Revascularization of multiple tibial arteries is not associated with improved limb salvage.

OBJECTIVE: We sought to determine the benefit of performing multiple tibial artery revascularization compared with single vessel revascularization for patients with chronic limb-threatening ischemia (CLTI). METHODS: We performed a single-center, retrospective cohort study of all patients with CLTI treated with below-the-knee endovascular intervention from 2012 to 2019. Group 1 included patients who had undergone single tibial artery revascularization. Group 2 included patients who had undergone multiple (two or more) tibial artery revascularization. More proximal disease, if present, was treated, in addition to the tibial disease. The primary endpoint was freedom from amputation. The secondary endpoints included the reintervention rates and all-cause mortality. RESULTS: A total of 527 limbs in 470 patients with CLTI (nonhealing ulcers, 62%; gangrene, 33%; and ischemic rest pain, 5%) were included in the present study. Of the 527 limbs, 245 (46%) had undergone single vessel revascularization and 282 (54%) had undergone multiple vessel revascularization. The mean follow-up was 19 ± 18 months. No difference was found in freedom from amputation between the two groups (68% vs 63%; P = .109). On multivariable analysis, the factors associated with amputation included dialysis (odds ratio [OR], 1.68; 95% confidence interval [CI], 1.16-2.45), dyslipidemia (OR, 1.37; 95% CI, 0.96-1.94), and gangrene (OR, 2.08; 95% CI, 1.50-2.98). No differences were found in the reintervention rates between the two groups (21.2% vs 16.7%; P = .13). The overall survival rate was 73% in both study groups. CONCLUSIONS: The results from the present large, single-center study have demonstrated that multiple below-the-knee vessel revascularization is not associated with improved limb salvage compared with single vessel revascularization.

Short-term outcomes of inner branches for endovascular repair of complex abdominal and thoracoabdominal aortic aneurysms.

OBJECTIVES: To report our early experience using endografts with inner branches for the treatment of complex abdominal aortic aneurysms and thoracoabdominal aortic aneurysms (TAAAs). METHODS: A retrospective analysis of all patients treated in our institution for complex abdominal aortic aneurysms and TAAAs with custom-made stent grafts consisting of one or more inner branches. Data collected included patients demographics, aortic aneurysm morphology, stent grafts features, perioperative morbidity and mortality and short-term reintervention and mortality rates. RESULTS: Twenty-seven patients (18 males, mean age 70 ± 7.1) were included. Indications for surgery included TAAAs (12, 41%) juxtarenal abdominal aortic aneurysms (10, 37%), type 1A endoleaks (4, 15%) and paraanastamotic aneurysms (1, 4%). A total of 90 inner branches were used. Twenty-one (78%) of the stent grafts consisted only of inner branches and six (22%) had a combination of inner branches with either fenestrations or outer branches. Technical success was achieved in 26/27 (96%) of the patients. There was one perioperative mortality. Six patients suffered from major perioperative adverse events. Mean follow-up was seven months (range 1-23). During the follow-up period, four patients (15%) required reinterventions. Branch-related reinterventions were performed in two (7%) patients. No occlusions of inner branches occurred during the follow-up. CONCLUSIONS: Inner branches in branched endovascular aneurysm repairs offer a feasible option for the treatment of complex abdominal aortic aneurysms and TAAAs. The procedures can be completed with high technical success and with acceptable short-term branch-related reintervention rates. Further follow-up is required to determine the long-term durability of this technology.

Inguinal lymphadenopathy as a predicting factor for ipsilateral primary limb amputation after a successful endovascular treatment.

PURPOSE: To assess the correlation between inguinal lymph node characteristics and ipsilateral limb amputation rates in patients with ischemic foot ulcers after a successful endovascular treatment. METHOD: A retrospective review of patients who were endovascularly treated for ischemic foot ulcers between January 2015 and May 2017. Technical success was defined as arterial recanalization with stenosis less than 30 % and ankle brachial index improvement by > 0.2 after 24 h. Unilateral lymph node size, contrast enhancement, necrosis, and perinodular fat stranding were assessed on pre-procedural CTA. Primary endpoints were amputation and sepsis within 12 months following treatment. The relationship between lymph node characteristics and limb amputation and septic shock were examined. RESULTS: Endovascular treatment of 202 limbs in 202 patients (135 males; median age 72.8 years [42.2-93.7]) was technically successful. Forty-two (20.8 %) patients underwent amputation, six (3 %) patients had septic shock. There was a significant difference in lymph node sizes between the amputated and the non-amputated limbs (P = 0.000). Lymph node characteristics (size, enhancement, necrosis, and perinodular fat stranding) were significantly related to amputation (P < 0.001). Patients with perinodular fat stranding or increased node size were 5.940 and 1.109 times more likely to undergo limb amputation, respectively. Lymph node characteristics were also significantly related to septic shock (P < 0.05). CONCLUSIONS: Certain lymph node characteristics are associated with amputation in patients with ischemic foot ulcers, after a technically successful endovascular treatment of the limb. Large lymph node size and perinodular fat stranding are predictive of limb amputation.

Secondary interventions after fenestrated and branched endovascular repair of complex aortic aneurysms.

OBJECTIVE: The use of fenestrated and branched endografts for the treatment of complex aortic aneurysms is increasing. Despite the low morbidity and mortality associated with these repairs, reintervention rates in the midterm and long term remain a concern. The purpose of this study was to investigate our experience with reinterventions after fenestrated and branched endovascular aneurysm repair (F/BEVAR). METHODS: We performed a retrospective analysis of all patients treated with F/BEVAR at our institution during the years 2009 to 2019. Among them, we identified those who required reinterventions during the period of follow-up. Data collected included patients' demographics, type of treated aneurysm, indications for reintervention, and methods of repair. RESULTS: During the study period, 47 patients underwent F/BEVAR. A total of 160 branches were placed. Of those, 12 patients (25%) underwent 15 secondary interventions for late-occurring complications. Among those requiring reinterventions, mean age was 70 years (range, 59-80 years), and 10 (83%) were male. The majority of those requiring reinterventions were treated for thoracoabdominal aortic aneurysms. Mean time to reintervention was 14 months (range, 2-32 months). Indications for reinterventions included separation of side branches from fenestrations (nine), separation of side branches (three), type IA endoleak (one), type II endoleak (one), and limb occlusion (one). All endoleaks were detected on routine follow-up imaging. All reinterventions were performed using endovascular techniques. Mean follow-up after reinvention was 22 months (range, 1-53 months). During this period, no patient required open conversion. Follow-up imaging revealed successful obliteration of the endoleak, and none experienced continued growth of the sac. CONCLUSIONS: Reinterventions after F/BEVAR are not uncommon. The majority of reinterventions are performed for endoleaks that are due to failure at the level of the fenestrations or component separation. These endoleaks can be treated successfully with endovascular methods and do not require open conversion. Because of the possibility of development of late endoleaks, continual monitoring of these patients is required after the primary procedure.

Selective Arterial Embolization for Large or Symptomatic Renal Angiomyolipoma: 10 Years of Follow-up.

OBJECTIVE: To assess long-term outcome after selective arterial embolization (SAE) as first-line treatment for large or symptomatic AML. DESIGN, SETTING, AND PARTICIPANTS: Data from a prospectively maintained database on 71 patients who underwent SAE for large or symptomatic AML were reviewed. Patients with sporadic and tuberous-sclerosis-complex (TSC) were included. OUTCOME MEASUREMENTS: The main endpoints were re-embolization rates, occurrence of clinical events related to AML, size of AML, and renal function. RESULTS: Thirteen (19.1%) patients reported at least 1 major clinical event. Major complications affected 2 patients (2.9%), both ending in complete loss of renal unit function. Four renal units (5.9%) were eventually treated surgically. The re-embolization rate was 41.1%, with an average time from the initial to a repeat SAE of 2.18 years (range 0.31-10.65 years). The size of the tumor prior to SAE and after 5 and 10 years of follow-up were 8.9 cm (7-12), 6.5 cm (4-7.5), 7 cm (4-7.8), respectively [median (IQR)]. These results are translated to a size reduction of 27% in 10 years follow-up. Patients with TSC had larger tumors on long-term follow-up (77.8 vs 41.3 mm, P = .045). The long-term follow-up estimated average glomerular filtration rate was 81.97 (range 26-196). No patient needed renal replacement therapy, and disease-specific survival was 100%. CONCLUSIONS: SAE is a safe treatment option for patients with symptomatic or large AML. It represents a minimally invasive intervention with good long-term outcome. SAE may be offered as first-line treatment in most cases, though, it is associated with high retreatment rates.

The use of optional inferior vena cava filters of type Optease in trauma patients--a single type of filter in a single Medical Center.

BACKGROUND: Venous thromboembolism (VTE) is a frequent complication of patients who experienced major trauma. Prevention of VTE is usually by thrombophylaxis and or by the use of a retrievable filter. Lately, the use of a retrievable filter in trauma patients has increased despite evidence cautioning against its use. AIMS: To evaluate complications related to a single type of filter prophylactically used in a tertiary trauma center and search for risk factors that may preclude filter retrieval METHODS: 142 patients aged 16 through 60 who experienced a major trauma and were treated with a prophylactic IVC filter of type optease were evaluated. RESULTS: The median time from trauma to filter insertion was 2days and low molecular weight heparin at prophylactic dose was initiated in 92% once the filter was inserted. Nine patients developed IVC thrombosis and one of them died despite the use of thrombolytic therapy. Another 8 patients developed lower extremities deep vein thrombosis. The filter was left in place in 13 more patients after attempted filter removal was unsuccessful. Among patients with successful removal, the median dwelling time was 30days. There was no relationship between successful removal and age, sex, BMI, Glasgow coma scale, or injury severity score of patients when first evaluated. CONCLUSIONS: Of concern is the persistent complications related to IVC filter even with the prophylactic use of anticoagulants and the dose of radiation trauma patients were exposed during insertion and retrieval of filter. Thus, the routine use of IVC filter in trauma patients may not be desirable.

Endovascular repair of complex aortic aneurysms.

BACKGROUND: Surgery for complex aortic aneurysms (thoracoabdominal, juxtarenal and pseudoaneurysms) is associated with a high morbidity and mortality rate. Branched and fenestrated stent grafts constitute a new technology intended as an alternative treatment for this disease. OBJECTIVES: To describe a single-center experience with fenestrated and branched endografts for the treatment of complex aortic aneurysms. METHODS: We reviewed all cases of complex aortic aneurysms treated with branched or fenestrated devices in our center. Data collected included device specifics, perioperative morbidity and mortality, re-intervention rates and mid-term results. RESULTS: Between 2007 and 2012 nine patients were treated with branched and fenestrated stent grafts. Mean age was 73 years. Mean aneurysm size was 63 mm. Perioperative mortality was 22% (2/9). During the follow-up, re-interventions were required in 3 patients (33%). Of 34 visceral artery branches 33 remained patent, resulting in a patency rate of 97%. Sac expansion was seen in a single patient due to a large endoleak. No late aneurysm-related deaths occurred. CONCLUSIONS: Branched and fenestrated stent grafts are feasible and relatively safe alternatives for the treatment of complex aortic aneurysms involving the visceral segment. Further research is needed to determine the long-term durability of this new technology.

Percutaneous transhepatic endoscopic holmium laser lithotripsy for intrahepatic and choledochal biliary stones.

PURPOSE: To report our approach for treating complicated biliary calculi by percutaneous transhepatic endoscopic biliary holmium laser lithotripsy (PTBL). PATIENTS AND METHODS: Twenty-two symptomatic patients (11 men and 11 women, age range 51 to 88 years) with intrahepatic or common bile duct calculi underwent PTBL. Nine patients had undergone previous gastrectomy and small-bowel anastomosis, thus precluding endoscopic retrograde cholangiopancreatography. In the other 13 patients, stone removal attempts by ERCP failed due to failed access or very large calculi. We used a 7.5F flexible ureteroscope and a 200-µm holmium laser fiber by way of a percutaneous transhepatic tract, with graded fluoroscopy, to fragment the calculi with direct vision. Balloon dilatation was added when a stricture was seen. The procedure was performed with the patient under general anaesthesia. A biliary drainage tube was left at the end of the procedure. RESULTS: All stones were completely fragmented and flushed into the small bowel under direct vision except for one patient in whom the procedure was aborted. In 18 patients, 1 session sufficed, and in 3 patients, 2 sessions were needed. In 7 patients, balloon dilatation was performed for benign stricture after Whipple operation (n = 3), for choledochalenteric anastomosis (n = 3), and for recurrent cholangitis (n = 1). Adjunctive "balloon push" (n = 4) and "rendezvous" (n = 1) procedures were needed to completely clean the biliary tree. None of these patients needed surgery. CONCLUSION: Complicated or large biliary calculi can be treated successfully using PTBL. We suggest that this approach should become the first choice of treatment before laparoscopic or open surgery is considered.

Optease vena cava filter optimal indwelling time and retrievability.

The purpose of this study was to assess the indwelling time and retrievability of the Optease IVC filter. Between 2002 and 2009, a total of 811 Optease filters were inserted: 382 for prophylaxis in multitrauma patients and 429 for patients with venous thromboembolic (VTE) disease. In 139 patients [97 men and 42 women; mean age, 36 (range, 17-82) years], filter retrieval was attempted. They were divided into two groups to compare change in retrieval policy during the years: group A, 60 patients with filter retrievals performed before December 31 2006; and group B, 79 patients with filter retrievals from January 2007 to October 2009. A total of 128 filters were successfully removed (57 in group A, and 71 in group B). The mean filter indwelling time in the study group was 25 (range, 3-122) days. In group A the mean indwelling time was 18 (range, 7-55) days and in group B 31 days (range, 8-122). There were 11 retrieval failures: 4 for inability to engage the filter hook and 7 for inability to sheathe the filter due to intimal overgrowth. The mean indwelling time of group A retrieval failures was 16 (range, 15-18) days and in group B 54 (range, 17-122) days. Mean fluoroscopy time for successful retrieval was 3.5 (range, 1-16.6) min and for retrieval failures 25.2 (range, 7.2-62) min. Attempts to retrieve the Optease filter can be performed up to 60 days, but more failures will be encountered with this approach.