Peri-Operative Management of Patients Undergoing Fenestrated-Branched Endovascular Repair for Juxtarenal, Pararenal and Thoracoabdominal Aortic Aneurysms: Preventing, Recognizing and Treating Complications to Improve Clinical Outcomes.

The advent and refinement of complex endovascular techniques in the last two decades has revolutionized the field of vascular surgery. This has allowed an effective minimally invasive treatment of extensive disease involving the pararenal and the thoracoabdominal aorta. Fenestrated-branched EVAR (F/BEVAR) now represents a feasible technical solution to address these complex diseases, moving the proximal sealing zone above the renal-visceral vessels take-off and preserving their patency. The aim of this paper was to provide a narrative review on the peri-operative management of patients undergoing F/BEVAR procedures for juxtarenal abdominal aortic aneurysm (JAAA), pararenal abdominal aortic aneurysm (PRAA) or thoracoabdominal aortic aneurism (TAAA). It will focus on how to prevent, diagnose, and manage the complications ensuing from these complex interventions, in order to improve clinical outcomes. Indeed, F/BEVAR remains a technically, physiologically, and mentally demanding procedure. Intraoperative adverse events often require prolonged or additional procedures and complications may significantly impact a patient's quality of life, health status, and overall cost of care. The presence of standardized preoperative, perioperative, and postoperative pathways of care, together with surgeons and teams with significant experience in aortic surgery, should be considered as crucial points to improve clinical outcomes. Aggressive prevention, prompt diagnosis and timely rescue of any major adverse events following the procedure remain paramount clinical needs.

The Italian Multicentre Registry of Fenestrated Anaconda™ Endografts for Complex Abdominal Aortic Aneurysms Repair.

OBJECTIVE: The aim was to describe the outcomes of the Anaconda™ Fenestrated endograft Italian Registry for complex aortic aneurysms (AAAs), unsuitable for standard endovascular aneurysm repair (EVAR). METHODS: Between 2012 and 2018 patients with a proximal neck unsuitable for standard EVAR, treated with the fenestrated Anaconda™ endograft, were prospectively enrolled in a dedicated database. Endpoints were peri-operative technical success (TS) and evaluation of type Ia/b or 3 endoleaks (T1/3 EL), target visceral vessel (TVV) occlusion, re-interventions, and AAA related mortality at 30 days, six months, and later follow up. RESULTS: One hundred twenty seven patients (74 ± 7 years, American Society Anesthesiology (ASA) II/III/IV: 12/85/30) were included in the study in 49 Italian Vascular Surgery Units (83 juxta/para-renal AAA, 13 type IV thoraco-abdominal AAA, 16 T1aEL post EVAR, and 15 short neck AAA). Configurations with one, two, three, and four fenestrations were used in 5, 56, 39, and 27 cases, respectively, for a total of 342 visceral vessels. One hundred and eight (85%) bifurcated and 19 (15%) tube endografts were implanted. In 35% (44/127) of cases the endograft was repositioned during the procedure, and 37% (128/342) of TVV were cannulated from brachial access. TS was 87% (111/127): five T1EL, six T3EL (between fenestration and vessel stent), and six loss of visceral vessels (one patient with a Type Ia EL had also a TVV loss) occurred. Thirty day mortality was 4% (5/127). Two of the five T1EL resolved spontaneously at 30 days. The overall median follow up was 21 ± 16 months; one T1EL (5%) occurred at six months and one T3EL (4%) at the three year follow up. Another two (3%) TVV occlusions occurred at six months and five (3%) at three years. The re-intervention rate at the 30 days, six months, and three year follow up was 5%, 7%, and 18 ± 5%, respectively. CONCLUSION: The fenestrated Anaconda™ endograft is effective in the treatment of complex AAA. Some structure properties, such as the re-positionability and the possibility of cannulation from above, are specific characteristics helpful for the treatment of some complex anatomies.

Aortic Epithelioid Angiosarcoma after Endovascular Aneurysm Repair.

We report a case of epithelioid angiosarcoma of the abdominal aortic wall after endovascular treatment for abdominal aortic aneurysm (EVAR). A 60-year-old male, treated 7 years before with EVAR, presented with abdominal back pain, general fatigue, and fever. It was assumed to be a graft infection with periaortic tissue compatible with an inflammatory reaction. The endograft was therefore completely removed and a Dacron silver aorto-bisiliac graft was implanted. After a few days the patient worsened, the angio-computed tomography scan showed a progressive increase of the periaortic mass and numerous small nodules in the abdomen were also detected. The patient was again brought to surgery, an axillo-bifemoral bypass was performed, and the aorto-bisiliac graft was removed but the patient died after surgery. The histological examination showed an aortic epithelioid angiosarcoma with peritoneal metastasis.

Surgery for acute lower limb ischemia in the elderly population: results of a comparative study.

BACKGROUND: To evaluate the outcome of surgical treatment of acute lower limb ischemia in elderly patients. The primary endpoints were early and midterm rates of survival and limb salvage. METHODS: A retrospective analysis involving 76 consecutive patients observed for acute lower limb ischemia between March 2005 and December 2008 who underwent revascularization was conducted. A total of 44 patients (group A) of age >80 years (average age: 86.9 ± 4.5 years; 13 men and 31 women) had a site of obstruction at the level of abdominal aorta in one case (2.3%), common-external iliac artery/common femoral artery in 15 (34.1%), superficial femoral artery/popliteal artery in 26 (59.1%), and infrapopliteal arteries in two (4.5%), and embolectomy, thrombectomy, bypass, and angioplasty was performed in 24 (54.5%), 11 (25.0%), eight (18.2%), and one (2.3%) case(s), respectively. A total of 32 patients (group B) of age <80 years (average age: 67.2 ± 12.2 years; 19 men and 13 women) with an analogous site of obstruction at the level of abdominal aorta in one case (3.1%), common/external iliac artery/common femoral artery in 12 (37.5%), superficial femoral artery/popliteal artery in three (9.4%), and infrapopliteal arteries in 16 (50.0%) underwent the same aforementioned procedures in 10 (31.3%), 12 (37.5%), nine (28.1%), and one (3.1%) case(s), respectively. RESULTS: At 30 days after surgery, survival and limb salvage were both 93.2% in group A versus 96.9% and 87.5%, respectively, in group B, whereas they were 93.2% and 65.8%, respectively, in group A versus 85.7% and 96.9%, respectively, in group B (p = 0.22 and p = 0.19, respectively) at the midterm control. The univariate and multivariate analyses showed that category 2b of acute ischemia (immediately-threatening) has a negative statistically significant influence on the survival rate (p = 0.01). CONCLUSIONS: Limb salvage rates after surgical intervention for acute lower limb ischemia in the elderly population are comparable with those of the younger population, whereas survival rates are lower, but without statistical significance. The only factor that negatively influences the survival rate is the 2b clinical category of acute ischemia, regardless of the age of the patient.

Helicobacter pylori and gastroesophageal reflux disease: a cross sectional study.

UNLABELLED: BACKGROUND\ AIMS: Helicobacter Pylori (H. Pylori) is a key pathogenetic factor in gastritis, peptic ulcer disease, gastric carcinoma and lymphoma but its relationship with gastroesophageal reflux disease (GERD) is controversial. The aim of the study is to estimate the possible association between the presence of H. pylori and GERD. METHODOLOGY: In this retrospective study we examined the endoscopy and pathology reports of all the 638 consecutive patients who had upper gastrointestinal endoscopy and adequate mucosal sampling in 2005 in our department at the University of Padova. Yates corrected chi2 test was used to compare the H. Pylori frequency in the different histological groups. Multinomial logistic regression was used to identify possible predictors of H. Pylori infection. RESULTS: In this selected population 133 patients were affected by H. Pylori infection (20.8%) and 107 were affected by GERD according to Montreal definition. No significant relation between H. Pylori infection and GERD or NERD (non erosive reflux disease) was evidenced. As expected histological gastritis at the examination confirmed to be the strongest predictor of infection with a odds ratio of 39.4 (95% CI 5.4-287.4, p < 0.01). Upper abdominal pain showed to be the only clinical independent predictors for the presence of H. Pylori infection with a odds ratio of 1.5 (95% CI 1.0-2.3, p = 0.04). CONCLUSIONS: Our study showed that in north eastern Italy there is no association between H. Pylori infection and GERD. On the contrary presence of histological gastritis and upper abdominal pain were confirmed to be significant predictors of H. Pylori infection. No endoscopic characteristic is significantly related to the presence of H. Pylori.

Intrasac fibrin glue injection after platinum coils placement: the efficacy of a simple intraoperative procedure in preventing type II endoleak after endovascular aneurysm repair.

OBJECTIVES: To verify in our experience if fibrin glue injection into the aneurysm sac, made at the end of endovascular aneurysm repair (EVAR), can reduce type II endoleak rates. METHODS: Between January 2005 and February 2008, 38 patients underwent EVAR for an unruptured abdominal aortic aneurysm. The first 20 consecutive patients (Group A) had standard EVAR while the last 18 patients (Group B) had EVAR with fibrin glue injection into the sac, regardless of type II endoleak's presence. RESULTS: There was no statistically significant difference between the two groups concerning the surgical time and the time of X-ray exposure (P=0.30 and 0.54, respectively). Type II endoleak rate was significantly higher in Group A compared to Group B (6 cases, 30% vs. 1 case, 5.5%, respectively, P=0.05). Primary short-term clinical success was 95% and 100%, respectively. At 12 months, selective lumbar embolization was performed in two patients in Group A and in one patient in Group B. Patients in Group A had less computed tomography (CT) studies than patients in Group B (2.0 vs. 1.2, respectively, P=0.024). CONCLUSIONS: Fibrin glue injection is a safe procedure and seems to reduce type II endoleak rates. Patients who received this procedure had fewer CT examinations, with reduced health-care costs.

Hypogastric artery bypass in open repair of abdominal aortoiliac aneurysm: a safe procedure.

OBJECTIVES: The aim of this study is to assess the immediate and mid-term results of hypogastric artery bypass (HAB) in open repair of abdominal aortic aneurysm (AAA). METHODS: The clinical data of 24 patients with an average age of 70.4 years [standard deviation (S.D.)+/-8.1 years] with AAA treated between January 2005 and December 2008 with HAB during open repair of aortoiliac aneurysm were reviewed. Eighteen patients received unilateral and six bilateral hypogastric bypasses, using a segment of Dacron graft prosthesis. Concomitant hypogastric eversion endarterectomy was associated in six cases (25%). Follow-up was complete in all the 24 patients and averaged 16.2 months (range 1-35). Postoperative imaging protocol involved a conventional Echocolordoppler and CT-scan. With respect to the operating time, the blood loss, the intensive care unit (ICU) and the length of ward admission (LWA) stay, we compared the 24 patients who underwent hypogastric bypass (group A) with the 50 patients who had bifurcated graft without hypogastric bypass (group B). RESULTS: Between the two groups, statistically different results were demonstrated only with respect to the duration of operation (h) (group A 5.19+/-1.38 vs. group B 4.39+/-1.32, P=0.0195). No statistical differences were noted for ICU stay (h) (group A median 21.50 vs. group B median 21.3, range 1 degrees -3 degrees quartile 19.75-23.50) and LWA stay (days) (group A median 8.50, range 1 degrees -3 degrees quartile 7.00-11.50 vs. group B median 8.0, range 1 degrees -3 degrees quartile 7.00-9.00). There were no operative deaths, bowel or intestinal ischemia in the early postoperative period between the two groups. In group A, one patient had transient renal failure and one patient had an acute coronary syndrome. In group B, one patient had a peripheral ischemia who required tibioperoneal embolectomy. The patency of the hypogastric grafts was demonstrated in all cases. CONCLUSIONS: In our experience, direct revascularization of the hypogastric artery to ensure pelvic vascularization in aortoiliac surgery appears a safe procedure.

Deep venous thrombosis after surgery for inflammatory bowel disease: is standard dose low molecular weight heparin prophylaxis enough?

BACKGROUND: Inflammatory bowel disease (IBD) and colorectal surgery are risk factors for deep venous thrombosis (DVT). The aim of this prospective study was to evaluate the effectiveness of standardized prophylactic low molecular weight heparin (LMWH) therapy in patients who underwent surgery for ulcerative colitis (UC) and Crohn's disease (CD). PATIENTS AND METHODS: Since 1999 all patients operated on for colorectal diseases in our institute have received 4,000 IU/day LMWH from the day of operation to discharge. The complete series of patients who had major colorectal surgery from 1999 until 2006 were reviewed for overt DVT episodes. Furthermore, 60 consecutive patients who were admitted for surgery for IBD were prospectively enrolled in the 2004-2006 period. Each patient underwent venous color Doppler ultrasound scan at admission and at discharge. Demographic data, disease activity, and clotting parameters were collected. Data were analyzed with Spearman's correlation test, multiple regression, and receiver operating characteristics (ROC) curves analysis. RESULTS: The rate of DVT in UC patients was significantly higher than in colorectal cancer patients (p = 0.009), and the odds ratio (OR) for postoperative DVT in UC patients was 7.4 (95% CI 1.4-44.4; p = 0.017). Female gender, UC diagnosis, active rectal bleeding, aPTT value, aCL IgM, abeta2 IgM, and pANCA levels significantly correlated with postoperative DVT. At multivariate analysis only aCL IgM levels were found to be independently associated with postoperative DVT (p = 0.05). CONCLUSIONS: In conclusion, our study showed that prophylactic therapy with 4,000 IU/day LMWH was not completely effective for the prevention of postoperative DVT in patients with CD, and even less so in those with UC. In these patients, a more tailored prophylactic therapy should be considered, and further randomized controlled trials testing the effectiveness of different prophylactic protocols would be advisable. Furthermore, aCL IgM serum levels might be helpful in identifying IBD patients who are at higher risk of postoperative DVT.

Lipid and phospholipid profile after bowel resection for Crohn's disease.

BACKGROUND AND AIM: Chronic inflammation, impaired intestinal adsorption, and bowel resection may have an impact on lipid metabolism before and after intestinal surgery for Crohn's disease (CD). The aim of this prospective study was to define the impact of intestinal surgery for CD on plasma phospholipid fatty acid (FA) composition and of serum plasma lipoprotein concentrations and to investigate the role of CD recurrence on lipid parameters. MATERIALS AND METHODS: Twenty-four consecutive patients who had intestinal surgery for CD since December 2004 to March 2006 were enrolled in this prospective study. The total amount of calorie intake and the quality of the aliments, systemic inflammatory activity, and plasma lipoproteins and phospholipid fatty acid composition were determined at operation and at follow-up. Statistical analysis was performed with pair-matched tests. RESULTS: The median follow-up was 6 (4-20) months. During the follow-up, no significant modification of body mass index was observed. An increase of high-density lipoprotein (HDL) cholesterol (p=0.02) without other modifications in the plasma phospholipid FA composition were evidenced after surgery. The comparison between colectomy and ileo-colonic or ileal resection groups did not show any significant difference in the lipoprotein concentration and phospholipid FA profile. The length of resected bowel did not show any significant correlation with any relevant difference in lipid, phospholipid profile, or in inflammatory parameters. Patients who experienced a recurrence of CD reported significantly higher levels of total (p<0.01), HDL (p=0.01), and low-density lipoprotein cholesterol (p=0.01) were observed in patients in remission than in those with recurrent active disease. CONCLUSIONS: Patients who are submitted to intestinal resection for CD improve their inflammatory status as well as their lipid metabolism, and CD recurrence, but not the extent of bowel resection, is the main predictor of alteration of serum lipid concentration.

Restorative proctocolectomy for ulcerative colitis: impact on lipid metabolism and adipose tissue and serum fatty acids.

The aim of this prospective study was to evaluate the changes of the metabolism of circulating and storage lipids in patients with ulcerative colitis after restorative proctocolectomy. Fifteen consecutive patients and 15 sex- and age-matched healthy controls were enrolled. Disease activity, diet, inflammatory parameters, plasma lipoprotein concentrations, and fatty acids (FA) of serum phospholipids and of the subcutaneous adipose tissue were assessed at colectomy and at ileostomy closure. In ulcerative colitis patients, total cholesterol and docosahexaenoic acid were lower than in healthy subjects (p < 0.01 and p < 0.05). The median interval between colectomy and ileostomy closure was 6 (range 2-9) months. During that interval, the inflammatory parameters improved, high-density lipoproteins (HDL) cholesterol increased (p < 0.01), and low-density (LDL) cholesterol decreased (p = 0.01). At ileostomy closure, serum arachidonic acid levels were increased (p = 0.04), whereas serum oleic acid level was decreased (p = 0.02). In this interval, no significant alteration, either in serum n-3 FA precursors or in the FA of subcutaneous adipose tissue, was observed. The increase of serum arachidonic acid after colectomy might suggest a lower utilization for inflammatory process. The reduction of LDL cholesterol is an index of malabsorption probably due to the accelerated transit and to the exclusion of the terminal ileum caused by the covering ileostomy.

Abdominal aortic aneurysm with coexistent horseshoe kidney.

Surgical repair of an abdominal aortic aneurysm (AAA) concomitant with a horseshoe kidney (HSK) may be technically demanding because of the complex anomalies of the kidney and of its collecting system and arteries, the greater risk of HSK-related complications, and the often unexpected intraoperative finding of HSK itself. We reviewed a database of more than 500 patients with AAA observed in our surgical department from 1994 to the time of writing. Five patients had AAA concomitant with HSK. Two of these patients did not undergo surgery because of the small dimension of the aneurysm or because of their poor health. The other three underwent successful repair of AAA with different techniques; namely, an aortobifemoral bypass via a thoracoabdominal retroperitoneal incision in one, a straight graft via an emergency median laparotomy in one, and an endovascular repair followed by open surgery 4 years later for endotension in one. Abnormal minor renal arteries were deliberately occluded and only one of these caused a minor renal infarct, but without functional impairment. These data and a review of the literature indicate that HSK should not preclude repair of coexistent AAA, as imaging procedures provide the information necessary to plan the best approach for each patient. Up-to-date surgical procedures, a posteriori retroperitoneal approach or endovascular repair, and deliberate occlusion of the minor renal arteries appear feasible and safe as they avoid most of the anatomical problems and provide results equivalent to those of uncomplicated aortic surgery.

Cytokine network in chronic perianal Crohn's disease and indeterminate colitis after colectomy.

Antitumor necrosis factor alpha (anti-TNF-alpha) therapy in perianal Crohn's disease (CD) is widely established but recent studies suggest that the underlying fistula tract and inflammation may persist. Treatment with a monoclonal antibody against interleukin (IL)-12 was reported to induce clinical responses and remissions in patients with active CD. The aim of our study was to analyze the cytokine network (TNF-alpha, IL-12, IL-1beta, and IL-6) in 12 patients with chronic perianal CD and a Crohn's disease activity index (CDAI) score <150 to exclude active intestinal disease, in 7 patients with indeterminate colitis (IC) after restorative proctocolectomy with perianal complications, in 7 patients with active intestinal CD without perianal manifestations, and in 19 healthy controls. Nonparametric Mann-Whitney U test and Spearman's rank correlation test were used. Serum TNF-alpha levels were significantly higher in patients with IC than perianal CD patients and healthy controls. Serum TNF-alpha levels significantly correlated with perianal CDAI score and with the presence of anal fistulas. Serum IL-12 levels correlated with the presence of anal strictures and were similar in all groups. Serum IL-6 levels were significantly higher in the presence of perianal fistulas and lower in the presence of anal strictures. Our study confirmed that TNF-alpha plays a major role in the perianal and intestinal CD. Furthermore, the significantly higher TNF-alpha serum levels in patients with IC suggest the use of anti-TNF-alpha in such patients. On the contrary, according to our results the efficacy of anti-IL-12 antibodies appears doubtful in chronic perianal CD or IC without anal strictures. The role of IL-6 as a systemic mediator for active chronic inflammation was confirmed and a possible role for its monoclonal antibody was suggested.

Risk factors of endoleak following endovascular repair of abdominal aortic aneurysm. A multicentric retrospective study.

Endoleak (EL) represents the most common complication following endovascular abdominal aortic aneurysm repair (EVAR). Unfortunately, the long-term results of EVAR and its durability have been questioned, and EL are variably associated with a risk of late failure. The aim of this retrospective study was to identify risk factors for this complication of aneurysm-endograft complex in patients who underwent EVAR. A group of 104 consecutive patients (99 men, 5 women; median age, 74 years; range, 50-89 years) were enrolled in the study. Both preoperative and follow-up imaging studies were obtained using helical computed tomography scanning at 1, 6, 12, 24, 36 months after EVAR and blindly reviewed by a surgeon and a radiologist. Twenty-seven (25.9%) patients developed EL during follow-up, of which 10 (37%) were primary (<30 days from EVAR), and 17 (63%) were secondary EL. Age and smoking did not affect the EL onset, while a body mass index >25 and a history or presence of arterial hypertension represented significant (p<0.05) risk factors. Moreover, both greatest diameter and maximum length of the aneurysm were significantly higher (p<0.01) in patients who developed EL. No relationship was found with the anatomical features of the aortic neck (i.e. length and diameter), and between the initial size of the aneurysm and the dimension at the time of EL. In conclusion, in our study, being overweight, arterial hypertension and the initial size of the aneurysm represent risk factors for EL development.

Intima-media thickness measurement of the carotid artery in patients with primary hyperparathyroidism. A prospective case-control study and long-term follow-up.

BACKGROUND: The intima-media thickness (IMT) measurement of the common carotid artery is recognized as a reliable marker of systemic atherosclerosis and may be useful in predicting the likelihood of cardiovascular events, since it is related to the extent and severity of coronary artery disease. The aims of this study were to analyze whether correlations exist between the IMT of the common carotid artery and the main clinical and biochemical parameters in patients with primary hyperparathyroidism (PHPT), and to evaluate the possible improvement of the IMT values following parathyroidectomy at long-term follow-up. PATIENTS AND METHODS: Twenty-seven patients (5 men, 22 women; median age 59 years, range 36-82 years) with biochemically confirmed PHPT (Group A, cases), and 27 gender- and age-matched healthy volunteers (Group B, controls) were prospectively enrolled in the study. All patients underwent ultrasound examination and the IMT of each carotid artery were recorded, averaging all values. The measurements were repeated 18-22 months (median 20) later in all patients. RESULTS: A significant (p < 0.05) correlation between age and both systolic BP and IMT, and between IMT and fasting glycaemia was found in each Group. There was an inverse relationship between IMT and serum parathyroid hormone (R = -0.56, p < 0.01), but no correlation (p=NS) was found between IMT and serum calcium (R = -0.14) or serum phosphate (R = 0.07). At follow-up a slight (10.4%) improvement in the mean IMT was observed among Group A patients (0.86 +/- 0.18 vs. 0.77 +/- 0.24; p = 0.12), but the difference was not significant. CONCLUSION: At long term follow-up, the IMT values did not improve significantly and no correlation was found between serum calcium and IMT. These results suggest that hypercalcemia does not represent a reliable risk of carotid atherosclerosis in patients with PHPT.

Laparoscopic colorrhaphy, irrigation and drainage in the treatment of complicated acute diverticulitis: initial experience.

The natural history of diverticulosis is worthy of note for its acute, sometimes recurrent, attacks of diverticulitis and the significant risk of serious complications, such as abscess, fistula and peritonitis. Most mild attacks of diverticulitis respond well to medical therapy while surgical treatment is indicated in the complicated forms of the disease. We evaluate the results of treatment of complicated acute diverticulitis by laparoscopic colorrhaphy, irrigation and drainage as a minimal surgical approach in 7 selected patients. We retrospectively analyzed all patients admitted to our institute for acute diverticulitis from 1996 to 2001. One hundred and thirty-five patients were admitted for acute sigmoid diverticulitis. Ninety-eight patients (72%) had their diverticular disease completely resolved after medical therapy, while 37 (28%) required a surgical approach. Seven patients underwent a laparoscopic colorrhaphy with irrigation and drainage. Laparoscopic procedures were completed in 6 patients. No perioperative morbidity or mortality was observed. All patients were discharged with no further re-operation. The technique could be considered a valid alternative for the management of complicated and perforated diverticulitis in selected patients.