[Trousseau's syndrome: a combination of cancer and hypercoagulability]. / Trousseaus syndrom ­ en kombination av cancer och hyperkoagulabilitet.

Trousseau's syndrome (TS) is a combination of cancer and hypercoagulability, considered to be a chronic disseminated intravasal coagulation which leads to venous thromboembolism and arterial thrombosis in cancer patients. In TS, thrombosis results from an activation of hemostasis by different mechanisms. Cardioembolic stroke is the most common type that occurs in patients with malignancy, partly due to cancer-related hypercoagulability. The classical presentation of TS comprises multiple bilateral ischemic brain lesions in both supra- and infratentorial regions of the brain. TS occurs most commonly in patients with lung, pancreas, breast and colon cancer, usually mucin-producing cancer. TS manifests most commonly within 30 days of occurrence of cancer symptoms or longer in local and metastatic cancer, respectively. Standard treatment of TS is low molecular weight heparin, whereas in recent years non-vitamin K oral anticoagulants have been tested and not shown better effect so far, but further studies are required.

[Argon plasma coagulation effective treatment of solitary rectal ulcer syndrome]. / Argonplasmakoagulation effektiv vid solitärt rektalt ulkussyndrom.

Solitary rectal ulcer syndrome (SRUS) is a rare disorder likely to be caused by a traumatic and ischemic mucosal injury related to latent or overt rectal prolapse. Mucosal damage can vary between erythema and up to intractable ulceration. The typical symptoms of SRUS may resemble those of inflammatory bowel disease (IBD)-related proctitis or rectal malignancy with mucus- and blood-mixed defecation with urgency and sometimes transient incontinence. The purpose of this paper is to raise awareness of this rare, quality-of-life impacting and difficult-to-treat disease and the not so well-known argon plasma coagulation (APC) treatment that can provide very good and long lasting symptom relief.

[Whipple's disease: very rare, fatal without treatment but easily cured]. / Whipples sjukdom: sällsynt, dödlig utan behandling, men lätt botad.

Whipple's disease is a chronic infectious disease that primarily affects the small intestine, but several organs can be involved simultaneously. The disease is caused by a gram-positive bacterium called Tropheryma whipplei. The disease is difficult to suspect because it is rare, and produces unspecific and long-term symptoms. Whipple's disease can lead to death if not treated. We here present a case of a man who presented with gastrointestinal symptoms in the form of diarrhea with blood, weight loss, fever, and lymphadenopathy and who was finally diagnosed with Whipple's disease 4 years after the occurrence of manifestations from the joints. The diagnosis was made both with 16S rRNA against Tropheryma whipplei and histopathologically from biopsy taken from the duodenum and distal ileum. The purpose of this case report is to raise awareness of a very rare disease that presented with a combination of symptoms similar to other and significantly more common diseases.

Endovascular Repair of Blunt Thoracic Aortic Trauma: Is Postimplant Hypertension an Incidental Finding?

BACKGROUND: Blunt thoracic aortic injury (BTAI) is the second most common cause of death in trauma patients. Nowadays, thoracic endovascular aortic repair (TEVAR) has become the treatment of choice because of lower rates of mortality, paraplegia, and stroke. However, concerns have been raised whether graft implantation is related to the development of hypertension in the postoperative period. The aim of this study was to report short- and long-term outcomes of patients undergoing TEVAR for BTAIs at a tertiary hospital and to investigate postimplant hypertension. METHODS: Between January 2005 and January 2016, 23 patients with blunt thoracic aortic trauma underwent TEVAR. Median age was 44 years (range, 18-73). Among them, 14 (60.9%) patients were diagnosed with aortic rupture, whereas 9 (39.1%) with pseudoaneurysm. Α single thoracic stent graft was deployed in 21 patients, and the rest 2 patients received 2 stent grafts. RESULTS: Complete exclusion of the injury was feasible in all subjects (100% primary success). The left subclavian artery (SCA) was intentionally covered in 6 patients (26%). Intraoperative complications included one nonfatal stroke managed conservatively and one external iliac artery rupture treated with iliofemoral bypass. One patient (4.3%) died on the first postoperative day in the intensive care unit (ICU) because of hemorrhagic shock. The overall 30-day mortality and morbidity were 4.3% and 8.7%, respectively. New-onset postimplantation arterial hypertension was observed in 8 (34.8%) previously nonhypertensive patients. Younger age (P = 0.027) and SCA coverage (P = 0.01) were identified as potential risk factors for the development of postimplant hypertension, whereas the presence of concomitant injuries (P = 0.3) and intraoperative complications (P = 0.1) were not. After a median follow-up of 100 months (range, 18-120), 6 of them still remain on antihypertensive therapy, whereas the other 2 did not require permanent treatment. CONCLUSIONS: TEVAR is a safe approach in the treatment of BTAI associated with low short- and long-term morbidity and mortality rates. Lower age and SCA coverage may contribute to the development of postimplant hypertension. Further larger cohort studies are warranted to elucidate the underlying mechanisms of postimplant hypertension.

Association between seven single nucleotide polymorphisms involved in inflammation and proteolysis and abdominal aortic aneurysm.

BACKGROUND: Abdominal aortic aneurysm (AAA) formation involves an inflammatory and proteolytic process. Previous studies suggest that AAA is a multifactorial disease with a strong genetic background. This study evaluated the role of seven important functional single nucleotide polymorphisms (SNPs) in AAA. METHODS: This was a case-control study of two independent populations: 397 AAA patients (mean aortic diameter, 6.2 ± 1.4 cm) and 393 controls (mean diameter, 2.4 ± .2 cm) recruited from Greece (the main cohort), and 400 patients (mean diameter: 5.4 ± 1 cm) and 400 controls (mean diameter, 2.4 ± .6 cm) recruited from the United Kingdom (replication cohort). The functional SNPs analyzed were rs3025058, rs3918242, rs2276109, rs1801133, rs1799752, rs1799983, and rs16874954. These regulate the following enzymes: matrix metalloproteinases (MMPs), angiotensin-converting enzyme, endothelial nitric oxide synthase, methylenetetrahydrofolate reductase (MTHFR), and platelet-activating factor acetylhydrolase or lipoprotein-associated phospholipase A2. RESULTS: Genotype distributions (univariate analyses) did not differ significantly between cases and controls in the main or the replication cohort, with the exception of the MMP-3 rs3025058 SNP, where differences were borderline significant (odds ratio [OR], 1.42; 95% confidence interval [CI], 1.02-1.97; P = .04) in the replication cohort. Adjusted analyses for age, sex, smoking, hypertension, and hypercholesterolemia disclosed no differences in either cohort. For SNPs that had previously been associated with AAA presence, meta-analysis of currently available data together with the two study cohorts disclosed positive associations for the MMP-3 rs3025058 (OR, 1.15; 95% CI, 1.06-1.25; P = .0009) and MTHFR rs1801133 (OR, 1.07; 95% CI, 1.02-1.12; P = .0088). CONCLUSIONS: The SNPs included in this analysis were not associated with AAA presence in either study population. However, meta-analysis of the currently available data disclosed a positive association for MMP-3 rs3025058 and MTHFR rs1801133.

Comparison of the impact of open and endovascular abdominal aortic aneurysm repair on renal function.

OBJECTIVE: The impact of any intervention on renal function is a crucial determinant of outcome. Open (OR) and endovascular (EVAR) abdominal aortic aneurysm (AAA) repair can affect renal function during the short and longer term. This study aimed to directly compare the effect of those different types of aneurysm repair during a period of 2 years. METHODS: This was a nested case-control study including patients undergoing either OR or EVAR of an infrarenal AAA. Three groups were included: OR, EVAR with suprarenal endograft fixation, and EVAR with infrarenal fixation. These were matched for age (within 2 years), sex, AAA size (within 1 cm), hypertension, smoking, and proximal neck diameter (within 5 mm). The primary end point was change in estimated glomerular filtration rate (eGFR) calculated by the Chronic Kidney Disease Epidemiology Collaboration formula at baseline, 6 months, 12 months, and 2 years. RESULTS: A total of 225 patients were included [(45 ORs matched vs 90 suprarenal and 90 infrarenal fixation EVARs; 35 women (16%); age, 71 ± 8 years; AAA size, 6.4 ± 1 cm]. Groups did not differ significantly in terms of diabetes, hypercholesterolemia, or baseline eGFR (P = .89). On average, those undergoing OR lost a mean 5.39 mL/min/1.73 m(2) (P = .48) within 1 year and 5.49 units (P = .42) after 2 years. The suprarenal fixation patients lost 5.58 units (P = .002) after 1 year and 6.57 units (P = .001) after 2 years. Finally, the infrarenal fixation patients lost 0.53 unit (P = .74) after 1 year and 2.24 units (P = .22) after 2 years. CONCLUSIONS: OR and suprarenal fixation EVAR are associated with significant declines in renal function during 2 years, in contrast to infrarenal EVAR fixation. The patterns of eGFR decline in OR and suprarenal fixation EVAR are not similar, suggesting different causal mechanisms.

Obesity as an independent predictor of outcome after endovascular abdominal aortic aneurysm repair.

BACKGROUND: Obesity is increasingly common in patients referred for the management of an abdominal aortic aneurysm (AAA). Evidence of the effect of obesity on outcomes after endovascular repair (EVAR) is not well established. We sought to compare the immediate and midterm outcomes of elective EVAR between obese and nonobese patients in a case control study. METHODS: Patients undergoing elective EVAR were divided in 2 groups: obese (defined as a body mass index [BMI] ≥30 kg/m(2)) and nonobese (mean BMI [kg/m(2)] ± SD: 33 ± 1 vs 25 ± 3). Both groups were case-matched for age, sex, smoking, and AAA diameter. One hundred fifty-nine patients were included (mean age: 69 ± 9 years; 10 women [9%]; mean BMI: 28 ± 5 kg/m(2); 53 were obese and 106 were nonobese). All aneurysms were successfully excluded. Mean follow-up was 34 ± 13 months. RESULTS: All patients who developed a complication within the perioperative period (≤30 days) were obese (P = 0.01). Thirteen patients (8.2%) died during follow-up (8 obese versus 5 nonobese; P = 0.76). Survival and non-procedure-related morbidity did not differ significantly between the obese and nonobese groups (P = 0.64 and 0.16; log-rank test). BMI was not associated with mortality or non-procedure-related morbidity on multivariate analysis (mortality-hazard ratio: 1.0 [95% confidence interval: 0.9-1.2]; P = 0.37; non-procedure-related morbidity-hazard ratio: 1.0 [95% confidence interval: 0.9-1.1], P = 0.2). CONCLUSIONS: This is the first case control study to assess the independent impact of obesity in the outcome after EVAR. No difference was documented with regards to mortality or non-aneurysm-related morbidity.

Impaired renal function is associated with mortality and morbidity after endovascular abdominal aortic aneurysm repair.

BACKGROUND: Renal function may be associated with poor outcome following endovascular abdominal aortic aneurysm repair (EVAR), but this relationship has not been adequately investigated. The aim of this study is to evaluate the association of estimated glomerular filtration rate (eGFR) with cardiovascular events and all-cause mortality after EVAR. METHODS: Prospective cohort study of patients undergoing elective EVAR; eGFR was calculated using the Chronic Kidney Disease Epidemiology Collaboration formula, and patients were divided in four groups (eGFR ≥ 90 mL/min/1.73 m(2), group 1; 60-89, group 2; 30-59, group 3; <30, group 4). Composite end point consisted of death, nonfatal myocardial infarction, stroke, and vascular complications. Kaplan-Meier curves were constructed, and between-group comparisons were performed adjusted for variables that differed at baseline. RESULTS: A total of 383 patients (mean age, 69 ± 8 years; mean abdominal aortic aneurysm diameter, 6.2 ± 1.4 cm) were included. Over a mean follow-up of 34 ± 12 months, the following events occurred: 20 deaths (5.2%), 15 nonfatal myocardial infarctions (3.9%), 9 nonfatal strokes (2.3%), and 7 peripheral vascular complications (1.8%). Patients with an eGFR <30 had the highest mortality (35%) and incidence of complications (80%) as per the end point (P = .009 and P < .001, respectively). Adjusted Cox-regression analysis showed that a higher eGFR at baseline by 1 mL/min/1.73 m(2) was associated with a 5% lower likelihood of complications as per the end point (P < .001; hazard ratio, 0.95; 95% confidence interval, 0.94-0.97) and a 6% lower likelihood of death (P < .001; hazard ratio, 0.94; 95% confidence interval, 0.92-0.97). CONCLUSIONS: Impaired renal function is associated with an increase in cardiovascular events and mortality following elective EVAR.

Suprarenal graft fixation in endovascular abdominal aortic aneurysm repair is associated with a decrease in renal function.

INTRODUCTION: Suprarenal endograft fixation is routinely used in the endovascular repair of abdominal aortic aneurysms (EVAR) to enhance proximal endograft attachment but can be associated with an adverse outcome in renal function. This prospective study assessed the effect of suprarenal fixation on serum creatinine concentration and estimated glomerular filtration rate (eGFR), calculated by the Modified Diet in Renal Disease equation, 12 months after elective EVAR. METHODS: Patients undergoing elective EVAR were divided into suprarenal vs infrarenal fixation groups matched for age, sex, smoking, and aneurysm diameter. Serum creatinine and eGFR were measured at baseline, 6, and 12 months. RESULTS: Included were 92 patients (two women) with a mean age of 71 ± 7 years, with 46 in each group. No device-related complications were noted. Serum creatinine did not differ significantly between groups at 6 (P = .24) or 12 (P = .08) months but significantly increased in the suprarenal group at 12 months (1.08 ± 0.36 to 1.16 ± 0.36 mg/dL; P < .001) vs baseline. The eGFR (mL/min/1.73 m(2)) did not differ significantly at baseline between the suprarenal (85 ± 27) and infrarenal (80 ± 28; P = .33) groups or at 6 months (88 ± 29 vs 77 ± 24, respectively; P = .07). At 12 months, the suprarenal group had a lower eGFR (73 ± 23) than the infrarenal group (84 ± 26; P = .027). The eGFR at 12 months showed a significant decrease in the suprarenal (80 ± 28 to 73 ± 23; P < .001) but not in the infrarenal group (85 ± 27 to 84 ± 26; P = .48). The drop in eGFR differed significantly at 12 months in the infrarenal vs the suprarenal (0.82 vs -6.94; P < .001) group. No patient progressed to end-stage renal disease or disclosed a drop in eGFR > 30%. CONCLUSIONS: In contrast to previous studies, this study suggests that suprarenal endograft fixation in elective EVAR is associated with a drop in eGFR at 12 months.

Anemia is associated with mortality following endovascular repair of abdominal aortic aneurysm.

AIM: The aim of this study was to compare midterm mortality between anemic and nonanemic patients undergoing endovascular repair of abdominal aortic aneurysm and to assess a correlation with markers of inflammation. METHODS: Anemia was defined as hemoglobin <13 (men) and <12 g/dL (women). The impact of anemia and inflammatory markers on mortality was assessed using Kaplan-Meier curves and Cox regression. RESULTS: A total of 224 patients (12 females [5.36%]; age: 69.73 ± 8.72 years) were included; 102 (45.53%) were anemic. Median follow-up was 17 months (interquartile range: 7-25 months). Nine patients died (1.79%; 8 anemic vs 1 nonanemic). Survival was lower for patients with anemia (log-rank, P = .01). White blood cell count and C-reactive protein (CRP) differed significantly (P < .001 and P = .01). Anemia and CRP were associated with decreased survival (Cox regression, P = .01, hazard ratio [HR]: 0.35, 95% confidence interval: 0.14-0.84 and P = .002, HR: 1.18, 95% CI: 1.06-1.31). CONCLUSION: Patients with anemia had decreased survival over the midterm; inflammatory markers were higher among this group.

Helical EndoStaples enhance endograft fixation in an experimental model using human cadaveric aortas.

OBJECTIVE: This study evaluated the contribution of Aptus EndoStaples (Aptus Endosystems, Sunnyvale, Calif) in the proximal fixation of eight endografts used in the endovascular repair of abdominal aortic aneurysms (EVAR). METHODS: Nine human cadaveric aortas were exposed, left in situ, and transected to serve as fixation zones. The Zenith (Cook, Bloomington, Ind), Anaconda (Vascutek, Inchinnan, Scotland, UK), Endurant (Medtronic, Minneapolis, Minn), Excluder (W. L. Gore and Associates, Flagstaff, Ariz), Aptus (Aptus Endosystems), Aorfix (Lombard Medical, Didcot, UK), Talent (Medtronic), and AneuRx (Medtronic) stent grafts were proximally deployed and caudal displacement force (DF) was applied via a force gauge, recording the DF required to dislocate each device ≥20 mm from the infrarenal neck. Measurements were repeated after four and six EndoStaples were applied at the proximal fixation zone, as well as after a Dacron graft was sutured at the proximal neck in standard fashion. Finally, a silicone tube was used as a control fixation zone to test the DF of grafts with EndoStaples in a material that exceeded the integrity of a typical human cadaveric aorta and provided a consistent substrate to examine the differential effect of variable degrees of EndoStaple implantation using zero, two, four, and six EndoStaples. RESULTS: In the cadaveric model, the mean DF required to dislocate the endografts without the application of EndoStaples was 19.73 ± 12.52 N; this increased to 49.72 ± 12.53 N (P < .0001) when four EndoStaples where applied and to 79.77 ± 28.04 N when six EndoStaples were applied (P = .003). The DF necessary to separate the conventionally hand-sutured Dacron graft from the aorta was 56 N. In the silicone tube model, the Aptus endograft without EndoStaples withstood 3.2 N of DF. The DF increased to 39 ± 3 N when two EndoStaples were added, to 71 ± 6 N when four were added, and to 98 ± 5 N when six were added. In eight of the 13 cadaver experiments conducted with four and six EndoStaples, the displacement occurred as a result of complete aortic transection proximal to the fixation site, indicating that aortic tissue integrity was the limiting factor in these experiments. CONCLUSIONS: The fixation of eight different endografts was increased by a mean of 30 N with four Aptus EndoStaples and by a mean of 57 N with six EndoStaples in this model. Endostaples can increase endograft fixation to levels equivalent or superior to that of a hand-sewn anastomosis. The application of six EndoStaples results in aortic tissue failure above the fixation zone, demonstrating fixation strength that exceeds inherent aortic integrity in these cadavers.

Inferior vena cava stent-graft placement to treat endoleak associated with an aortocaval fistula.

PURPOSE: To report a case in which a persistent high-flow type II endoleak after endovascular aneurysm repair (EVAR) of a leaking abdominal aortic aneurysm (AAA) complicated by an aortocaval fistula was repaired with a stent-graft in the inferior vena cava (IVC). CASE REPORT: A 76-year-old man underwent emergent EVAR with an aortomonoiliac device to exclude a leaking 9-cm AAA. The 30-day computed tomography (CT) scan showed 2-mm sac expansion and a type II endoleak arising from a lumbar artery; the outflow vessel was the inferior vena cava (IVC) via a fistula that was not depicted on the non-contrast preoperative CT or the intraoperative angiogram. No intervention was deemed necessary at the time. Six months after EVAR, the AAA had not expanded further, but the fistula between the sac and the IVC was larger in diameter. A tubular stent-graft was implanted in the IVC to seal the defect. No complications have been noted up to 36 months after the IVC stent-graft procedure. CONCLUSION: Aortocaval fistulae should be excluded in the case of persistent type II endoleaks after EVAR for ruptured AAAs. IVC endografting is a minimally invasive alternative to treat such a complication, with promising midterm results in this patient.

Emergency endovascular treatment of popliteal aneurysms.

Popliteal artery aneurysm (PAA), despite being rare, is the most common peripheral aneurysm. It can present as acute thrombosis and occlusion of the aneurysmal segment, and distal embolization, causing either chronic or acute limb ischemia. It has traditionally been treated with open surgical reconstruction. Endovascular repair of PAAs has recently been applied electively with a favourable early and mid-term outcome; however there is a lack of reports on the endovascular treatment of PAAs presenting with acute complications. This report describes the treatment of a thrombosed PAA in a 58 year old male using an endovascular stent-graft and also provides a systematic review of the literature on the emergency endovascular treatment of PAAs.

Reporting mid- and long-term results of endovascular grafting for abdominal aortic aneurysms using the aortomonoiliac configuration.

PURPOSE: This study evaluated the feasibility, efficacy, and durability of a specific aortomonoiliac endograft for the treatment of abdominal aortic aneurysm (AAA) during a midterm follow-up. METHODS: From January 2002 until November 2008, 106 patients (6 women; mean age, 73.37 +/- 7.39 years) were treated for an AAA using an EndoFit aortomonoiliac graft (LeMaitre Vascular, Burlington, Mass). All procedures were elective. RESULTS: Mean follow-up was 34.9 months (SD, 20.08; range, 2-81 months). Long-term data (follow-up >60 months) were available for nine patients, none of which reported any vascular or procedure related complications. Three of the 106 patients (2.83%) died during early follow-up (<30 days); eight died during late follow-up (7.54%). Endograft infection developed in two patients (1.88%), and an aortoduodenal fistula developed in two (1.88%). Also observed were 15 type II (14.15%) and three type I (2.83%) endoleaks. Femorofemoral bypass thrombosis was detected in two patients (1.88%). CONCLUSION: In this retrospective analysis, the aortomonoiliac configuration for elective AAA repair was proven to be safe and efficacious. Midterm and long-term follow-up results in this series compare well with previously reported results for AAA endografting using both bifurcated and aortomonoiliac endoprostheses.

Minimally invasive endovascular intervention in emergent and urgent thoracic aortic pathologies: single center experience.

INTRODUCTION: We report mid-term results from the endovascular treatment of acute thoracic aortic pathologies in a single center. METHODS: We retrospectively interrogated our clinical database and identified the following patients who were treated for an acute thoracic aortic pathology during a 3-year period (January 2003 to February 2006) with the deployment of a thoracic endograft: 8 male patients diagnosed with a thoracic aortic pseudoaneurysm and/or a thoracic aortic disruption following blunt chest trauma; 1 male patient with a large mobile mural thrombus of the descending thoracic aorta; 1 patient with an aortobronchial fistula; and 8 patients with a symptomatic descending thoracic aortic aneurysm. RESULTS: Complete exclusion of the lesion was achieved in all patients. No procedure-related deaths occurred. Postoperative complications included one case of a distal type 1 endoleak, repaired with re-intervention and deployment of an extension graft, and 1 case of moderate graft kinking without further complications. CONCLUSION: The endovascular treatment of acute thoracic aortic pathologies is technically feasible and safe. Early and intermediate results are promising.

Aortoduodenal fistulas after endovascular stent-graft repair of abdominal aortic aneurysms: single-center experience and review of the literature.

PURPOSE: To report a single-center experience with aortoduodenal fistula (ADF) after successful endovascular aneurysm repair (EVAR) of an infrarenal abdominal aortic aneurysm (AAA). METHODS: Five patients (all men; mean age 68.4 years, range 60-75) developed an ADF between 18 days to 1 year after successful EVAR using 3 types of commercially available endografts: 1 bifurcated Anaconda, 1 unibody Powerlink, and 3 EndoFit stent-grafts in a tubular (n=1) or aortomonoiliac configuration (n=2). The internal iliac artery was not occluded in any of the cases. RESULTS: Hematemesis and diffuse abdominal pain constituted the main symptoms leading to the diagnosis of ADF, which was confirmed on computed tomography. Infection was the etiology of the ADF in 3 patients; all underwent emergency surgical exploration, but 1 died in hospital; the other 2 have survived from 1 to 3 years after an emergency procedure. The other 2 ADFs developed in patients with large type I endoleaks; 1 patient died before surgery could be performed and the other one 18 hours after laparotomy. All stent-grafts were removed; none displayed any defects. CONCLUSION: ADF is a rare but dangerous complication of EVAR. The sequela may be primarily attributed to graft infection, as seen in this series. However, the exact pathogenesis of the pathology remains largely unknown. Prompt diagnosis and intervention are crucial to avoid a fatal outcome.

Anaconda aortic stent-graft: single-center experience of a new commercially available device for abdominal aortic aneurysms.

PURPOSE: To report a retrospective evaluation of the efficacy and midterm clinical results of the Anaconda stent-graft in the endovascular repair of infrarenal abdominal aortic aneurysms. METHODS: Fifty-one patients (48 men; mean age 71+/-8 years, range 62-89) were treated with the Anaconda stent-graft from January 2006 to September 2007. Six patients were considered at high risk for open repair (defined as ASA grade 3) and 10 had undergone previous laparotomy. The mean neck diameter and length were 26 mm (range 22-30) and 18.5 mm (range 14-35), respectively. Mean proximal neck angulation was 30 degrees (range 5-60). Severe iliac artery tortuosity (>60 degrees ) was seen in 20 (39%) patients; 3 (6%) had a proximal aneurysm neck angle >45 degrees. RESULTS: The technical success rate was 100%; intraprocedurally, 7 (14%) stent-grafts were repositioned to address renal artery occlusion by the graft (n = 1) or type I endoleak. This maneuver resolved 6 of the 7 situations; a remaining endoleak required a proximal cuff to seal it. The procedural success rate (no major complication at 30 days) was 94%. The mean follow-up was 16 months (range 1-21). Five (10%) endoleaks (1 type I, 4 type II) and 1 (2%) graft migration occurred. The overall reintervention rate was 6%. Two (4%) patients died in late follow-up. CONCLUSION: The Anaconda stent-graft appears both safe and effective in terms of midterm clinical outcome and compares favorably with previously reported EVAR results. The ability to reposition the stent-graft is a particular advantage.

EndoFit stent-graft repair of isolated common iliac artery aneurysms with short necks.

PURPOSE: To evaluate the feasibility and efficacy of repairing isolated iliac artery aneurysms with short proximal necks (<10 mm) by implanting the EndoFit stent-graft. METHODS: Seven patients (6 men; median age 73 years, range 70-78) were diagnosed with an isolated common iliac artery (CIA) aneurysm that featured a short proximal landing zone, complicating endovascular treatment. The median aneurysm diameter was 4.4 cm (range 3.5-7.0), and the median proximal neck length was 7 mm (range 5-9).The aneurysms were treated using the EndoFit stent-graft, which can be deployed in a short proximal landing zone. The modified technique involves the deployment of the graft directly above the aneurysm sac without obstructing the contralateral iliac axis, thus affixing the bare proximal stent in the terminal aorta. Follow-up was performed by clinical evaluation and computed tomography at 1, 6, and 12 months postoperatively. RESULTS: The EndoFit stent-graft was successfully deployed in all cases, with complete aneurysm exclusion. In 1 case, the deployment of a second cuff was necessary to secure complete aneurysm exclusion. The median follow-up was 18 months, during which no deaths occurred, and no endoleak or stent-graft migration was observed. Endograft thrombosis occurred in 1 case due to graft angulation caused by external iliac artery stenosis and kinking. None of the aneurysms has ruptured, and there have been no serious complications. CONCLUSION: Direct endoluminal repair of isolated CIA aneurysms with short proximal necks is feasible using this technique. Efficacy and long-term results are to be confirmed by larger scale series over a long time period.

Management of cervical paragangliomas: review of a 15-year experience.

BACKGROUND AND AIMS: Cervical paragangliomas are highly vascular neoplasms and should be considered in the evaluation of all lateral neck masses. The aim of this study is to review an institutional experience in the management of these tumors. MATERIALS AND METHODS: Thirteen patients with 14 paragangliomas were treated in our institution during a period of 15 years. There were eight women (61.5%) and five men (38.5%) with a mean age of 41.3+/-15 years. A painless lateral neck mass was the main finding in 69.2% of patients. There was no evidence of a functional tumor. Carotid angiography was performed in all patients to define the vascular anatomy of the lesion. The 78.6% of paragangliomas underwent selective embolization of the major feeding arteries. Surgical resection followed within the next 48 h. RESULTS: The majority of the lesions were paragangliomas of the carotid bifurcation (85.7%), while one patient was diagnosed with a jugular and one with a vagal paraganglioma. In one patient, bilateral paragangliomas in the carotid bifurcation were detected. There was no evidence of malignancy in any case. Preoperative embolization has proven successful in reducing tumor vascularity. Vascular reconstruction was necessary in one patient. The main postoperative complication was transient cranial nerve deficit in seven (53.8%) patients, and a permanent Horner's syndrome was documented in one patient. No stroke occurred. The jugular paraganglioma was treated with irradiation due to skull base extension with significant symptomatic relief. CONCLUSION: Combined therapeutic approach with preoperative selective embolization followed by surgical resection by an experienced team offers a safe and effective method for complete excision of the tumors with a reduced morbidity rate.

Endovascular AAA repair with the aortomonoiliac EndoFit stent-graft: two years' experience.

PURPOSE: To evaluate the feasibility and efficacy of a specific aortomonoiliac endograft and the durability of the femorofemoral bypass for treatment of abdominal aortic aneurysm (AAA). METHODS: From 2002 to 2004, 39 high-risk (ASA III/IV) patients (36 men; median age 74 years, range 63-84) with AAA (n = 33) or AAA and common iliac artery aneurysm (n = 6) were treated with an EndoFit aortomonoiliac endograft and femorofemoral crossover bypass. The contralateral iliac axis was obstructed with an endoluminal occluder. Patients were followed with contrast-enhanced computed tomography at 1, 6, 12, and 24 months. RESULTS: EndoFit AMI stent-grafts were implanted successfully in all patients. Perioperative mortality was zero. Endoleak occurred in 3 (7.7%) cases. A proximal type I endoleak was identified at 1 month and was treated with a proximal cuff. Two type II endoleaks are under surveillance because the aneurysm sac shows no enlargement. Thrombosis of the femorofemoral graft occurred in 1 case during the immediate postoperative period due to insufficient inflow from a residual stenosis of the endograft (primary patency 97.5%). The deficit was treated successfully (secondary patency 100%). Two (5.1%) tunnel hematomas were treated conventionally. Median follow-up was 14 months (range 6-30). All patients are alive. None of the aneurysms has ruptured or been converted to an open procedure. Graft migration, serious infection, paraplegia, distal embolization, or any other serious complication has not been observed. CONCLUSIONS: In high surgical risk patients with complex iliac anatomy, aortomonoiliac endograft with femorofemoral crossover bypass is feasible and efficacious. Moreover, the midterm patency of the extra-anatomic bypass appears quite satisfactory.