Open and endovascular treatment by covered and multilayer stents in the therapy of renal artery aneurysms: mid and long term outcomes in a single center experience.

AIM: The purpose of this paper is to evaluate the mid and long terms outcomes of open and endovascular surgical treatment, as well as multilayer stent, in patients affected by Renal Artery Aneurysm (RAA). PATIENTS AND METHODS: Twenty five patients with RAA (24 monolateral and 1 bilateral aneurysm, 26 aneurysms) were observed between 2000 and 2015: 4 were not treated due to the small size of the aneurysm (< 2.5 cm); out of the remaining, 16 underwent endovascular treatment, 2 were treated by open surgery consisting in aneurysmectomy and graft reconstruction and 5 (in 1 patient bilateral) were treated by ex vivo repair and autotransplantation. RESULTS: Out of the 22 patients treated for RAA, one patient operated upon open surgery presented an early thrombosis of a PTFE graft, followed by nephrectomy (4.7%); one patient underwent autotransplantation showed an ureteral kinking without functional consequences. In a follow-up ranging from 1 and 11 years (mean 5 years), no deaths were observed; all the renal arteries repaired were patents and 16 out of 21 patients had a significative reduction of systemic blood pressure. DISCUSSION: The choice of the best treatment is based on aneurysm's morphology according to Rundback's classification. The type I, involving the main renal artery, is always treated by endovascular approach; type II, involving renal artery bifurcations may be treated by open surgery or multilayer stents; type III (hilar or intraparenchymal aneurysms) needs only an open surgical treatment as autotransplantation. CONCLUSION: Based on our experience it seems that most of RAAs may be treated by endovascular technique. The ex vivo autotransplantation represents the first-line treatment in hilar and intraparenchymal aneurysms. Multilayer stents seem to have good outcome in the treatment of aneurysms involving arterial bifurcations. Mid and long term results, related to kidney preservation and to normalization of blood pressure, seems satisfying.

Classic and endovascular surgical management of isolated iliac artery aneurysms.

AIM: Isolated iliac artery aneurysm is a rare pathology that is often asymptomatic for long periods; this late diagnosis exposes patients to a high risk of death following aneurysm rupture. The aim of this study was to establish the most suitable diagnostic approach, the correct indications for treatment, and the most appropriate tactics and surgical technique. METHODS: Twenty-eight patients were observed over 13 years. Aneurysmal involvement was unilateral in 22 cases and bilateral in the remaining 6 patients. Preoperative diagnostic tests included eco-colour Doppler (ECD) and angio-CT in all cases, with angio-MR and angiography as more selective procedures. Seventeen patients underwent conventional open surgery with prosthetic replacement of the aneurysmatic tract, 7 patients were treated using endovascular exclusion, and lastly 4 were monitored over time. RESULTS: There was no perioperative mortality for either treatment. During the postoperative period following conventional open surgery, complications included one case of severe respiratory failure, one microembolism of the lower limb, and 2 periprosthetic hematoma. During the follow-up, we observed one pseudo-aneurysm, 3 cases of retrograde ejaculation and one patient with erectile dysfunction after traditional surgery; there was one minor endoleak after endovascular exclusion. CONCLUSIONS: Our experience suggests that ECD is a useful method for arriving at an early diagnosis, while angio-CT imaging is essential for a correct preoperative study. Aneurysms with a diameter equal or greater than 3 cm or that present annual increases in excess of 5 mm represent a correct indication for treatment. Conventional open surgery is the treatment of choice for young patients in good general conditions. Endovascular exclusion is indicated when the patient's clinical conditions contraindicate open surgery and the morphology of the aneurysmal arterial district allows the endoprosthesis to be safely implanted.

Embolism to the brain during carotid stenting and surgery.

UNLABELLED: The aim of this study was to assess the prevalence and clinical relevance of microembolism in one hundred unselected patients submitted to 50 carotid endarterectomy (CEA) and 50 carotid stenting (CAS) procedures from January 2005 to January 2006 for hemodynamic lesions of the carotid bifurcation (> 70% stenosis). MATERIAL AND METHODS: High-resolution Colour-Flow Mapping (CFM), Transcranial Doppler (TCD), cerebral computed tomography (CT) or magnetic resonance (MR) and four psychometric tests (Mini mental state, Beck depression inventory, Zung anxiety inventory, SF-12) were carried out in the preoperative evaluation in all the patients. In the CEAs loco-regional anesthesia (100%), patch angioplasty (84%) and Pruitt- Inahara shunt (4%) were employed; in the CASs local anesthesia (100%), three different carotid stents (Precise-Cordis, Acculink-Guidant and Carotid Wallstent-Boston Scientific) and three temporary distal filter protection devices (Angioguard-Cordis, Accunet-Guidant, Filterwire-EZ- Boston Scientific), without pre-dilatation, were employed. TCD monitoring was used intra-operatively and 12 hours post-operatively to evaluate the presence and the number of microembolic events (ME's) and to investigate the efficiency of neuroprotective filter devices. The efficacy of the in situ opened filter was judged evaluating the decrease of mean blood velocity in ipsilateral middle cerebral artery and the reduction rate of microembolic events (number of microemboli detected during the entire procedure/number of microemboli detected during the filter positioning). Diffusion-weighted magnetic resonance imaging (DWI) of the brain was obtained within 24 to 48 hours after the procedures to detect new ischemic brain lesions. Psychometric tests were repeated at the discharge of the patient and after two months to evaluate cognitive faculties. RESULTS: During postoperative period (30 days) and follow-up, no procedure-related death and three regressive minor strokes occurred : 1 in CEA (2%) and 2 in CASs (4%) ; a cranial nerve lesion occurred in CEA (2%). TCD monitoring showed ME's (a mean of five events) in 37 CEAs (74%) and in 50 CASs (100%) (a mean of 60 ME's). In five patients submitted to CAS repeated microemboli occurred during one hour postoperative TCD control (10%). A 10-30% decrease of mean blood velocity basal value was recorded in the ipsilateral middle cerebral artery when the filter device was opened. A mean 70% reduction of ME's was obtained with a cerebral protection system deployed. Postoperative DWI detected new focal ischemic lesions in 24 patients [22 after CAS (44%) (a mean of 5 new ipsi and contra-lateral lesions) , and 2 after CEA (4%). Cognitive capability worsened in 20 patients [18 after CAS (36%) e 2 after CEA (4%)]. CONCLUSIONS: Mortality and morbidity rates of patients submitted to CAS are comparable to the results obtained by CEA. A great number of ME's are recorded by TCD during endovascular procedures, more than during open surgery. ME's due to CAS are reduced by filter protection devices, but the cognitive faculties in a great number of "asymptomatic" patients are decreased after CAS.

Renal Stenting for Kidney Salvage in the Management of Renal Artery Atherosclerotic Stenosis.

We studied the usefulness of preoperative resistance index to select patients who will benefit most from renal stenting. Sixty-two patients underwent renal stenting. All had chronic renal insufficiency with serum creatinine values ranging from 1.5 to 2.5 mg/dL and blood urea nitrogen between 80 and 107 mg/dL. All treated renal artery stenosis were >70%. Reduction in blood pressure in the early stages was observed in 39 (62.9%) patients; 31 (79.4%) patients returned to preoperative values within 12 months. A progressive reduction in creatinine values and blood urea nitrogen was reached in 43 (69.4%) patients, 12 (19.4%) patients remained unchanged, and the remaining 7 (11.2%) patients worsened. The best improvement in renal function was obtained in patients with a resistance index of ≤0.75 A preoperative resistance index up to 0.75 could be used as an indicator to predict which candidates will have improved renal function after stenting.

Efficacy of an intravenous low-molecular-weight dermatan sulphate (Desmin) in patients with acute proximal deep venous thrombosis and silent pulmonary embolism. A pilot study.

Ten patients affected by proximal deep venous thrombosis were treated in an open study with a low-molecular-weight dermatan sulphate (Desmin), administered at doses of 400 mg (intravenous bolus) followed by 1200 mg/day infused intravenously for 10 days, without activated partial thromboplastin adjustment. The evolution of the deep vein thrombosis and the presence of silent pulmonary embolism were evaluated by phleboscintigraphy and lung scan, performed before treatment and after 10 days of treatment, and by repeated echocolour-Doppler examination (every 2 days during treatment). The evolution of deep vein thrombosis showed a considerable improvement; similarly, lung scan showed a substantial reperfusion of lung, with regression of perfusional deficit. Repeated echocolour-Doppler examination of the deep venous system during treatment did not document further thrombus extension in any patient. Tolerance and safety were excellent. No adverse effects were observed. These preliminary results indicate that the tested dose of Desmin can be effective in treating deep vein thrombosis and silent pulmonary embolism.

Aorto-iliac/femoral reconstructions in patients with vasculogenic impotence.

One hundred and forty-eight patients out of 386 undergoing aorto-iliac or aortofemoral bypass had preoperative impotence, 37 of these were diabetics. In all of them Doppler studies revealed a penile/brachial pressure index less than 0.6 and an abnormal waveform analysis. Nocturnal penile tumescence was investigated in 44 cases and found to be abnormal. Angiography showed unilateral or bilateral obstructive lesions of the hypogastric arteries in 80%, in addition to aortic, common and external iliac and femoral lesions. One hundred and thirty patients (87.8%) had straight aorto-iliac/femoral bypass grafts inserted without a direct attempt to revascularise the hypogastric arteries but 24 had distal anastomoses to the bifurcation of the common iliac artery. In the remaining 18 patients the hypogastric artery was reconstructed on one side by an additional bypass or reimplantation on the graft. In 22 of 106 patients (20.7%) undergoing aortofemoral bypass, 18 of 24 (75%) with the distal anastomosis to the iliac bifurcation, and 14 of the 18 (77.7%) with revascularisation of the hypogastric arteries, erectile function was regained. A good result was obtained in only five of the diabetic patients (13.5%). Our experience suggests that: (1) impotence, as indicated by non-invasive investigations, was vasculogenic in origin since patients with the most effective revascularisation of the hypogastric arteries had the best results; (2) when it is feasible, revascularisation of the hypogastric arteries should be carried out more often, during the aorto-iliac or aortofemoral reconstructions, particularly in younger impotent patients; (3) aorto-iliac revascularisation restores potency in only a few diabetic patients.

[Phlebography with MR in the study of deep venous thrombosis]. / Flebografia con RM nello studio delle trombosi venose profonde.

MR phlebography was recently proposed as a possible alternative to contrast venography in the detection of deep venous thrombosis. We focused our work on the study of the pelvic veins since it is at this level that contrast venography and the other noninvasive techniques, i.e., phlebography, impedance plethysmography and US, exhibit their major limitations. Thirty patients underwent MR phlebography: 13 of them had a diagnosis of DVT of the pelvic venous district and the other 17 had negative results for this condition. All the patients were also examined with color-Doppler US at the pelvis and legs. In all the patients submitted to MR phlebography, thrombosis site and presence were demonstrated, with diagnostic information also on its extent and adhesion to vein wall. To conclude, MR phlebography can provide contrast venography-like images in a noninvasive way, with high accuracy (100% sensitivity and 90% specificity) especially in the pelvic district where the limitations of other techniques are more apparent. Larger series of patients must be studied to assess the actual role of MR phlebography in the patients with DVT or at high risk for this condition.

Role of MR venography in the evaluation of deep venous thrombosis.

PURPOSE: MR venography has been recommended for the evaluation of deep venous thrombosis. The purpose of our study was to determine the role of MR venography, in particular at the level of the pelvis where other diagnostic modalities show major limitations. MATERIALS AND METHODS: Forty-three patients with clinical suspicion of deep venous thrombosis were examined by means of pelvic MR venography. In all cases, a 2D-TOF sequence was used with cranial arterial presaturation. In selected cases, i.e. when a small intraluminal filling defect was present, a cine-PC sequence was used in addition in order to exclude the presence of a pulsatility artifact as causing the filling defect. In all cases, contrast venography was also performed and considered to be the standard of reference. RESULTS: MR venography showed 26 patients to be positive for deep venous thrombosis at the pelvic level. These positive results were correct in 25 cases. The analysis of the results provided values of sensitivity and specificity of respectively 100% and 94%, with an overall accuracy of 97.6%. CONCLUSIONS: Our results indicate that MR can provide highly accurate images, similar to those of contrast venography, in a noninvasive fashion. It is particularly useful in the pelvic region where the limitations of other imaging modalities are more evident.