Stent-Assisted Coil Embolization of a Saccular Visceral Aortic Aneurysm: Case Report and Review of the Literature.

PURPOSE: We present the results of unconventional endovascular treatment of a voluminous (65 mm) saccular visceral aortic aneurysm in a 78-year-old woman. Patient was deemed unfit for open surgery due to comorbidities. Fenestrated or branched endografting was also excluded due to the small diameter of the aorta, the severe stenosis at the origin of celiac trunk, and the anomalous origin of superior mesenteric artery arising infrarenally. CASE REPORT: After a preliminary selective angiography of the superior mesenteric artery showing valid anastomotic network with celiac trunk branches, an aortic self-expandable bare stent (Jotec E-XL) was deployed in the visceral aorta. Aneurysm sac embolization (Penumbra detachable Ruby Coils) in a coil-jailing technique was performed. Finally, an aortic cuff endograft (Gore) was deployed immediately above the origin of the left renal artery to cover the wide neck of the saccular aneurysm and improve sac exclusion. Hospital stay was uneventful, computed tomography (CT) at 12-month demonstrated aneurysm shrinkage to 62 mm without images of endoleak. Literature review showed how this technique has successfully been applied to manage similar cases of postsurgical and posttraumatic saccular aortic aneurysms in high-risk patients; however, long-term results are still unknown. CONCLUSION: Coil-jail technique for the treatment of saccular aortic aneurysms can be considered an alternative when open surgery or conventional endovascular treatment is not feasible. Technical success and mid-term outcomes are promising but strict follow-up is recommended. CLINICAL IMPACT: This study aims to share the unconventional endovascular treatment of a visceral aortic aneurysm in a patient unfit both for open and traditional endovascular surgery. To the best of our knowledge this is one of the first cases published in Literature, for this reason, a step-by-step video has been created to describe the procedure. Literature review was then performed to analyze midterm results of this technique. Despite being a treatment that is not recommended for conventional cases, the knowledge of endovascular devices and techniques may help to manage or simplify complex aortic diseases.

Long-Term Outcomes of Open and Endovascular Abdominal Aortic Repair in Younger Patients.

BACKGROUND: Aim of this study is to evaluate long-term results in abdominal aortic aneurysm (AAA) surgery by either open aortic repair (OAR) or endovascular aortic repair (EVAR) in patients under 70 years of age. METHODS: A retrospective analysis of a prospectively collected database of patients with age under 70 years old undergoing elective infrarenal AAA surgery between 2010 and 2018 was performed. The study population was divided into 2 groups: OAR and EVAR. Primary end points were overall survival and aneurysm-related death, while secondary outcomes were need for reintervention and development of minor and major complications. RESULTS: One hundred ninety-one patients younger than 70 years old treated with elective AAA surgery were enrolled: 157 OAR (98% males, mean age 65 ± 4 years) and 34 EVAR (94% males, mean age 66 ± 4 years). Hospital stay, 30-day mortality, and need for reintervention were similar; OAR population presented higher incidence of postoperative major complications (18% vs. 2.9%; P = 0.01) while minor complications were 32% in the OAR versus 21% in the EVAR group (P = 0.08). Median follow-up was 69 months for OAR (interquartile range [IQR] 53 months) vs. 79 months (IQR 51 months) for EVAR (P = 0.9): long-term AAA-related reinterventions were more frequent after EVAR (1.9% OAR vs. 17% EVAR; P = 0.01) while AAA-related long-term mortality was similar in both subgroups (1.3% OAR and 3% EVAR; P = 0.8). At univariate analysis higher risk of reintervention was reported for conical necks in the EVAR group (P = 0.03) and for the concomitant presence of iliac aneurysms in both groups (P = 0.01). CONCLUSIONS: According to our data, EVAR in young patients is presenting an excessive rate of reintervention compared to OAR. The presence of conical neck is an independent predictor of EVAR failure and late reintervention, while it does not play a significant role in the OAR group. Open surgery should be considered the first option in younger patients with a long-life expectancy.

Physician-modified fenestrated Navion endograft for the treatment of a symptomatic postdissection thoracoabdominal aneurysm.

We report the case of a physician-modified four-fenestration endograft for the emergent treatment of a 65-year-old patient with postdissection thoracoabdominal aneurysm deemed unfit for open surgery. The patient, after elective thoracic endovascular aneurysm repair as the first stage of a preplanned two-stage total thoracoabdominal endovascular repair, presented acute onset of dyspnea and thoracic pain. Computed tomography angiography (CTA) showed signs of contained rupture. The Valiant Navion thoracic endograft was used for the creation of a physician-modified four-fenestration stent graft. A diameter-reducing wire technique was used to constrain posteriorly the prosthetic graft and to allow intraprocedural partial deployment. The modified stent graft was finally folded into its original sheath and implanted; four balloon-expandable stent grafts were used as bridging components. Postoperative CTA showed a residual type IIIc endoleak that was treated with a relining procedure 4 months later. At the 20-month follow-up, the patient is alive and well and CTA shows complete seal of the thoracic aneurysm with persisting small type IIIc endoleak in the abdominal aneurysm. A physician-modified endograft can be considered a valuable option in case of urgent treatment of TAAA in patients deemed unfit for open surgery when off-the-shelf devices are not available or contraindicated.

Long Term Outcomes of Endovascular Aortic Repair in Patients With Abdominal Aortic Aneurysm and Ectatic Common Iliac Arteries.

OBJECTIVE: The purpose of this study was to evaluate the long term results of endovascular aneurysm repair (EVAR) in patients with abdominal aortic aneurysm (AAA) and ectatic common iliac arteries (CIAs). METHODS: In a retrospective analysis of a prospectively collected database in two high volume centres, patients with AAAs undergoing elective standard EVAR were divided into two groups: those with both CIA diameters <18 mm, and those with at least one ectatic iliac artery (CIA ≥ 18 mm). Patients with an intentional external iliac artery landing zone were excluded. Primary outcomes were survival and freedom from re-intervention. Secondary end points were EVAR failure and iliac related endoleak and iliac re-intervention. RESULTS: From 2000 to 2015, 648 patients were included in the study, 277 (43%) had at least one CIA ≥ 18 mm. Pre-operative risk factors were similar between the two groups, with the exception of chronic renal insufficiency (p = .010) and cerebrovascular events (p = .040), which were higher in the ectatic CIA group. At 30 days from primary procedure, there was a higher rate of type Ib endoleak in patients with ectatic iliacs (p = .020). A statistically significant increase in the incidence of late type Ib endoleak in patients with ectatic iliac arteries was confirmed at a mean follow up of 74.8 months (p = .01). The need for iliac related re-intervention was higher in patients with CIAs ≥18 mm (odds ratio 1.94; 95% confidence interval 1.1-3.2). CONCLUSION: Ectatic iliac arteries are considered suitable landing zones for EVAR, although there is an increased risk of secondary interventions in time mainly due to late CIA dilation and secondary type Ib endoleak. Patients receiving EVAR with flared iliac limbs may benefit a more intensive surveillance to avoid late failures.

Impact of the Supra-Aortic Trunks and Circle of Willis Patency on the Neurological Compensation during Carotid Endarterectomy.

BACKGROUND: One of the most critical phases of carotid endarterectomy (CEA) is the carotid cross-clamping test, which is a concrete evaluation of efficacy of collateral cerebral perfusion. Some studies revealed a strong correlation between tolerance to carotid cross-clamping and postoperative transient ischemic attack (TIA)/stroke complications. The aim of the study is to make a global analysis of supra-aortic trunks (SAT) and circle of Willis (CoW) patency to predict the tolerance to carotid cross-clamping preoperatively. METHODS: We observed retrospectively 503 patients who underwent CEA under local anesthesia between January 2012 and 2017. We analyzed single preoperative risk factors, drug therapy, and vessels patency of the group of patients who did or did not present neurological symptoms at carotid cross-clamping. Afterward, we created a cerebral perfusion score (PTOT) to estimate the efficacy of collateral cerebral perfusion and we compared the results from both groups. The score ranges from 0 (hypothetical total occlusion of the SAT and CoW) to 0.65 in case of patency of all arterial districts. Moreover, we evaluated postoperative complication rates. RESULTS: Patients with previous neurological symptoms, female gender, and diabetes correlate with a lower tolerance to carotid cross-clamping (odds ratio: 2.57, 2.78, and 2.57, respectively; P value < 0.05). The SAT and CoW score revealed that patients with score <0.2 more frequently did not tolerate carotid cross-clamping (P value 0.01). Patients who required an intraoperative shunt presented a higher risk of TIA/stroke within 30 days from surgery than those with a better neurological compensation (P value 0.03). CONCLUSIONS: The efficacy of cerebral mechanisms of compensation during carotid cross-clamping reflects the capability of the brain to adapt to ischemic insults, and this also correlates with the postoperative risk of TIA/stroke. It is possible to identify preoperatively patients with a higher risk of neurological intolerance at carotid cross-clamping. This score could be a useful method to make a further stratification of risk of neurological complications and eventually to prefer a general anesthesia and the use of shunt for those with PTOT < 0.2.

Successful percutaneous transgluteal embolization of a complex arteriovenous malformation feeding a hypogastric artery aneurysm.

Pelvic arteriovenous malformation (AVM) is a rare condition mostly requiring a complex therapeutic strategy. The surgical approach is challenging and burdened by relatively high mortality and morbidity rates. No guidelines are available for the endovascular treatment of AVM because the literature is limited to small case series and case reports. We present a complex case of a pelvic AVM associated with an internal iliac artery aneurysm in a patient previously treated with a common to external prosthetic substitution for aneurysm and proximal ligation of internal iliac artery.

U Stent-Graft Technique as a Treatment for Homolateral Metachronous Common Iliac and Internal Iliac Arteries Aneurysms after Open Surgery.

We report a case of a metachronous common iliac artery and the internal iliac artery (IIA) aneurysm developed 8 years after an aortobi-femoral bypass for treatment of abdominal aortic aneurysm associated at chronic occlusion of the right iliac axis. To exclude the metachronous aneurysm on the left iliac axis and to maintain the pelvic circulation, an external to IIA endografts were positioned ("U stent-graft technique"). At 6-month follow-up, the computed tomography scan showed patency of the endografts, of the bypass and of the IIA, without endoleak, or other adverse events.

Open Surgical Treatment of a Severe Case of Obstructive Calcifying Aortic Disease.

The obstructive calcifying aortic disease refers to severe calcifications of the descending aorta that obstruct or slow blood flow. Here, we report the case of a 65-year-old woman with recent onset of a very tight intermittent claudication and concomitant severe and uncontrolled hypertension, treated with a bypass graft between the proximal descending thoracic aorta and the supravisceral abdominal aorta.

Use of Contrast-Enhanced Ultrasound in Carotid Atherosclerotic Disease: Limits and Perspectives.

Contrast-enhanced ultrasound (CEUS) has recently become one of the most versatile and powerful diagnostic tools in vascular surgery. One of the most interesting fields of application of this technique is the study of the carotid atherosclerotic plaque vascularization and its correlation with neurological symptoms (transient ischemic attack, minor stroke, and major stroke) and with the characteristics of the "vulnerable plaque" (surface ulceration, hypoechoic plaques, intraplaque hemorrhage, thinner fibrous cap, and carotid plaque neovascularization at histopathological analysis of the sample after surgical removal). The purpose of this review is to collect all the original studies available in literature (24 studies with 1356 patients enrolled) and to discuss the state of the art, limits, and future perspectives of CEUS analysis. The results of this work confirm the reliability of this imaging study for the detection of plaques with high risk of embolization; however, a shared, user-friendly protocol of imaging analysis is not available yet. The definition of this operative protocol becomes mandatory in order to compare results from different centers and to validate a cerebrovascular risk stratification of the carotid atherosclerotic lesions evaluated with CEUS.

Rupture of giant superficial femoral artery aneurysm in a leukemic patient submitted to chemotherapy.

The superficial femoral artery (SFA) is a relatively rare location for lower limb aneurysmatic disease. In the literature, this disease is described an association between a relatively high growth rate and/or the rupture of aneurysms and chemotherapeutic agents. We report a case of the rupture of a giant SFA aneurysm in a patient during chemotherapy for acute lymphatic leukemia.

Abdominal aortic endograft collapse due to false lumen radial force of an acute type B aortic dissection.

We report a case of abdominal endograft proximal collapse due to acute type B aortic dissection in a patient previously treated with endovascular repair (EVAR) for an infrarenal abdominal aortic aneurysm. Patient underwent axillobifemoral bypass grafting, in emergency. The postoperative computed tomography scan showed reexpansion of the occluded endograft. The patient died after 2 days with evidence of progression of the thrombosis of the false lumen and with involvement of renal, visceral, and medullar artery. EVAR collapse associated to acute type B aortic dissection is a challenging condition, which requires aggressive approach.

Fungal infection of aortic Endograft because of Aspergillus fumigatus.

A 59-year-old male, referred to our center with a ruptured aortic aneurysm, underwent urgent endovascular repair and femoro-femoral crossover bypass. An endograft infection because of Aspergillus fumigatus occurred about 20 days after surgery. We removed the endograft and femoral prosthesis and we then performed an aorto-bi-iliac bypass with autogenous reversed superficial femoral veins. Five days after surgery, the patient died. Microbiological examination and postmortem examination showed the presence of A. fumigatus in femoral prosthesis, aortic wall, and periaortic exudate.

Pulmonary embolism due to popliteal vein aneurysm during pregnancy induced by in vitro fertilization.

Popliteal vein aneurysms (PVAs) are rare but may cause severe and even fatal complications, such as pulmonary embolism (PE). A woman at the eighth week of pregnancy came to our attention because of a thrombosis of a previously undetected left PVA, diagnosed after a PE episode. Surgery was delayed until after delivery and breastfeeding, during which anticoagulant therapy was established.

A retrospective study on early carotid endarterectomy within 48 hours after transient ischemic attack and stroke in evolution.

BACKGROUND: Large randomized controlled trials have shown that carotid endarterectomy (CEA) is beneficial in the treatment of recent severe symptomatic carotid stenosis. Data are lacking concerning the risks of early CEA (<48 hours) for stroke in evolution (SIE) or crescendo transient ischemic attack (CTIA). The primary end point of this retrospective study was to evaluate the incidence of stroke, major adverse cardiac events (MACEs), and death within the first 30 days after early CEA performed within 48 hours in patients presenting with transient ischemic attack (TIA)/SIE. METHODS: Between 2001 and 2010, we treated 3,023 carotid artery stenoses, 29.5% (891/3,021) of which were in symptomatic patients. Early CEA within 48 hours after acute TIA/SIE was performed in 176 patients. Patients were divided into 3 groups for analysis of outcome after early CEA in symptomatic patients according to their initial neurologic deficit. Group 1 included 55 patients with TIA (single); group 2 included 55 patients with CTIA, and group 3 included 66 patients with SIE. Carotid artery stenosis was evaluated by duplex ultrasonography (DS). All patients were pre- and postoperatively visited by an experienced consultant neurologist who evaluated the neurologic status according to the modified Rankin Scale and the National Institutes of Health Stroke Scale (NIHSS). At admission, surgery was not performed on patients with disabling neurologic deficit (NIHSS score: >6) except for 4 selected cases (NIHSS score range: 8-14), patients with cerebral lesions >3 cm in diameter, patients with the presence or suspicion of parenchymal hemorrhage, patients with occlusion of the middle cerebral artery, and those who were deemed unfit for surgery. Clinical and DS follow-up examinations were performed after 6 and 12 months and annually thereafter. The mean duration of follow-up was 29.4 months (range: 0-120 months). RESULTS: The cumulative TIA/stroke/myocardial infarction/death rate at 30 days was 3.9% (7/176). TIA and stroke rates were 0% (0/176) and 3.4% (6/176), respectively. The stroke rate in groups 1, 2, and 3 was 1.8% (1/55), 0% (0/55), and 7.6% (5/66), respectively. No hemorrhagic strokes, TIAs, or MACEs were detected after surgery. Stroke risk was higher in group 3 than in groups 1 or 2, but the differences in the 3 groups were not statistically significant (group 1 vs. group 2: 1/55 vs. 0/55 events [P = 0.3151]); group 1 vs. group 3: 1/55 vs. 5/66 events [P = 0.3020]; and group 2 vs. group 3: 0/55 vs. 5/66 events [P = 0.1039]. Thirty-day follow-up was available for all patients, while long-term follow-up (mean: 32.7 ± 26.8 months) was available only for 158 patients (1 patient died and 17 were lost to follow-up). CONCLUSIONS: CEA can be performed with an acceptable risk in properly selected symptomatic patients within 48 hours after TIA or SIE. The benefits of early CEA in symptomatic patients include the prevention of recurrent stroke.

Open conversion after endovascular aortic aneurysm repair: a single-center experience.

BACKGROUND: The endovascular treatment of an abdominal aortic aneurysm (AAA) is a treatment with low risk and good reported results. This retrospective study analyzed experience with patients requiring surgical conversion after endovascular abdominal aortic aneurysm repair (EVAR). METHODS: A total of 26 patients underwent open conversion (OC) after EVAR (18 endografts implanted at the authors' center and 8 in other centers). Patients were divided into 2 groups: early conversion if OC was performed within 30 days from the primary EVAR, and late conversion if OC was performed at least 30 days after EVAR. The authors analyzed all data on OC and the postoperative course. RESULTS: In this series, OC was performed for 22 endoleaks (13 type I, 5 type II, 2 type III, and 2 type V, which in 5 cases these were associated with AAA ruptures), 2 renal artery coverages, and 2 endograft infections. Six (23%) patients underwent early conversion with a mortality rate of 50%, and 20 (77%) had late conversion with a mortality rate of 20%. The overall mortality rate after OC, occurring before hospital discharge or within 30 days, was 26.9% (7 of 26). CONCLUSIONS: Endoleaks remain the weak point of endografts and can result in aneurysm rupture/death. Urgent OC and infections engender a high mortality. Elective OC can be performed with very low mortality and acceptable morbidity. Lifelong surveillance is necessary to detect and treat endoleaks.