Efficacy and Safety of Endovascular Fenestrated and Branched Grafts Versus Open Surgery in Thoracoabdominal Aortic Aneurysm Repair: An Updated Systematic Review, Meta-analysis, and Meta-regression.

OBJECTIVE: To provide an updated systematic review and meta-analysis with meta-regression of efficacy and safety of fenestrated/branched endovascular repair of thoracoabdominal aortic aneurysms (TAAAs) compared with open repair. BACKGROUND: Endovascular repair of TAAAs may be a promising alternative to open surgery by reducing invasiveness and expanding the eligible population, but evidence remains limited. METHODS: We applied "Prepared Items for Systematic Reviews and Meta-analysis" guidelines to retrieve, quantitatively pool, and critically evaluate the efficacy and safety (including 30-day mortality, reintervention, spinal cord injury [SCI], and renal injury) of both approaches. Original studies were retrieved from PubMed, Embase, and Cochrane Library until April 20, 2022, excluding papers reporting <10 patients. Pooled proportions and means were determined using a random-effect model. Heterogeneity between studies was evaluated with I2 statistics. RESULTS: Sixty-four studies met the predefined inclusion criteria. Endovascular cohort patients were older and had higher rates of comorbidities. Endovascular repair was associated with similar proportions of mortality (0.07, 95% confidence intervals [CI]: 0.06-0.08) compared with open repair (0.09, 95% CI: 0.08-0.12; P = 0.22), higher proportions of reintervention (0.19, 95% CI: 0.13-0.26 vs 0.06, 95% CI: 0.04-0.10; P < 0.01), similar proportions of transient SCI (0.07, 95% CI: 0.05-0.09 vs 0.06, 95% CI: 0.05-0.08; P = 0.28), lower proportions of permanent SCI (0.04, 95% CI: 0.03-0.05 vs 0.06, 95% CI: 0.05-0.07; P < 0.01), and renal injury (0.08, 95% CI: 0.06-0.10 vs 0.13, 95% CI: 0.09-0.17; P = 0.02). Results were affected by high heterogeneity and potential publication bias. CONCLUSIONS: Despite these limitations and the lack of randomized trials, this meta-analysis suggests that endovascular TAAA repair could be a safer alternative to the open approach.

Skeletal and dental effects of serial extractions performed with or without maxillary expansion-A retrospective controlled study.

OBJECTIVES: The study aimed to compare severe crowding treatment's skeletal and dental effects by serial extractions or maxillary expansion and serial extractions in the mixed dentition phase. SETTING AND SAMPLE POPULATION: The retrospective controlled study included lateral cephalograms of 78 subjects aged 8.5 ± 1.4 years, 52 consecutively treated because of severe crowding, and 26 untreated controls matched for baseline age and observational period. METHODS: Subjects were clustered according to the treatment modality, either serial extraction (EX) or expansion and extraction (EXP-EX) group. Sagittal and vertical skeletal as well as dental cephalometric parameters were assessed at baseline and after the eruption of all permanent posterior teeth, and group comparisons were performed. RESULTS: Both treatment modalities significantly affected the vertical skeletal parameters in terms of decreasing the mandibular and occlusal plane inclination and increasing the facial height index. A distinct treatment effect on the gonial angle was observed, with a significant decrease in its superior part observed in both extraction groups. The annualized changes in the superior part of the gonial angle significantly differ (P = .036) between the Control (-0.04 ± 0.6), EX (-0.44 ± 0.6) and EXP-EX (-0.34 ± 0.5) groups. Upper and lower incisor inclination did not change significantly in any of the groups; however, the interincisal angle at follow-up was significantly smaller in the Control compared with both treated groups. CONCLUSIONS: Serial extractions and a combination of maxillary expansion and serial extractions have similar significant skeletal effects, mainly affecting vertical cephalometric parameters if performed during the pre-pubertal growth phase.

Endovascular Oriented Classification and Treatment of Celiac Trunk Aneurysms: 10 Years Experience.

OBJECTIVE: To propose an endovascular-oriented classification of celiac trunk aneurysms (CTa) and discuss single center results of this rare pathology. METHODS: Data of all patients admitted to our institution for CTa from 2011 to 2021 were prospectively collected. Of them, those who underwent endovascular treatment were retrospectively analyzed. All preoperative CT scans were reviewed and CTa were classified in 4 different configurations based on progressive distal landing zone. We excluded from the classification all cases with median arcuate ligament syndrome (MALS), patients with coexistent aortic dilation or no endovascular proximal neck. Preoperative demographics, intraoperative data and post-operative complications were recorded. All-cause late mortality and complications were identified through a review of office charts and telephone assessment. RESULTS: During the study period 19 patients were referred to our Institution for CTa. Ten patients underwent endovascular treatment (ET). In 6 cases a watchful waiting strategy was adopted, 2 (10.5 %) patients refused ET and one patient without suitable proximal landing zone (< 10 mm) was not proposed to open surgical repair for surgical contraindication but is followed by strict instrumental and clinical evaluation. Six (60%) patients presented type 2 CTa; all of them underwent ET requiring positioning of covered stent-graft and SA embolization. Three (30%) patients presented type 3 CTa; all of them underwent ET with covered stent-graft deployment over the GDA with preliminary embolization. One (10%) patient presented type 4 CTa that was treated by means of covered stent-graft deployment along the right hepatic artery with left hepatic artery embolization. Overall, no major complications and perioperative mortality was observed. CONCLUSION: Celiac trunk aneurysms are rare, and no classifications have still been presented. Stent-graft exclusion provides excellent short-term outcome with no significant morbidity and mortality rate when technically feasible.

Outcomes of routine use of percutaneous access with large-bore introducer sheaths (>21F outer diameter) during endovascular aneurysm repair.

OBJECTIVE: The objective of this study was to evaluate the performance of percutaneous femoral access with large-bore sheaths (>21F outer diameter) mainly employed for thoracic and thoracoabdominal aortic endovascular treatment and to stratify the outcomes on the basis of the introducer size. METHODS: Between December 2015 and December 2018, all consecutive patients who received endovascular repair through a percutaneous approach with a suture-mediated vascular closure device (VCD) and the preclose technique were included in a retrospective single-center study called Totally Percutaneous Approach to Endovascular Treatment of Aortic Aneurysms (PEVAR-PRO). The morphologic characteristics of the access vessels and patients' demographics were recorded, and 30-day closure success was defined as the primary end point. Analysis of the closure success comparing large-bore sheaths vs small-bore sheaths (≤21F outer diameter) was performed after 1:1 propensity score matching of preoperative confounding variables. RESULTS: The closure success rate of the entire study cohort was 94% (622 femoral accesses in 360 patients; median age, 74 years; 84% male). Univariate analysis identified eight different factors associated with failure, but only two remained significant on multivariate analysis: diabetes (odds ratio [OR], 2.8; 95% confidence interval [CI], 1.3-6.2; P = .011) and common femoral artery stenosis >50% (OR, 4.5; 95% CI, 1.3-13.7; P = .019). After propensity score matching (1:1, 172 femoral accesses per group), closure success rate was not significantly different between large-bore and small-bore sheaths (90.7% vs 93.0%; P = .43). Multivariate analysis of the large-sheath group identified two factors associated with failure: small (<9 mm) femoral arteries (OR, 6.9; 95% CI, 1.5-31.6; P = .13) and access vessel calcifications involving more than one-third of the circumference (OR, 7.9; 95% CI, 2.1-29.4; P = .002). Neither previous femoral cutdown (44 accesses [23%]) nor percutaneous closure with VCDs (38 accesses [20%]) affected the closure success rate in the large-sheath group. Closure failure did not significantly increase the need for postoperative blood transfusions or hospital length of stay. CONCLUSIONS: Off-label use of VCDs and the preclose technique for percutaneous approach with large-bore sheaths needed for complex aortic endovascular procedures is safe and feasible. Closure success rate is not significantly different from that obtained with on-label application of VCDs with smaller sheaths.

Thoracic Endovascular Aortic Repair With Additional Distal Bare Stents in Type B Aortic Dissection Does Not Prevent Long-Term Aneurysmal Degeneration.

PURPOSE: TEVAR (thoracic endovascular aortic repair) + PETTICOAT (Provisional ExTension to Induce COmplete ATtachment) technique has been selectively employed since 2005 at our institution during endovascular treatment of type B aortic dissection (TBD). The aim of this study is to evaluate the long-term (>5 years) clinical results and the evolution of aortic volume. MATERIALS AND METHODS: All the patients receiving an endovascular treatment for TBD with the PETTICOAT technique were collected in a prospectively maintained database and follow-up computed tomography scan were retrospectively analyzed. Study endpoints included short- and long-term clinical success (absence of need for reintervention) and any major adverse event. The volumes of thoracic and abdominal aorta at long-term follow-up were also analyzed. RESULTS: Twenty-eight patients received a TEVAR + PETTICOAT and were followed up (median follow-up 85 months). Primary 30-day clinical success rate was 82% with an adverse event rate of 31%; 4 type I endoleak and 1 retrograde dissection were recorded. Secondary mid-term clinical success was 96% while the long-term clinical success rate was 79%. Six cases (21%) received either an open repair or an endovascular repair for a significant distal aortic enlargement at follow-up. With regards to volumetric analysis, an increase of overall (thoracic and abdominal) aortic volume was observed in 8 cases mainly related to an increase (mean: +31%) of the abdominal volume that was observed in 11 cases. CONCLUSIONS: PETTICOAT technique does not protect from long-term significant aneurysmal degeneration that may require aortic open or endovascular reinterventions. Aortic growth occurs mainly in the bare-stented aorta and thus, life-long surveillance is advisable in these patients.

Carotid to subclavian bypass and Amplatzer vascular plug subclavian endovascular occlusion before thoracic open or endovascular repair.

OBJECTIVE: The aim of this study was to evaluate the safety and effectiveness of endovascular occlusion of the prevertebral subclavian artery (SA) using an Amplatzer vascular plug after prophylactic revascularization with carotid-subclavian bypass (CSB) in the setting of endovascular thoracic stent grafting or open arch repair with frozen elephant trunk. METHODS: All patients who underwent SA plug embolization (SAPE) and CSB from September 2009 to December 2018 were enrolled in a registered study (SAPE study: clinicaltrials.govNCT03620006). The primary end point was technical success, defined as complete occlusion of the origin of the SA, and how it was influenced by SA anatomy. The secondary end points were access vessel complications, cerebrovascular events, and CSB patency. RESULTS: The 101 SAPE procedures were performed using a type I (35 patients) or a type II (66 patients) Amplatzer vascular plug. A percutaneous ipsilateral upper extremity access was used in 66% of patients and a radial artery access was used in 50% of procedures. The 30-day primary technical success rate was 95% (five patients received an additional plug during the index); five type IC endoleaks were observed and successfully treated either with surgical ligation (in open arch repair procedures) or secondary embolization procedure (thoracic endovascular aneurysm repair group). Three access vessel complications (3%) were recorded with percutaneous brachial approach. At a median follow-up time of 11 months (range, 2-19 months), no new-onset type IC endoleak was observed, and the CSB patency rate was 97%. CONCLUSIONS: SAPE after CSB is feasible and safe, and has low incidence of type IC endoleaks. Further device developments are needed to better adapt to the subclavian anatomy.

Staged Fenestrated/Branched Repair of Postdissecting Thoracoabdominal Aneurysm With Candy-Plug False Lumen Occlusion for Spinal Cord Preconditioning.

Purpose: To describe a possible application of thoracic false lumen occlusion techniques with a Candy-Plug occluder to induce false lumen thrombosis for preconditioning the spinal cord during staged fenestrated repair of postdissecting thoracoabdominal aneurysms. Technique: A Candy-Plug occluder is deployed within the thoracic false lumen after proximal entry tear coverage with a standard thoracic stent-graft during staged repair of postdissecting thoracoabdominal aneurysms. The blockade of thoracic false lumen retrograde reperfusion from distal entry tears induces a controlled thrombosis of both the thoracic false lumen and intercostal arteries. Then, when the fenestrated device is delivered 4 to 6 weeks later, the procedure is completed with standard techniques according to the staging protocols of individual centers. Conclusion: A new possible application of a Candy-Plug false lumen occlusion technique might be an intermediate procedure aimed at preconditioning the spinal cord by occluding the thoracic false lumen during complex staged fenestrated thoracoabdominal repairs.

Vascular Injury Due to Humerus Fracture in Pediatric Age: When the Treatment Is Mandatory.

BACKGROUND: Pink pulseless hand syndrome is a rare condition of vascular injury due to distal humerus fracture. It is characterized by radial and ulnar pulselessness in a complex of good hand perfusion which can remain pink and warm. The management and treatment of this condition is still very debated. METHODS: We report 4 cases of arm traumas which occurred in pediatric patients. In all cases, after the fixation of the fracture by the orthopedic surgeon, the clinical evaluation and duplex ultrasound demonstrated the so called "pink pulseless hand syndrome." RESULTS: We decided to proceed with an immediate surgical exploration and decompression followed by a prompt recovery of the pulsatility. Postoperative course was uneventful. At 3-year follow-up, the young patients have a normal hand function with no neurovascular damages and regular peripheral signals. CONCLUSIONS: Physical and ultrasound examination in cases of pediatric humerus fractures is important to show vascular complications before the orthopedic treatment which is usually privileged. In case of vascular damages, urgent surgical exploration can be the unique choice for a correct treatment.

Open and endovascular elective treatment of abdominal aortic aneurysms: a real-world experience.

PURPOSE: To present a real-world experience of the elective treatment of abdominal aortic aneurysms (AAAs) using both open repair (OR) and endovascular repair (EVAR). METHODS: Data from patients treated consecutively between January 1, 2000 and December 31, 2014 were collected retrospectively and reviewed. The primary outcomes were 30-day mortality and complication rates, freedom from reintervention, and survival in the long-term. RESULTS: We analyzed data on 1112 patients (660 EVAR, 452 OR). The 30-day mortality and complications rates were higher after OR than after EVAR (2.9 vs. 1.1%, P = .03 and 24.7 vs. 1.1%, P < .0001, respectively). At 10 years, survival was 66.1 ± 3.2% after OR and 78.1 ± 2.2% after EVAR (P = .0006) and freedom from reintervention was 93.5 ± 1.8% after OR and 88.4 ± 1.8% after EVAR (P = .005). The preoperative aneurysm diameter was significantly associated with the development of type Ia endoleaks after EVAR (P < .0001) and of a proximal pseudoaneurysm after OR (P < .0001). CONCLUSION: In the long-term, EVAR was associated with higher reintervention rates, but better survival than OR. The preoperative AAA diameter was the most important predictor of the development of endoleaks after EVAR and proximal pseudoaneurysm after OR.

Use of Edibles as Effective Tools in Myofunctional Therapy: A Pilot Study.

AIM: The aim of this retrospective study is to explore the introduction of edible spread cream and small candies as tools to improve motivation and compliance in young children undergoing myofunctional therapy, with the purpose of optimizing oral functions, including swallowing. METHODS: Six patients, one female and five males, between the ages of 7 and 14 years, presenting with atypical swallowing, were evaluated and treated at the clinic of the University of L'Aquila. The patients included in the study were randomly divided into two groups and were treated with two different treatment protocols: Group A: traditional myofunctional therapy and traditional tools; Group B: same exercises as group A, but with edible tools (spreadable cream and small candies). RESULTS: As expected, the two patients who used edible tools demonstrated increased motivation and collaboration during myofunctional therapy. CONCLUSIONS: Patient compliance, especially in very young patients, limits the effectiveness of myofunctional therapy; therefore, creative solutions are needed to achieve greater cooperation, and edible tools can play a significant part in retraining correct swallowing. Although the sample of this pilot study is small, the results suggest that using actual edible tools in myofunctional therapy could increase compliance and provide better results in myofunctional therapy.

Comparison of the Accuracy of Two Transfer Caps in Positional Transmission of Palatal Temporary Anchorage Devices: An In Vitro Study.

The aim of this study was to compare the positional information transfer accuracy of palatal temporary anchorage devices (TADs) of two different brands of transfer caps: PSM and Leone. Thirty plaster casts of maxillary dental arches were chosen for master models. A couple of Leone TADs were inserted in each master model. For each master model, two analysis models were created: using two transfer caps, Leone and PSM, the impressions were taken, the analogues were connected on the transfer caps, and the casts were poured. Using digital methods and equipment, such as a 3D scanner, a 3D analysis and a comparison of the accuracy of the two transfer caps in transferring the positional information of the TADs was then made. The data obtained were analyzed using the Mann-Whitney U-test at a significance level of α = 0.05. PSM transfer caps showed higher error frequency in almost all measurements. Only two measurements had a larger error in the analysis models made with Leone transfer caps. The Mann-Whitney U-test found a significant difference between the error levels of TADs found in the analysis models created with PSM transfer caps. Leone transfer caps showed greater reliability in TADs positional information transmission.

Fixed and removable orthodontic retainers, effects on periodontal health compared: A systematic review.

The aim of this systematic review is to analyze the properties of the different types of orthodontic retainers, identify their differences and define which type of device is most effective and less harmful to periodontal health. Methods: A literature search was carried out by a reviewer by consulting PubMed, Lilacs, Embase, Medline full text, Scopus, Web of Science, Cochrane library, and Science Direct electronic databases for biomedical and health literature as well as the grey literature and setting up the search from December 2010 without any restriction about articles languages. Results: The results showed that patients who wear retainers for a long period have significant differences in clinical parameters compared to patients without retainers. The type of retainer chosen also significantly influences the overall periodontal health of patients. Fixed retainers, both glass-fibre reinforced and steel wire retainers, proved to be the retainer type with the highest plaque and calculus accumulation values compared to removable retainers. In addition, among fixed retainers, glass-fibre reinforced retainers proved to be those that mostly promote the plaque and calculus accumulation in the application site. Conclusion: Fixed retainers are the best devices to maintain the alignment of mandibular anterior teeth in the long term. Among these devices, stainless steel lingual retainers, plain or braided, should remain the first choice. Although they are also susceptible to periodontal complications, their effect on periodontal health can be considered statistically insignificant if compared to glass-fibre reinforced retainers which, showing worse periodontal complications, should not be used.

Late surgical conversion of failed Multilayer Flow Modulator stenting in thoraco-abdominal aneurysms.

OBJECTIVES: The aim of this study was to report the outcomes of open or hybrid repair of failed thoraco-abdominal aortic aneurysm endovascular treatment with Multilayer Flow Modulator (MFM) stents. METHODS: All patients who underwent open or hybrid repair of a failed MFM aortic treatment were retrospectively analysed. Perioperative and postoperative data, as well as midterm survival, were assessed. RESULTS: Between 2013 and 2020, 39 patients received an open or hybrid conversion after endovascular treatment. Five of them [13%; 4 males; median age 68 years (interquartile range 66-76)] were previously treated with aortic MFM stents (Cardiatis, Isnes, Belgium). Among these, the median interval between index repair and conversion was 84 months (interquartile range 75-84). The median aneurysm diameter was 9.6 cm (interquartile range 8-10). Renovisceral vessels steno-occlusion was highly prevalent: 2 renal arteries were occluded; 3 coeliac trunks, 2 renal arteries and 1 superior mesenteric artery had a >70% ostial stenosis. Open standard thoraco-abdominal aneurysm conversion was performed in 3 fit patients, while a hybrid approach with visceral debranching and tube endografting was performed in 2 high-risk patients. Two patients (2 open repairs) died intraoperatively, and 1 (hybrid repair) postoperatively. The 2 successfully treated patients are alive at 4- and 34-month follow-up, respectively, with patent visceral branches. CONCLUSIONS: Open or hybrid thoraco-abdominal aortic aneurysm treatment after failed endovascular aortic repair with MFM stents might be the only surgical option to address sac enlargements and ruptures or branch-related failures. However, both procedures had a poor prognosis due to both the impaired preoperative patient's status and the surgical complexity in the presented series.

Role of preoperative serum creatinine and estimated glomerular filtration rate values in asymptomatic patients undergoing carotid endarterectomy.

BACKGROUND: The aim of this study was to evaluate the effect of chronic kidney disease (CKD), assessed by preoperative estimated glomerular filtration rate (eGFR) and serum creatinine (Cr), on postoperative outcomes and long-term survival in asymptomatic patients undergoing carotid endarterectomy (CEA). METHODS: We examined data about patients that underwent CEA between January 2002 and September 2014 in our Institution. Retrospective analysis to assess preoperative comorbidities and postoperative complications was performed. Modification of Diet in Renal Disease (MDRD) formula was used to calculate eGFR. Patients were divided into four groups based on values of preoperative eGFR: group A (≥90 mL/min/1.73 m2), group B (89-60 mL/min/1.73 m2), group C (59-30 mL/min/1.73 m2) and group D (≤29 mL/min/1.73 m2), and into two groups based on preoperative Cr values: group 1 (<1.5 mg/dL) and group 2 (≥1.5 mg/dL). Primary outcomes were death or the development of one or more postoperative major complications within 30 days after surgery, for each group. Survival curves of Kaplan-Meier were plotted for each group of patients to assess long-term mortality. RESULTS: During the study period, 853 CEAs in 808 patients were performed, of which 682 CEA in 645 patients for asymptomatic carotid artery stenosis. Symptomatic patients (19.58%) and patients receiving hemodialysis (0.46%) were excluded. Among CEAs analyzed, 678 (99.4%) had preoperative Cr values recorded and 637 (93.4%) had preoperative eGFR values recorded. The number of patients in each group according to eGFR values was 84 (13.2%) for group A, 250 (39.3%) for group B, 271 (42.5%) for group C and 32 (5.0%) for group D; according to Cr values was 609 (89.8%) for group 1 and 69 (10.2%) for group 2. One death and 24 (3.52%) postoperative major complications, of which 20 postoperative neurological events (NE) and 4 postoperative myocardial infarctions (MI), occurred within 30 days after surgery. The median follow-up was 55 months (IQR 27-84). Regarding general population, multivariate analysis with age found no significant correlation between Cr and primary outcomes, to the contrary of eGFR (OR=1.02; CI: 1.01-1.02; P<0.0001). No significant differences were observed concerning primary outcomes according to eGFR and Cr groups. Five-year survival rates for groups A, B, C and D were 98±0.02%, 90±0.02%, 80±0.03% and 56±0.12% respectively (P<0.0001) and 88±0.02% and 62±0.08% for group 1 and 2 respectively (P<0.0001). CONCLUSIONS: eGFR and Cr classes are not a dependable method in evaluating postoperative complications risk after CEA in asymptomatic patients, although preoperative eGFR values influence 30-days morbility. Both eGFR and Cr groups are reliable predictors to discriminate among asymptomatic patients candidates for CEA, based on their life expectancy.