS: We included 18 patients (16 males), aged 72 ± 9 years, achieving 100% technical success. Mean preprocedure aortic aneurysm sac volume was 195 ± 117 mL with a perfused aneurysm volume of 97 ± 60 mL. A mean of 24 ± 12 SMP devices per patient were used (range 5-45, corresponding to 6.25-56.25 mL expanded embolic material volume). All evaluable patients exhibited sac regression except 2 patients yet to reach 3-month follow-up. At mean 11 ± 7 months (range 3-24), change in aneurysm volume from baseline was -30 ± 21 mL (p < 0.001). In 8 patients, aneurysm regression was observed despite type 2 endoleaks in 6 and type 1A endoleaks in 2, none of them requiring further intervention to date. No morbidity or mortality related to this treatment occurred. CONCLUSIONS: SMP devices for aortic aneurysm sac embolization during endovascular repair appear feasible and safe in this small case series. Prospective studies are needed. KEY POINTS: • Shape memory polymer is a novel, self-expanding, porous, and radiolucent embolic device material. • Aortic aneurysm sacs were treated with polymer devices immediately following endograft placement. • Aortic aneurysm sac regression was observed in all patients with over 3-month follow-up. • Aortic aneurysm sac regression was observed even in the presence of endoleaks.

Single Angio-Seal vascular closure device for transfemoral access exceeding 8F.

BACKGROUND: This was a retrospective single-center evaluation for off-label use of a single Angio-Seal-VIP 8F vascular closure device (VCD) (Terumo Interventional Systems, Somerset, NJ, USA) for retrograde transfemoral arterial access exceeding 8F. METHODS: Between 2010 and 2018, in 32 consecutive patients (3 females; mean age 67±9; range 46-86 years) retrograde femoral access was performed in 48 groins for aortoiliac stent or stent graft implantations using 9-14F sheaths. For vascular closure, one single Angio-Seal™-VIP 8F was used. Procedural success, closure-related complications, and risk factors were retrospectively evaluated using patient characteristics, duplex-ultrasound, and contrast-enhanced computed tomography angiography (CTA). Receiver-operating-characteristics were used for statistical analysis. RESULTS: Technical success for deployment of VCD was 100%. Visual inspection and duplex-ultrasound confirmed immediate hemostasis in 100%. Postinterventional CTA depicted major vascular access site complications in 6.3% (3/48 groins) requiring surgical treatment. A subgroup of 13 patients underwent surgical cut-down one day after VCD deployment as part of a two-staged complex endovascular aortic aneurysm repair procedure, allowing for visual assessment of prior used undersized Angio-SealTM. Patient's height (p=0.028) and severe access site calcifications (p=0.028) proved as predictors for one vessel occlusion and two pseudoaneurysms. Low body-mass-index (BMI) showed a non-significant trend. Sheath-size, common femoral artery depth, or body weight were not indicative for occurrence of complications. CONCLUSIONS: In selected cases, without availability of appropriate VCDs, a single Angio-SealTM-VIP 8F served as a feasible option to achieve sufficient hemostasis of transfemoral access exceeding 8F without relevant bleeding complications. Very low BMI, tall body-height, and severe atherosclerosis were identified to predispose to access site complications.

Life-threatening arterioureteral fistula treatment by endovascular complete anatomic iliac artery bifurcation reconstruction.

We present an endovascular approach for anatomic reconstruction of the iliac bifurcation in life-threatening arterioureteral fistula without sacrificing the pelvic arterial vascular supply. Five consecutive patients suffering from acute onset of significant gross hematuria caused by iliac-ureteral fistula resulting from previous oncologic surgery and radiation therapy were treated by transfemoral stent graft implantation in a double-barrel technique. Iliac-ureteral pseudoaneurysm coverage succeeded in an iliac neobifurcation with preservation of pelvic perfusion. Follow-up ranging from 9 to 37 months confirmed cessation of hematuria. One patient experienced stent graft thrombosis of the external iliac artery as a result of large cervical cancer invasion treated by crossover bypass. In all other patients, stent grafts were patent.

Organ-Preserving Surgical Treatment of a Horseshoe Kidney Occupied by a Large Renal Cell Carcinoma with Extensive Venous Invasion: A Case Report.

The horseshoe kidney is one of the most common congenital disorders affecting the urogenital system. Following a fusion of the lower kidney poles, which in turn lead to the formation of an isthmus, this anatomical variation is accompanied by other characteristic properties like an incomplete ascension, ventral rotation of the pelvices as well as atypical vascular supply. Even though renal carcinoids and Wilms tumors are more common in horseshoe kidneys, the incidence of renal cell carcinomas seems to be unaffected. Here we report the case of a locally advanced renal cell carcinoma with extensive venous invasion occurring in a horseshoe kidney and its complex surgical management. The whole primary tumor as well as a majority of venous tumor thrombi could be removed by a combination of 2/3 nephrectomy and cavotomy with thrombectomy. During 1 year of follow-up, the patient neither suffered from a tumor relapse, nor did he require renal replacement therapy. Thus, we conclude that even in cases of RCC where advanced disease is associated with complex anatomical situations, organ-preserving surgical treatment should be pursued to achieve excellent functional and oncological results.

Endovascular anatomic reconstruction of the iliac bifurcation with covered stentgrafts in sandwich-technique for the treatment of complex aorto-iliac aneurysms.

OBJECTIVE: Endovascular anatomic reconstruction of iliac artery bifurcation in aorto-iliac aneurysms using commercial stentgrafts in sandwich-technique by bilateral transfemoral approach. METHODS: 24 patients (mean 73.8±standard deviation 6.8years) with complex aorto-iliac aneurysms (AAA): n=17; diameter 64±15 [48-100]mm; common-iliac-artery (CIA): n=27; 43±15 [30-87]mm; internal-iliac-artery (IIA): n=14; 28±8 [15-43]mm) were prospectively enrolled for EVAR with preservation of the IIA (n=31; bi-lateral n=7). Maintenance of antegrade flow to IIA by iliac reconstruction was performed in sandwich-technique prior to EVAR. Follow-up of 15.0±10.8 [1-40]months included contrast-enhanced ultrasound and computed-tomography after 1week, 3, 6 and every 12months. RESULTS: Initial technical success for anatomic reconstruction of the iliac arteries in 31 instances was 100%. Primary patency of iliac neo-bifurcations was 90.9% (20/22) at 6months and 84.2% (16/19) at 1year. Postprocedural gutter-endoleaks type 1b were obvious in 6.5% (2/31) of cases, which disappeared 3months later. Aortic/iliac aneurysm-size after 1year decreased (>5mm) in 61.5% of patients. No aneurysm-size increase or late rupture occurred. CONCLUSIONS: Endovascular reconstruction of the iliac bifurcation with commercial standard stentgrafts is safe and effective. Transfemoral approach allows extension of distal landing zone for EVAR while preserving the internal iliac artery blood-flow, even in unfavorable iliac anatomy.

Paclitaxel-coated balloon angioplasty for symptomatic central vein restenosis in patients with hemodialysis fistulas.

PURPOSE: To report a retrospective observational analysis of standard balloon angioplasty (BA) vs. paclitaxel-coated balloon angioplasty (PCBA) for symptomatic central vein restenoses in patients with impaired native hemodialysis fistulas. METHODS: A retrospective review was conducted of 27 consecutive patients (15 men; mean age 66 ± 13.8 years, range 39-90) with 32 central vein stenoses (CVS; 6 axillary, 11 subclavian, 12 brachiocephalic, and/or 3 superior caval veins) treated successfully using BA. Freedom from reintervention after BA of de novo lesions was 7.4 ± 7.9 months (range 1-24). Twenty-five (92.6%) patients developed symptomatic restenoses and were treated one or more times by BA (n = 32) or PCBA (n = 20) using custom-made paclitaxel-coated balloons (diameter 6-14 mm). RESULTS: Technical (< 30% residual stenosis) and clinical (functional fistula) success rates for the initial and secondary angioplasty procedures were 100%. No minor/major procedure-associated complications occurred. Mean follow-up was 18.4 ± 17.5 months. Kaplan-Meier analysis for freedom from target lesion revascularization (TLR) found PCBA superior to BA (p = 0.029). Median freedom from TLR after BA was 5 months; after PCBA, > 50% of patients were event-free during the observation period (mean freedom from TLR 10 months). Restenosis intervals were prolonged by PCBA (median 9 months) vs. BA (median 4 months; p = 0.023). CONCLUSION: Paclitaxel-coated balloon angioplasty of central vein restenosis in patients with hemodialysis shunts yields a statistically significant longer freedom from TLR compared to standard balloon angioplasty.

Mechanical recanalization of subacute vessel occlusion in peripheral arterial disease with a directional atherectomy catheter.

PURPOSE: To retrospectively examine the technical feasibility and safety of directional atherectomy for treatment of subacute infrainguinal arterial vessel occlusions. METHODS: Five patients (one woman, four men, age range 51-81 years) with peripheral arterial disease who experienced sudden worsening of their peripheral arterial disease-related symptoms during the last 2-6 weeks underwent digital subtraction angiography, which revealed vessel occlusion in native popliteal artery (n = 4) and in-stent occlusion of the superficial femoral artery (n = 1). Subsequently, all patients were treated by atherectomy with the SilverHawk (ev3 Endovascular, USA) device. RESULTS: The mean diameter of treated vessels was 5.1 ± 1.0 mm. The length of the occlusion ranged 2-14 cm. The primary technical success rate was 100%. One patient experienced a reocclusion during hospitalization due to heparin-induced thrombocytopenia. There were no further periprocedural complications, in particular no peripheral embolizations, until hospital discharge or during the follow-up period of 1 year. CONCLUSION: The recanalization of infrainguinal arterial vessel occlusions by atherectomy with the SilverHawk device is technically feasible and safe. In our limited retrospective study, it was associated with a high technical success rate and a low procedure-related complication rate.

Prostheto-ureteral fistula: a rare complication after aortic graft surgery.

Prostheto-ureteral fistula after aortic graft surgery is a potentially life-threatening, rare pathology. We report the successful treatment of a prostheto-ureteral fistula that caused hematuria with hemorrhagic shock in two patients by explantation of aortic prosthetic grafts and implantation of a silver-bonded prosthetic graft (Intergard S, Intervascular). These cases show that this surgical procedure is effective, and that straightforward diagnostic procedures are necessary to initiate correct therapeutic approach without delay. Various different possible risk factors for the formation of a prostheto-ureteral fistula are also discussed.