Stent-Assisted Coil Embolization of a Saccular Visceral Aortic Aneurysm: Case Report and Review of the Literature.

PURPOSE: We present the results of unconventional endovascular treatment of a voluminous (65 mm) saccular visceral aortic aneurysm in a 78-year-old woman. Patient was deemed unfit for open surgery due to comorbidities. Fenestrated or branched endografting was also excluded due to the small diameter of the aorta, the severe stenosis at the origin of celiac trunk, and the anomalous origin of superior mesenteric artery arising infrarenally. CASE REPORT: After a preliminary selective angiography of the superior mesenteric artery showing valid anastomotic network with celiac trunk branches, an aortic self-expandable bare stent (Jotec E-XL) was deployed in the visceral aorta. Aneurysm sac embolization (Penumbra detachable Ruby Coils) in a coil-jailing technique was performed. Finally, an aortic cuff endograft (Gore) was deployed immediately above the origin of the left renal artery to cover the wide neck of the saccular aneurysm and improve sac exclusion. Hospital stay was uneventful, computed tomography (CT) at 12-month demonstrated aneurysm shrinkage to 62 mm without images of endoleak. Literature review showed how this technique has successfully been applied to manage similar cases of postsurgical and posttraumatic saccular aortic aneurysms in high-risk patients; however, long-term results are still unknown. CONCLUSION: Coil-jail technique for the treatment of saccular aortic aneurysms can be considered an alternative when open surgery or conventional endovascular treatment is not feasible. Technical success and mid-term outcomes are promising but strict follow-up is recommended. CLINICAL IMPACT: This study aims to share the unconventional endovascular treatment of a visceral aortic aneurysm in a patient unfit both for open and traditional endovascular surgery. To the best of our knowledge this is one of the first cases published in Literature, for this reason, a step-by-step video has been created to describe the procedure. Literature review was then performed to analyze midterm results of this technique. Despite being a treatment that is not recommended for conventional cases, the knowledge of endovascular devices and techniques may help to manage or simplify complex aortic diseases.

Long-Term Outcomes of Open and Endovascular Abdominal Aortic Repair in Younger Patients.

BACKGROUND: Aim of this study is to evaluate long-term results in abdominal aortic aneurysm (AAA) surgery by either open aortic repair (OAR) or endovascular aortic repair (EVAR) in patients under 70 years of age. METHODS: A retrospective analysis of a prospectively collected database of patients with age under 70 years old undergoing elective infrarenal AAA surgery between 2010 and 2018 was performed. The study population was divided into 2 groups: OAR and EVAR. Primary end points were overall survival and aneurysm-related death, while secondary outcomes were need for reintervention and development of minor and major complications. RESULTS: One hundred ninety-one patients younger than 70 years old treated with elective AAA surgery were enrolled: 157 OAR (98% males, mean age 65 ± 4 years) and 34 EVAR (94% males, mean age 66 ± 4 years). Hospital stay, 30-day mortality, and need for reintervention were similar; OAR population presented higher incidence of postoperative major complications (18% vs. 2.9%; P = 0.01) while minor complications were 32% in the OAR versus 21% in the EVAR group (P = 0.08). Median follow-up was 69 months for OAR (interquartile range [IQR] 53 months) vs. 79 months (IQR 51 months) for EVAR (P = 0.9): long-term AAA-related reinterventions were more frequent after EVAR (1.9% OAR vs. 17% EVAR; P = 0.01) while AAA-related long-term mortality was similar in both subgroups (1.3% OAR and 3% EVAR; P = 0.8). At univariate analysis higher risk of reintervention was reported for conical necks in the EVAR group (P = 0.03) and for the concomitant presence of iliac aneurysms in both groups (P = 0.01). CONCLUSIONS: According to our data, EVAR in young patients is presenting an excessive rate of reintervention compared to OAR. The presence of conical neck is an independent predictor of EVAR failure and late reintervention, while it does not play a significant role in the OAR group. Open surgery should be considered the first option in younger patients with a long-life expectancy.

Proportional meta-analysis of open surgery or fenestrated endograft repair for postdissection thoracoabdominal aneurysms.

OBJECTIVE: To determine outcomes of postdissection thoracoabdominal aneurysms by either open or endovascular repair with fenestrated or branched endografts. METHODS: A systematic review was conducted for open or endovascular repair of postdissection thoracoabdominal aneurysms, between January 2009 and February 2020. A meta-analysis was performed for postoperative complications and both early and late mortality and reinterventions. RESULTS: Fifteen noncomparative studies (eight endovascular repair and seven open repair) were suitable for meta-analysis. Overall, 1337 patients were included, 1068 in the open repair group (73% male; mean age 58 years) and 269 in the endovascular repair group (79% male; mean age 65 years). The 30-day mortality was 6% for open repair vs 3% for endovascular repair (P = .35), whereas the 30-day reintervention rate was 3% for open repair vs 1% for endovascular repair (P = .66). The only significant difference was reported for 30-day respiratory complication rate (30% open repair vs 2% endovascular repair; P < .01). The incidence of spinal cord ischemia was 9% for open repair vs 8% for endovascular repair (P = .95). The mean follow-up was 44 months: 48 months (range, 10-72 months) after open repair and 17 months (range, 12-25 months) after endovascular repair (P < .01). Late aortic reinterventions were more frequent after endovascular repair (11% vs 32%; P < .001). The late overall mortality rate was 19% for open repair vs 7% for endovascular repair (P = .08), whereas aortic-related mortality was 7% for open repair vs 3% for endovascular repair (P = .22). CONCLUSIONS: In the absence of comparative studies, this meta-analysis showed that endovascular repair seems to be a viable alternative for patients unfit for open repair.

Late outcomes of different hypogastric stent grafts in aortoiliac endografting with iliac branch device: Results from the pELVIS Registry.

OBJECTIVE: The objective of this study was to evaluate long-term results of self-expanding vs balloon-expandable hypogastric stent grafts in conjunction with iliac branch devices (IBDs) for aortoiliac aneurysm repair in a multicenter experience (pErformance of iLiac branch deVIces for aneurysmS involving the iliac bifurcation [pELVIS] Registry). METHODS: All patients electively treated for aortoiliac aneurysm with the Cook IBD (Cook Medical, Bloomington, Ind) in nine European centers were reviewed. Clinical and imaging data were prospectively collected in each center, and a multicenter database was created and interrogated. The primary outcome was the primary patency of the IBDs. For the purpose of this investigation, three subgroups were identified: patients receiving a hypogastric balloon-expandable stent graft (BESg); those with a self-expanding stent graft (SESg); and those with any stent graft plus relining with a bare-metal stent (RESg). RESULTS: Between 2005 and 2017, there were 691 patients who underwent 747 elective endovascular repairs of aortoiliac aneurysms (n = 518 [75.0%]) or isolated iliac aneurysms (n = 173 [25.0%]) with Cook IBDs (n = 56 bilateral) in nine European centers. Mean age was 72 years (range, 41-93 years); 658 (95.2%) patients were male. In 364 patients (52.7%), BESg was used; in 127 (18.4%), SESg; and in 200 (28.9%), RESg. At 30 days, there were 3 (0.4%) perioperative deaths, 3 (0.4%) technical failures, 7 (1.0%) graft thromboses, 30 (4.3%) reinterventions, and 1 (0.1%) conversion to open repair. After a mean follow-up of 32 months (range, 0-128 months), 28 (3.7%) IBD occlusions and 17 (2.3%) IBD-related endoleaks occurred. In 10 patients, iliac diameter increased >5 mm (1.4%). Overall primary patency was 99.2% at 1 month, 97.9% at 12 months, and 95.1% at 72 months. Primary patency was not significantly different in the BESg vs SESg or RESg cohorts (P = .4). During follow-up, there were 126 (18.2%) reinterventions, 93 (13.5%) of which were IBD related, including 11 (1.6%) conversions. Overall, freedom from reintervention and conversion was 90.4% at 12 months and 71.0% at 72 months. IBD-related reinterventions during follow-up in the three cohorts were not significantly different (P = .3) Overall survival was 71.3% at 72 months without differences between the subgroups. At multivariate analysis, aneurysmal hypogastric artery (P < .001; Exp [B] = 4.44) and bilateral treatment (P = .02; Exp [B] = 1.87) were associated with an increase in late failure. CONCLUSIONS: In this wide real-world experience, long-term results of endovascular treatment of aortoiliac aneurysms with the IBD are favorable, with a low rate of late graft occlusion and aneurysm-related death. No significant differences in clinical outcomes were observed in patients receiving hypogastric BESg vs SESg or endovascular relining.

Long Term Outcomes of Endovascular Aortic Repair in Patients With Abdominal Aortic Aneurysm and Ectatic Common Iliac Arteries.

OBJECTIVE: The purpose of this study was to evaluate the long term results of endovascular aneurysm repair (EVAR) in patients with abdominal aortic aneurysm (AAA) and ectatic common iliac arteries (CIAs). METHODS: In a retrospective analysis of a prospectively collected database in two high volume centres, patients with AAAs undergoing elective standard EVAR were divided into two groups: those with both CIA diameters <18 mm, and those with at least one ectatic iliac artery (CIA ≥ 18 mm). Patients with an intentional external iliac artery landing zone were excluded. Primary outcomes were survival and freedom from re-intervention. Secondary end points were EVAR failure and iliac related endoleak and iliac re-intervention. RESULTS: From 2000 to 2015, 648 patients were included in the study, 277 (43%) had at least one CIA ≥ 18 mm. Pre-operative risk factors were similar between the two groups, with the exception of chronic renal insufficiency (p = .010) and cerebrovascular events (p = .040), which were higher in the ectatic CIA group. At 30 days from primary procedure, there was a higher rate of type Ib endoleak in patients with ectatic iliacs (p = .020). A statistically significant increase in the incidence of late type Ib endoleak in patients with ectatic iliac arteries was confirmed at a mean follow up of 74.8 months (p = .01). The need for iliac related re-intervention was higher in patients with CIAs ≥18 mm (odds ratio 1.94; 95% confidence interval 1.1-3.2). CONCLUSION: Ectatic iliac arteries are considered suitable landing zones for EVAR, although there is an increased risk of secondary interventions in time mainly due to late CIA dilation and secondary type Ib endoleak. Patients receiving EVAR with flared iliac limbs may benefit a more intensive surveillance to avoid late failures.

Oxygen Delivery Therapy with EPIFLO Reduces Wound Hyperperfusion in Patients with Chronic Leg Ulcers: A Laser Speckle Contrast Analysis.

BACKGROUND: Today transdermal continuous oxygen therapy (TCOT) is used in wound care to promote healing by improving local hypoxia and preventing infection, and it has been described to reduce local inflammation over 1 month of administration. The present study aims to investigate the effects of this treatment on wound microcirculation through laser speckle contrast analysis (LASCA). METHODS: 20 adult patients (mean age: 76 ± 11.5 years) were prospectively enrolled. Inclusion criteria were presence of venous or mixed lower limb ulcers from three or more months without dimension reduction and without indication to surgery and weekly treatment by our outpatient clinic with silver dressings. Subjects underwent 1 month of TCOT (EPIFLO®) in addition to foam dressing. The primary endpoint was the comparison of ulcer and healthy skin perfusion through LASCA, performed before and after the treatment period. Secondary considered endpoints were wound area, wound area severity index and PUSH Tools 3.0 ulcer severity scales, and pain assessment (Numerical Rating Scale [NRS]). RESULTS: Before treatment, the wound area was significantly more perfused than healthy skin (+45%; P = 0.005). At the end of the study, this difference was not significant anymore (+20.5%; P = 0.11). Ulcer perfusion decreased (-12.5%, P = 0.047), whereas healthy skin perfusion did not vary significantly. A reduction of the wound dimension (median difference: 2 cm; P = 0.009) and pain (median difference: 2 NRS point; P < 0.001) after therapy were assessed. CONCLUSIONS: LASCA shows that 1 month of TCOT can help reduce hyperperfusion of ulcer bed in patients with chronic lower limb ulcers, strengthening the hypothesis that this treatment effectively contrasts inflammation. This could correlate with the area and pain reduction assessed; however, the absence of a control group in this study does not allow a generalization of this hypothesis. Larger, controlled trials are needed to properly assess the relationship between TCOT effects on wound microenvironment and effective healing process.

A Rare Nitinol Double-Layer Micromesh Carotid Stent Complication: Late Thrombosis-First Case Reported in Literature.

Endovascular treatment of carotid artery stenosis is a valuable alternative to open surgery, and the evolution of stent materials and cerebral protection devices significantly decreased postoperative neurological complications. Among these, the introduction of nitinol double-layer micromesh stent seems to guarantee a reduced perioperative and postoperative cerebral embolization. Long-term results are however still not available to make a global evaluation of these stents. We present the case of a 66-year-old female patient treated for asymptomatic carotid stenosis complicated by a symptomatic partial stent thrombosis occurred three months after carotid artery stenting.

Impact of the Supra-Aortic Trunks and Circle of Willis Patency on the Neurological Compensation during Carotid Endarterectomy.

BACKGROUND: One of the most critical phases of carotid endarterectomy (CEA) is the carotid cross-clamping test, which is a concrete evaluation of efficacy of collateral cerebral perfusion. Some studies revealed a strong correlation between tolerance to carotid cross-clamping and postoperative transient ischemic attack (TIA)/stroke complications. The aim of the study is to make a global analysis of supra-aortic trunks (SAT) and circle of Willis (CoW) patency to predict the tolerance to carotid cross-clamping preoperatively. METHODS: We observed retrospectively 503 patients who underwent CEA under local anesthesia between January 2012 and 2017. We analyzed single preoperative risk factors, drug therapy, and vessels patency of the group of patients who did or did not present neurological symptoms at carotid cross-clamping. Afterward, we created a cerebral perfusion score (PTOT) to estimate the efficacy of collateral cerebral perfusion and we compared the results from both groups. The score ranges from 0 (hypothetical total occlusion of the SAT and CoW) to 0.65 in case of patency of all arterial districts. Moreover, we evaluated postoperative complication rates. RESULTS: Patients with previous neurological symptoms, female gender, and diabetes correlate with a lower tolerance to carotid cross-clamping (odds ratio: 2.57, 2.78, and 2.57, respectively; P value < 0.05). The SAT and CoW score revealed that patients with score <0.2 more frequently did not tolerate carotid cross-clamping (P value 0.01). Patients who required an intraoperative shunt presented a higher risk of TIA/stroke within 30 days from surgery than those with a better neurological compensation (P value 0.03). CONCLUSIONS: The efficacy of cerebral mechanisms of compensation during carotid cross-clamping reflects the capability of the brain to adapt to ischemic insults, and this also correlates with the postoperative risk of TIA/stroke. It is possible to identify preoperatively patients with a higher risk of neurological intolerance at carotid cross-clamping. This score could be a useful method to make a further stratification of risk of neurological complications and eventually to prefer a general anesthesia and the use of shunt for those with PTOT < 0.2.

Early Carotid Endarterectomy Provides a Better Neurological Outcome in Symptomatic Patients: A Single-Center Experience.

BACKGROUND: Many studies confirmed the role of early carotid endarterectomy (CEA) to prevent recurrent stroke or transient ischemic attack; however, the mid-long-term neurological benefit is still not completely investigated. The purpose of the study was to evaluate the role of early CEA on the perioperative and postoperative stroke/death complications of patients with a symptomatic carotid stenosis. METHODS: Ninety consecutive patients were referred to our center for a symptomatic carotid stenosis. They were divided into 2 groups according to the time to surgery: G1 within 2 weeks (39 patients) and G2 from 2 weeks to thereafter (51 patients). Neurological assessment was performed with the National Institutes of Health Stroke Scale (NIHSS) at presentation and at follow-up. Echo color Doppler ultrasound was performed at 1-6 months and then yearly. RESULTS: The presentation of neurological symptoms differed significantly between the 2 groups; in fact, minor stroke was more frequent in G1, whereas transient ischemic attack was more frequent in G2 (P value = 0.027). No significant differences emerged between the 2 groups on the surgical intervention or perioperative complications. The study showed a significant improvement of the neurological impairment (evaluated with a reduction of NIHSS score) of patients in G1 compared with G2 (P value = 0.01). CONCLUSIONS: Neurological recovery after a symptomatic carotid stenosis is strictly correlated to the variable "time to surgery." A higher sensitization of the general population on the early recognition of the symptoms and a strict collaboration with neurologists is mandatory to reduce time to CEA and improve clinical outcomes.

Acute kidney injury after open and endovascular elective repair for infrarenal abdominal aortic aneurysms.

OBJECTIVE: The aim of this study was to evaluate the incidence of acute kidney injury (AKI) after open and endovascular abdominal aortic aneurysm repair according to the Aneurysm Renal Injury Score classification. METHODS: We retrospectively evaluated 431 patients undergoing elective open aortic repair (OAR; n = 285) or endovascular repair (n = 146) for infrarenal aortic aneurysm. All data regarding preoperative and postoperative serum creatinine concentrations and postoperative outcomes were assessed. Univariate and multivariate logistic regression models investigated the association between AKI and different risk factors and complications. RESULTS: The incidence of AKI was significantly higher after OAR (26.3% vs 5.5%; P < .001). A significant share of patients who experienced AKI were restored to preoperative renal function at discharge (62.5% vs 77.5% in the endovascular and OAR groups, respectively; P = .37). Preoperative serum creatinine concentration was significantly higher in those patients who further developed AKI (1.25 vs 1.04 mg/dL; P < .001). At the multivariate analysis, AKI was significantly associated with current smoking (odds ratio [OR], 2.05; 95% confidence interval [CI], 1.19-3.52; P = .01), hypertension (OR, 2.46; 95% CI, 1.21-4.3; P = .01), chronic renal disease (OR, 2.53; 95% CI, 1.42-4.53; P < .001), OAR (OR, 7.3; 95% CI, 3.25-16.42; P < .001), and arrhythmias (OR, 3.16; 95% CI, 1.09-9.13; P = .03). AKI stage did not affect postoperative outcomes, except for a longer hospital stay in patients in stage 2 and stage 3 compared with stage 1. CONCLUSIONS: AKI is a common but often reversible complication, especially after OAR. There is an urgent need of a common classification for AKI after aortic surgery. New diagnostic markers for AKI should be evaluated in large-scale studies to assess their reliability.

Preoperative and Postoperative Evaluation of New Double Mesh Carotid Stents with Contrast-Enhanced Ultrasound and Diffusion-Weighted Imaging.

In this case series, we selected 4 patients with asymptomatic severe carotid stenosis due to unstable plaques, which were identified with contrast-enhanced ultrasound. These patients underwent carotid stenting with a new generation double mesh stent. Diffusion-weighted magnetic resonance imaging (DW-MRI) was executed before and after the procedure to detect early cerebral microembolizations. No early neurological complications occurred nor cerebral microembolizations were detected at DW-MRI. New double mesh carotid stents appear to be a safe option also in asymptomatic patients with unstable plaques at high risk for surgery.

Serum Procalcitonin as a Valuable Diagnostic Tool in the Early Detection of Infectious Complications after Open Abdominal Aortic Repair.

BACKGROUND: Aortic aneurysm repair is a resolutive and effective surgical operation, which can be associated with severe postoperative complications. Procalcitonin (PCT) in clinical practice could play a role in early diagnosis and monitoring of therapy for complications, especially infections, making for timely and more effective interventions. Our aim was to investigate whether PCT could be a predictive marker in early diagnosis of infectious complications after open abdominal aortic surgery. METHODS: Eighty-three consecutive patients who underwent elective open aortic repair at our institution were enrolled. Blood samples were taken before surgery, and each day over the 7-day postoperative period, and measurement of serum PCT, C-reactive protein (CRP), and leukocytes levels were carried out. Data regarding clinical progress, instrumental examinations, and blood chemistry were prospectively collected. RESULTS: Postoperative infectious complications occurred in 24 patients. Within 30 days, 1 death occurred. In the study sample, we found a significant difference in PCT curves of patients with and without infectious complications, especially on third postoperative day (POD; P = 0.004). On analysis of the area under the curve (AUC curve), PCT was shown to be a fair predictor in distinguishing cases with infectious complications (AUC, 0.765 on third POD; CI, 0.638-0.877). Conversely, other inflammatory markers commonly used (leucocytes and CRP) had similar trends in patients with and without postoperative infections. CONCLUSIONS: On the basis of the results collected in this pilot study, despite some limitations, PCT could be considered a better marker of infectious complications after open abdominal aortic repair, when compared with other routinely used parameters.

Mediastinoscopy-assisted Treatment of an Aberrant Right Subclavian Artery.

Aberrant right subclavian artery (ARSA) is a rare congenital anomaly characterized by the origin of the right subclavian artery from the aortic arch distally to the left subclavian artery. We describe the case of a young patient with symptomatic ARSA treated by mediastinoscopy-assisted ligation at its origin and subclavian-carotid transposition.

Contrast-Enhanced Sonographic Follow-up After Stenting of Visceral Artery Aneurysms.

We report 2 cases of exclusion of visceral artery aneurysms. The first was a common hepatic artery aneurysm treated with a multilayer stent; the second was a celiac trunk aneurysm excluded by a covered stent. Computed tomographic angiography was performed at regular intervals after each procedure, together with echo color Doppler imaging and contrast-enhanced sonography. Computed tomographic angiography and contrast-enhanced sonography were able to detect endoleaks in both patients and the related inflow vessel; moreover, diameter measurements of the sacs were identical. In our preliminary experience, contrast-enhanced sonography appeared to be as accurate as computed tomographic angiography after endovascular visceral artery aneurysm exclusion.

Successful management with 2 overlapping bare stents for post-carotid endarterectomy carotid pseudoaneurysm secondary to carotid shunt.

Pseudoaneurysms are a rare complication of carotid endarterectomy. We successfully excluded with 2 overlapping bare stents a distal carotid artery pseudoaneurysm very likely induced by a Pruitt-Inahara shunt 2 months after carotid endarterectomy.

Open Surgical Treatment of a Severe Case of Obstructive Calcifying Aortic Disease.

The obstructive calcifying aortic disease refers to severe calcifications of the descending aorta that obstruct or slow blood flow. Here, we report the case of a 65-year-old woman with recent onset of a very tight intermittent claudication and concomitant severe and uncontrolled hypertension, treated with a bypass graft between the proximal descending thoracic aorta and the supravisceral abdominal aorta.

Contrast-enhanced ultrasound to predict the risk of microembolization during carotid artery stenting.

OBJECTIVES: Cerebral microembolization, one of the most frequent complications of carotid artery stenting, is associated with an increased risk of peri- and post-procedural stroke and transient ischemic attack and a mid-term risk of neurocognitive decline. A valuable tool to evaluate carotid plaque instability and risk of embolization is contrast-enhanced ultrasound. With this prospective study we sought to determine the correlation between contrast enhancement of the plaque and cerebral microembolization after carotid stent deployment and to evaluate the clinical impact of the neurological injury. MATERIALS AND METHODS: Thirty-five consecutive patients with carotid artery stenosis and indications for endovascular stenting were enrolled. Before the procedure, patients were evaluated with contrast-enhanced ultrasound to define plaque enhancement (signal intensity). All endovascular procedures were performed under cerebral filter protection. Diffusion-weighted magnetic resonance imaging scans to detect microemboli were obtained before and 48 h after the stent deployment. The Ray auditory verbal learning test to assess neurocognitive function was administered before and 1 month after the procedure. RESULTS: Nineteen patients (54 %) developed new cerebral ischemic lesions after carotid artery stenting. Contrast enhancement of the plaque was greater in the patients with post-procedural microembolization than in those without it [maximum signal intensity 26 ± 7.7 vs. 21 ± 5.2, respectively, (p = 0.039), mean signal intensity, 20.7 ± 6.1 vs. 16.5 ± 5.3, respectively (p = 0.048)]. No correlation was found between neurocognitive test scores and microembolization or plaque enhancement. CONCLUSION: Contrast enhancement of the carotid plaque is strongly associated with post-procedural microembolization and for this reason it can be considered a reliable tool for an accurate selection of patients undergoing this endovascular treatment. However, the neurocognitive test scores performed in this study are not enough sensible to appreciate the impact of the neurological injury on the day life activities.

Pulmonary embolism due to popliteal vein aneurysm during pregnancy induced by in vitro fertilization.

Popliteal vein aneurysms (PVAs) are rare but may cause severe and even fatal complications, such as pulmonary embolism (PE). A woman at the eighth week of pregnancy came to our attention because of a thrombosis of a previously undetected left PVA, diagnosed after a PE episode. Surgery was delayed until after delivery and breastfeeding, during which anticoagulant therapy was established.

Inferior vena cava prosthetic replacement in a patient with horseshoe kidney and metastatic testicular tumor: technical considerations and review of the literature.

BACKGROUND: Seminomatous and non-seminomatous Germ Cell Tumors (GCT) of the testis are a rare cancer, with an estimated incidence of 56.3 per million white males and 10 per million black males in the United States.The association between non-seminomatous GCT and horseshoe kidney is a rare event and is seen in about 1.3% of patients requiring retroperitoneal lymph node dissection. To our knowledge, no cases have been reported in which replacement of the IVC was also necessary. CASE PRESENTATION: We report the case of a 22-year-old man with horseshoe kidney and metastatic non-seminomatous germ cell tumor involving the wall of the inferior vena cava.Following post-chemotherapy retroperitonal lymph node dissection, the inferior vena cava was replaced with an expanded polytetrafluoroethylene graft.At 2-years follow-up, the patient was in good health and the graft was patent. No clinical or diagnostic signs of renal impairment or recurrence of neoplastic disease were noted. CONCLUSION: Radical surgery is warranted in patients with non-seminomatous germ cell tumor metastasizing to the retroperitoneal lymph nodes. When vena cava replacement is required, and the situation is further complicated by horseshoe kidney, as in this case, surgical technique will rely on multidisciplinary surgical treatment planning by a team composed of urologists, vascular surgeons and oncologists.

Multicentre experience of antegrade thoracic endovascular aortic repair for the treatment of thoracic aortic diseases.

OBJECTIVES: The goal of this multicentre retrospective cohort study was to evaluate technical success and early and late outcomes of thoracic endovascular repair (TEVAR) with grafts deployed upside down through antegrade access, to treat thoracic aortic diseases. METHODS: Antegrade TEVAR operations performed between January 2010 and December 2021 were collected and analysed. Both elective and urgent procedures were included. Exclusion criteria were endografts deployed in previous or concomitant surgical or endovascular repairs. RESULTS: Fourteen patients were enrolled; 13 were males (94%) with a mean age of 71 years (interquartile range 62; 78). Five patients underwent urgent procedures (2 ruptured aortas and 3 symptomatic patients). Indications for treatment were 8 (57%) aneurysms/pseudoaneurysms, 3 (21%) dissections and 3 (21%) penetrating aortic ulcers. Technical success was achieved in all procedures. Early mortality occurred in 4 (28%) cases, all urgent procedures. Median follow-up was 13 months (interquartile range 1; 44). Late deaths occurred in 2 (20%) patients, both operated on in elective settings. The first died at 19 months of aortic-related reintervention; the second died at 34 months of a non-aortic-related cause. Two patients (14%) underwent aortic-related reinterventions for late type I endoleak. The survival rate of those having the elective procedures was 100%, 84% and 67% at 12, 24 and 36 months, respectively. Freedom from reintervention was 92%, 56% and 56% at 12, 24 and 36 months, respectively. CONCLUSIONS: Antegrade TEVAR can seldom be considered an alternative when traditional retrograde approach is not feasible. Despite good technical success and few access-site complications, this study demonstrates high rates of late type I endoleak and aortic-related reinterventions.