Iliac Conduits for Endovascular Treatment of Aortic Pathologies: A Systematic Review and Meta-analysis.

PURPOSE: The treatment of thoracoabdominal aortic aneurysm has largely shifted to endovascular techniques. However, severe iliofemoral arterial disease often presents a challenge during these interventions. As a result, iliac conduits have been introduced to facilitate aortic endovascular therapy. The goal of the current study was to gauge utilization and to analyze iliac artery conduit outcomes to facilitate endovascular therapy to treat aortic pathologies. MATERIALS AND METHODS: A meta-analysis of 14 studies was conducted with the use of random effects modeling. The incidence of periprocedural adverse events was gauged based on iliac conduit vs nonconduit cases and planned vs unplanned iliac conduit placement. Outcomes of interest included length of hospital stay, morbidity and mortality associated to conduits, and all-cause mortality. RESULTS: Iliac conduits, either open or endo-conduits, were utilized in 17% (95% CI: 9%-27%) of 16,855 cases, with technical successful rate of 94% (95% CI: 80%-100%). Periprocedural complications occurred in 32% (95% CI: 22%-42%) of the cases, with overall bleeding complication rate being 10% (95% CI: 5%-16%). Female patients, positive history for smoking, pulmonary disease, and peripheral artery disease at baseline were associated with more frequent utilization of iliac conduits. Conduit use was associated with longer hospitalization, higher periprocedural all-cause mortality (OR: 2.85; 95% CI: 1.75-4.64; p<0.001), and bleeding complication rate (OR: 2.38; 95% CI: 1.58-3.58; p<0.001). Sensitivity analysis among conduit cases showed that planned conduits were associated with fewer periprocedural complications compared to unplanned conduits (OR: 0.38; 95% CI: 0.20-0.73; p=0.004). CONCLUSION: Iliac conduit placement is a feasible strategy, associated with high technical success to facilitate complex aortic endovascular repair. However, periprocedural adverse event rate, including bleeding complications is not negligible. All-cause mortality and morbidity rates among cases that require iliac conduits should be strongly considered during clinical decision making. High-quality comparative analyses between iliac conduit vs nonconduit cases and between several types of iliac conduit grafts aiming at facilitating endovascular aortic repair are still needed to determine the best strategy to address challenging iliac artery accesses.

Polidocanol Plus Glucose Versus Glucose Alone for the Treatment of Telangiectasias: Triple Blind, Randomised Controlled Trial (PG3T).

OBJECTIVE: The aim of this study was to compare the effectiveness and safety of two sclerosing agents used to treat telangiectasias in the lower limbs: 0.2% polidocanol + 70% hypertonic glucose (HG) vs. 75% HG alone. METHODS: A prospective, randomised, triple blind, controlled, parallel group trial with patients randomly assigned in a 1:1 ratio between January and December 2015, with a two month follow up, from a single academic medical centre in Brazil, was carried out. Participants were women aged 18-65 years with telangiectasias on the lateral aspect of one thigh, classified as C1EpAsPn who underwent sclerotherapy in a single session with 0.2% polidocanol + 70% HG or 75% HG alone to treat the telangiectasias on an area limited by a rectangular template. The primary effectiveness endpoint was elimination of 75% of the telangiectasias within 60 days vs. the pre-treatment pattern. The length of vessels was measured on images obtained before and after treatment using ImageJ software. Safety outcomes were analysed immediately, 7 days, and 60 days after the treatment, and included pigmentation. RESULTS: A total of 115 patients were included, 98 of whom completed the study. Sclerotherapy with 0.2% polidocanol + 70% HG was significantly more effective than with 75% HG alone to treat telangiectasias in the target area (82.2% vs. 63.9%; p < .001); considering a minimum improvement of 75%, there was a 0.49 risk reduction (95% confidence interval 0.24-0.98; p = .047). No severe adverse events occurred in either group. Pigmentation was the most common minor adverse event and was significantly shorter in length in the group treated with 0.2% polidocanol + 70% HG (median 0 cm vs. 0.5 cm, respectively; p = .033). CONCLUSION: Polidocanol 0.2% plus 70% HG had better results than 75% HG alone in sclerosing telangiectasias. No severe adverse events occurred. Pigmentation occurred in both groups and was shorter in length in the group treated with 0.2% polidocanol + 70% HG.

Pentasaccharides for the treatment of deep vein thrombosis.

BACKGROUND: Standard treatment of deep vein thrombosis (DVT) is based on antithrombotic therapy, initially with parenteral administration of unfractionated heparin or low molecular weight heparins (LMWH) for five to seven days, then subsequent long-term therapy with oral vitamin K antagonists (e.g. warfarin). Pentasaccharides are novel anticoagulants that may be favourable over standard therapy due to their predictable effect, no need for frequent monitoring or re-dosing, and few known drug interactions. Heparin-induced thrombocytopenia, a harmful effect of heparins, appears to be rare during treatment with pentasaccharides. OBJECTIVES: To assess the efficacy and harms of pentasaccharides for the treatment of deep vein thrombosis. SEARCH METHODS: The Cochrane Vascular Information Specialist (CIS) searched the Specialised Register (22 March 2017) and the Cochrane Central Register of Controlled Trials (CENTRAL) (2017, Issue 2) (searched 22 March 2017). We searched clinical trials databases for details of ongoing or unpublished studies and the reference lists of relevant articles for additional citations. SELECTION CRITERIA: We included randomised controlled trials in which people 18 years of age or older with a DVT confirmed by standard imaging techniques were allocated to receive a pentasaccharide (fondaparinux, idraparinux, or idrabiotaparinux) for the treatment of DVT in comparison with standard therapy or other treatments. DATA COLLECTION AND ANALYSIS: We extracted data characterising the included trials according to the methods, participants, interventions, and outcomes. We assessed risk of bias using Cochrane's 'Risk of bias' tool and employed the GRADE methodology to evaluate the quality of the evidence.The main primary outcome for efficacy was recurrent venous thromboembolism (VTE), and the main primary outcome for harm was major and clinically relevant bleeding. Since our outcomes were dichotomous, we calculated the risk ratio (RR) with a 95% confidence interval (CI). We combined the effects of different comparisons through a meta-analysis using a fixed-effect model. MAIN RESULTS: We included five randomised controlled trials of 6981 participants comparing pentasaccharides with standard therapy or other pentasaccharides. The quality of the evidence varied depending on the outcome and was judged as of moderate to very low quality. We downgraded the quality of the evidence due to risk of bias or imprecision, or both.Two studies evaluated fondaparinux, at doses of 5.0 mg, 7.5 mg, and 10.0 mg, plus vitamin K antagonist in comparison with standard therapy. A meta-analysis of these two studies showed no clear difference in the risk of recurrent VTE (RR 0.80, 95% CI 0.43 to 1.47; 2658 participants); moderate-quality evidence. The frequencies of major bleeding were similar between interventions in the initial period of treatment (approximately five days) (RR 1.15, 95% CI 0.39 to 3.44; 2645 participants) and at three months' follow-up (RR 1.05, 95% CI 0.64 to 1.71; 2645 participants). We judged the quality of the evidence as moderate.One study (757 participants) compared idrabiotaparinux (3.0 mg) with idraparinux (2.5 mg) and demonstrated no clear difference in the risk of recurrent VTE at six months' follow-up (RR 0.72, 95% CI 0.31 to 1.69); low-quality evidence. Major bleeding during the initial treatment period was not reported. Major bleeding at six-month follow-up was less frequent in participants receiving idrabiotaparinux versus participants treated with idraparinux (RR 0.21, 95% CI 0.06 to 0.71); low-quality evidence.The effect of an initial treatment with LMWH followed by three months of idraparinux (10 mg) showed no clear difference from standard therapy for risk of recurrent VTE (RR 1.51, 95% CI 0.26 to 8.90; 263 participants); very low-quality evidence; one study. Major bleeding during the initial treatment period was not reported. The frequency of major and other clinically relevant bleeding at three months' follow-up ranged from 2% to 15% in participants receiving LMWH and increasing doses of idraparinux of 2.5 mg, 5 mg, 7.5 mg, or 10 mg. When dosage groups were combined, there was no clear difference in major plus other clinically relevant bleeding or in major bleeding alone between the idraparinux treatment group and the standard therapy group (RR 1.30, 95% CI 0.70 to 2.40; 659 participants; RR 3.76, 95% CI 0.50 to 28.19; 659 participants, respectively); very low-quality evidence.One study (2904 participants) compared idraparinux (2.5 mg) to standard therapy. There was no clear difference in the risk of recurrent VTE at three months' follow-up (RR 0.98, 95% CI 0.64 to 1.48); low-quality evidence. Major bleeding during the initial treatment period was not reported. Major bleeding at three months of follow-up appeared to be similar in the idraparinux group and the standard therapy group (RR 0.71, 95% CI 0.34 to 1.47); very low-quality evidence. AUTHORS' CONCLUSIONS: We found moderate-quality evidence that the effects of fondaparinux at doses of 5.0 mg, 7.5 mg, and 10.0 mg plus vitamin K antagonist are similar in terms of recurrent VTE and risk of major bleeding compared with standard treatment for DVT.Low-quality evidence suggests equal efficacy of idraparinux at 2.5 mg and the equimolar dose of 3.0 mg of idrabiotaparinux with regard to recurrent VTE, but a higher frequency of major bleeding was observed in participants treated with idraparinux.We judged evidence on the effectiveness of idraparinux compared with standard therapy, with or without initial treatment with LMWH, and on associated bleeding risk to be low to very low quality, therefore we have very limited confidence in the estimated effects.The observed similar effectiveness in terms of recurrent DVT and harmful effects in terms of bleeding risk with fondaparinux plus vitamin K antagonist compared to standard treatment for DVT suggest that it may be an alternative to conventional anticoagulants for the treatment of DVT in certain circumstances.

Morphofunctional characterization of decellularized vena cava as tissue engineering scaffolds.

Clinical experience for peripheral arterial disease treatment shows poor results when synthetic grafts are used to approach infrapopliteal arterial segments. However, tissue engineering may be an option to yield surrogate biocompatible neovessels. Thus, biological decellularized scaffolds could provide natural tissue architecture to use in tissue engineering, when the absence of ideal autologous veins reduces surgical options. The goal of this study was to evaluate different chemical induced decellularization protocols of the inferior vena cava of rabbits. They were decellularized with Triton X100 (TX100), sodium dodecyl sulfate (SDS) or sodium deoxycholate (DS). Afterwards, we assessed the remaining extracellular matrix (ECM) integrity, residual toxicity and the biomechanical resistance of the scaffolds. Our results showed that TX100 was not effective to remove the cells, while protocols using SDS 1% for 2h and DS 2% for 1h, efficiently removed the cells and were better characterized. These scaffolds preserved the original organization of ECM. In addition, the residual toxicity assessment did not reveal statistically significant changes while decellularized scaffolds retained the equivalent biomechanical properties when compared with the control. Our results concluded that protocols using SDS and DS were effective at obtaining decellularized scaffolds, which may be useful for blood vessel tissue engineering.

Endovascular repair of a complex giant infrarenal abdominal aortic aneurysm.

Giant aortic aneurysms (transverse diameter greater than 10.0 cm) are rare and open surgery is often the treatment of choice. We report an infrarenal saccular giant aortic aneurysm (measuring 25 cm in transverse diameter), which was treated with endovascular repair, with immediate technical success. No similar report of a giant infrarenal aortic aneurysm treated with an endovascular technique was found in the literature. High-risk patients could possibly benefit from the endovascular technique. Nevertheless, patient survival remains strongly influenced by comorbidities.

Recanalization rates after acute deep vein thrombosis: a single-center experience using a newly proposed vein diameter variation index.

BACKGROUND: Duplex ultrasound scanning (DUS) is the method of choice for diagnosis of deep vein thrombosis (DVT). However, only a few studies have performed prospective serial DUS after an acute episode of DVT to assess its evolution. This study aimed to report our experience using DUS combined with a thrombosis score (TS) and a newly proposed vein diameter variation index (VDVI) to evaluate the rate of resolution of DVT by assessing and quantifying the early stages of vein recanalization in proximal vein segments within 6 months after an episode of acute lower extremity DVT. METHODS: Twelve patients with first episode of acute lower extremity DVT confirmed by DUS as occurring in ≤10 days after the onset of venous thrombosis symptoms were followed up prospectively for 6 months. TS and VDVI were calculated at 1, 3, and 6 months to assess vein recanalization. Intra-thrombus arteriovenous fistula formation was also investigated and related to the recanalization process. RESULTS: Seven (58%) women were included, with a total cohort median age of 53.5 ± 19 years. The left lower extremity was affected in 7 (58%) patients. DVT was diagnosed in 55 proximal vein segments. All patients had proximal DVT, with involvement of the external iliac, femoral, and popliteal veins. After 6 months, there was a significant decrease in TS and increase in VDVI (P < 0.001) in all proximal vein segments assessed, indicating thrombus regression. The more distal the DVT was, the faster was the VDVI increase, with most popliteal veins being recanalized at 3 months (P < 0.001). Intra-thrombus arteriovenous fistula was identified in 50% of patients at 1 month while on anticoagulation. CONCLUSIONS: The combined use of two different DUS-based assessment tools, TS and the proposed VDVI, provided an effective method to prospectively assess vein recanalization rates after an episode of acute lower extremity DVT in this series of patients and may allow a correct evaluation of DVT and its resolution or progression.

Atherectomy to treat femoropopliteal atherosclerotic disease.

Atherectomy as an endovascular modality to treat peripheral arterial disease has gained traction over the past 10 years. Unlike most other available technologies, atherectomy works by physically debulking atherosclerotic plaque via a variety of mechanisms being the femoropopliteal segment the most targeted one. The aims of this review were to detail the types of atherectomy available, existing evidence available for atherectomy use in the femoropopliteal segment as compared to other interventions, critical appraisal of its current use and the possible influences on its indication. Future steps regarding atherectomy usage and data presentation are also described.

Impacts of ischemic preconditioning in liver resection: systematic review with meta-analysis.

OBJECTIVE: To assess the beneficial effects of ischemic preconditioning (IPC) in liver resection and evaluate its applicability in clinical practice. SUMMARY BACKGROUND DATA: Liver surgeries are usually associated with intentional transient ischemia for hemostatic control. IPC is a surgical step that intends to reduce the effects of ischemia-reperfusion; however, there is no strong evidence about the real impact of the IPC, and it is necessary to effectively clarify what its effects are. METHODS: Randomized clinical trials were selected, comparing IPC with no preconditioning in patients undergoing liver resection. Data were extracted by three independent researchers according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, Supplemental Digital Content 1, http://links.lww.com/JS9/A79 . Several outcomes were evaluated, including postoperative peaks of transaminases and bilirubin, mortality, length of hospital stay, length of stay in the ICU, bleeding, and transfusion of blood products, among others. Bias risks were assessed using the Cochrane collaboration tool. RESULTS: Seventeen articles were selected, with a total of 1052 patients. IPC did not change the surgical time of the liver resections while these patients bled less (Mean Difference: -49.97 ml; 95% CI: -86.32 to -13.6; I2 : 64%), needed less blood products [relative risk (RR): 0.71; 95% CI: 0.53-0.96; I2 =0%], and had a lower risk of postoperative ascites (RR: 0.40; 95% CI: 0.17-0.93; I2 =0%). The other outcomes had no statistical differences or could not have their meta-analyses conducted due to high heterogeneity. CONCLUSIONS: IPC is applicable in clinical practice, and it has some beneficial effects. However, there is not enough evidence to encourage its routine use.

Results of open pararenal abdominal aortic aneurysm repair: Tabular review of the literature.

Open surgical repair of complex abdominal aortic aneurysms requires more extensive dissection and aortic clamping above the renal or mesenteric arteries. Although results of open surgical series have shown variation, morbidity and mortality is higher compared with infrarenal aortic aneurysm repair. Potential complications include renal insufficiency, mesenteric ischemia, multisystem organ failure, and death. Although endovascular treatment with fenestrated and branched endografts might potentially decrease the risk of complications and mortality, its role is not yet defined and the technology is not widely available. Issues related to durability of the procedure and secondary interventions might limit its application to patients with higher risk or those with hostile anatomy. This article summarizes the clinical results of open surgical repair of pararenal abdominal aortic aneurysms to provide a benchmark for comparison with results of endovascular treatment, using fenestrated and branched techniques.

Experiência preliminar com novo filtro de veia cava: resultados de 15 implantes / Preliminary experience with a new vena cava filter: results of 15 implantations

Este estudo apresenta resultados preliminares obtidos com um novo filtro permanente de veia cava, baseado no desenho de Greenfield, com três hastes prolongadas de um total de seis, para dar estabilidade central ao filtro na luz da veia cava. Neste artigo, relatamos sua avaliação clínica preliminar quanto à aplicabilidade, eficácia e segurança. De agosto de 2004 a dezembro de 2006, 15 filtros foram implantados em nove homens e seis mulheres, com idades variando de 38 a 79 anos (média de 57,8 anos). O acesso foi feito sempre por via transjugular. As indicações foram: trombose venosa proximal, com contra-indicação de anticoagulação em 12 pacientes; complicações hemorrágicas com anticoagulação em dois pacientes; e embolia pulmonar, apesar de anticoagulação adequada, em um paciente. Os filtros foram avaliados quanto à liberação, inclinação, mau posicionamento e perfuração de cava. No seguimento, avaliou-se trombose no local de acesso, tromboembolismo venoso recorrente, migração do filtro e trombose de cava pelo ultra-som. Nenhum paciente recebeu anticoagulantes no seguimento. O filtro foi liberado com sucesso em todos os casos sem mau posicionamento, inclinação, perfuração ou trombose de acesso. Os pacientes foram seguidos entre 3 e 23 meses (média de 11 meses). Nenhum paciente teve recorrência de tromboembolismo venoso. Não houve casos de trombose de veia cava ou migração do filtro. Óbito ocorreu em sete casos, todos relacionados com a moléstia de base. Os resultados preliminares indicam potencial eficácia e segurança do uso do novo filtro no período estudado.

This study presents preliminary results obtained from a new permanent filter, based on Greenfield's filter design, with prolongations on three of six struts to stabilize it centrally in the vena caval lumen. The preliminary clinical evaluation of the filter with regard to feasibility, efficacy and safety is reported. From August 2004 to December 2006, 15 vena cava filters were deployed in nine men and six women, who ranged in age from 38 to 79 years (mean, 57.8 years). The approach used was always transjugular. Indications for filter placement were proximal deep venous thrombosis with a contraindication to anticoagulation in 12 patients; hemorrhagic complications with anticoagulation in two patients; and pulmonary embolism, despite adequate anticoagulation in one patient. New vena cava filters were evaluated for releasing, tilting, malpositioning and caval perforation. Follow-up included assessment of access site thrombosis and filter migration, recurrent venous thromboembolism, and caval thrombosis by duplex ultrasound. No patient received anticoagulants in the follow-up. In all patients the filter was successfully released, with no malpositioning, tilting, perforation or access thrombosis. The patients were followed for 3 to 23 months (mean = 11 months). No patient developed recurrent venous thromboembolism. No other patients developed inferior vena cava thrombosis or filter migration. Death occurred in seven patients, all related to baseline illness. This preliminary study suggests good feasibility and safety of the new filter up to the observation period.