The Effect of Transfusion of Two Units of Fresh Frozen Plasma on the Perioperative Fibrinogen Levels and the Outcome of Patients Undergoing Elective Endovascular Repair for Abdominal Aortic Aneurysm.

BACKGROUND: We aimed to investigate whether the transfusion of 2 units of fresh frozen plasma (FFP) immediately post aneurysm exclusion has any effect on the perioperative fibrinogen levels and the outcome of patients undergoing elective endovascular repair (EVAR) of abdominal aortic aneurysm (AAA). METHODS: Consecutive infrarenal AAA patients undergoing elective EVAR with the bifurcated Endurant-II stent-graft (Medtronic) were recruited from 2 vascular units. The first unit has a routine policy of administering 2 units of FFP immediately upon aneurysm exclusion (FFP group), whereas the second unit has no such policy (control group). Serum fibrinogen levels were measured on admission and 24 hr post-EVAR and the perioperative change in fibrinogen (Δfib) was calculated (24-hr postoperative minus preoperative fibrinogen). The 2 groups were compared with regards to the perioperative fibrinogen levels (preoperative, 24-hr postoperative, and Δfib) and the outcome (endoleaks, reinterventions, major adverse cardiovascular events, death) during follow up. RESULTS: A total of 70 patients (41 in the FFP group, 29 controls) were examined. There were 68 men, the mean age was 70 ± 7 years and the maximum AAA diameter was 63.3 ± 13.8 mm. During the follow up (34 ± 19 months), a total of 6 endoleaks were recorded (2 type Ia, 2 type Ib and 1 type II). Mean preoperative fibrinogen, 24-hr postoperative fibrinogen and Δfib was 391.1 ± 92.8 mg/dL, 367.7 ± 97.8 mg/dL and -23.5 ± 51.02 mg/dL, respectively. There was a trend for the fibrinogen to fall 24 hr postprocedure, but this was not statistically significant (P = 0.07). There was a weak negative association between Δfib and endoleaks (P = 0.007, r = -0.29). Compared to controls, the FFP group had a higher 24-hr postoperative fibrinogen (401.8 ± 112.9 mg/dL vs. 319.3 ± 34.9 mg/dL, P < 0.0001) and a lower Δfib (-3.00 ± 56.01 mg/dL vs. -52.48 ± 21.15 mg/dL, P < 0.0001). No significant difference was observed between the 2 groups with regards to endoleaks, reinterventions, major adverse cardiovascular events, or deaths. CONCLUSIONS: Transfusion of 2 units of FFP postaneurysm exclusion prevents a significant drop in plasma fibrinogen 24 hr post-EVAR, but the impact on clinical outcome has yet to be defined.

Endovascular Treatment of a Chronically Thrombosed Abdominal Aortic Aneurysm: Technical Considerations.

BACKGROUND: Chronic thrombosis of an abdominal aortic aneurysm (AAA) is a rare entity and the ideal management is debatable. METHODS AND RESULTS: A 74-year-old man presented with an enlarging chronically thrombosed AAA and incapacitating bilateral claudication, worse on the left side. We opted for an endovascular approach. Under local anesthesia and via a left axillary and left femoral cutdown, an aorto-uni-iliac stent graft (Endurant, Medtronic) was implanted down the left common iliac artery. A femorofemoral crossover bypass was not necessary because the right leg circulation was considered adequate on completion of the endovascular procedure. He had an uneventful recovery. His left leg symptoms were completely resolved and he was able to walk with only moderate right leg claudication after 300-400m. CONCLUSIONS: Endovascular treatment of a chronically thrombosed AAA can be performed under local anesthesia and is a safe alternative to open surgery in high-risk patients. The long-term results need further investigation.

Endovascular Management of a Distally Migrated Bifurcated Endograft with a New Bifurcated Endograft.

A 75-year-old man presented with abdominal and lumbar pain 6 years after previous endovascular repair of an abdominal aortic aneurysm. At the time of the initial operation, the aneurysm measured 6.0 cm in maximum diameter and a bifurcated Anaconda (Vascutek) endograft had been implanted. This time, computed tomography showed a distally migrated endograft which had been folded within the sac and the aneurysm measured 8.4 cm in maximum diameter. We opted to treat this by endovascular means deploying a new bifurcated endograft with suprarenal fixation within the old one. We consider the different management options and discuss the associated technical difficulties.

Association Between Perioperative Fibrinogen Levels and the Midterm Outcome in Patients Undergoing Elective Endovascular Repair of Abdominal Aortic Aneurysms.

BACKGROUND: We investigated the potential association between perioperative fibrinogen levels and outcome in patients undergoing elective endovascular abdominal aneurysm repair (EVAR) of abdominal aortic aneurysms (AAAs). METHODS: Consecutive patients with an intact AAA undergoing elective EVAR with a specific bifurcated endograft (Endurant, Medtronic) were recruited between December 2012 and October 2016. Preoperative and 24-hr postoperative fibrinogen levels were recorded, and potential associations with outcome were tested. Primary outcome measures included endoleaks, lower limb ischemic complications, including endograft limb occlusion, and aneurysm-related reinterventions. RESULTS: Ninety-four patients (91 male, mean age 71.8 ± 8.0 years) with an intact AAA were enrolled in the study. The technical success was 98% (2 failures: 1 type Ia endoleak on completion angiography, 1 lower limb ischemia immediately postoperatively requiring femoral endarterectomy). There was 1 death during the first 30 days due to myocardial infarction (1%). Another patient died 15 months after the procedure from cardiac causes. During the existing follow-up (mean 14.8 ± 14.3 months), 14 patients (15%) developed an endoleak (4, type Ia endoleak and 10, type II endoleak), 6 patients (6.3%) had lower limb ischemia/endograft limb occlusion, and 10 patients (10.6%) required reintervention. Compared with the preoperative values, no significant change occurred with regard to the fibrinogen levels 24 hr after procedure (mean preoperative fibrinogen 360 ± 101 mg/dl vs 24-hr postoperative fibrinogen 349 ± 105 mg/dl, P = 0.1). Neither preoperative nor 24-hr postoperative fibrinogen levels were significantly associated with the development of endoleaks, lower limb ischemia, or reinterventions. However, the difference in fibrinogen levels (baseline to 24 hr after procedure) was significantly higher in patients with endoleaks (median -65 mg/dl vs. 15 mg/dl, P = 0.04). CONCLUSIONS: Perioperative fibrinogen levels may play a role in predicting midterm outcomes in patients undergoing elective EVAR and appears to be associated, directly or indirectly, with the development of endoleaks. Further studies are needed to investigate these findings and explore future therapeutic implications.

Retroperitoneal Liposarcoma Masquerading as an Impending Rupture of Inflammatory Abdominal Aortic Aneurysm.

BACKGROUND: We present a unique case scenario of a periaortic liposarcoma masquerading as an impending rupture of an inflammatory abdominal aortic aneurysm (AAA). METHODS AND RESULTS: A 57-year-old man was referred to our unit for an emergency endovascular repair of "an inflammatory AAA with computed tomography (CT) features of impending rupture." He underwent an uneventful endovascular repair with a bifurcated endograft (C3; Gore, Flagstaff, AZ). Seven weeks later, CT showed that the periaortic "mass" grew larger and asymmetric, and a CT-guided needle biopsy suggested the presence of a high-grade malignant mesenchymal tumor. He underwent laparotomy and excision of the retroperitoneal tumor en bloc with the anterior wall of the infrarenal aorta. The endograft acted as an excellent "safety net" providing adequate hemostatic control and obviating the need for aortic cross-clamping and repair of the aortic defect with a patch or tube graft. CONCLUSIONS: The learning point from the present case is that when faced with an inflammatory AAA and/or retroperitoneal fibrosis, the rare possibility of a retroperitoneal neoplasm should be kept in mind.

Traumatic Knee Dislocation and Popliteal Artery Injury: A Case Series.

Popliteal artery injury is a potentially limb-threatening complication of traumatic knee dislocation. We describe 2 such cases that had been treated in our unit over the last decade. The first one was a 23-year-old woman who injured her right knee during a long jump competition, and the second was a 27-year-old man who had a motorbike accident. Both suffered traumatic knee dislocation along with significant ligament and neurovascular injuries. In the first patient, the popliteal artery was found thrombosed due to intimal rupture and required thrombectomy and vein patch repair, whereas in the second patient, the artery was completely transected and required end-to-end anastomosis. Both limbs were successfully revascularized and required subsequent orthopedic procedures to stabilize the knee joint. Traumatic knee dislocations are rare injuries that may be associated with potentially devastating vascular complications. A prompt diagnosis and timely arterial repair is of paramount importance if limb salvage is to be achieved.

Rupture after Previous Endovascular Aneurysm Repair due to Type IA Endoleak: Complete Endograft Preservation Is Feasible with Proximal Suturing, Aortic Neck Banding, and Sac Plication.

Rupture of an abdominal aortic aneurysm (AAA) after previous endovascular repair (EVAR) may require endograft explantation and replacement with a prosthetic surgical graft. Recent reports have suggested that total endograft removal during late surgical conversion in the nonruptured setting may not be necessary and that preserving functional parts of the endograft may improve results. Similar techniques may be used for ruptured cases diminishing the magnitude of an already difficult and complex procedure. We describe the successful treatment of a ruptured AAA after previous EVAR with complete endograft preservation by combining transmural endograft fixation with sutures, proximal aortic neck banding, and sac plication.

Outcome after Endovascular Repair of Subacute Type B Aortic Dissection: A Combined Series from Two Greek Centers.

BACKGROUND: The aim of this study is to document the outcome following endovascular treatment of subacute type B aortic dissection (AD). METHODS: Between October 2000 and June 2014, 40 patients (33 men, mean age 65 [range 35-87] years) with type B AD underwent thoracic endovascular aortic repair (TEVAR) during the subacute phase (defined as 15-90 days from the onset of symptoms). Indications for intervention were acute aortic enlargement, resistant hypertension, and/or intractable pain. The primary outcome was survival. Secondary outcome measures included reinterventions and aortic remodeling (i.e., the fate of the false lumen [FL] post-TEVAR, which was classified as complete, partial, or no thrombosis of the FL). RESULTS: The intraprocedural technical success was 95% (2 proximal endoleaks). Three patients died within 30 days (7.5%), all 3 from dissection-related causes (retrograde type A AD in 2, ruptured thoracic aorta in 1). Another 11 deaths occurred during follow-up (median 64 months, range 1-167), 3 of which were dissection-related. The 1-, 3-, and 5-year Kaplan-Meier survival probability was 87.5%, 79%, and 71.5%, respectively. With regard to the aortic remodeling, there was complete FL thrombosis in 10 (25%) patients, partial thrombosis in 22 (55%), and patent FL with no thrombosis in 8 (20%) patients. There was no statistically significant association between FL status and survival, or between FL status and initial extent of dissection. However, there was a statistically significant association between FL status and reinterventions, the latter being more frequent in patients with no FL thrombosis. CONCLUSIONS: TEVAR for subacute type B AD appears to be associated with acceptable perioperative and long-term results. In contrast to previous reports, there is still a risk for postoperative retrograde type A AD even when patients are treated in the subacute phase when the aorta is less fragile. Aortic remodeling occurs in the majority of patients, but requires frequent aortic reinterventions, an observation that underlines the need for life-long surveillance.

The Profile of Circulating Matrix Metalloproteinases in Patients Undergoing Lower Limb Endovascular Interventions for Peripheral Arterial Disease.

BACKGROUND: Matrix metalloproteinases (MMPs) play a significant role in the development and progression of atherosclerotic vascular disease. We aimed to document the profile of circulating MMPs in peripheral arterial disease (PAD) patients undergoing lower limb endovascular revascularization. METHODS: A total of 46 patients (37 male; mean age 66 ± 11 years) undergoing elective lower limb percutaneous revascularization (angioplasty/stent) for symptomatic PAD were recruited from 2 vascular centers. Exclusion criteria were: acute limb ischemia, active infection and/or wet gangrene, liver disease, end-stage renal disease, and cancer. Patients having open revascularization or hybrid (open combined with endovascular) procedures were also excluded. Peripheral venous blood samples were taken on admission and 24 hrs after the procedure. Levels of MMP-2, MMP-3, MMP-7, and MMP-9 were measured along with tissue inhibitors of MMPs (TIMPs) 1 and 2. RESULTS: Compared to baseline values, there was a significant elevation in serum MMP-3 (P = 0.014) and MMP-7 (P = 0.008) levels, whereas serum MMP-9 showed a nonsignificant trend to increase (P = 0.169). On the other hand, no significant alterations were found 24 hrs after angioplasty/stenting with regard to the MMP-2 level and TIMP-1 and 2 levels. CONCLUSIONS: This study documented the periprocedural profile of circulating MMPs in patients undergoing angioplasty/stenting for PAD. The implications of increased MMP-3 and MMP-7 activity after peripheral endovascular interventions and their potential clinical relevance require further investigation.

Use of Endurant Stent-Graft Aortic Extensions for the Treatment of Focal Aortic Pathology.

BACKGROUND: To describe our experience with the endovascular treatment of focal abdominal aortic pathology with an adequate distal neck length using Endurant (Medtronic) aortic extension cuffs. METHODS: From July 2010 to May 2015, 16 patients (14 male), with a mean age of 73.6 years (range, 59-88), were treated for focal abdominal aortic pathology using only Endurant (Medtronic) aortic cuff extensions. The indication for intervention was a saccular abdominal aortic aneurysm (AAA) in 5 patients, a fusiform aortic aneurysm in 6 patients, abdominal aortic dissection in 2 patients, an aortic juxtarenal rupture in 1 patient, a large anastomotic pseudoaneurysm of previous bifurcated open repair in 1 patient, and a juxtarenal aneurysm above a previous open AAA repair. Aortic lesions had a mean diameter of 52.9 (range, 32-90) mm. All patients were operated under local anesthesia with unilateral femoral exposure. A single 70-mm long Endurant aortic extension was deployed in 5 cases, while in the remaining 11 cases, 2 cuffs were used with the "telescopic" (double tube) technique. A chimney technique was performed in 5 cases (with a bare metal stent in the renal artery in 3 and a stent graft in the celiac artery in 2). RESULTS: The intraoperative technical success was 100% with no endoleaks on completion angiogram. There was no 30-day mortality. One patient developed acute limb ischemia immediately postoperatively and was treated successfully with thrombectomy. During a mean follow-up of 21.9 months, 1 patient died 2 months after the procedure due to cardiac arrest unrelated to his aortic operation. There was 1 early type IIb endoleak (present at the 30-day follow-up computerized tomography scan), which disappeared 10 months after the procedure. Finally, 1 patient was diagnosed with a type II endoleak and stable diameter 53 months postoperatively, while to date there are no cases of stent-graft migration. CONCLUSIONS: The use of Endurant aortic extensions in aneurysms with adequate distal neck is a safe, simple, customizable, and cost-effective method which presents similar early results with standard endovascular aneurysm repair technique.

Endovascular management of lap belt-related abdominal aortic injury in a 9-year-old child.

Blunt abdominal aortic trauma is a rare occurrence in children with only a few patients having been reported in the literature. Most such cases have been described in the context of lap belt injuries. We report a 9-year-old boy who suffered lap belt trauma to the abdomen during a high-speed road traffic accident resulting to the well-recognized pattern of blunt abdominal injury, that is, the triad of intestinal perforation, fractures of the lumbar spine, and abdominal aortic injury. The latter presented with lower limb ischemia due to dissection of the infrarenal aorta and right common iliac artery. Revascularization was achieved by endovascular means using 2 self-expanding stents in the infrarenal aorta and the right common iliac artery. This case is one of the few reports of lap belt-related acute traumatic abdominal aortic dissection in a young child and highlights the feasibility of endovascular management in the pediatric population.

A systematic review and meta-analysis of abdominal compartment syndrome after endovascular repair of ruptured abdominal aortic aneurysms.

OBJECTIVE: Limited data exist regarding the development of abdominal compartment syndrome (ACS) after endovascular repair of ruptured abdominal aortic aneurysms (RAAAs). We aimed to record the incidence, management, and outcome of this complication. METHODS: A systematic review and meta-analysis of the English language literature was undertaken through June 2012. Articles reporting data on outcome after endovascular repair of RAAAs were identified, and information regarding ACS was sought. RESULTS: Included were 39 eligible studies reporting 1134 patients. The pooled perioperative mortality was 21% (95% confidence interval [CI], 18%-24%). A total of 109 cases of ACS were recorded. There was significant within-study heterogeneity (Cochran Q = 94.1; P < .0001), and the pooled ACS rate was 8% (95% CI, 5.6%-10.8%). Only six studies accurately defined ACS, and four focused specifically on ACS. When the meta-analysis was repeated after including only studies with a definition and those focusing on ACS, the pooled rate increased to 17% (95% CI, 10%-26%) and 21% (95% CI, 13%-30%), respectively. A random-effects meta-regression analysis investigating the effect of ACS and other risk factors on mortality revealed a significant linear correlation between hemodynamic instability and death (r = 0.303) and a nonlinear (second degree polynomial) association between bifurcated endograft approach and death (R(2) = 0.348; P = .0027). However, no statistically significant association could be found between ACS and death. A further meta-regression analysis failed to identify any statistically significant predictors of ACS. Treatment included open decompression in 86 patients, percutaneous drainage in 18 (catheter only in five, combined with tissue plasminogen activator infusion in 13), and conservative measures in five. Data on outcome of ACS were only available for 76 patients; 35 of these died, for a mortality rate of 47%. CONCLUSIONS: The pooled ACS rate was calculated at 8%, but this figure may be >20% with improved awareness and vigilant monitoring. Although no statistically significant association could be found between ACS and death, almost half the patients who developed ACS after endovascular repair of RAAAs were likely to die.

Spontaneous rupture of the visceral abdominal aorta: endovascular management using the periscope graft technique.

PURPOSE: To describe the endovascular management of a spontaneous rupture of the visceral abdominal aorta. CASE REPORT: A 69-year-old man presented as an emergency with a ruptured non-aneurysmal visceral abdominal aorta that extended from just below the celiac trunk to the right renal artery; the superior mesenteric artery (SMA) appeared to be occluded. The rupture was presumed to be due to a penetrating atherosclerotic ulcer. An endovascular approach was devised in which an Excluder aortic cuff would be deployed immediately below the origin of the celiac artery, covering the ruptured aortic segment and the occluded SMA. However, a second cuff was required distally to seal the rupture. To maintain perfusion to the right renal artery, a Viabahn stent-graft was deployed into the renal artery using the periscope technique. A stent was also required in the celiac trunk, which had been inadvertently covered. The patient had an uneventful recovery; follow-up imaging at 1 year revealed no endoleak and resolution of the hematoma. CONCLUSION: Spontaneous rupture of a non-aneurysmal visceral abdominal aorta is extremely challenging and potentially fatal. Endovascular management using the periscope stent-graft technique to facilitate aortic stent-grafting may offer an attractive bailout option with satisfactory early results.

Management of Postfasciotomy Wounds and Skin Defects Following Complex Vascular Trauma to the Extremities Using the External Tissue Extender System.

Management of large postfasciotomy wounds and/or skin and soft tissue defects after major vascular trauma to the extremities can be challenging. The External Tissue Extender (Blomqvist; ETE), a skin-stretching device, which consists of silicone tapes and plastic stoppers, approximates wound margins and facilitates delayed primary closure. We describe our experience with the use of ETE in 5 patients (4 males) with a total of 8 wounds (7 postfasciotomy, 1 soft tissue defect) over the past 12 years. The mean patient age was 32 (range 17-61) years. The wounds involved the lower limb in 3 patients and the upper limb in 2, whereas the injured arteries were the popliteal in 3, the axillary in 1, and the brachial in 1. The mean wound length was 24 cm (range 9-37 cm), and the mean number of ETE silicone tapes used per wound was 13 (range 5-19). The median duration of ETE therapy was 7 days (range 4-7). ETE therapy resulted in sufficient wound approximation to allow complete closure with conventional suturing in 7 out of the 8 wounds. Of these, one developed infection that required drainage, debridement, and resuturing. All wounds achieved satisfactory healing status and all limbs had been salvaged. In conclusion, the ETE is a useful, easy-to-use, and simple adjunct that may facilitate delayed primary closure of large postfasciotomy wounds or extensive skin and soft tissue defects following complex vascular trauma to the extremities.

The Impact of Aortic Occlusion Balloon on Mortality After Endovascular Repair of Ruptured Abdominal Aortic Aneurysms: A Meta-analysis and Meta-regression Analysis.

INTRODUCTION: We aimed to investigate whether the use of aortic occlusion balloon (AOB) has an impact on mortality of patients undergoing endovascular repair of ruptured abdominal aortic aneurysms (RAAAs). METHODS: A meta-analysis of the English-language literature was undertaken through February 2013. Articles reporting data on outcome after endovascular repair of RAAAs were identified and information regarding the use of AOB was sought. RESULTS: Included in this meta-analysis were 39 eligible studies reporting 1277 patients. The pooled perioperative mortality was 21.6% (95% CI 18.1-25.1%). There was significant within-study heterogeneity (I(2) 50.2%, P < 0.001). A total of 200 patients required AOB with an estimated pooled proportion of 14.1% (8.9-19.3%). Individual random-effects meta-regression investigating the effect of AOB and other risk factors on mortality revealed a significant linear association of hemodynamic instability, bifurcated endograft approach, and primary conversion to open repair with mortality and a nonlinear (second degree polynomial) association of AOB with mortality. On multivariable meta-regression models, both hemodynamic instability and AOB were found to be statistically significant, independent predictors of mortality. In particular, there was a statistically significant negative correlation between AOB and mortality and a positive effect of hemodynamic instability on mortality. In practical terms, mortality was significantly higher in studies with a higher proportion of hemodynamically unstable patients and lower in studies with a higher rate of AOB use. CONCLUSION: This study provides meta-analytical evidence that the use of an AOB in unstable RAAA patients undergoing endovascular repair may improve the results.

Endovascular Repair of Abdominal Aortic Aneurysms with the Anaconda™ Stent Graft: Mid-term Results from a Single Center.

INTRODUCTION: We aimed to report our experience with the Anaconda™ stent graft (Vascutek, Terumo, Inchinnan, Scotland, UK) for the endovascular treatment of abdominal aortic aneurysms (AAAs). METHODS: The vascular unit database was interrogated to identify all AAA patients who underwent endovascular repair with the Anaconda™ device between March 2007 and June 2014. The peri-operative, short-term, and mid-term outcome was recorded focusing on complications and re-interventions. RESULTS: Sixty-eight patients had been treated during the study period. Seven of these were symptomatic, one presented with an inflammatory aneurysm, and five presented with a ruptured AAA. The primary and the assisted primary technical success were 86.7 and 97.1%, respectively. There was no 30-day mortality in the elective or symptomatic group, but two of the ruptured AAA patients died. During a mean follow-up of 29 months (range 1-87), 14 patients died, none from aneurysm-related causes. A total of 11 endoleaks (17.5%) were detected in 10 patients during follow-up (1 type Ia, 4 type Ib, 6 type II), 4 of which required re-intervention (all for type Ib endoleak). Two iliac limbs occluded during the follow-up. The estimated overall survival, endoleak-free survival and re-intervention-free survival probability were 88.2, 78.4, and 83.4% at 1 year; 85.9, 73.8, and 78.9% at 2 years; and 80.6, 71.3, and 70.5% at 3 years, respectively. CONCLUSION: Based on this series, the Anaconda™ stent graft appears to be safe and effective for the endovascular treatment of AAAs. Both the short-term and the mid-term results are satisfactory.

Ruptured mycotic common femoral artery pseudoaneurysm: fatal pulmonary embolism after emergency stent-grafting in a drug abuser.

The rupture of a mycotic femoral artery pseudoaneurysm in an intravenous drug abuser is a limb- and life-threatening condition that necessitates emergency intervention. Emergency stent-grafting appears to be a viable, minimally invasive alternative, or a bridge, to subsequent open surgery. Caution is required in cases of suspected concomitant deep vein thrombosis in order to minimize the possibility of massive pulmonary embolism during stent-grafting, perhaps by omitting stent-graft postdilation or by inserting an inferior vena cava filter first. We describe the emergency endovascular management, in a 60-year-old male intravenous drug abuser, of a ruptured mycotic femoral artery pseudoaneurysm, which was complicated by a fatal pulmonary embolism.