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2.
J Vasc Surg ; 2024 Jul 09.
Artigo em Inglês | MEDLINE | ID: mdl-38992807

RESUMO

OBJECTIVE: To report outcomes of urgent juxta/para-renal aneurysms (J/P-AAAs) managed by off-the-shelf multibranched thoracoabdominal endografts (Cook, T-branch). METHODS: In this observational, multicenter, retrospective study, patients with J/P-AAAs treated by urgent endovascular repair by T-branch in 23 European aortic centers, from 2013 to 2023, were analyzed. Contained J/P-AAAs rupture, presence of related symptoms, and aneurysm diameter >70mm were considered as indication for urgent repair. Technical success (TS), spinal cord ischemia (SCI) and 30-day/hospital mortality were assessed as early outcomes. Survival, freedom from (FF) reinterventions and target arteries instability (TAI) were evaluated during follow-up. RESULTS: Overall, 197 patients [J-AAAs:64(33%), P-AAAs:95(48%), previous failed-EVAR 38(19%)] were analyzed. The mean age and aneurysm diameter was 75+8 years and 76+4 mm, respectively. The ASA score was 3 and 4 in 118(60%) and 79(40%) patients. Rupture, symptoms and diameter >70mm were present in 51(26%), 110(56%) and 53(27%) patients, respectively. An adjunctive proximal thoracic endograft was used in 28(14%) cases. The mean aortic coverage between the upper portion of the endograft and the lowest renal artery was 154+49mm. Single-stage repair and cerebral-spinal-fluid drainage were reported in 144(73%) and 53(27%) cases, respectively. TS was achieved in 182(92%) cases (rupture:84% vs no rupture:95%; P:.02). Failures consist of target artery loss (11-6%: renal artery - 9; celiac trunk - 2), type I-III endoleak (2-1%) and 24-h mortality (2-1%). Rupture was a risk-factor for technical failure (P:.02;OR:3.8;95%CI:1.1-12.1). Overall, 15(8%) patients had persistent SCI (rupture:14% vs no rupture:5%) with 11(6%) cases of paraplegia (rupture:10% vs no rupture:5%; P:.001). Rupture (P:.04;OR:3.1;95%CI:1.1-8.9) and adjunctive proximal thoracic endograft (P:.01;OR:4.1;95%CI:1.3-12.9) were risk-factors for SCI. Twenty-two (11%) patients died within 30-day or during a prolonged hospitalization. Previous failed-EVAR (P:.04;OR:3.6;95%CI:1.1-12.3), paraplegia (P:<.001;OR:9.9;95%CI:1.6-62.2), postoperative mesenteric complications (P:.03;OR:10.4;95%CI:1.2-93.3) as well as cardiac (P:.03;OR:8.2;95%CI:2.0-33.0) and respiratory (P:<.001;OR:10.1;95%CI:2.9-35.2) morbidities were associated with 30-day/hospital mortality. The mean follow-up was 19+5months. Estimated 3-year survival and FF-reinterventions was 58% and 77%, respectively. TAI occurred in 27(14%) patients (occlusion:15, endoleak:14) with an estimated 3-year FF-TAI of 72%. CONCLUSIONS: Urgent repair of J/P-AAAs by T-branchis feasible and effective with satisfactory TS and 30-day/hospital mortality in high-risk patients. However, extensive aortic coverage is necessary, leading to a not negligible SCI rate, especially in case of aortic rupture or when adjunctive thoracic endografts are necessary. Previous failed-EVAR, postoperative mesenteric complications as well as cardiac and respiratory morbidities were associated with 30-day/hospital mortality and they should be subjected to more research for the purpose of improving outcomes.

3.
J Vasc Surg ; 2024 Jul 17.
Artigo em Inglês | MEDLINE | ID: mdl-39029810

RESUMO

INTRODUCTION: This study aimed to assess the impact of urgency on early and midterm outcomes of the Candy-Plug (CP) technique for distal false lumen (FL) occlusion in thoracic endovascular aortic repair (TEVAR) for aortic dissection (AD). METHODS: The CP registry was reviewed, and patients were categorized into elective and urgent/emergent groups for analysis. Endpoints included technical success, clinical success, early (30-day) computed tomography angiography (CTA) findings, early (30-day) mortality, adverse events, aortic remodeling in patients with available CTA follow-up and re-intervention. RESULTS: A total of 155 patients received a custom-made Candy-Plug with 32 patients (44% males, mean age 61±9 years) were treated urgently vs. 123 patients (63% males, mean age 62±11 years) electively. The primary CP rate was higher in the urgent group; (28/32, (88%) in the urgent group vs. 96/123 (78%) in the elective group, p=051). The mean contrast volume was higher in the urgent group; (157±56ml in the urgent group vs. 130±71ml in the elective group, p=.017). Technical success was achieved in all patients in both groups. Clinical success was achieved in 25/32 (78%) patients in the urgent group vs. 113/123 (92%) in the elective group, p=.159. The early mortality rate was 4/32, (13%) patients in the urgent group vs. 1/123 (1%) in the elective group, p=.120). There was no statistically significant difference regarding the early adverse events between the urgent and elective CP groups. Early aortic-related re-interventions were required in 6/32 (19%) patients in the urgent group vs. 6/123 (5%) in the elective group, p=.094. Thoracic aortic aneurysm sac regression was lower in the urgent group (5/28, (18%) in the urgent group vs. 63/114 (55%) in the elective group, p=001). Stable thoracic aortic aneurysm sac was higher in the urgent group (22/28, (79%) in the urgent group vs. 47/114 (41%) in the elective group, p=000). An increase in thoracic aortic aneurysm sac occurred in 1/28 (4%) patient in the urgent group vs. 4/114 (4%) patients in the elective group, p=.096. CONCLUSION: The urgent use of the CP technique for distal FL occlusion in AD was feasible and effective. The decrease in aortic FL sac diameter may be affected by the urgent use of CP due to limited sizing availability. However, it achieved high rate of aortic remodeling.

4.
EJVES Vasc Forum ; 61: 113-115, 2024.
Artigo em Inglês | MEDLINE | ID: mdl-38884075

RESUMO

Introduction: Acute limb ischaemia resulting from foreign body embolisation is an infrequent yet critical complication associated with vascular closure devices (VCDs). Despite the widespread use of VCDs, rare complications such as fragment emboli pose unique challenges, necessitating heightened clinical awareness. This case report presents a case of acute limb ischaemia caused by a VCD malfunction following an endovascular procedure. Report: A 70 year old male who was diagnosed with a severe claudication of the lower extremity (Rutherford III) due to right common iliac stenosis, underwent angioplasty using a FemoSeal (Terumo Ltd., Surrey, UK) to close the right femoral artery access. Two weeks later, the patient presented with acute lower limb ischaemia due to a right popliteal-tibial occlusion. Emergency surgical thrombo-embolectomy was successfully performed from a medial popliteal approach, and the thrombus, which contained a polymer disc from the VCD at its distal end, was completely removed. Discussion: Despite VCDs being proven safe and efficient, rare complications such as fragment emboli can occur, and physicians should be aware of the possible delayed onset of symptoms. Moreover, the radiolucent nature of the polymer disc in a FemoSeal complicates diagnostic imaging. While endovascular approaches exist, open surgery is a safe and effective strategy for retrieving fragments and treating the patient in acute limb ischaemia cases. Conclusion: Physicians should remain vigilant for embolic risks associated with vascular closure devices, even with suitable anatomy and following guidelines, especially considering the trend toward early ambulation and discharge.

7.
J Vasc Surg ; 79(5): 1024-1025, 2024 May.
Artigo em Inglês | MEDLINE | ID: mdl-38642968
8.
J Vasc Surg ; 2024 Mar 08.
Artigo em Inglês | MEDLINE | ID: mdl-38462062

RESUMO

OBJECTIVE: Management of follow-up protocols after endovascular aortic repair (EVAR) varies significantly between centers and is not standardized according to sac regression. By designing an international expert-based Delphi consensus, the study aimed to create recommendations on follow-up after EVAR according to sac evolution. METHODS: Eight facilitators created appropriate statements regarding the study topic that were voted, using a 4-point Likert scale, by a selected panel of international experts using a three-round modified Delphi consensus process. Based on the experts' responses, only those statements reaching a grade A (full agreement ≥75%) or B (overall agreement ≥80% and full disagreement <5%) were included in the final document. RESULTS: One-hundred and seventy-four participants were included in the final analysis, and each voted the initial 29 statements related to the definition of sac regression (Q1-Q9), EVAR follow-up (Q10-Q14), and the assessment and role of sac regression during follow-up (Q15-Q29). At the end of the process, 2 statements (6.9%) were rejected, 9 statements (31%) received a grade B consensus strength, and 18 (62.1%) reached a grade A consensus strength. Of 27 final statements, 15 (55.6%) were classified as grade I, whereas 12 (44.4%) were classified as grade II. Experts agreed that sac regression should be considered an important indicator of EVAR success and always be assessed during follow-up after EVAR. CONCLUSIONS: Based on the elevated strength and high consistency of this international expert-based Delphi consensus, most of the statements might guide the current clinical management of follow-up after EVAR according to the sac regression. Future studies are needed to clarify debated issues.

10.
Cardiovasc Diagn Ther ; 14(1): 59-71, 2024 Feb 15.
Artigo em Inglês | MEDLINE | ID: mdl-38434560

RESUMO

Background: Endomyocardial biopsies (EMB) are recommended for the detection of acute cardiac rejection (ACR) despite limited sensitivity. We report the long-term post-transplant results of Doppler echocardiography as a noninvasive alternative of routine EMB. Methods: Two cohorts of heart transplantation (HT) recipients were chronologically defined as follows: the Dual Monitoring Cohort (DMC) from January 1990 to December 1997 included patients who underwent routine EMB and Doppler echocardiography within 24 hours for ACR surveillance; and the "Echo-First Cohort" (EFC), including patients transplanted from January 1998 to December 2018 with Doppler echocardiography as first-line approach for ACR surveillance. Echocardiographic measurements of interest were collected: early diastolic (E) wave peak velocity; pressure half time (PHT) and isovolumetric relaxation time (IVRT). Post-transplant outcomes were reviewed and the Kaplan-Meier approach was used for survival estimates. Inter-operator variability for ultrasound measurements was investigated. Data were collected from medical records from January 2019 to December 2020. Results: A total of 228 patients were included, 99 patients in the DMC and 129 in the EFC. Overall, 5-, 10- and 15-year survival rates were 65.4%, 55.5% and 44.1% respectively, without any significant difference between the two cohorts (log rank test, P=0.71). Echocardiography variables and EMB findings were associated with a mean area under the receiver operating characteristic curve (AUC-ROC) of 0.73 [95% confidence interval (CI): 0.54-0.91], 0.74 (95% CI: 0.54-0.94) and 0.75 (95% CI: 0.57-0.94) respectively for E wave, PHT and IVRT. IVRT and PHT were significantly decreased, and E wave significantly increased, in case of histologically proven ACR. Inter-operator variability was not significant for E wave and IVRT measurements (P=0.13 and 0.30 respectively). Conclusions: Doppler echocardiography as a first-line method for surveillance of ACR did not impair long-term results after HT. These findings suggest that this non-invasive approach might be a reasonable alternative to systematic EMB, limiting risk and improving the quality of life.

11.
J Vasc Surg ; 79(6): 1390-1400.e8, 2024 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-38325564

RESUMO

OBJECTIVE: This study aims to evaluate a fully automatic deep learning-based method (augmented radiology for vascular aneurysm [ARVA]) for aortic segmentation and simultaneous diameter and volume measurements. METHODS: A clinical validation dataset was constructed from preoperative and postoperative aortic computed tomography angiography (CTA) scans for assessing these functions. The dataset totaled 350 computed tomography angiography scans from 216 patients treated at two different hospitals. ARVA's ability to segment the aorta into seven morphologically based aortic segments and measure maximum outer-to-outer wall transverse diameters and compute volumes for each was compared with the measurements of six experts (ground truth) and thirteen clinicians. RESULTS: Ground truth (experts') measurements of diameters and volumes were manually performed for all aortic segments. The median absolute diameter difference between ground truth and ARVA was 1.6 mm (95% confidence interval [CI], 1.5-1.7; and 1.6 mm [95% CI, 1.6-1.7]) between ground truth and clinicians. ARVA produced measurements within the clinical acceptable range with a proportion of 85.5% (95% CI, 83.5-86.3) compared with the clinicians' 86.0% (95% CI, 83.9-86.0). The median volume similarity error ranged from 0.93 to 0.95 in the main trunk and achieved 0.88 in the iliac arteries. CONCLUSIONS: This study demonstrates the reliability of a fully automated artificial intelligence-driven solution capable of quick aortic segmentation and analysis of both diameter and volume for each segment.


Assuntos
Aortografia , Angiografia por Tomografia Computadorizada , Aprendizado Profundo , Valor Preditivo dos Testes , Interpretação de Imagem Radiográfica Assistida por Computador , Humanos , Reprodutibilidade dos Testes , Feminino , Masculino , Idoso , Pessoa de Meia-Idade , Automação , Estudos Retrospectivos , Idoso de 80 Anos ou mais , Conjuntos de Dados como Assunto , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Aneurisma da Aorta Abdominal/cirurgia
12.
J Vasc Surg ; 79(6): 1306-1314.e2, 2024 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-38368998

RESUMO

OBJECTIVE: Radiation exposure during complex endovascular aortic repair may be associated with tangible adverse effects in patients and operators. This study aimed to identify the steps of highest radiation exposure during fenestrated endovascular aortic repair (FEVAR) and to investigate potential intraoperative factors affecting radiation exposure. METHODS: Prospective data of 31 consecutive patients managed exclusively with four-fenestration endografts between March 1, 2020, and July 1, 2022 were retrospectively analyzed. Leveraging the conformity of the applied technique, every FEVAR operation was considered a combination of six overall stages composed of 28 standardized steps. Intraoperative parameters, including air kerma, dose area product, fluoroscopy time, and number of digital subtraction angiographies (DSAs) and average angulations were collected and analyzed for each step. RESULTS: The mean procedure duration and fluoroscopy time was 140 minutes (standard deviation [SD], 32 minutes), and 40 minutes (SD, 9.1 minutes), respectively. The mean air kerma was 814 mGy (SD, 498 mGy), and the mean dose area product was 66.8 Gy cm2 (SD, 33 Gy cm2). The percentage of air kerma of the entire procedure was distributed throughout the following procedure stages: preparation (13.9%), main body (9.6%), target vessel cannulation (27.8%), stent deployment (29.1%), distal aortoiliac grafting (14.3%), and completion (5.3%). DSAs represented 23.0% of the total air kerma. Target vessel cannulation and stent deployment presented the highest mean lateral angulation (67 and 63 degrees, respectively). Using linear regression, each minute of continuous fluoroscopy added 18.9 mGy of air kerma (95% confidence interval, 17.6-20.2 mGy), and each DSA series added 21.1 mGy of air kerma (95% confidence interval, 17.9-24.3 mGy). Body mass index and lateral angulation were significantly associated with increased air kerma (P < .001). CONCLUSIONS: Cannulation of target vessels and bridging stent deployment are the steps requiring the highest radiation exposure during FEVAR cases. Optimized operator protection during these steps is mandatory.


Assuntos
Implante de Prótese Vascular , Procedimentos Endovasculares , Doses de Radiação , Exposição à Radiação , Humanos , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/instrumentação , Exposição à Radiação/prevenção & controle , Exposição à Radiação/efeitos adversos , Estudos Retrospectivos , Masculino , Feminino , Idoso , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/instrumentação , Fatores de Tempo , Radiografia Intervencionista/efeitos adversos , Fatores de Risco , Prótese Vascular , Idoso de 80 Anos ou mais , Stents , Resultado do Tratamento , Medição de Risco , Duração da Cirurgia , Aortografia , Pessoa de Meia-Idade , Angiografia Digital , Exposição Ocupacional/prevenção & controle , Exposição Ocupacional/efeitos adversos , Fluoroscopia , Correção Endovascular de Aneurisma
13.
Eur J Vasc Endovasc Surg ; 67(2): 192-331, 2024 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-38307694

RESUMO

OBJECTIVE: The European Society for Vascular Surgery (ESVS) has developed clinical practice guidelines for the care of patients with aneurysms of the abdominal aorta and iliac arteries in succession to the 2011 and 2019 versions, with the aim of assisting physicians and patients in selecting the best management strategy. METHODS: The guideline is based on scientific evidence completed with expert opinion on the matter. By summarising and evaluating the best available evidence, recommendations for the evaluation and treatment of patients have been formulated. The recommendations are graded according to a modified European Society of Cardiology grading system, where the strength (class) of each recommendation is graded from I to III and the letters A to C mark the level of evidence. RESULTS: A total of 160 recommendations have been issued on the following topics: Service standards, including surgical volume and training; Epidemiology, diagnosis, and screening; Management of patients with small abdominal aortic aneurysm (AAA), including surveillance, cardiovascular risk reduction, and indication for repair; Elective AAA repair, including operative risk assessment, open and endovascular repair, and early complications; Ruptured and symptomatic AAA, including peri-operative management, such as permissive hypotension and use of aortic occlusion balloon, open and endovascular repair, and early complications, such as abdominal compartment syndrome and colonic ischaemia; Long term outcome and follow up after AAA repair, including graft infection, endoleaks and follow up routines; Management of complex AAA, including open and endovascular repair; Management of iliac artery aneurysm, including indication for repair and open and endovascular repair; and Miscellaneous aortic problems, including mycotic, inflammatory, and saccular aortic aneurysm. In addition, Shared decision making is being addressed, with supporting information for patients, and Unresolved issues are discussed. CONCLUSION: The ESVS Clinical Practice Guidelines provide the most comprehensive, up to date, and unbiased advice to clinicians and patients on the management of abdominal aorto-iliac artery aneurysms.

15.
J Vasc Surg ; 79(5): 1251-1261.e4, 2024 May.
Artigo em Inglês | MEDLINE | ID: mdl-37757916

RESUMO

OBJECTIVE: Despite open surgical repair (OSR) of abdominal aortic aneurysms being considered as a durable solution, disease progression and para-anastomotic aneurysms may require further repair, and fenestrated and branched endovascular aneurysm repair (F/BEVAR) may be applied to address these pathologies. The aim of this systematic review was to assess technical success, mortality, and morbidity (acute kidney injury, spinal cord ischemia) at 30 days, and mortality and reintervention rates during the available follow-up, in patients managed with F/BEVAR after previous OSR. METHODS: The PRISMA statement was followed, and the study was pre-registered to the PROSPERO (CRD42022363214). The English literature was searched, via Ovid, using MEDLINE, EMBASE, and CENTRAL databases, through November 30, 2022. Observational studies and case series with ≥5 patients (2000-2022), reporting on F/BEVAR outcomes after OSR, were considered eligible. The Newcastle-Ottawa Scale and GRADE were used to assess the risk of bias and quality of evidence. The primary outcome was technical success, mortality, and morbidity at 30 days. Data on the outcomes of interest were synthesized using proportional meta-analysis. RESULTS: The initial search yielded 1694 articles. Eight retrospective studies (476 patients) were considered eligible. In 78.3% of cases, disease progression set the indication for reintervention. Technical success was estimated at 96% (95% confidence interval [CI], 89%-98%; I2 = 0%; 95% prediction interval [PI], 79%-99%). Thirty-day mortality was 2% (95% CI, 1%-9%; I2 = 0%; 95% PI, 0%-28%). The estimated spinal cord ischemia and acute kidney injury rates were 3% (95% CI, 1%-9%; I2 = 0%; 95% PI, 0%-30%) and 6% (95% CI, 2%-15%; I2 = 0%; 95% PI, 1%-40%), respectively. During follow-up, overall mortality was 5% (95% CI, 2%-12%; I2 = 34%; 95% PI, 0%-45%) and aorta-related mortality was 1% (95% CI, 0%-2%; I2 = 0%; 95% PI, 0%-3%). The rate of reinterventions was 16% (95% CI, 9%-26%; I2 = 22%; 95% PI, 3%-50%). CONCLUSIONS: According to the available literature, F/BEVAR after OSR may be performed with high technical success and low mortality and morbidity during the perioperative period. Follow-up aortic-related mortality was 1%, whereas the reintervention rates were within the standard range following F/BEVAR.

20.
J Endovasc Ther ; : 15266028231210214, 2023 Nov 19.
Artigo em Inglês | MEDLINE | ID: mdl-37981580

RESUMO

INTRODUCTION: This study aimed to evaluate the impact of COVID on total case load and peri-operative outcomes in patients undergoing open surgical repair (OSR) and endovascular repair (ER) of complex aortic aneurysms (cAAs). METHODS: A single-center retrospective analysis of prospective data of patients managed with elective cAA ER or OSR from January 2018 to December 2021 was conducted. A comparative analysis on the impact of the COVID-19 pandemic on the case volume and on the 30-day outcomes was assessed using time periods, before (2018-2019) and during the pandemic (2020-2021). RESULTS: During the 4-year study period, 255 patients with cAA were managed with ER and 576 with OSR. The pandemic did not reduce the cAA ER volume (p=0.12), but a statistically significant reduction in OSR case load was recorded (p=0.04). Following OSR, hospital length of stay (11.1 vs 10.3 days), and early mortality (6.94% vs 4.63%), were similar before and during the pandemic. In the ER cohort, baseline characteristics, early mortality (3.6% vs 4.1%, p=0.976), and morbidity (10% vs 14%, p=0.44), were comparable during the 2 periods. For ER cases, the hospital and intensive care unit (ICU) stay both decreased significantly (8±8-6±7 days, p<0.001 and 2±4 vs 1±6 days p=0.01, respectively) during the pandemic. CONCLUSION: Resource pressures drove modifications in clinical practice to reduce the length of hospitalization, without compromising the clinical outcomes, in patients undergoing ER of cAA. This modification was not effective in patients undergoing OSR that resulted in a significant decrease of this activity. CLINICAL IMPACT: The pandemic did not reduce complex endovascular repair (ER) volume (p=0.12) while a significant reduction in open surgical repair (OSR) case load was recorded (p=0.04). For the endovascular cohort, early mortality (p=0.976) and morbidity (p=0.44) remained stable, while the hospital and intensive care unit (ICU) stay decreased (p<0.001 and p=0.01, respectively) during the pandemic.

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