Hybrid endografts in 'wide neck' abdominal aortic aneurysm in patients unfit for open surgery: The Funnel Technique - Case report and review of the literature.

OBJECTIVES: Abdominal aortic aneurysms with a wide proximal neck (>32 mm) are a contraindication for the use of conventional abdominal endovascular stent grafts because of their limited maximum proximal diameter (36 mm). In these cases, it is customary to resort to sophisticated techniques such as parallel or fenestrated grafts. In very selected cases, such as symptomatic wide neck aneurysm or patient with limited life expectancy, Funnel Technique may find an indication. METHODS: It consists in placing a bifurcated endograft in the abdominal aorta embricated with a thoracic endograft as a proximal cuff in an infrarenal position. RESULTS: In the literature review, we found 32 cases of this technique, whose characteristics are collected in a table. CONCLUSION: The Funnel Technique, taking advantage of the larger diameters of the thoracic prostheses, may easily treat abdominal aortic aneurysm cases with a wide neck.

Early evaluation of precise deployment with the new low-profile Zenith Alpha Thoracic Endoprosthesis in thoracic aortic disease.

BACKGROUND: Endovascular treatment of thoracic aortic disease currently allows to treat high-risk patients with better results than open repair. It represents the first option for treatment according to the most recent guidelines. The aim of the study is to evaluate the early results of the low-profile Zenith Alpha Thoracic Endoprosthesis (ZATE). METHODS: Between October 2012 and July 2015, 14 asymptomatic patients were treated with ZATE. 10 patients were male, mean age was 71, 7 years (range 58-85 years). 8 patients presented with atherosclerotic aortic aneurysm (7 thoracic aneurysm and 1 type I thoracoabdominal aneurysm), 2 chronic type B aortic dissection, 1 type IV endoleak 5 years after TEVAR, 3 aortic arch penetrating ulcers complicated by pseudoaneurysm. Hybrid staged procedures in 11 patients included 7 total aortic arch debranching (1 single [innominate] chimney stent-graft + carotid-carotid-subclavian), 2 carotid-carotid-subclavian artery bypass, 2 carotid-subclavian artery bypass. RESULTS: No 30-day mortality or major complications were observed. The mean length of stay was 7.3 days (range 4-14 days). Mean procedure time, X ray time and Contrast load were 115 minutes (range 90-150 minutes), 20 minutes (range 10-30) and 79 mL (range 40-120 mL) respectively. 25 stent-grafts were implanted. The mean follow-up was 21 months (range 14-32 months). No mortality and no major complications were observed during the follow-up. In case of arch debranching with landing 0 and 1 zone the mean distance between the beginning of the endoprosthesis and the debranching inflow vessel was 5.5±2.4 mm. CONCLUSIONS: The use of ZATE could be a viable alternative for treating patients with aortic arch proximal landing zone to facilitate the precise deployment. Larger case studies and longer follow-up are needed.

A retrospective study on short-term results with straight graft vs. bifurcated graft in abdominal aortic aneurysms: a single center experience.

BACKGROUND: The aim of this paper was to compare in a retrospective study the outcome of aortoaortic graft (straight graft) versus aortoiliac graft (bifurcated graft) with regards to periprocedural and 30-day after surgery complications. METHODS: From January 2004 to December 2009 377 patients underwent elective open surgery for infrarenal abdominal aortic aneurysm. Data were collected in a dedicated database. Group A includes patients treated with straight graft (N.=186) whereas group B, patients treated with bifurcated graft (N.=191). Outcome data include duration of surgical procedure, blood loss, peri- and postprocedural complications, hospital stay, 30-day mortality and complications. Following some authors, we set our cut-off for choosing a bifurcated graft when one or both Iliac Arteries were wider than 18 mm in diameter and the patient had a reasonable life expectancy. RESULTS: Duration of surgical procedure was 183 minutes in the group A vs. 216 minutes in the group B (P<0.01). Blood loss was 554 mL and 720 mL, in the groups A and B respectively (P<0.01). The difference between other results evaluated was not statistically significant. CONCLUSIONS: In statistics terms, this retrospective study showed no relevant differences between straight graft and bifurcated graft with regard to mortality and major complications during the peri- and postoperatory period. Hence, as a conclusion, we could assert that if the iliac artery diameter is 18 mm a bifurcated graft could be used, without any increase in morbidity and mortality rates.

Treatment with aromatase inhibitors and markers of cardiovascular disease.

PURPOSE: The cardiovascular effects of estrogen deprivation induced by aromatase inhibitors are unknown. We carried out a cross-sectional study to evaluate the effect of estrogen deprivation induced by aromatase inhibitors on markers of cardiovascular risk. METHODS: We enrolled 410 postmenopausal women: 200 consecutive breast cancer patients treated with aromatase inhibitors for a median of 53 months (range 23-122) and 210 volunteer controls. Carotid intima-media thickness, presence of carotid stenosis, and presence of abdominal aortic aneurism were evaluated through an ultrasound examination. RESULTS: Average carotid intima-media thickness was 0.97 ± 0.02 mm and 1.08 ± 0.02 mm for breast cancer group and control group, respectively (p < 0.005). The incidence of carotid stenosis in the two groups was similar: 24.2 % in the breast cancer group and 28.6 % in the control group (OR 0.80; 95 % CI 0.51-1.25; p = 0.32). No aneurismatic dilatation of the aorta was recorded. Average abdominal aortic diameter was 14.9 ± 2.4 mm in the breast cancer group and 15.0 ± 2.4 mm in the control group. CONCLUSIONS: Our study showed no association between treatment with aromatase inhibitors for five or less years and increased carotid intima-media thickness and higher prevalence of carotid stenosis or abdominal aortic aneurism. The lack of impact on these markers suggests that cardiovascular risk is not increased by treatment with aromatase inhibitors.

In Vitro Evaluation of Upstream and Downstream Influences on Blood Pressure of the Hybrid Treatment of Thoracoabdominal Aortic Aneurysms.

BACKGROUND: The aim of our study was to assess, by means of an experimental model, whether different geometries in retrograde bypass and stent-graft deployment may affect upstream and downstream blood pressure in hybrid treatment. METHODS: An in vitro model of the arterial circulation has been prepared, which consists of a peristaltic pump, silicon tubes with geometrical and mechanical properties close to realistic arteries, a terminal reservoir kept at constant pressure, and a sequence of pressure transducers. The system allows us to study the pressure wave propagation in physiological conditions and simulate the patient's conditions as a result of debranching in 2 different configurations. RESULTS: In configuration 1, the mean pressure value (Kpa) was 4.72 in silicone tube before stent graft and debranching, 4.59 in visceral and renal bypass, and 4.38 in silicone tube after stent graft and debranching. In configuration 2, the mean pressure value (Kpa) was 5.22 in silicone tube before stent graft and debranching, 4.48 in visceral and renal bypass, and 4.99 in silicone tube after stent graft and debranching. CONCLUSION: The experimental data suggest that the debranching geometry and the material of the grafts and stent grafts change significantly the physiological arterial pressure possibly leading to an augmented pressure upstream of the stent grafts, owing to retrograde pressure waves toward the heart, and a decreased pressure downstream visceral and renal arteries.

A true giant aneurysm of the anterior tibial artery.

Aneurysms of the anterior tibial artery are rare. We will describe a case of a woman with an asymptomatic true aneurysm of the anterior tibial artery. The patient presented with a pulsatile mass in the lateral face of the distal portion of the left leg, and both ultrasound examination and computed tomography angiography scan showed a giant aneurysm of the anterior tibial artery. We chose open treatment.