Late Neck Related Adverse Events are Rare Among Patients with Wide Aortic Neck Undergoing Endovascular Aneurysm Repair with the Ovation Endograft.

BACKGROUND: Patients with wide aortic necks undergoing Endovascular Aneurysm Repair (EVAR) have been shown to be at a higher risk for neck-related complications. We aim to examine outcomes of EVAR with an endograft exerting minimal outward pressure (Ovation-Endologix) in patients with a large baseline neck diameter. METHODS: We performed a retrospective single center study, including consecutive patients undergoing EVAR with the Ovation system from May 2011 to April 2021. Patients were divided in Groups 1 and 2 if the 20, 23, 26, 29 mm or the 34 mm proximal diameter main body was used, respectively. According to the instructions for use of the device, for neck diameters 27-30 mm the 34 mm main body is required. Primary endpoint was rate of neck related complications during follow-up, (type Ia endoleak, migration >10 mm and neck-related re-interventions) and rate of aortic neck dilatation (AND). AND was determined based on multiple aortic neck diameters that were recorded and compared between the 1-month computed tomography angiography (CTA) after EVAR and the last available follow-up CTA.Secondary endpoints were peri-procedural and follow-up outcomes such as endoleaks, reinterventions and overall mortality. RESULTS: In total 281 patients were included, 222 in Group 1 and 59 in Group 2. Patients in Group 2 presented significantly shorter neck length, higher neck angulation and more common reversed tapered configuration. Median follow-up was 36 months (Range: 6-106). Early and late type Ia endoleak was observed in 4 and 2 patients in each group, respectively (P = 0.063 and P = 0.195, respectively). Distal migration was observed in 2 patients in Group 2 and AND was recorded in 2 patients in each group (P = 0.195). Freedom from the primary endpoint was estimated at 98%, 94%, 94% at 12-, 36-, 60-months for Group 1 and at 98%, 95%, 86% for Group 2 (P-Value 0.266). Probability of survival was 95%, 86%, 75% at 12-, 36-, 60-months for Group 1 and 83%, 77%, 72% for Group 2 (P-Value 0.226).Multivariate regression analysis identified neither Group 1 versus Group 2 nor absolute value of aortic neck diameter as significant predictors of neck-related adverse events. Neck diameters did not display significant differences over time in any of the levels evaluated. CONCLUSIONS: EVAR with the Ovation endograft results in low rates of late neck related complications which is also true for patients with wide baseline aortic necks.

Prediction of abdominal aortic aneurysm growth by artificial intelligence taking into account clinical, biologic, morphologic, and biomechanical variables.

OBJECTIVES: To develop a prediction model that could risk stratify abdominal aortic aneurysms (AAAs) into high and low growth rate groups, using machine learning algorithms based on variables from different pathophysiological fields. METHODS: A cohort of 40 patients with small AAAs (maximum diameter 32-53 mm) who had at least an initial and a follow-up CT scan (median follow-up 12 months, range 3-36 months) were included. 29 input variables from clinical, biological, morphometric, and biomechanical pathophysiological aspects extracted for predictive modeling. Collected data were used to build two supervised machine learning models. A gradient boosting (XGboost) and a support vector machines (SVM) algorithm were trained with 60% and tested with 40% of the data to predict which AAA would achieve a growth rate higher than the median of our study cohort. Receiver operating characteristics (ROC) curves and areas under the curve (AUC) were used for the evaluation of the developed algorithms. RESULTS: XGboost achieved the highest AUC in predicting high compared to low AAA growth rate with an AUC of 81.2% (95% CI from 61.1 to 100%). SVM achieved the second highest performance with an AUC of 68.8% (95% CI from 46.5 to 91%). Based on the best performing algorithm, variable importance was estimated. Diameter-diameter ratio (maximum diameter/neck diameter), Tortuosity from Renal arteries to aortic bifurcation, and maximum thickness of the intraluminal thrombus were found to be the most important factors for model predictions. Other factors were also found to play a significant but less important role. CONCLUSIONS: A prediction model that can risk stratify AAAs into high and low growth rate groups could be developed by analyzing several factors implicated in the multifactorial pathophysiology of this disease, with the use of machine learning algorithms. Future studies including larger patient cohorts and implementing additional risk markers may aid in the establishment of such methodology during AAA rupture risk estimation.

Dual-Energy Computed Tomography as an Adjunct in the Evaluation of Peripheral Chronic Total Occlusions: A Feasibility Study.

This study investigated the role of dual-energy computed tomography (CT) for lesion characterization in patients with peripheral arterial disease manifesting with chronic total occlusions (CTOs). Forty-one symptomatic patients with CTOs underwent dual-energy CT angiography before endovascular treatment. The lesions were subsequently analyzed in a dedicated workstation, and 2 indexes-dual-energy index (DEI) and effective Z (Zeff)-were calculated, ranging from 0.0027 to 0.321 and from 6.89 to 13.02, respectively. Statistical analysis showed a significant correlation between the DEI and Zeff values (P < .001). The interobserver intraclass correlation coefficient was 0.91 for the mean Zeff values and 0.86 for the mean DEI values. This technique could potentially provide useful information regarding the composition of a CTO.

Editor's Choice - Endovascular Aneurysm Repair in High Risk Patients: A Systematic Review and Meta-Analysis.

OBJECTIVE: To investigate outcomes of endovascular aneurysm repair (EVAR) in high risk patients. METHODS: Bibliographic sources (MEDLINE, EMBASE, CINAHL, and CENTRAL) were searched using combinations of thesaurus and free text terms. The review protocol was registered in PROSPERO (CRD42021287207) and reported according to PRISMA 2020. Pooled estimates were calculated using odds ratio (OR) or hazard ratio (HR) and 95% confidence interval (CI) applying the Mantel-Haenszel or inverse variance method. EVAR peri-operative mortality in high risk patients over time was examined with mixed effects meta-regression. The GRADE framework was used to rate the certainty of evidence. RESULTS: The pooled peri-operative mortality in 18 416 high risk patients who underwent EVAR was 3% (95% CI 2.3 - 4%) and has significantly reduced over time (year of publication p = .003; median study point p = .023). The peri-operative mortality was significantly lower in high risk patients treated with EVAR compared with open repair (OR 0.64; 95% CI 0.45 - 0.92), but no significant difference was found in overall (HR 1.06; 95% CI 0.76 - 1.49) or aneurysm related mortality (HR 0.57; 95% CI 0.21 - 1.55). No significant difference was found in overall mortality between high risk patients treated with EVAR vs. no intervention (HR 0.42; 95% CI 0.14 - 1.26), but the aneurysm related mortality was significantly lower in the former (HR 0.30; 95% CI 0.14 - 0.63). The peri-operative mortality was higher in high risk than normal risk patients treated with EVAR (OR 2.33; 95% CI 1.75 - 3.10), as was the overall mortality (HR 3.50; 95% CI 2.55 - 4.80). The certainty of evidence was very low for EVAR vs. open surgery or no intervention and low for high vs. normal risk patients. CONCLUSION: The EVAR peri-operative mortality in high risk patients has improved over time. Even though the aneurysm related mortality of EVAR is lower compared with no intervention, EVAR may confer no overall survival benefit.

Radiomics and machine learning to predict aggressive type 2 endoleaks after endovascular aneurysm repair: a proof of concept.

BACKGROUND: Persistent type 2 endoleaks (T2EL) require lifelong surveillance to avoid potentially life-threatening complications. PURPOSE: To evaluate the performance of radiomic features (RF) derived from computed tomography angiography (CTA), for differentiating aggressive from benign T2ELs after endovascular aneurysm repair (EVAR). MATERIAL AND METHODS: A prospective study was performed on patients who underwent EVAR from January 2018 to January 2020. Analysis was performed in patients who were diagnosed with T2EL based on the CTA of the first postoperative month and were followed at six months and one year. Patients were divided into two groups according to the change of aneurysm sac dimensions. Segmentation of T2ELs was performed and RF were extracted. Feature selection for subsequent machine-learning analysis was evaluated by means of artificial intelligence. Two support vector machines (SVM) classifiers were developed to predict the aneurysm sac dimension changes at one year, utilizing RF from T2EL at one- and six-month CTA scans, respectively. RESULTS: Among the 944 initial RF of T2EL, 58 and 51 robust RF from the one- and six-month CTA scans, respectively, were used for the machine-learning model development. The SVM classifier trained on one-month signatures was able to predict sac expansion at one year with an area under curve (AUC) of 89.3%, presenting 78.6% specificity and 100% sensitivity. Similarly, the SVM classifier developed with six-month radiomics data showed an AUC of 95.5%, specificity of 90.9%, and sensitivity of 100%. CONCLUSION: Machine-learning algorithms utilizing CTA-derived RF may predict aggressive T2ELs leading to aneurysm sac expansion after EVAR.

Discrimination of High-Risk Type-2 Endoleak after Endovascular Aneurysm Repair through CT Perfusion: A Feasibility Study.

A type-2 endoleak after an endovascular aneurysm repair is the most prevalent type of endoleak, but as the clinical consequence of its diagnosis is uncertain, at present, management decisions are solely based on aneurysm sac growth. The aim of this study was to investigate the potential of various computed tomography perfusion parameters for their ability to distinguish high-risk type-2 endoleaks from low-risk type-2 endoleaks after an endovascular aneurysm repair.

Endovascular Aneurysm Repair with Bifurcated Stent Grafts in Patients with Narrow Versus Regular Aortic Bifurcation: Systematic Review and Meta-analysis of Comparative Studies.

BACKGROUND: Narrow aortic bifurcation (NAB) is considered as a risk factor for endograft limb thrombosis. The purpose of the study was to investigate the effect of narrow aortic bifurcation on outcomes of elective endovascular aneurysm repair (EVAR). METHODS: A systematic review that conformed to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was performed. We searched electronic bibliographic databases using a combination of controlled vocabulary (thesaurus) and free-text terms to identify relevant studies comparing outcomes of EVAR in patients with NAB versus those with regular aortic bifurcation. Pooled estimates of dichotomous outcomes were calculated using odds ratio (OR) and those of continuous outcomes using mean difference and 95% confidence interval (CI). To account for expected heterogeneity, the random-effects model was applied for statistical analysis. RESULTS: Six observational studies were included, reporting a total of 2,673 patients (412 with NAR and 2,261 with friendly anatomy). Perioperative mortality was similar between the groups (OR 1.14, 95% CI 0.30-4.34, P = 0.85, I2 = 0%). Limb stenosis and kinking requiring additional intraoperative procedures was significantly more common among patients with NAB (OR 3.02, 95% CI 2.16-4.22, P < 0.00001, I2 = 0%). Nevertheless, 30-day reintervention rate was similar between the groups, as was the rate of limb occlusion during follow-up. CONCLUSIONS: Available evidence suggests that at the expense of significantly more intraoperative additional procedures, EVAR with bifurcated devices can be safely performed in patients with NAB.

Endovascular Treatment of Malignant Superior Vena Cava Syndrome through Upper-Limb Access: A Comparison between Venous-Dedicated and Conventional Stents.

PURPOSE: To retrospectively evaluate the technical and clinical outcomes of superior vena cava (SVC) stent placement through upper-limb venous access in malignant SVC syndrome (SVCS) and compare the efficacy of different nitinol stent types. MATERIALS AND METHODS: Between 2006 and 2018, 156 patients (132 male; mean age, 62 y; age range, 33-81 y) underwent SVC stent placement for malignant obstructions through upper-limb venous access with 1 of 3 types of nitinol stent: 1 venous-dedicated (Sinus-XL stent) and 2 non-venous-dedicated (E-Luminexx Vascular Stent and Protégé GPS). Cases of common femoral vein access or non-nitinol stents were excluded from further analysis. The mean duration of follow-up was 8 mo. RESULTS: Technical success was achieved in 99.3% of cases. One patient died during the procedure as a result of cardiac tamponade. Balloon predilation was performed in 10 patients and postdilation in 126. Mean procedural time was 34.4 min (range, 18-80 min). Overall survival rates were 92.3%, 57.3%, and 26.8%, and overall primary patency rates were 94.5%, 84.8% and 79.6%, at 1, 6, and 12 mo, respectively. There were no statistically significant differences in primary patency rates between venous- and non-venous-dedicated stents or among different Stanford SVCS grading groups (P > .05). CONCLUSIONS: SVC stent placement through an upper-limb approach is a safe, fast, and effective technique. There is no evident benefit of venous-dedicated vs non-venous-dedicated stents in the treatment of malignant SVCS.

Common left carotid bifurcation at C7-Th1 level: a rare anatomical variant.

The left common carotid artery usually bifurcates to the internal and external carotids at or near the superior border of thyroid cartilage. In head and neck surgery, the common carotid arteries are important landmarks, defining the plane of dissection during radical neck surgeries. According to the literature, many variations exist regarding the carotid bifurcation. Anatomical knowledge of these variants is important for surgical approaches in the head and neck regions, to avoid devastating complications that may occur, mainly during anterior neck dissections. We report an interesting case of a 75-year-old male patient with low bifurcation of the left common carotid artery, accidentally found during a routine carotid Doppler ultrasonography. Bifurcation was located at the C7-Th1 intervertebral disc height, approximately 4 cm from the aortic arch.

Transurethral holmium laser intravesical tape excision following TVT procedure: results from seven patients in a 12-month follow-up.

INTRODUCTION AND HYPOTHESIS: The aim of this study is to evaluate the efficacy and the safety of the holmium:YAG laser for intravesical mesh excision in female patients with urinary bladder erosion complicated tension-free vaginal tape (TVT) procedure. METHODS: Between June 2, 2008 and December 31, 2009, seven patients who underwent laser excision of an intravesically protruding tape were followed up every 3 months for a total period of 1 year by disease-specific questionnaires, physical examination, cough stress test, urine analysis, urine bacterial culture, ultrasound and uroflowmetry. Filling cystometry was offered preoperatively and at the 3rd month, while cystoscopy was offered preoperatively and at the 1st month. The presenting symptoms were dysuria, urgency, hematuria, and recurrent lower urinary tract infections. Holmium laser was used for ablation and removal of the tape. The postoperative period was uneventful. RESULTS: There was a substantial improvement in the urgency status, in the maximum flow rate (Q (max)) from 11.29 ml/s to 19.43 ml/s, in the voided volume (VV) from 185 ml to 251.43 ml and in the maximum cystometric capacity (C) from 237.86 ml to 310.64 ml pre- and postoperative, respectively. CONCLUSIONS: Holmium laser ablation represents a simple, safe and efficacious procedure to manage intravesical mesh complications following TVT procedure.

Dual-energy CT angiography in imaging surveillance of endovascular aneurysm repair - Preliminary study results.

PURPOSE: To investigate the value of dual-energy CT imaging to discriminate low- from high- risk type II endoleaks (T2EL) after endovascular aneurysm repair (EVAR). METHOD: Study participants were consecutive patients referred for CT at 1-month post-EVAR. CT imaging acquisition included a dual-energy CT angiography (DECTA) and a delayed single-energy CT (SECT) imaging. Patients diagnosed with T2EL were re-examined at 6-months post-EVAR to assess the aneurysm sac growth (ASG). Upon ASG recorded, patients were categorized as having low- (group A) or high- risk (group B) T2EL. DECTA image data were employed to calculate the normalized effective atomic number (NZeff), the normalized iodine concentration, the slope of HUendoleak/HUaorta against monochromatic energy, the dual-energy index and an improvised endoleak index (EI) for each T2EL. Statistical analysis was employed to compare all above parameters regarding their ability to differentiate low- from high- risk T2EL. RESULTS: Among 40 patients examined at 1-month post-EVAR, 14 patients were diagnosed with T2EL. NZeff and EI were found to be significantly lower in group A. NZeff was found to have the highest power to discriminate high-risk T2EL with an area-under-curve of 86.7%, showing100% specificity and 60% sensitivity. The optimal contrast-to-noise ratio for T2EL demonstrated a median peak conspicuity level at 54-keV. The mean effective dose from DECTA and SECT scans was 27.8% lower compared to the sum of three SECT acquisitions. CONCLUSIONS: NZeff and EI were found to have a significant power in predicting the aggressiveness of T2EL lesions. Virtual monochromatic images at 54-keV may enhance T2EL detection efficiency.

Evaluation of foot hypoperfusion and estimation of percutaneous transluminal angioplasty outcome in patients with critical limb ischemia using intravoxel incoherent motion microperfusion MRI.

OBJECTIVES: To emerge hypoperfusion of lower limbs in patients with critical limb ischemia (CLI) using Intravoxel Incoherent Motion microperfusion magnetic resonance imaging (IVIM-MRI). Moreover to examine the ability of IVIM-MRI to differentiate patients with severe peripheral arterial disease (PAD) from normal subjects and evaluate the percutaneous transluminal angioplasty (PTA) results in patients with CLI. METHODS: Eight patients who presented with CLI and six healthy volunteers were examined. The patients underwent IVIM-MRI of lower extremity before and following PTA. The imaging protocol included sagittal diffusion-weighted (DW) sequences. DW images were analyzed and color parametric maps of the micro-circulation of blood inside the capillary network (D*) were constructed. The studies were evaluated by two observers to define interobserver reproducibility. RESULTS: Technical success was achieved in all patients (8/8). The mean ankle-brachial index increased from 0.35 ± 0.2 to 0.76 ± 0.25 (p < 0.05). Successful revascularization improved IVIM microperfusion. Mean D* increased from 279.88 ± 13.47 10-5 mm2/s to 331.51 ± 31 10-5 mm2/s, following PTA, p < 0.05. Moreover, PAD patients presented lower D* values as compared to healthy individuals (279.88 ± 13.47 10-5 mm2/s vs 332.47 ± 22.95 10-5 mm2/s, p < 0.05, respectively). Good interobserver agreement was obtained with an ICC = 0.84 (95% CI 0.64-0.93). CONCLUSIONS: IVIM-MRI can detect differences in microperfusion between patients with PAD and healthy individuals. Moreover, significant restitution of IVIM microperfusion is found following successful PTA. ADVANCES IN KNOWLEDGE: IVIM-MRI is a safe, reproducible and effective modality for evaluation of lower limb hypoperfusion in patients with PAD. It seems also to be a helpful tool to detect changes of tissue perfusion in patients with CLI following revascularization.

Curative embolization of iatrogenic inferior mesenteric arteriovenous fistula 14 years after right hemicolectomy.

Inferior mesenteric arteriovenous fistula (IMAVF) is a rare condition with 40 reported cases. It can be of congenital, idiopathic or acquired etiology. Acquired IMAVF occurs after trauma or has an iatrogenic origin due to abdominal interventions, mainly operations involving the left hemi-colon. A new case of iatrogenic IMAVF is described, which became symptomatic 13 years after right hemicolectomy and was diagnosed radiologically one year later. This case was treated successfully by means of endovascular arterial embolization. To our knowledge, this is only the second reported case of acquired IMAVF following right hemicolectomy.

Dynamic CT perfusion imaging for type 2 endoleak assessment after endograft placement.

Endovascular repair of abdominal aortic aneurysm is a widely performed treatment method due to its minimal invasiveness, reduced need for intensive care unit (ICU), shorter hospitalization and lower 30-day morbidity and mortality compared to open surgery. Endoleak is the drawback of this procedure and is considered the main culprit for re-interventions due to the risk of late aneurysm sac growth and rupture. Type 2 endoleak (T2EL) is the most common type of endoleak which is also the most controversial regarding its management. The aim of this paper is to investigate the potential of dynamic contrast-enhanced CT for the assessment of T2EL after endovascular aneurysm repair using qualitative and quantitative image analysis of the aneurysmal sac.

Large adrenal metastasis in non-small cell lung carcinoma. Case report and literature review.

Adrenal metastases are frequent in patients with non-small cell lung carcinoma (NSCLC). We present a case of a large adrenal metastasis from NSCLC and we discuss the relevant literature. In such cases, early surgical intervention is recommended to avoid spontaneous rupture of the tumor and improve patient survival.

Giant internal iliac artery aneurysm successfully treated with endovascular stent-graft placement.

An 88-year-old male patient of high surgical risk was presented with left sciatic pain symptoms and a palpable pulsatile left lower abdominal mass. He was operated 8 years ago for a large infrarenal aortic aneurysm. Computed tomography angiography (CTA) revealed a giant 161 mm left internal iliac aneurysm with multilocular appearance and left sacral bone erosion causing the symptoms. Endovascular repair was successfully performed using a monotubular iliac stent-graft. Follow-up CTA showed absence of contrast enhancement and a fully thrombosed sac. Patient recovered completely and was discharged 1 month after the procedure in a relatively good condition, nevertheless sciatic symptoms remained.

Eroded Tape: A Case of an Early Vesicoscopy Rather Than Laser Melting.

OBJECTIVE: To report our experience on vesicoscopic excision of eroded foreign material in the bladder. MATERIALS AND METHODS: The use of xenografts in female urology is becoming more prevalent and so are their complications. Erosion of foreign material into the bladder often goes unrecognized for a long time and patients are troubled by irritative urinary symptoms, recurrent infections, and stone formation. The treatment of such erosions is traditionally reported through the transurethral route using laser or electrocautery to cut the foreign material. Such methods have a high rate of incomplete material removal and as a result a high recurrence rate. Leaving a urothelial defect results in prolonged time to symptom resolution. Between 2012 and 2015, 5 patients with eroded tapes were referred for tertiary care to King's College Hospital and Ygia Polyclinic; all patients had undergone a variety of endoscopic, vaginal, and/or open attempts for mesh removal that failed. We offered vesicoscopic excision of the eroded portion of the tape. RESULTS: We here report 5 cases with tape erosions referred to our team that were treated with vesicoscopic excision of the material and primary closure of the urothelial defect. The foreign material was completely removed in all cases and there is no recurrence at a median follow-up of 30 months. CONCLUSION: Vesicoscopic excision of bladder-eroded foreign material is feasible and efficient. We recommend this technique to be considered as a primary approach to tapes eroding into the bladder.