Endovascular treatment of a giant renal artery aneurysm associated with an arteriovenous fistula: Report of a case and review of the literature.

Renal artery aneurysm (RAA) concomitant with a renal arteriovenous fistula (RAVF) has been infrequently reported in the literature. We report a case of a 42-year-old man suffering from a giant RAA combined with a congenital high-flow RAVF. The contrast-enhanced CTA showed a 12.7-cm RAA synchronous with an RAVF between the right renal artery and a draining vein. After a comprehensive preoperative assessment, an endovascular approach was decided. Successful embolization was performed using an Amplatzer vascular Plug, and multiple coils. Completion angiogram demonstrated no flow into the RAA. The results of longterm follow-up demonstrate that endovascular techniques are safe and effective for the management of RAAs combined with high-flow RAVF.

Bilateral Endograft Limb Occlusion after Endovascular Aortic Repair: Predictive Factors of Occurrence.

BACKGROUND: Bilateral limb occlusion after endovascular aortic repair (EVAR) is relatively uncommon. The aim of this study was to investigate the incidence of bilateral endograft limb occlusion after EVAR and identify potential anatomical predictive factors of occurrence. METHODS: A total of 579 patients underwent elective EVAR for abdominal aortic aneurysm between January 2010 and December 2015. All patients presenting with unilateral and bilateral occlusions were prospectively analyzed. A group of patients who underwent EVAR but did not present with endograft limb occlusion were matched for sex, age, and commercial type of endograft and were used as controls. RESULTS: Overall, 21 (3.6%) patients were complicated with unilateral endograft limb occlusion, whereas 8 (1.4%) of them presented with sequential (in different time) bilateral limb occlusion. We found that iliac artery angulation ≥60°, iliac perimeter calcification ≥50%, and endograft oversizing in the common iliac artery of more than 15% had the same impact and could equally result in limb occlusion. We coded the variables angle, calcification, and endograft limb oversizing of the common iliac artery with a score from 0 to 2 as follows: (1) 0: angle <60° in both limbs, 1: angle ≥60° in one limb, 2: angle ≥60° in both limbs; (2) 0: calcification <50%: in both limbs, 1: calcification ≥ 50%: in one limb, 2: calcification ≥ 50%: in both limbs; and (3) 0: endograft limb oversizing <15%, 1: endograft limb oversizing ≥15% in one limb, 2: endograft limb oversizing ≥15% in both limbs. A composite variable, consisting of the sum of scoring in variables was analyzed, with a score from 0 to 6. Our study showed that it was the most probable to be in the control group when score in the composite variable was 0-3, it was the most probable to have unilateral limb occlusion when score was 4-5, and finally, it was the most probable to have bilateral limb occlusion when score in the composite variable was equal to 6. CONCLUSIONS: Our study evidenced that the highest probability for bilateral limb occlusion occurred when implantation of a more than 15% oversized endograft in iliac arteries with iliac artery angulation ≥60° and iliac perimeter calcification ≥50% was present in both iliac arteries. It is therefore clear that limb occlusion requires the synergistic effect and interaction of bilateral multiple thrombogenic components in the iliac artery before it is manifested.

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.

Acute Early Carotid Stent Thrombosis: A Case Series.

BACKGROUND: Acute early carotid stent thrombosis (AcuteCST) is a rare complication after carotid artery stenting (CAS). The purpose of this retrospective study was to investigate the incidence, causes, and optimal management of AcuteCST. METHODS: Medical records of all patients undergoing CAS between 2008 and 2016 were retrospectively reviewed. The time of thrombosis, grade of stenosis, lesion side, preprocedural and postprocedural anticoagulants, causes, symptoms, treatment, recanalization, and outcome were reviewed. RESULTS: Overall, 674 patients were treated with CAS. Four cases of AcuteCST were identified (0.59%). In the first patient, the stent thrombosis was attributed to dissection caused by filter deployment within a distal internal carotid artery with 360° coiling. Notably, in 3 of the 4 cases of thrombosis a second overlapping stent had been deployed. In total, 41 patients of the cohort under investigation underwent overlapping stent deployment. The use of a second overlapping stent as a bail-out procedure due to dissection or malposition or due to long lesions was correlated with increased rate of thrombosis (3/41 [7.3%] vs. 1/633 [0.002%]). In 2 patients, carotid stents were thrombosed within 2 hr of the procedure. Endovascular thrombus aspiration and subsequent eversion carotid endarterectomy with stent explantation in the first patient and intrathrombus urokinase administration with thromboaspiration and additional stent placement in the second patient were followed. In the other 2 patients having their carotid stents thrombosed 3 and 4 days after the procedure, treatment with low weight molecular heparin and antiplatelet regimens was followed. CONCLUSIONS: The use of overlapping stents in the carotid artery is a predisposing factor for AcuteCST. Prognostic factors of this potentially devastating complication are the initial clinical presentation expressing the grade of ischemic brain damage, the accurate and timely recognition of the thrombosis, and the prompt restoration of oxygenated blood flow into the viable tissue at risk of infarction.

Treatment of Type II Endoleak and Aneurysm Expansion after EVAR.

BACKGROUND: The management of type II endoleak causing sac enlargement continues to be a topic of debate. The purpose of this study was to examine and compare the outcomes between open surgical technique with sacotomy and suturing of the feeding vessels to interventional embolization in patients with aneurysm sac expansion after endovascular aneurysm repair (EVAR). METHODS: Inclusion criteria for intervention in patients with prior EVAR and type II endoleak were asymptomatic expanding aneurysm sac > 5 mm between 2 consecutive follow-up computed tomography angiography scans and symptomatic aneurysm sac expansion. Age, sex, comorbidities, clinical presentation, commercial type of endograft of prior EVAR, aneurysm sac increase, type of treatment, morbidity, mortality, and follow-up were also recorded. RESULTS: A total of 694 consecutive patients were operated with EVAR during the study period. Among them, 29 patients (4.2%) were presented with a type II endoleak that required reintervention. Ten patients (34.5%) were treated with embolization. We recorded a 50% technical success in the group of primary translumbar embolization and 67% in the group of intra-arterial embolization. Twenty-two patients were treated with laparotomy and open ligation of the culprit arteries causing the type II endoleak. Among them, 3 patients (13.6%) had been initially treated with unsuccessful embolization. Periprocedural intervention complications for the embolization group (10%, 1/10) included 1 psoas hematoma. On the contrary, complications after primary open ligation were 13.6% (3/22) and included 1 proximal dislocation treated with endograft explantation, 1 distal dislocation, and 1 limb ligation with femoral-femoral bypass which resulted in colonic ischemia and death (4.5%). CONCLUSIONS: Open surgical repair with sacotomy and suturing of the feeding vessels appeared to have better outcome regarding the exclusion of the aneurysm but was associated with a higher incidence of severe complications and one related death. If these results are confirmed in larger series, endovascular approach should be the preferred treatment option.

Endovascular management of infected iliofemoral pseudoaneurysms - a systematic review.

We conducted a systematic review regarding the efficacy and outcome of endovascular treatment of infected iliofemoral arterial pseudoaneurysms with covered stents. 35 cases were identified, including 5 own. 22 pseudoaneurysms were located in the femoral area and 13 in the iliac vessels. The most commonly reported complaints were pulsatile groin mass (40 %), sepsis (37.1 %), active bleeding (31.4 %), and groin infection with purulent discharge (17.1 %). S. aureus (65.7 %) and Streptococcus species (22.9 %) were the most common microbes isolated. Factors for the development of infected pseudoaneurysms were intravenous drug use (20 %), infection of anastomosis in bypass surgery (22.9 %), cancer (14.3 %), history of multiple hip operations (14.3 %), renal transplantation (2.9 %), and obesity (5.7 %). The most commonly used covered stents were Viabahn (22.9 %),Jostent (17.1 %), Fluency (14.3 %), and Wallgraft (14.3 %). In 15 cases, surgical debridement and/or drainage was also performed.The mean follow-up was 15.8 months. There were only 2 cases of stent graft thrombosis (5.7 %). 2 patients required an open vascular bypass procedure at a later stage. One death was attributed to procedure-related complications (2.9 %). The infection rate of the deployed stent graft in follow-up was 3.4 %. Endovascular exclusion of an infected pseudoaneurysm with primary stent grafting and drainage may be an option in high-risk patients.
.

Endovascular treatment of tandem lesions of the carotid arteries.

BACKGROUND: High-grade stenoses of both common (CCA) and the internal (ICA) carotid arteries are rare and represent a therapeutic dilemma for the treating physician. The aim of this article is to present our experience with fully endovascular repair of those lesions. METHODS: Between January 2011 and December 2012, 5 patients (all male, age 73.6 years) with concomitant CCA and ICA stenoses were treated endovascularly. All patients were asymptomatic. The lesions involved the left carotid in 3 and the right carotid in 2 cases. Common carotid artery stenosis was located at the ostium (1 patient), the middle (3 patients) and the distal segment (1 patient) of the CCA. In 3 cases, CCA stenting was initially performed followed by ICA treatment, whereas in the remaining 2, ICA stenting preceded CCA stenting. A filter embolic protection device was used in 2 cases. RESULTS: All procedures were successfully completed. Technical success rate was 100%. Mortality rate was 0%. One patient experienced transient neurologic complication. An 82-year-old who underwent left mid-CCA and ICA stenosis without embolic protection device suffered a transient ischemic attack with dysarthria lasting for a few minutes. A 73-year-old patient with left CCA and ICA stenosis and occlusion of the right ICA who underwent stenting under cerebral protection experienced symptoms consistent with cerebral hyperperfusion. Patients were followed up for a mean of 6 months. No neurologic complications or stent restenosis were detected. CONCLUSIONS: Angioplasty and stenting is a technically feasible method for the treatment of concomitant CCA and ICA stenosis with acceptable short- and mid-term results.

Endograft infection and treatment with preservation of the endograft: early results in 3 cases.

We present 3 cases of stent graft infection in patients who were treated with preservation of the endograft. In the first patient, the contamination of the endograft was the consequence of a bleeding aortoenteric fistula, whereas in the second patient, the endograft was implanted into a ruptured contaminated aortic aneurysm because of the patient's hemodynamic instability. In the third patient, the presence of a consistent type Ia endoleak after a chimney graft procedure followed by secondary interventions led to an infection of the stent graft. In each case, a laparotomy was performed with debridement, followed by appropriate antibiotic therapy. The first patient suffered a fatal pulmonary embolism. The other 2 patients are alive 4 and 24 months after the diagnosis of endograft infection. In unstable patients or those with severe comorbidities who cannot tolerate endograft excision and aortic reconstruction, surgical debridement followed by appropriate antibiotic therapy can be a temporary or bridging solution.

Results of carotid artery stenting with transcervical access.

OBJECTIVE: Carotid artery stenting (CAS) is usually performed with femoral access; however, this access may be impeded by anatomic limitations. Moreover, many embolic events happen during aortic arch catheterization. To overcome these problems, transcervical access to the carotid artery can be used as an alternative approach for CAS. METHODS: An electronic search of the literature using PubMed was performed. All studies reporting the results of CAS using the transcervical approach were retrieved and analyzed. RESULTS: The analysis included 12 studies reporting the results of 739 CAS procedures performed in 722 patients (mean age, 75.5 years). Of 533 lesions reported, 235 (44%) were symptomatic, with no data regarding symptomatic status available for 206 lesions. Two techniques were used: direct CAS with transcervical access (filter protected or unprotected) in 250 patients and CAS with transcervical access under reversed flow (with arteriovenous shunt in most cases) in 489 patients. Local anesthesia was used in 464 of 739 procedures (63%), and the remaining were performed under general anesthesia or cervical block. Technical success was 96.3% for 579 procedures with available data (558 successful procedures and 21 failures: inability to cross the lesion, 10; dissection, 5; failure of predilatation, 1; stent thrombosis, 1; patient agitation, 1; and no data, 3). The incidence of conversion to open repair was 3.0% (20 of 579 procedures: 18 carotid endarterectomies and two common carotid-internal carotid bypass grafts). Stroke occurred in eight patients (two fatal) and a fatal myocardial infarction in one patient. The incidence of stroke, myocardial infarction, and death was 1.1%, 0.14%, and 0.41%, respectively. The incidence of stroke was 1.2% (3 of 250) in direct CAS with transcervical access and 1.02% (5 of 489) in CAS under reversed flow (P > .05). Transient ischemic attack occurred in 20 patients (2.7%). Local complications were encountered in 17 of 579 CAS (2.9%), comprising 15 hematomas and two patients with transient laryngeal palsy. CONCLUSIONS: CAS with the transcervical approach is a safe procedure with low incidence of stroke and complications. It can be used as an alternative to femoral access in patients with unfavorable aortoiliac or aortic arch anatomy.

The chimney graft technique for preserving visceral vessels during endovascular treatment of aortic pathologies.

OBJECTIVE: Patients with juxtarenal, pararenal, or thoracoabdominal aneurysms require complex surgical open repair, which is associated with increased mortality and morbidity. The "chimney graft" or "snorkel" technique has evolved as a potential alternative to fenestrated and side-branched endografts. The purpose of this study is to review all published reports on chimney graft (CG) technique involving visceral vessels and investigate the safety and efficacy of the technique. METHODS: Studies were included in the present review if visceral revascularization during endovascular treatment of aortic pathologies was achieved via a CG implantation. Reports on the chimney technique for aortic arch branches revascularization were excluded. A multiple electronic health database search was performed on all articles published until April 2011. RESULTS: The electronic literature search yielded 15 reports that fulfilled the inclusion criteria. A total of 93 patients (81.3% male; mean age, 71.9 ± 0.9 years) were analyzed. In 77.4% of the patients, the CG procedure was applied for the treatment of abdominal aortic aneurysms. Out of the 93 patients, 24.7% were operated on in an urgent setting (symptomatic or ruptured aneurysm). A total of 134 CGs were implanted: 108 to the renal arteries, 20 to the superior mesenteric artery, five to the celiac trunk, and one to the inferior mesenteric artery. In 57 patients, a single CG was deployed; in 32 patients, two CGs; in three patients, three CGs; and in one patient, four CGs were deployed. Ninety-four percent of CGs were directed proximally, whereas 6.0% were directed caudally. Primary technical success was achieved in all patients. A total of 13 patients (14.0%) developed a type I endoleak. Three were detected and treated intraoperatively. Postoperatively, 10 type I endoleaks were revealed, four of which required secondary intervention. During a mean follow-up period of 9.0 ± 1.0 months, 131 of 134 (97.8%) CGs remained patent. Two CGs to the renal arteries and one to the superior mesenteric artery occluded. Postoperatively, 11.8% of patients suffered renal function impairment and 2.1% a myocardial infarction. Ischemic stroke presented in 3.2% of patients. The 30-day in-hospital mortality was 4.3%. CONCLUSIONS: The role of the chimney technique in the management of complex abdominal aortic aneurysms is still unclear. This technique has relatively good results, considering the anatomic limitations of the aortic neck. However, long-term endograft durability and proximal fixation remains a significant concern. Thus, there is a reasonable hesitation to embrace the method for widespread use in the absence of long-term data.

Systemic inflammatory response to renal artery percutaneous angioplasty with stent placement and the risk for restenosis: a pilot study.

PURPOSE: Time changes in plasma concentrations of six different cytokines were investigated to evaluate the inflammatory response to renal artery stent placement. MATERIALS AND METHODS: A total of 22 patients (17 men; mean age, 66 years +/- 13) with ostial renal artery stenosis and poorly controlled hypertension treated with stent placement were studied. Blood samples were collected at baseline and at 24 hours and 6 months after the intervention. Plasma concentrations of (i) tumor necrosis factor-alpha, (ii) interleukin-6 (IL-6), (iii) monocyte chemoattractant protein-1, (iv) intercellular adhesion molecule-1, (v) vascular cell adhesion molecule-1, and (vi) regulated upon activatin normal T-cell expressed presumed secreted were measured. Restenosis diagnosed with imaging follow-up at 6 months was recorded. Plasma concentrations of the aforementioned cytokines were compared between patients with and without restenosis. RESULTS: IL-6 concentration increased significantly 24 hours after stent placement (8.3 pg/mL +/- 1.24 vs. 2.76 pg/mL +/- 1.27 at baseline) and returned to baseline levels (2.6 pg/mL +/- 1.77) at 6-month follow-up (P < .0001). No significant changes occurred in the concentrations of any other cytokines at the three time points. Baseline and 6-month concentrations of IL-6 were significantly higher in patients with restenosis than in those without restenosis (8.13 pg/mL +/- 4 vs 0.75 pg/mL +/- 0.47 [P < .005] and 9.55 pg/mL +/- 6.5 vs 0.42 pg/mL +/- 0.35 [P < .02], respectively). CONCLUSIONS: Renal artery angioplasty with stent placement induces an inflammatory response, as evidenced by increased IL-6 production. Additionally, IL-6 seems to identify patients prone to develop restenosis; therefore, it might be used as an early predictor of restenosis after renal angioplasty with stent placement. However, larger studies are required to confirm IL-6 as a potential predictor of restenosis.

Successful pancreaticoduodenectomy with immediate vascular reconstruction in a patient with cancer of the pancreatic head and celiac artery stenosis. A case report.

CONTEXT: Celiac artery stenosis is observed in a significant percentage of individuals in the general population. Although usually clinically silent and insignificant, due to the presence of extensive collaterals between the celiac artery and the superior mesenteric artery, celiac artery stenosis may be associated with potentially catastrophic ischemic complications in patients undergoing pancreaticoduodenectomy, due to the abrupt interruption of the collateral pathways. Therefore, revascularization may be indicated in selected patients with celiac artery stenosis undergoing a PD. CASE REPORT: We present a patient with celiac artery stenosis diagnosed intraoperatively during a PD, who underwent vascular reconstruction at the time of the PD. In the immediate postoperative period, he developed hepatic ischemia due to stenosis at the anastomosis of the stent with the hepatic artery. He was subsequently treated successfully with the endovascular placement of a stent. In retrospect, a careful reevaluation of the preoperative abdominal CT scan showed the stenosis at the origin of celiac artery. CONCLUSION: A careful evaluation of abdominal CT scan is required to preoperatively identify this not uncommon vascular obstructive disease, especially in asymptomatic patients. Otherwise, the astute surgeon should suspect celiac artery stenosis based on intraoperative findings/changes immediately following ligation of the gastroduodenal artery during a PD.

Revisiting endovascular treatment in below-the-knee disease. Are drug-eluting stents the best option?

Patients with below-the-knee arterial disease are primarily individuals suffering from critical limb ischemia (CLI), while a large percentage of these patients are also suffering from diabetes or chronic renal failure or both. Available data from randomized controlled trials and their meta-analysis demonstrated that the use of infrapopliteal drug-eluting stents (DES), in short- to medium- length lesions, obtains significantly better results compared to plain balloon angioplasty and bare metal stenting with regards to vascular restenosis, target lesion revascularization, wound healing and amputations. Nonetheless, the use of this technology in every-day clinical practice remains limited mainly due to concerns regarding the deployment of a permanent metallic scaffold and the possibility of valid future therapeutic perspectives. However, in the majority of the cases, these concerns are not scientifically justified. Large-scale, multicenter randomized controlled trials, investigating a significantly larger number of patients than those already published, would provide more solid evidence and consolidate the use of infrapopliteal DES in CLI patients. Moreover, there is still little evidence on whether this technology can be as effective for longer below-the-knee lesions, where a considerable number of DES is required. The development and investigation of new, longer balloon-expanding or perhaps self-expanding DES could be the answer to this problem.

Laparoscopic cholecystectomy after open cholecystostomy for gallbladder empyema: a case report.

The case of a patient with gallbladder empyema initially drained through a minilaparotomy procedure under local anesthesia with a tube cholecystostomy is reported in this paper. Eight weeks later, the patient underwent an elective interval laparoscopic cholecystectomy. At laparoscopy, the gallbladder and the cholecystostomy tube were dissected free from the abdominal wall and the greater omentum, which was attached to the gallbladder. The tube was removed from the gallbladder fundus, and the operation was completed laparoscopically without any major problems.

Patient radiation exposure measurements during interventional procedures: a prospective study.

This is a prospective study with the purpose of assessing patient radiation dose and stochastic risk (risk for fatal cancer) in a patient population undergoing interventional radiological (IR) procedures. Measurements were performed on 36 consecutive patients undergoing percutaneous transluminal angioplasty (PTA, n=18), transjugular intrahepatic portosystemic shunt (TIPS, n=3), diagnostic angiography (DA, n=6), arterial embolization (AE, n=3), and hepatic neoplasm chemoembolization (HCE, n=6). Kerma area product (KAP) was used as a measure of x-ray exposure to the patient. Mean KAP value per procedure was 79+/-50 Gy cm for PTA, 139+/-55 Gy cm for TIPS, 110+/-44 Gy cm for DA, 325+/-145 Gy cm for AE, and 150+/-76 Gy cm for HCE. Forty-six percent of total KAP value was attributed to fluoroscopy. In conclusion, we showed that a linear correlation between effective dose and KAP was found (r=0.84), which could be used for estimating patient effective dose using KAP measurements. Small changes to the number of digital frames acquired result in substantial change of the total KAP in interventional radiological procedures. Stochastic risk from IR procedures is quite low for the patient. Measuring KAP is a simple and accurate method, which provides the interventional radiologist with a good estimation of the patient's relative risk for stochastic effects.

New Chimney after Chimney EVAR for the Treatment of Type Ia Endoleak.

The chimney graft (CG) technique can be a useful alternative in treating aortic aneurysms with challenging anatomy, regarding the proximal sealing zone. We describe the case of a patient who developed a type Ia endoleak after chimney endovascular aneurysm repair for a juxtarenal AAA and underwent a proximal CG reconfiguration and implantation of an aortic cuff. The crossing configuration of the CGs should be avoided as it may compromise the circumferential apposition of the endograft and impede the thrombosis of the perigraft gutters. A proximal reconfiguration of the CGs, in case of type Ia endoleak is a useful option. The long-term efficacy of this option should be evaluated by meticulous follow-up.

Acute Carotid Stent Thrombosis: A Comprehensive Review.

Acute carotid stent thrombosis (ACST) is a rare complication that can lead to dramatic and catastrophic consequences. A rapid diagnosis and prompt recanalization of the internal carotid artery are needed to minimize the ischemic insult and the reperfusion injury. We reviewed the current literature on this devastating complication of CAS with the intention of investigating the potential causative factors and to define the appropriate management. According to our study discontinuation of antiplatelet therapy, resistance to antiplatelet agents and inherent or acquired thrombotic disorders are the main causes of thrombosis. Technical intraprocedural parameters such as dissection, atheroma prolapse, kinking of the distal part of internal carotid artery and embolic protection device occlusion can also result in early carotid stent thrombosis. Rapid reperfusion ensures an improved neurological outcome and a better prognosis in the short and long term. Thrombolysis, mechanical thrombectomy or thromboaspiration in combination with drug or thrombolytic therapy, surgical therapy and re-angioplasty are treatment options that have been used with encouraging results. In conclusion, optimal perioperative antiplatelet treatment as well as technical considerations regarding the carotid artery stenting plays a determinant role.