Endovascular Treatment of Severely Calcified Femoropopliteal Lesions Using the "Pave-and-Crack" Technique: Technical Description and 12-Month Results.

PURPOSE: To report midterm results of the "pave-and-crack" technique to facilitate safe and effective scaffolding of heavily calcified femoropopliteal lesions in preparation for delivery of a Supera interwoven stent. METHODS: Data were collected retrospectively on 67 consecutive patients (mean age 71±8 years; 54 men) treated with this technique between November 2011 and February 2017 at a single center. A third (22/64, 34%) of the patients had critical limb ischemia (CLI). Most lesions were TASC D (52/67, 78%), and the majority were occlusions (61/66, 92%). The mean lesion length was 26.9±11.2 cm. Nearly two-thirds (40/64, 62%) had grade 4 calcification (Peripheral Arterial Calcium Scoring System). To prepare for Supera stenting, the most heavily calcified segments of the lesion were predilated aggressively to obliterate recoil. A Viabahn stent-graft was then implanted to "pave" the lesion and protect from vessel rupture as aggressive predilation continued until the calcified plaque was "cracked" before lining the entire lesion with a Supera stent. Patency and target lesion revascularization (TLR) rates were estimated using the Kaplan-Meier method. RESULTS: Procedural success was achieved in 100% and technical success (residual stenosis <30%) in 98% (66/67). The mean cumulative stent lengths were 16±9 cm for the Viabahn and 23±12 cm for the Supera. Only 2 complications occurred (distal embolization and access-site pseudoaneurysm). Two CLI patients died within 30 days, and 3 patients (all claudicants) underwent a TLR. Patients were followed for a mean 19±18 months, during which another 2 CLI patients died and 1 patient had a major amputation. One-year primary and secondary patency estimates were 79% and 91%, respectively; freedom from TLR was 85%. CONCLUSION: Despite severe lesion calcification, patients experienced high technical success and a safe and durable therapy at midterm follow-up with the femoropopliteal "pave-and-crack" technique.

Increased circulating chemerin in patients with advanced carotid stenosis.

BACKGROUND: Chemerin is an adipokine which plays a crucial role in atherosclerosis. Here, we examined whether circulating chemerin is enhanced in patients with advanced carotid stenosis. METHODS: Chemerin was quantified in 178 patients prior to carotid end arterectomy (CEA) and in age- and gender-matched controls (n = 163). Chemerin levels were related to anthropometric, clinical and metabolic characteristics of the patients. RESULTS: Chemerin levels were higher in patients compared to controls (p <  0.001). Chemerin correlated to parameters associated with inflammation such as C-reactive protein (CRP, p <  0.001), leukocyte blood count (p <  0.001) and circulating TNF-α (p = 0.004) in the patients. Chemerin levels did not differ between asymptomatic (n = 93) and symptomatic patients who experienced an ischemic event within 6 months prior to CEA (n = 85). However, in the case of high-grade carotid stenosis (≥ 90%), chemerin levels were higher in symptomatic (n = 44) compared to asymptomatic patients (n = 41, p = 0.014). Chemerin was increased in patients with (n = 50) compared to patients without (n = 128) coronary artery disease (CAD, p = 0.002). A high level of chemerin increases the risk for CAD in patients (p = 0.0013). CONCLUSIONS: Circulating chemerin is increased and correlates to inflammatory parameters in patients with advanced carotid stenosis.

Endovascular Repair of the Thoracic or Thoracoabdominal Aorta Following the Frozen Elephant Trunk Procedure.

BACKGROUND: This study evaluated the outcomes of endovascular repair of the thoracoabdominal aorta following the frozen elephant trunk (fET) procedure. METHODS: Between October 2014 and July 2018, 249 patients underwent thoracic or thoracoabdominal endovascular aortic repair in our institution. Of these, 10 patients (50% male) underwent second-stage endovascular repair after previous fET implantation. Feasibility and outcomes were evaluated. RESULTS: The mean interval between fET implantation and the second-stage endovascular repair was 136 days (range, 14-282 days). Indications for second-stage endovascular repair were thoracoabdominal aortic aneurysm Crawford type I (n = 3) or Crawford type II (n = 4) and complicated residual aortic dissection after fET (n = 3). We implanted 4 branched custom-made devices and 4 off-the-shelf thoracic stent grafts. Two patients were treated using the provisional extension to induce complete attachment (PETTICOAT) technique through a percutaneous access. The median intensive care unit stay was 1 day (range, 0-3 days), and median hospital stay was 7 days (range, 5-12 days). Spinal cord preconditioning was performed in 70% of our patients with zero paraplegia at 30 days. Computed tomographic scans at 8.5 ± 11.4 months of follow-up showed complete false lumen thrombosis of all type B aortic dissections and 1 type III endoleak with constant aneurysm diameter. Branch patency was 100%. CONCLUSIONS: Second-stage endovascular repair after a previous fET is feasible with good midterm results. This staged hybrid procedure is extremely effective in patients whose aneurysms are confined both to the arch and thoracoabdominal aorta, leading to an excellent functional result. In case of favorable anatomy, endovascular repair in residual type B aortic dissection led to complete false lumen thrombosis.

Free cholesterol, cholesterol precursor and plant sterol levels in atherosclerotic plaques are independently associated with symptomatic advanced carotid artery stenosis.

BACKGROUND AND AIMS: Circulating sterols result either from cholesterol (CH) synthesis or intestinal uptake. They are mainly esterified and can be oxygenated. Sterols accumulate in atherosclerotic plaques whereby their clinical impact is uncertain. Here, we determined associations between circulating and plaque sterol levels in patients with advanced carotid artery stenosis in respect to a prior ischemic event and statin treatment. METHODS: Free and esterified CH, CH precursors and plant sterols as well as oxysterols were quantified by liquid chromatography-tandem mass spectrometry in 63 consecutive patients undergoing carotid endarterectomy. RESULTS: CH, CH precursors, plant sterols and oxysterols accumulated in carotid artery plaques. Absolute circulating sterol levels were not predictive for their corresponding plaque levels. After normalisation to CH, plant sterol but not oxysterol levels correlated between plasma and plaques. Among the circulating sterols, oxysterols occurred proportionally less in plaques. Furthermore, CH and plant sterols were less esterified in plaques than in plasma. Patients who experienced a prior ischemic event (n = 29) and asymptomatic patients had, except for lanosterol, comparable circulating sterol levels. In contrast, the absolute plaque levels of free CH, CH precursors and plant sterols as well as oxysterols were increased in symptomatic compared to asymptomatic patients. These differences remained significant for free CH, precursors and 3 out of 4 analyzed plant sterols after adjustment to the most influencing covariates - statin treatment, type 2 diabetes and age. CONCLUSIONS: Increased absolute plaque levels of free CH, precursors and plant sterols predict an ischemic event in patients with advanced carotid artery stenosis.

Retroperitoneal space-occupying lesion with displacement of the inferior vena cava.

INTRODUCTION: The differential diagnosis and therapy of retroperitoneal masses suspicious for soft tissue tumors remains difficult and needs individual decisions as to the best management of patients. We report an unusual case of retroperitoneal schwannoma (RS). PRESENTATION OF CASE: We report on a 57-year-old female patient with a retroperitoneal space-occupying lesion with displacement, but no infiltration of surrounding vessels, especially the inferior vena cava. As presence of malignancy could not be completely excluded by imaging and biopsy, we performed an open resection of the tumor with plastic reconstruction of the right renal vein. Curative resection of the tumor could be achieved and benign RS verified. DISCUSSION: Preoperative work-up, including a broad spectrum of differential diagnoses, and consecutive appropriate surgical resection are challenging. Characteristic features of the pre-therapeutic diagnostics of retroperitoneal schwannomas are discussed and differential diagnostic considerations as well as surgical therapeutic options are outlined. CONCLUSION: Deeper understanding of retroperitoneal schwannomas gained from preoperative radiologic diagnostics may serve to underline the need for targeted biopsy. This and its histopathological examination necessitate expert interventional radiologists and pathologists. Thus, even the pre-therapeutic diagnostic management should be performed in a specialized center. If doubts remain regarding the entity of the retroperitoneal lesion and findings are still controversial after thorough assessment, surgical oncologic resection represents the therapy of choice, if the surgical risk is adequate.

Technical limitations of REBOA in a patient with exsanguinating pelvic crush trauma: a case report.

BACKGROUND: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an effective adjunct in hemodynamic unstable patients with uncontrolled and non-compressible torso hemorrhage promoting temporary stability during injury repair. The aim of our study was to analyze real life usability of REBOA based on a case report and to review the literature with respect to its possibilities and limitations. CASE PRESENTATION: We present the case of a 17-years old female patient who sustained a severe roll-over trauma and pelvic crush injury as a bicyclist by a truck. Upon arrival of the first responders, the patient was awake, alert, and following commands.Subsequent to lifting the truck, the patient became hypotensive and required cardiopulmonary resuscitation, application of a pelvic binder, and endotracheal intubation at the accident scene. She was then admitted by ambulance to our trauma center under ongoing resuscitative measures. After primary survey, it was decided to perform a REBOA with surgical approach to the left femoral artery. Initial insertion of the catheter was successful but could not be advanced beyond the inguinal region. Hence, the patient was transferred to the operating room (OR) but died despite maximum therapy. In the OR and later autopsy, we found a long-distance ruptured and dehiscent external iliac artery with massive bleeding into the pelvis in the context of a bilateral vertical shear fractured pelvic bone. CONCLUSION: REBOA can be a useful adjunct but there is a major limitation with potential vascular injury after pelvic trauma. In these situations, cross-clamping the proximal aorta or pre-peritoneal pelvic packing as "traditional" approaches of hemorrhage control during resuscitation may be the most considerable methods for temporary stabilization in severely injured trauma patients. More clinical and cadaveric studies are needed to further understand indications and limitations of REBOA after severe pelvic trauma.

Factors associated with morbidity and in-hospital mortality after surgery beyond the age of 90: Comparison with outcome results of younger patients matched for treatment.

BACKGROUND: Surgical outcome to extremes of age is understudied. The purpose of this study was to evaluate the patient characteristics and incidence of postoperative morbidity and in-hospital mortality among patients aged 90 years and older who underwent surgery in comparison to younger controls. METHODS: Patients aged 90 years or older (n = 80; mean age, 92.36 ± 2.37) were matched for surgical treatment with patients aged 79 years or younger (n = 80; mean age, 55.98 ± 15.95) taken from the same cohort. RESULTS: The overall morbidity and mortality rates were 57.5% and 31.3% in the elderly vs. 47.5% and 23.1% in the younger group respectively. Patient groups aged 90 years or older and 79 years or younger each had 4 and 6 predictive factors for morbidity and 10 and 9 predictive factors for mortality respectively. CONCLUSION: while advanced age carries an increased risk of morbidity and mortality, it seems that age in itself is no barrier to surgery. Despite the comparably high prevalence of chronic disease, elderly patients in this study fared quite well.

Single-center experience with vascular closure devices in real-world endovascular peripheral interventions.

BACKGROUND: The aim of the current study was to evaluate the efficacy and safety of vascular closure devices (VCDs) in non-cardiac endovascular interventions. METHODS: Retrospective analysis of consecutive patients submitted to endovascular interventions, with deployment of 2327 vascular closure devices. Demographic, clinical/periprocedural, post-operative, complication and reintervention data were reviewed. RESULTS: A total of 2107 patients (1409 [66.9%] men) were included. Perclose ProGlide® (Abbott Vascular) was employed 1683 times (72.3%), Angio-Seal™ (St. Jude Medical Inc.) 463 (19.9%) and 181 (7.8%) Exoseal® (Cordis). Patients were 70.4±11 years old. Of all vascular approaches, 1794 were retrograde (77.1%) and 533 antegrade (22.9%), with sheath size ranging from 5 to 8 French. Overall success rate was 95.2% and did not significantly vary according to the device. Overall failure rate was 4.8%, with high puncture site, morbid obesity, previous total anticoagulation and severe calcification being related to worse efficiency results. Major complications occurred in 15 patients (0.6%). All patients were evaluated before discharge from the hospital, and were scheduled to return for ambulatory follow-up visits at 30 days postoperatively. Control duplex ultrasonography was performed on a regular basis, or within this period in case of clinical complain/signs. CONCLUSIONS: Vascular closure devices proved to be safe and effective in this study. Additional prospective randomized studies are recommended.

Ischaemic preconditioning of the spinal cord to prevent spinal cord ischaemia during endovascular repair of thoracoabdominal aortic aneurysm: first clinical experience.

AIMS: The purpose of our study was to report our experience with minimally invasive segmental artery coil embolisation (MISACE) to prevent spinal cord ischaemia (SCI) after endovascular repair (ER) of thoracoabdominal aortic aneurysm (TAAA). METHODS AND RESULTS: A cohort of 57 patients with TAAAs was treated by MISACE followed by ER between October 2014 and December 2017. The TAAA Crawford classification was: type I, n=5; type II, n=12; type III, n=27; type IV, n=13. The average maximum aortic diameter was 62.7±8.8 mm. Patients had a median of 5 coiled SAs (range: 1-19). MISACE was completed in one (n=22), two (n=24), three (n=7), four (n=3) or five (n=1) sessions. The maximum number of coiled SAs per session was six. After completion of MISACE, 77.7% of direct segmental arterial flow was occluded. After a mean of 83±62 days, 55 of the patients received total ER of their TAAA. At 30 days after ER, no patient developed SCI and three patients had died. CONCLUSIONS: MISACE to precondition the paraspinous collateral network prior to endovascular repair of thoracoabdominal aortic aneurysm is clinically feasible. The safety profile is promising and there is good reason to explore this new staging strategy further.

Drug-Coated Balloons for Complex Femoropopliteal Lesions: 2-Year Results of a Real-World Registry.

OBJECTIVES: The authors sought to investigate the efficacy of a drug-coated balloon (DCB) for treatment of complex femoropopliteal lesions. BACKGROUND: Superiority of DCBs compared with uncoated balloon angioplasty for femoropopliteal interventions has been demonstrated in randomized trials for short lesions. Their performance in complex lesions with higher restenosis rates is unclear. METHODS: Patency, target lesion revascularization (TLR) rate, clinical improvement, and safety endpoints of femoropopliteal lesions in 288 limbs (n = 260) treated with the In.Pact Pacific or Admiral DCB (Medtronic, Minneapolis, Minnesota) were retrospectively analyzed for up to 2 years of follow-up. Predictors of restenosis were identified by logistic regression. RESULTS: Lesions were de novo in 51.7%, restenosis in 11.1%, and in-stent restenosis in 37.2%. Mean lesion length was 24.0 ± 10.2 cm, and 65.3% were occluded. Stent implantation was performed in 23.3%. Kaplan Meier estimates of primary patency were 79.2% and 53.7% for all lesions at 1 and 2 years, respectively, whereas freedom from TLR was 85.4% and 68.6%. Primary patency for in-stent restenosis treatment was 76.6% and 48.6%, and freedom from TLR was 83.0% and 58.7% at 1 and 2 years, respectively. Rutherford category improved from a median 3.3 to 1.2 at 1 year, and to 1.1 at 2 years. Major amputation rate was 2.1% at 2 years. No adverse events were thought to be attributable to the coating of the balloon. CONCLUSIONS: These results suggest that DCB are safe and effective in delaying rather than preventing restenosis in long, complex lesions and restenosis of the femoropopliteal tract. Further studies are recommended to confirm these results.