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BACKGROUNDS: Intravenous thrombolysis (IVT) is the mainstay of treatment for patients presenting with acute ischemic stroke, while carotid endarterectomy (CEA) is indicated in patients with symptomatic carotid stenosis. However, the impact of prior IVT on the outcomes of CEA (IVT-CEA) is not clear. The aim of this study was to determine whether IVT may create additional stroke and death risk for CEA, compared to CEA performed in the absence of a history of recent IVT, and to determine the optimal timing for CEA after IVT METHODS: We conducted a systematic review and metanalysis on studies comparing the outcomes of IVT-CEA versus CEA, using Medline, Embase and Cochrane databases. RESULTS: We included 11 retrospective comparative studies, in which 135644 patients underwent CEA and 2070 underwent IVT-CEA. The pooled rate of perioperative stroke was 4.2% in the IVT-CEA group and 1.3% in the CEA group (OR 0.44, 95% CI 0.12-1.58, p =.21), with a high heterogenicity (I2 = 93%). The rate of stroke/death was 5.9% in patients undergoing IVT-CEA 1.9% in those receiving CEA only (OR 0.42, 95% CI 0.15-1.14, I2 = 92%, p=.09); after exclusion of studies including TIA as presenting symptom, stroke/death risk was 3.6% in IVT-CEA and 3.0% in CEA (OR 1.42, 95%CI 0.80-2.53, I2=50%, p=.11). The risk of stoke decreased with a delay in the performance of CEA (p=.268). Using results of the meta-regression, the calculated delay of CEA that allows for a <6% risk was 4.6 days. Compared to CEA, patients undergoing IVT-CEA had a significantly higher risk of ICH (2.5% vs 0.1% OR 0.11, 95% CI 0.06-0.21, I2 = 28%, p < .001) and neck haematoma requiring reintervention (3.6% vs 2.3%, OR 0.61, 95% CI 0.43-0.85, I2 = 0%, p = .003). CONCLUSION: In patients presenting with an acute ischemic stroke, CEA can be safely performed after a prior endovenous thrombolysis, maintaining a stroke/death risk <6%. After IVT, CEA should be deferred for at least 5 days to minimize the risk for ICH and neck bleeding.
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The aim is to describe the technical feasibility, early outcomes, and graft stability of the Excluder iliac branch endoprosthesis (W.L. Gore & Associates) used as an infrarenal abdominal bifurcated endograft in cases unsuitable for standard endovascular aortic repair. The technique was used in 13 cases with abdominal and/or iliac aneurysms (n = 6), occlusive disease (n = 3), or complex aneurysms in association with a proximal fenestrated/branched endograft (n = 4). Technical success was 100%, and there were no adverse events, with 100% graft stability at 3 months. This case series demonstrates, in extremely selected cases, the feasibility and safety of Excluder iliac branch endoprosthesis used as an infrarenal aortic bifurcated device.
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OBJECTIVE: The aim of this study was to report the outcomes of endovascular urgent thoracoabdominal aortic (TAAA) repair, using an off-the-shelf preloaded inner branch device (E-nside; Artivion). METHODS: Data from a physician-initiated national multicenter registry, including patients treated with E-nside endograft (INBREED) were prospectively collected (2020-2024); only urgent cases were included in this study. Primary outcomes were technical success and mortality at 30 days. Secondary outcomes were spinal cord ischemia rate, stroke rate, major adverse events (MAE) as also branch instability at 12 months. RESULTS: Of 185 patients enrolled in the INBREED, 64 (34.5%) were treated in a urgent setting and were included in the study. Reason for urgent repair was presence of aneurysm-related symptoms in 31 patients (48.4%), a contained rupture in eight (12.5%), and a large aneurysm >80 mm in 25 (39.1%). Extent of repair was I to III in 32 patients (50%) and IV in 32 (50%); 18 (28%) had a narrow (<25 mm) paravisceral aortic lumen. An adjunctive proximal thoracic endograft was deployed in 29 patients (45.3%); a distal bifurcated abdominal endograft was used in 33 (51.5%). Two hundred forty-nine target vessels (97.2%) were successfully incorporated through an inner branch from an upper arm (81.2%) or femoral (18.8%) access. A balloon expandable stent was used in 184 (75.7%) target vessels, a self-expandable stent in 59 (24.3%). Mean time for target vessel bridging was 39.9 ± 28.4 minutes per target vessel. Thirty-day cumulative major adverse event (MAE) rate was 28%, and mortality occurred in five patients (9.1%). There was one postoperative stroke (1.6%), and the spinal cord ischemia (SCI) rate was 8% (n = 5). For the 249 target vessels successfully incorporated through an inner branch, 1-year freedom from target vessel instability was 93% ± 3% after 1 year. CONCLUSIONS: The E-nside represents a valid solution for the urgent treatment of TAAAs, including symptomatic and ruptured TAAAs, as well as large asymptomatic TAAAs that cannot wait for a custom-made device. The preloaded inner branches and available proximal and distal graft diameters might be useful in urgent settings and provided satisfactory early and 1-year results, in terms of both endograft and target vessel stability. Further studies are required to assess the clinical role of E-nside for urgent TAAA repair.
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We describe the feasibility and safety of a standardized approach for four-fenestrated physician-modified endograft (PMEG) placement to treat complex abdominal aortic aneurysms using the Valiant Captivia platform (Medtronic). The standardization is based on specific selection criteria for anatomical feasibility, measurement method, and modification technique of a single endograft type. Six cases (two juxtarenal, two pararenal, and two type IV thoracoabdominal aneurysms) were treated, with 24 target vessels incorporated with fenestrations. Four cases were treated in an urgent setting and two were elective. The time modification required was 121 ± 18 minutes. Technical success was 100%, with no mortality or complications at 30 days. Postoperative computed tomography at 3 months demonstrated complete aneurysm exclusion, without a type I or III endoleak, no main graft- or fenestration-related loss of integrity, and no target vessel misalignment or stent fracture. The present standardized approach seems safe and feasible and might represent an initial benchmark for comparison with future studies.
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OBJECTIVE: This study aimed to compare two commercially available off the shelf branched endografts for thoraco-abdominal aortic aneurysm (TAAA) repair, namely the E-nside (Artivion) and Zenith t-Branch (Cook Medical) devices. METHODS: This multicentre retrospective study (2020 - 2023) included patients treated by branched endovascular aortic repair (BEVAR) for TAAA using the inner branched E-nside or the outer branched t-Branch. Endpoints were 30 day technical success and major adverse events (MAEs) as well as one year freedom from target vessel instability and main endograft instability. RESULTS: The study included 163 patients: 79 (307 target vessels) treated with E-nside and 84 (325 target vessels) with t-branch. Aneurysm extent was I - III in 91 patients (55.8%; 47% of E-nside and 66% of t-Branch) and IV in 72 patients (44.2%; 53% of E-nside and 34% of t-Branch) (p = .011). An adjunctive proximal thoracic endograft was used in 43% of E-nside vs. 69% of t-Branch (p < .001), with less frequent thoracic endografting (14% vs. 76%; p < .001) and shorter length of coverage (p = .024) in extent IV TAAA treated by E-nside. E-nside cases had shorter renal artery bridging lengths (66 ± 17 mm vs. 76 ± 20 mm; p < .010) and less frequent use of a distal bifurcated endograft (53% vs. 80%; p < .001). Comparing 30 day results, the mortality rate was 1% vs. 2% (p = .62), any MAE occurred in 18% vs. 21% (p = .55), the stroke rate was 3% vs. 0% (p = .23), and the elective spinal cord ischaemia rate was 5% vs. 8% (p = .40) for E-nside and t-Branch, respectively. At one year, freedom from target vessel instability was 96 ± 3% for E-nside and 95 ± 3% for t-Branch (p = .58), and freedom from endograft instability was 98 ± 2% vs. 97 ± 3% (p = .46), respectively. CONCLUSION: Both off the shelf devices provided excellent early and one year results. The E-nside may require shorter thoracic aortic coverage and bridging length for the renal arteries, and less frequent implantation of a concomitant proximal thoracic or distal abdominal bifurcated endograft. However, these aspects did not determine significant differences in clinical outcomes.
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Aneurisma da Aorta Torácica , Implante de Prótese Vascular , Prótese Vascular , Procedimentos Endovasculares , Complicações Pós-Operatórias , Desenho de Prótese , Humanos , Aneurisma da Aorta Torácica/cirurgia , Aneurisma da Aorta Torácica/mortalidade , Aneurisma da Aorta Torácica/diagnóstico por imagem , Estudos Retrospectivos , Feminino , Masculino , Idoso , Procedimentos Endovasculares/instrumentação , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Implante de Prótese Vascular/instrumentação , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/mortalidade , Resultado do Tratamento , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/epidemiologia , Fatores de Tempo , Idoso de 80 Anos ou mais , Pessoa de Meia-Idade , StentsRESUMO
(1) Background: Sleep-disordered breathing represents a growing public health concern, especially among children and adolescents. The main risk factors for pediatric sleep-disordered breathing in school-age children are tonsillar and adenoid hypertrophy. Adenoidectomy, often in combination with tonsillectomy, is the primary treatment modality for pediatric sleep-disordered breathing. This study aims to comprehensively investigate various risk and protective factors in children with sleep-disordered breathing undergoing adenotonsillar or adenoidal surgeries. We also aim to explore the differences in neuropsychological profiles. (2) Methods: This is an observational, retrospective cohort study. We collected information on adenoidectomy or adenotonsillectomy in children referred to our center. We reviewed the clinical history and preoperative visits and collected data through a telephone questionnaire. The Pediatric Sleep Questionnaire (PSQ) and the Pediatric Quality of Life Inventory (PedsQL) screen sleep-disordered breathing and quality of life, respectively. The data were statistically analyzed using SPSS version 22.0 for Windows (SPSS Inc., Chicago, IL, USA). (3) Results: The study involved 138 patients, but only 100 children participated. A higher percentage of patients with sleep-disordered breathing were observed to have mothers who smoked during pregnancy. A smaller proportion of patients with sleep-disordered breathing habitually used a pacifier. A rise in physical score was associated with a reduced PSQ at follow-up (p = 0.051). An increase in the overall academic score was related to a decrease in the PSQ at follow-up (p < 0.001). A more significant proportion of patients undergoing adenotonsillectomy were observed to have a history of prematurity and cesarean birth. (4) This comprehensive study delves into the intricate interplay of risk and protective factors impacting children with sleep-disordered breathing undergoing adenotonsillectomy and adenoidectomy.
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Narrow paravisceral aortic true lumen in postdissection thoracoabdominal aneurysm, represents a challenging situation when branched endovascular aneurysm repair is required; it may be responsible for intraprocedural technical difficulties, such as inadequate main endograft deployment, difficult vessels catheterization, or long-term branch instability related to compression. We describe the case of a 56-year-old man with post-type B thoracoabdominal aortic aneurysm and a severely narrow true lumen (10 mm) at the paravisceral segment. Endovascular aortic septostomy was performed first, to erase the narrow paravisceral aortic true lumen, and subsequently allow branched endograft adequate expansion and regular vessels catheterization.
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OBJECTIVE: The aim of this study was to evaluate the role of intravascular ultrasound (IVUS) for the technical assessment of kissing stents (KSs) and covered endovascular reconstruction of the aortic bifurcation (CERAB) in the treatment of aortoiliac obstructive disease involving the aortic bifurcation. METHODS: We conducted a single-center retrospective review of patients undergoing endovascular treatment of severe aorto-iliac obstructive disease (2019-2023). IVUS was performed in patients treated by KSs or CERAB according to preoperative indications, in cases of moderate/severe calcifications, mural thrombus, total occlusions, and lesion extension towards the proximity of renal or hypogastric arteries. Indications for IVUS-guided intraoperative revisions were residual stenosis or compression >30%, incomplete stent-to-wall apposition, or flow-limiting dissection at the landing site. Follow-up assessment was performed at 6 and 12 months, and then yearly. Thirty-day outcomes and 2-year patency rates were evaluated. Logistic regression was used to identify factors associated with significant technical defects detected by IVUS needing intraoperative revision. RESULTS: IVUS was used for the technical assessment of 102 patients treated by KSs (n = 57; 56%) or CERAB (n = 45; 44%) presenting with severe intermittent claudication (39%), rest pain (39%), or ischemic tissue loss (25%). Twenty-nine significant technical defects were identified by IVUS in 25 patients (25%) who then had successful intraoperative correction by additional ballooning (n = 23; 80%) or stenting (n = 6; 20%). Patients with a severely calcified chronic total occlusion (odds ratio, 1.85; 95% confidence interval, 1.01-5.27; P = .044) or severely calcified narrow aortic bifurcation with <12 mm diameter (odds ratio, 2.34; 95% confidence interval, 1.10-8.64; P = .032) were at increased risk for IVUS-guided intraoperative revision. There were no postoperative deaths and no major adverse events. Two-year primary patency was 100%. CONCLUSIONS: IVUS was used for the technical assessment of KSs/CERAB in a selected cohort of patients with severe aorto-iliac obstructive disease. This allowed the identification and intraoperative correction of a significant technical defect not detected by completion angiogram in one-quarter of patients, achieving optimal 2-year results. IVUS assessment of KSs/CERAB may be considered especially in patients with a calcified total occlusion or narrow aortic bifurcation.
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Doenças da Aorta , Procedimentos Endovasculares , Artéria Ilíaca , Stents , Ultrassonografia de Intervenção , Grau de Desobstrução Vascular , Humanos , Estudos Retrospectivos , Masculino , Feminino , Idoso , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/instrumentação , Resultado do Tratamento , Pessoa de Meia-Idade , Doenças da Aorta/diagnóstico por imagem , Doenças da Aorta/cirurgia , Doenças da Aorta/fisiopatologia , Artéria Ilíaca/diagnóstico por imagem , Artéria Ilíaca/fisiopatologia , Artéria Ilíaca/cirurgia , Fatores de Tempo , Idoso de 80 Anos ou mais , Valor Preditivo dos Testes , Fatores de Risco , Arteriopatias Oclusivas/diagnóstico por imagem , Arteriopatias Oclusivas/fisiopatologia , Arteriopatias Oclusivas/cirurgiaRESUMO
Endovascular aortic arch repair (Ar-TEVAR) with single-branch, off-the-shelf Nexus aortic arch system has shown promising early and 3-year outcomes. There is lack of data regarding long-term results of this specific device, particularly regarding patency of supra-aortic bypasses and stability of the connection between the 2 modules. This case report describes 6-year clinical and imaging follow-up of a 74-year-old patient who underwent Ar-TEVAR with Nexus. Over 6 years, the patient experienced minor complications unrelated to the device. The patency of supra-aortic bypasses and integrity of the device's connection were confirmed. Computed tomography angiography constantly showed exclusion of the aneurysm and reduction of the aneurysmal sac. In conclusion, although extended research and broader data are needed, this case provides encouraging evidence of long-term results of Ar-TEVAR with Nexus.
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Aneurisma da Aorta Torácica , Implante de Prótese Vascular , Procedimentos Endovasculares , Humanos , Idoso , Prótese Vascular , Angiografia por Tomografia Computadorizada , Implante de Prótese Vascular/métodos , Stents , Aneurisma da Aorta Torácica/diagnóstico por imagem , Aneurisma da Aorta Torácica/cirurgia , Seguimentos , Resultado do Tratamento , Aorta Torácica/diagnóstico por imagem , Aorta Torácica/cirurgia , Estudos RetrospectivosRESUMO
Patients with aortic arch pathologies after surgery for type-A acute aortic dissection represent a challenging population since open surgery is associated with a non-negligible rate of mortality and complications. Microinvasive endovascular aortic arch repair Arch-Thoracic EndoVascular Aortic Repair (Ar-TEVAR) has shown promising results in high-risk patients. Ar-TEVAR is usually performed under general anaesthesia. We report the case of an 83-year-old man with a history of ascending aorta replacement for type-A acute aortic dissection who was referred for an anastomotic pseudoaneurysm. Ar-TEVAR using an off-the-shelf single-branch aortic arch stent graft was chosen. In order to further minimize procedural invasiveness, monitored anaesthesia care (local anaesthesia with sedation and analgesia) was performed since it provides less stress on the cardiovascular and respiratory systems and overall leads to a faster recovery especially in elderly patients.
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Anestesia , Aneurisma da Aorta Torácica , Dissecção Aórtica , Implante de Prótese Vascular , Procedimentos Endovasculares , Masculino , Humanos , Idoso , Idoso de 80 Anos ou mais , Aorta Torácica/cirurgia , Prótese Vascular , Correção Endovascular de Aneurisma , Aneurisma da Aorta Torácica/cirurgia , Stents , Resultado do Tratamento , Dissecção Aórtica/cirurgia , Estudos RetrospectivosRESUMO
BACKGROUND: Carotid artery stenting (CAS) using first-generation single-layer stents is widely accepted as a good alternative to standard carotid endarterectomy (CEA) but it is associated with worse outcomes in terms of both plaque prolapse and cerebral embolization. AIM: To evaluate the perioperative and midterm outcomes of CAS using the new-generation RoadsaverTM dual-layer micromesh-covered carotid stent. METHODS: Herein, we present the results of an observational, retrospective, multicentric study on non-consecutive patients who underwent the CAS procedure between January 2017 and December 2022 at three Italian, high-volume vascular surgery centers. The inclusion criteria were the patients' eligibility for the CAS procedure in accordance with the current Italian guidelines, and the implantation of a Roadsaver stent. Both symptomatic and asymptomatic patients were included in the study. The patients requiring reintervention for carotid restenosis following CEA were also included. Perioperative data regarding procedural success was defined as the successful implantation of the device in the desired position, less than 30% residual stenosis, and the absence of intraoperative neurological complications. The primary outcome was any adverse cerebrovascular event such as stroke or transient ischemic attack (TIA) during the procedure and/or after discharge. The secondary outcomes were the need for further intervention, and all-cause death following procedure. RESULTS: Three-hundred-fifty-three (353) patients were included in our study; the mean age was 74.3 years. A total of 5.9% of the patients were symptomatic on their operated side, while 7.3% had contralateral carotid occlusion. A cerebral embolic protection device (CPD) was employed in all patients. A total of 13.3% of the patients were operated on for restenosis after CEA Technical success was achieved in 96.9% of the cases with an intraoperative report of six TIAs (1.7%) and six ipsilateral strokes (1.7%). The mean hospital stay was 1.8 days. The thirty-day follow up showed one TIA and one more stroke. At the mean 35-month follow-up time, the primary outcome was present in six patients (1.7%), where four TIAs (1.1%) and two strokes (0.5%) were reported. Restenosis occurred in five patients (1.4%). Death for any cause was reported in 11 patients (3.1%). CONCLUSIONS: As most recent, high-quality studies show, the CAS procedure with second-generation devices such as the Roadsaver stent is safe and effective in preventing carotid-related cerebrovascular events in both symptomatic and asymptomatic patients. The intraoperative and postoperative cerebrovascular complication rate in high volume centers is very low, ensuring confidence in its employment for the CAS procedure along with a CPD as a valid alternative to CEA.
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OBJECTIVE: To investigate the effect of narrow paravisceral aorta (NPA) on target vessel instability (TVI) after fenestrated-branched endovascular aortic repair. METHODS: We conducted a single-center retrospective study (2014-2023) of patients treated by fenestrated-branched endovascular aortic repair for thoracoabdominal aortic aneurysms (TAAA) or pararenal aortic aneurysms. The paravisceral aorta was defined as the aortic segment limited by the diaphragmatic hiatus proximally and the emergence of lower renal artery distally, and was considered "narrow" in case of a minimum inner diameter of <25 mm. The minimum aortic diameter, location, longitudinal extension, angulation, calcification, and thrombus thickness of NPA were evaluated at the preoperative computed tomography angiogram. End points were 30-day technical success and freedom from TVI. RESULTS: There were 142 patients with JRAA/pararenal aortic aneurysm (n = 85 [59%]) and extent IV (n = 24 [17%]) or extent I-III (n = 33 [23%]) TAAA, with 513 target arteries successfully incorporated through a fenestration (n = 294 [57%]) or directional branch (n = 219 [43%]). A NPA was present in 95 patients (70%), 73 (86%) treated by fenestrated endovascular aortic repair (FEVAR) and 22 (39%) by branched endovascular aortic repair (BEVAR). The overall 30-day mortality was 2% and technical success was 99%, without differences between NPA and non-NPA (P = .99). Kaplan-Meier estimated freedom from TVI at 4 years was 82%, 81% (95% CI, 75-95) in patients with a NPA and 80% (95% CI, 68-94) and in those without NPA (P = .220). The result was maintained for both FEVAR (NPA: 81% [95% CI, 62-88]; non-NPA: 76% [95% CI, 60-99]; P = .870) and BEVAR (NPA: 77% [95% CI, 69-99]; non-NPA: 80% [95% confidence interval (CI) 66-99]; P = .100). After multivariate analysis, the concomitant presence of a NPA <20 mm and angulation of >30° was significantly associated with TVI in FEVAR (HR, 3.21; 95% CI, 1.03-48.70; P = .036), being the result mostly driven by target vessel occlusion. In BEVAR, a NPA diameter of <25 mm was not associated with TVI (HR, 2.02; 95% CI, 0.59-5.23; P = .948); after multivariate analysis, the use of outer branches in case of a NPA longitudinal extension of >25 mm (hazard ratio [HR], 3.02; 95% CI, 1.01-36.33; P = .040) and NPA severe calcification (HR, 1.70; 95% CI, 1.00-22.42; P = .048) were associated with a higher chance for TVI. CONCLUSIONS: FEVAR and BEVAR are both feasible in cases of NPA and provide satisfactory target vessels durability. The use of outer branches should be avoided in cases with an inner aortic diameter of <25 mm with a longitudinal extension of >25 mm or moderate to severe NPA calcifications. In FEVAR, bridging stent patency may be negatively influenced by NPA of <20 mm in association with aortic angulation of >30°.
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Aneurisma da Aorta Abdominal , Aneurisma da Aorta Torácica , Implante de Prótese Vascular , Procedimentos Endovasculares , Humanos , Correção Endovascular de Aneurisma , Prótese Vascular , Aneurisma da Aorta Torácica/diagnóstico por imagem , Aneurisma da Aorta Torácica/cirurgia , Aneurisma da Aorta Torácica/etiologia , Implante de Prótese Vascular/efeitos adversos , Estudos Retrospectivos , Complicações Pós-Operatórias/diagnóstico por imagem , Complicações Pós-Operatórias/etiologia , Fatores de Risco , Procedimentos Endovasculares/efeitos adversos , Resultado do Tratamento , Fatores de Tempo , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Aneurisma da Aorta Abdominal/cirurgia , Aneurisma da Aorta Abdominal/etiologia , Aorta/cirurgiaRESUMO
OBJECTIVE: The aim of this study was to investigate the outcomes of primary determinate and indeterminate target vessel endoleaks (TVELs) after fenestrated-branched endovascular aortic repair (F-BEVAR). METHODS: We conducted a single-center retrospective study (2014-2023) on F-BEVAR for thoracoabdominal (TAAAs) or pararenal aortic aneurysms (PRAAs). TVELs were classified as "primary" if present at the first postoperative computed tomography angiogram. Endoleaks were defined "determinate" (dELs) if the cause (type Ic or IIIc) and implicated target vessel were identifiable and "indeterminate" (iELs) if contrast enhancement was detectable at the level of fenestrations/branches without any evident source. Endoleaks involving multiple inflows (type II and target vessels) were defined as "complex" (cELs). Endpoints were endoleak spontaneous resolution, 1-year aneurysm sac failure to regress (>5 mm diameter decrease), and 4-year endoleak-related secondary interventions. Kaplan-Meier estimates and Cox regression were used for the analysis. RESULTS: There were 142 patients with JRAAs/PRAAs (n = 85; 60%) or TAAAs (n = 57; 40%), with 513 target arteries incorporated through a fenestration (n = 294; 57%) or directional branch (n = 219; 43%). Fifty-nine primary TVELs (12%) were identified in 35 patients (25%), a dEL in 20 patients (14%) and iEL in 15 (11%); 22 (15%) had a determinate or indeterminate cEL. Overall spontaneous resolution rate was 75% (95% confidence interval [CI], 51%-87%) at 4 years. cELs (odds ratio [OR], 5.00; 95% CI, 1.10-49.4; P < .001) and iELs after BEVAR (OR, 9.43; 95% CI, 3.41-56.4; P = .002) were more likely to persist >6 months, and persistent forms were associated with sac failure to regress at 1 year (OR, 1.72; 95% CI, 1.03-12.59; P = .040). Overall freedom from endoleak-related reinterventions was 85% (95% CI, 79%-92%) at 4 years, 92% (95% CI, 87%-97%) for those without primary TVELs and 62% (95% CI, 46%-84%) for those with any primary TVEL (P < .001). In particular, cELs (hazard ratio, 1.94; 95% CI, 1.4-18.81; P = .020) were associated with an increased need for reintervention. In case a secondary intervention was needed, iEL or cEL had an increased risk for multiple secondary procedures (hazard ratio, 2.67; 95% CI, 1.22-10.34; P = .034). CONCLUSIONS: Primary TVELs are frequent after F-BEVAR, and a clear characterization of the endoleak source by computed tomography angiogram is not possible in 40% of patients. Most primary TVELs spontaneously resolve, but during follow-up, patients with any primary TVEL experience a worsened freedom from endoleak-related reinterventions that is mostly driven by persistence of cELs and post-BEVAR iELs. Multiple secondary procedures may be required in case of iELs or cELs.
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Aneurisma da Aorta Abdominal , Aneurisma da Aorta Torácica , Implante de Prótese Vascular , Procedimentos Endovasculares , Humanos , Endoleak/diagnóstico por imagem , Endoleak/etiologia , Endoleak/terapia , Correção Endovascular de Aneurisma , Aneurisma da Aorta Torácica/diagnóstico por imagem , Aneurisma da Aorta Torácica/cirurgia , Aneurisma da Aorta Torácica/complicações , Implante de Prótese Vascular/efeitos adversos , Estudos Retrospectivos , Fatores de Risco , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/métodos , Resultado do Tratamento , Fatores de Tempo , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Aneurisma da Aorta Abdominal/cirurgia , Aneurisma da Aorta Abdominal/complicações , Prótese Vascular/efeitos adversosRESUMO
OBJECTIVE: The use of intravascular ultrasound (IVUS) reduces contrast medium use and radiation exposure during conventional endovascular aneurysm repair (EVAR). The aim of this study was to evaluate the safety and efficacy of IVUS in detecting bridging stent graft (bSG) instability during fenestrated and branched EVAR (F/B-EVAR). METHODS: This was a prospective observational multicentre study. The following outcomes were evaluated: (1) technical success of the IVUS in each bSG, (2) IVUS findings compared with intra-operative angiography, (3) incidence of post-operative computed tomography angiography (CTA) findings not detected with IVUS, and (4) absence of IVUS related adverse events. Target visceral vessel (TVV) instability was defined as any branch or fenestration issues requiring an additional manoeuvre or re-intervention. Any IVUS assessment that detected stenosis, kinking, or any geometric TVV issue was considered to be branch instability. All procedures were performed in ad hoc hybrid rooms. RESULTS: Eighty patients (69% males; median age 72 years; interquartile range 59, 77 years) from four aortic centres treated with F/B-EVAR between January 2019 and September 2021 were included: 70 BEVAR (21 off the shelf; 49 custom made), eight FEVAR (custom made), and two F/B-EVAR (custom made), for a total of 300 potential TVVs. Two TVVs (0.7%) were left unstented and excluded from the analysis. The TVVs could not be accessed with the IVUS catheter in seven cases (2.3%). Furthermore, 17 (5.7%) TVVs could not be examined due to a malfunction of the IVUS catheter. The technical success of the IVUS assessment was 91.9% (274/298), with no IVUS related adverse events. Seven TVVs (2.5%) showed signs of bSG instability by means of IVUS, leading to immediate revisions. The first post-operative CTA at least 30 days after the index procedure was available in 268 of the 274 TVVs originally assessed by IVUS. In seven of the 268 TVVs (2.6%) a re-intervention became necessary due to bSG instability. CONCLUSION: This study suggests that IVUS is a safe and potentially valuable adjunctive imaging technology for intra-operative detection of TVV instability. Further long term investigations on larger cohorts are required to validate these promising results and to compare IVUS with alternative technologies in terms of efficiency, radiation exposure, procedure time, and costs.
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Aneurisma da Aorta Abdominal , Aneurisma da Aorta Torácica , Implante de Prótese Vascular , Procedimentos Endovasculares , Masculino , Humanos , Idoso , Feminino , Correção Endovascular de Aneurisma , Prótese Vascular , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Aneurisma da Aorta Abdominal/cirurgia , Aneurisma da Aorta Abdominal/etiologia , Implante de Prótese Vascular/efeitos adversos , Aneurisma da Aorta Torácica/cirurgia , Stents , Estudos Prospectivos , Resultado do Tratamento , Procedimentos Endovasculares/efeitos adversos , Fatores de Risco , Desenho de Prótese , Ultrassonografia de IntervençãoRESUMO
Carotid artery stenting (CAS) represents today an accepted option for the treatment of severe carotid artery stenosis. The evolution of materials, techniques, perioperative medical management and patients' selection, has allowed to progressively reduce CAS complications. However, the main drawback of CAS is still represented by the risk of cerebral embolization, that may occur during several steps of the procedure and also in the early postoperative period. Preoperative carotid plaque morphological characteristics may have a great role in determining the risk of embolization during CAS. This review summarizes the current knowledge on carotid plaque characteristics that may influence the risk of complication during CAS. This information may be important for the optimization of CAS patients' selection and adaptation of the materials and techniques.
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Estenose das Carótidas , Embolização Terapêutica , Endarterectomia das Carótidas , Placa Aterosclerótica , Humanos , Estenose das Carótidas/diagnóstico por imagem , Estenose das Carótidas/cirurgia , Stents , Artérias Carótidas , Placa Aterosclerótica/complicações , Placa Aterosclerótica/terapia , Endarterectomia das Carótidas/métodos , Resultado do Tratamento , Fatores de RiscoRESUMO
[This corrects the article DOI: 10.3389/fcvm.2022.802183.].
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OBJECTIVE: This single centre, retrospective study (2014 - 2022) on juxta-, pararenal, or thoraco-abdominal aortic aneurysms treated by fenestrated endovascular aortic repair (FEVAR) was conducted to investigate the clinical impact and determinants of fenestration to target vessel misalignment in FEVAR. METHODS: Pre-operative supracoeliac, pararenal, and infrarenal aortic angles were measured on three dimensional computed tomography angiography (CTA) reconstructions. Two components of misalignment were measured on the first post-operative CTA: horizontal misalignment (angle between the fenestration and the target vessel ostium on perpendicular CTA cuts) and vertical misalignment (vertical distance between the fenestration and the target vessel at its origin). Endpoints were freedom from target vessel instability (TVI) and alignment change over time. RESULTS: Of 65 patients treated by FEVAR, 60 (202 target arteries) with juxta-, pararenal (80%), or thoraco-abdominal aortic aneurysm (20%) were included. Mean horizontal misalignment was 9 ± 12° (median 5°; IQR 0 - 16) and mean vertical misalignment was 0.7 ± 1 mm (median 0 mm, IQR 0 - 1). Freedom from TVI was 92% (95% CI 88 - 98) at 36 months. Horizontal misalignment > 15° was significantly associated with TVI (HR 5.19; 95% CI 1.54 - 17.48; p = .008); vertical misalignment did not significantly impact TVI (HR 0.99; 95% CI 0.56 - 1.73; p = .97). By multivariable analysis, pararenal aortic angle (OR 1.01 per increased degree of angulation; 95% CI 1.00 - 1.02; p = .044), bridging distance > 5 mm (OR 1.07; 95% CI 1.02 - 1.11; p = .003), and use of higher profile endografts in tortuous iliac access (OR 7.55; 95% CI 4.55 - 1.11; p = .003) were associated with clinically significant misalignment. Bridging distance > 5 mm (OR 2.00; 95% CI 1.02 - 11.29; p = .044), degree of baseline misalignment (OR 1.04; 95% CI 1.01 - 1.08; p = .036), and persistence of any primary endoleak for > 6 months (OR 5.85; 95% CI 1.23 - 29.1; p = .023) were associated with misalignment increase during follow up. CONCLUSION: Horizontal misalignment > 15° is associated with worsened target vessel outcomes. This may occur as a result of excessive iliac access tortuosity, high pararenal aortic angulation, and bridging distance > 5 mm.
RESUMO
BACKGROUND: Fusobacterium necrophorum is an anaerobic, gram-negative, non-motile, filamentous, non-spore forming bacillus found in the oral cavity, gastrointestinal tract, and female genital tract, responsible of a rare disease named Lemierre Syndrome, characterized by septic thrombophlebitis of the internal jugular vein, which mainly affects previously healthy adolescents and young adults; some risk factors are reported, as smoking or primary viral or bacterial infection leading to the disruption of mucosa. The syndrome originates commonly from an upper respiratory infection such as pharyngotonsillitis, acute otitis media, cervical lymphadenitis, sinusitis, or odontogenic abscess, and may result in multiorgan metastasis, more frequently leading to pulmonary complications, especially lung abscesses. CASE PRESENTATION: We describe two cases of adolescents with atypical Lemierre Syndrome evaluated in a tertiary care center, one with a confirmed infection by Fusobacterium necrophorum and one with a presumptive diagnosis based on clinical features, who developed lung abscesses needing a prolonged antibiotic course and hospitalization. Of interest, both were user of electronic cigarette, configuring a possible new risk factor. The proper diagnosis of Lemierre Syndrome is often difficult to establish, so a high degree of suspicion is needed, especially in the case of lung abscesses in otherwise healthy adolescents. CONCLUSION: The current study will contribute to providing insight into Lemierre Syndrome clinical presentation and management in adolescents, promoting awareness for a rare but potentially fatal disease. Moreover, it suggests a possible relationship between Lemierre syndrome and the use of electronic cigarette, that should be investigated by future studies.
Assuntos
Sistemas Eletrônicos de Liberação de Nicotina , Síndrome de Lemierre , Abscesso Pulmonar , Tromboflebite , Adulto Jovem , Humanos , Feminino , Adolescente , Síndrome de Lemierre/complicações , Síndrome de Lemierre/diagnóstico , Síndrome de Lemierre/microbiologia , Abscesso Pulmonar/etiologia , Abscesso Pulmonar/complicações , Antibacterianos/uso terapêuticoRESUMO
We describe the feasibility of a technique for temporary aneurysm sac reperfusion after endovascular single-stage thoracoabdominal aortic aneurysm exclusion, to be used in the case of postoperative spinal cord ischemia. Two cases were treated for impending rupture of a thoracoabdominal aortic aneurysm. Before completion of sac exclusion, a supplementary buddy wire (V-18 control guidewire; Boston Scientific) was advanced in parallel fashion from the left percutaneous femoral access into the aneurysmal sac on the posterior aspect of the endograft. Distal aneurysm exclusion was completed using the main superstiff guidewire, and the femoral access was closed with a percutaneous closure device (ProGlide; Abbott) in standard fashion, leaving in place the sole V-18 guidewire, draped in sterile fashion. In the case of spinal cord ischemia, the "safe-line" can be rapidly used for spinal reperfusion after trans-sealing exchange with a 6F, 65-cm-long Destination sheath (Terumo) connected to a 6F introducer on the contralateral femoral artery.
RESUMO
BACKGROUND: The aim of this work is to value cost-effectiveness of complex aortoiliac occlusive disease (AIOD) revascularization, by comparing in-hospital clinical outcomes and detailed costs of hospitalization of open and endovascular techniques. METHODS: This observational single-center retrospective cohort study included all patients who underwent AIOD revascularization from May 2008 to February 2018 and met inclusion and exclusion criteria. Patients were divided into 2 groups: open surgical repair and endovascular repair. Inclusion criteria were type C and D AIOD, and type of intervention: aorto-bifemoral bypass and covered kissing stenting. Costs were directly compared between the 2 groups, and subsequently a multivariate logistic regression model was performed to define which group most influenced major in-hospital costs. Cox proportional hazard models were used to identify predictors of long-term mortality and primary patency (PP). RESULTS: The 2 groups included 50 patients each, and all patients had a bilateral iliac axis revascularization. Mean age was 67 ± 9 years and 71% of patients were males. The open surgical repair group had a significantly longer length of hospitalization (P < 0.001) and in-hospital medical complications rate (22%, P = 0.003). No differences were found in the total cumulative cost of hospitalization, including ward, intensive care unit, and operating room. In a multivariate logistic model, higher total hospitalization costs were not significantly associated with either one or the other type of treatment. We did not find any statistically significant differences in overall medium-term survival (P = 0.298) and PP (P = 0.188), which were not influenced by the type of revascularization on Cox proportional hazard models (overall survival: hazard ratio 2.09 confidence interval 95% [0.90-4.84] P = 0.082; PP: hazard ratio 1.82 confidence interval 95% [0.56-6.16] P = 0.302). CONCLUSIONS: Total in-hospital stay cost analysis did not reveal significant differences between aorto-bifemoral bypasses and covered kissing stentings for AIOD revascularization.