Infrarenal EVAR for Penetrating Aortic Ulcer: A Comparative Study with Abdominal Aortic Aneurysm.

BACKGROUND: Endovascular aortic repair (EVAR), currently the preferred treatment for abdominal aortic aneurysm (AAA), has been described also for penetrating aortic ulcers (PAU) of the infrarenal aorta. However, data on its performance in this particular setting are still sparse in the literature. Aim of this study is to compare patient clinical characteristics, aorto-iliac features, and post-operative outcomes between infrarenal PAU and AAA treated by standard EVAR. METHODS: In this retrospective observational case-control multicenter study, the patients treated for infrarenal PAU (G1) with EVAR in 2 high-volume European centers from January 2014 to December 2019 were prospectively entered into a dedicated database and retrospectively analyzed. A 4-fold control group (G2) of infrarenal AAA patients, homogeneous for age and gender, was also considered. Preoperative clinical characteristics, aorto-iliac features (rupture, aortic maximum diameter, proximal neck diameter and length, aortic bifurcation diameter, distance between the lowest renal artery and the aortic bifurcation [RA-AoBi], severe aortic calcification), technical success, 30-day (morbidity, reintervention, complications, mortality) and follow-up outcomes (freedom from reintervention [FFR] and survival) were compared in the 2 groups (chi square/Fisher exact test, t-student test, Mann-Whitney test, logistic regression and Kaplan-Meier analysis). RESULTS: Seventy-three patients (age 78 ± 7 years; male 84.9%) were included in G1 and 299 (age 78.4 ± 6.6 years; male 89.3%) in G2. At the time of diagnosis, G1 patients were more often symptomatic compared with G2 (odds ratio OR 10.21, 95% confidence interval CI 4.17-24.99, P < 0.001). At preoperative computed tomography angiography, G1 patients had more ruptures (OR 8.11, 95% CI 3.50-18.78, P < 0.001), smaller maximum diameter (OR 1.05, 95% CI 1.03-1.08, P < 0.001), longer and narrower proximal neck (OR 0.97, 95% CI 0.95-0.99, P = 0.020 and OR 1.47, 95% CI 1.32-1.64, P < 0.001, respectively) narrower aortic bifurcation (OR 1.34, 95% CI 1.24-1.45, P < 0.001), lower RA-AoBi (OR 1.09, 95% CI 1.07-1.12, P < 0.001), and more severe aortic calcification (OR 57, 95% CI 16-198, P = 0.001). Technical success (G1 98.6% vs G2 95.7% P = 0.320), 30-day morbidity (G1 2.7% vs G2 8.7% P = 0.133), reintervention (G1 2.7% vs G2 2.3% P = 0.691), complications (G1 6.8% vs G2 8% P = 0.737) and mortality (G1 1.4% vs 2% P = 0.720) were comparable in the 2 groups. The mean follow-up was 17.7 ± 16.4 months in G1 and 18.8 ± 15.1 in G2 (P = 0.576). Late FFR and survival were comparable in the 2 groups (1-year FFR: G1 94.8% vs G2 97.5%, P = 0.995; 1-year survival: G1 91.7% vs G2 92.3%, P = 0.960). CONCLUSIONS: Infrarenal PAU are more often symptomatic with a higher rupture rate compared to infrarenal AAA. Despite some negative anatomical characteristics (narrower aortic bifurcation, lower RA-AoBi, extensive calcification), the results of EVAR are extremely satisfactory in this setting, suggesting that endovascular exclusion could be considered a valid treatment for infrarenal PAU.

Carotid endarterectomy in asymptomatic octogenarians: Outcomes at 30 days and 5 years.

BACKGROUND: The following study investigated the 30-day and 5-year relative survival rate and freedom from neurological events in asymptomatic carotid stenosis (ACS) octogenarians who had undergone elective carotid endarterectomy (CEA). METHODS: Between January 2008 and June 2014, a retrospective review was conducted on ACS patients who had undergone elective CEA. The patients' sample was divided into two groups: Group A (GA) included octogenarians and Group B (GB) included younger patients. The GA patients were subjected to a risk-scoring system and follow-up. The two groups were compared analysing the following primary endpoints: 30-day mortality, stroke, stroke/death and acute myocardial infarction (AMI); GA patients' survival rate and freedom from neurological events at 5 years. The 30-day secondary endpoints included carotid shunting, redo surgical, need for general anaesthesia with preserved consciousness (GAPC) conversion and length of hospital stay. RESULTS: We identified 620 patients with ACS, of them 144 (23.2%) belonged to the GA and 476 (76.8%) belonged to the GB. No statistical difference between the two groups was found regarding the primary and secondary endpoints. One hundred nineteen of 144 GA patients (82.6%) underwent the follow-up; the median follow-up was 78.3 months. The GA patients' 5-year survival rate was 62%, while freedom from cerebral events was 94.9%. Analysis regarding GA patients' 5-year survival rate revealed a significantly lower percentage among the patients with a severe risk score compared with those with a moderate risk score (respectively, 29.5% vs 67.7%; p = .005). The multivariate analysis showed that chronic obstructive pulmonary disease (COPD) and chronic kidney disease (CKD) were independently associated with lower survival. CONCLUSIONS: The 30-day outcomes of CEA in octogenarians are comparable to those in younger patients. Comprehensive life expectancy and preoperative score, rather than age alone, should be taken into account before performing CEA on octogenarian patients, considering the short- and long-term efficacy in stroke prevention.

Outcomes of Surgical and Endovascular Treatment for Arterial Lesions in Intravenous Drug Abusers.

BACKGROUND: The objective of this study is to report an 18-year single-center experience in the surgical and endovascular treatment of arterial complications due to self-injection in drug abuser patients. METHODS: This retrospective single-center study was conducted analyzing a prospectively collected database including all endovascular or surgical procedures performed from January 2007 to December 2019 for any arterial complication due to self-injection in drug abuser patient. Collected data were patient demographic and comorbidity, site and type of arterial lesion (pseudoaneurysm [PA], arteriovenous fistula [AVF]), signs of systemic or local infection, and procedural data (endovascular/surgical treatment). End points were rate of postoperative complications, reintervention rate, limb salvage, and patients' early and long-term survival. RESULTS: In 11 patients (median age 36 years, range 27-47; male 73%), 13 arterial lesions were treated: 10 (77%) PA, 2 (15%) PA associated with AVF, and 1 (8%) isolated AVF. Arterial lesion involved common femoral artery in 5 (38%), superficial femoral artery in 4 (31%), profunda femoral artery in 1 (8%), brachial artery in 2 (15%), and subclavian artery in 1 (8%). Signs of infections were present in 9 of the 13 cases (69%). The treatment was surgical in 11 (85%) cases: 7 interposition graft (6 great saphenous vein, 1 arterial cryopreserved homograft), 2 direct reconstruction, 1 patch plasty with pericardium bovine patch, and 1 arterial ligation. Endovascular treatment was performed in 2 cases: 1 noninfected PA of the superficial femoral artery, and 1 55-mm PA of the postvertebral segment of the right subclavian artery with clinical sign of hemodynamic instability. At 1 month, postoperative complication rate was 8% (one lower limb claudication after superficial femoral artery ligation). Reintervention rate was 8% (interposition graft rupture for repeated self-injections). Limb salvage and patient survival were both 100%. Median follow-up was 5 years (range 1 month to 11.3 years); surgical group: median 8.2 years (range 2 months to 11.3 years); endovascular group: median 3.5 months (range 1-6). During follow-up, neither complications nor reinterventions occurred, and limb salvage was 100% for both groups. At 2, 4, and 6 years, overall estimated patient survival was 91%, 81%, and 81%, respectively, with no procedure-related death. CONCLUSIONS: After surgical or endovascular management of arterial lesions due to self-injection in drug abuser patients, complications occur mainly in the postoperative period. During follow-up, the surgical procedures have low rate of complications, reinterventions, and procedure-related mortality, whereas for the endovascular treatment the mid-term outcomes remain unknown.

The Utility of Intraoperative Contrast-enhanced Ultrasound for Immediate Treatment of Type Ia Endoleak during EVAR: Initial Experience.

Objectives Type Ia endoleak (EL) after endovascular abdominal aortic repair (EVAR) may be misdiagnosed at completion angiography. Intraoperative contrast-enhanced ultrasound (CEUS) may play a role in early detection and immediate treatment of type Ia EL. Methods From January 2017 to April 2018, patients treated with EVAR underwent intraoperative CEUS. After endograft deployment and ballooning, digital subtraction angiography (DSA) and intraoperative CEUS were performed in a blinded fashion. All cases of type Ia EL at DSA or CEUS were considered. Results Type Ia EL detected at intraoperative CEUS and undetected at DSA was defined in 2 patients. The former was solved with intraoperative re-ballooning; in the latter case, a Palmaz stent deployment was required. The resolution of type Ia EL was detected at intraoperative CEUS control and post-operative computed tomography angiography (CTA). In another patient, the DSA detected a type Ia EL, but intraoperative CEUS reveal a type II EL from lumbar arteries. Post-operative CTA confirm the type II EL. Conclusions The reported cases prove the clinical utility of the intraoperative CEUS, permitting the early identification of 2 type Ia EL. In addition, the intraoperative CEUS is useful in case of dubious type Ia EL at DSA, avoiding unnecessary intraoperative adjunctive procedure or post-operative CTA.

One-year experience in carotid endarterectomy combining general anaesthesia with preserved consciousness and sequential carotid cross-clamping.

BACKGROUND AND AIM OF THE WORK: We report 1-year single-centre experience in carotid endarterectomy (CEA) combining general anaesthesia with preserved consciousness (GAPC) and standardized carotid sequential cross-clamping, for our protocol effectiveness evaluation in reduction of perioperative stroke, death or cardiologic complications. METHODS: We considered all patients who underwent CEA in 2016. All patients underwent superficial cervical plexus block and GAPC with Remifentanil. The surgical technique consisted of common carotid artery (CCA) cross-clamping, carotid bifurcation isolation, external (ECA) and internal carotid artery (ICA) cross-clamping. After CCA cross-clamping, we performed a neurological tolerance test (NTT); this allowed selective shunting only for positive NTT. Primary end-points were: transient ischemic attack (TIA)/stroke, myocardial infarction, death in perioperative period. Secondary end-points were: carotid shunting, peripheral cranial nerves injuries (PCNI), GAPC intolerance, other complications, reintervention in perioperative period, length of hospital stay. RESULTS: 104 consecutive patients underwent CEA with this protocol in the considered period. Twenty-seven (25.9%) patients were symptomatic. Mean clamping time was 48±13.5 minutes. Five cases (4.8%) requested internal carotid artery shunting. No TIA/stroke, myocardial infarction or death were recorded in the perioperative period. PCNI were observed in 19 cases (18.2%) in the immediate post-operative period; 16 of them (84.2%) showed complete or partial resolution at discharge. Only one patient (0.9%) showed GAPC intolerance. No other complication occurred. Three patients (2.9%) underwent reintervention for neck haematoma drainage. Mean hospital stay were 3±0.9 days. CONCLUSIONS: GAPC associated with sequential carotid cross-clamping appeared to be safe and effective in prevention of major neurological and cardiologic complications during CEA.